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For instance, when intra-portal insulin levels are increased [e.g., obesity, Cushings syndrome or due to treatment with glucocorticoids and glucagon-like peptide-1 receptor agonists (GLP-1RA)] or decreased (e.g., anorexia nervosa and T1D) in disease states, these secondary changes (secondary association) alters hepatic GH sensitivity resulting in discordant GH and IGF-I levels (high GH/low IGF-I levels and low GH/high IGF-I levels, respectively)

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Contact your GP or prescribing clinician if : Fatigue is severe, persistent, or worsening despite implementing dietary and lifestyle strategies You experience additional concerning symptoms such as chest pain, significant breathlessness, palpitations, dizziness, or fainting episodes There are signs of dehydration including dark urine, reduced urination, dry mouth, or confusion Gastrointestinal symptoms (nausea, vomiting, diarrhoea) are severe or preventing adequate nutrition and hydration You notice unexplained weight loss beyond expected therapeutic effects, or difficulty maintaining adequate food intake Fatigue is accompanied by mood changes , particularly low mood, loss of interest in activities, or thoughts of self-harm You have severe, persistent abdominal pain (especially if radiating to the back) with or without vomiting, which could indicate pancreatitis [1] You develop right upper abdominal pain, fever, or yellowing of the skin/eyes , which could suggest gallbladder disease [1] If you have diabetes and take insulin or sulfonylureas: symptoms of hypoglycaemia (sweating, trembling, hunger, confusion) alongside fatigue Seek urgent medical care (call 999 or go to A&E) for severe chest pain, acute severe breathlessness, or new neurological symptoms like facial drooping or sudden weakness

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Alternating without a proper washout period can result in unpredictable drug interactions and loss of appetite suppression during transitions

Most patients report reduced appetite, decreased interest in foods they normally crave, and a genuine sensation of fullness with smaller portions