Low-value clinical practices – defined as diagnostic or therapeutic interventions that provide limited clinical benefit and may be associated with unnecessary risks or costs – remain common in endocrinology and nutrition. The Spanish Society of Endocrinology and Nutrition (SEEN) presents this second edition as an updated set of recommendations on “what not to do” in clinical practice, developed by its sections and working groups. The methodological process included the selection of relevant topics, systematic literature review, and multidisciplinary consensus. Key areas addressed include diabetes, obesity, nutrition, gonads, lipids, laboratory, mineral metabolism, and imaging, identifying low-value interventions and offering alternatives based on the best available evidence. The implementation of these recommendations aims to optimize care quality, reduce risks, and contribute to the sustainability of the healthcare system.
Las prácticas clínicas de escaso valor, entendidas como aquellas intervenciones diagnósticas o terapéuticas que aportan un beneficio clínico limitado y pueden conllevar riesgos o costes injustificados, siguen siendo frecuentes en endocrinología y nutrición. La Sociedad Española de Endocrinología y Nutrición (SEEN) presenta en esta segunda edición una actualización de recomendaciones sobre “qué no hacer” en la práctica clínica, elaboradas por sus áreas de conocimiento y grupos de trabajo. El proceso metodológico incluyó la selección de temas relevantes, revisión sistemática de la literatura y consenso multidisciplinar. Se abordan áreas clave como diabetes, obesidad, nutrición, gónadas, lípidos, laboratorio, metabolismo mineral e imagen, identificando intervenciones de bajo valor y ofreciendo alternativas basadas en la mejor evidencia disponible. La aplicación de estas recomendaciones pretende optimizar la calidad asistencial, reducir riesgos y contribuir a la sostenibilidad del sistema sanitario.
Low-value clinical practices – defined as those that offer little or no clinical benefit and may entail unjustified risks or costs – remain common in health care and represent a substantial proportion of overall health expenditure.1,2 Avoiding such practices, optimizing resources, and minimizing patient harm are essential responsibilities of both clinicians and health authorities.
Several scientific societies emphasize that reducing these practices is critical to preventing complications arising from cascades of unnecessary diagnostic and therapeutic procedures, as well as to containing health care costs without compromising quality of care.1 Recent studies highlight that overuse of tests, procedures, and treatments can cause direct harm and contribute to patient psychological distress.3,4
Strategies to reduce low-value practices include continuous clinician education based on guidelines, audits and feedback, decision-support tools, and active patient participation in shared decision-making.5,6 Initiatives to identify low-value practices and improve appropriateness—such as Choosing Wisely or, in Spain, GuiaSalud, Essencial, DianaSalud, and MAPAC—have shown usefulness, although results vary depending on context and implementation fidelity.7
Aware of this problem, the Spanish Society of Endocrinology and Nutrition (SEEN) published 1 year ago a compilation of recommendations on low-value clinical practices issued by its different working groups and areas of expertise.8 This article presents a new selection of recommendations with broader participation across the society’s groups and areas.
MethodsThis project was approved by the SEEN board of directors in September 2023. The areas of expertise participating in this article included diabetes, obesity, and nutrition, as well as the working groups on gonads, lipids and cardiovascular risk, laboratory, mineral metabolism, and imaging. The methodology followed was identical to that previously published.8 In summary, each coordinator appointed a lead responsible for selecting the health problem, conducting the literature search, and drafting the recommendations. Topic selection was based on clinical relevance, prevalence, and the severity of problems arising from inappropriate practices. The literature review prioritized clinical practice guidelines, systematic reviews, and randomized controlled trials. Recommendations were structured into three sections: definition of the low-value practice, evidence source, and justification based on published data. All members of each group reviewed and commented on the recommendations before their final approval by the SEEN board.
RecommendationsDiabetesRecommendation #1Do not routinely use acetylsalicylic acid (ASA) in patients with diabetes without established cardiovascular disease (CVD). Assess risk–benefit in high-risk individuals.
Source of evidenceMeta-analyses, clinical trials, and scientific society guidelines.9–17
JustificationAlthough ASA may reduce cardiovascular events, this benefit is offset by an increased risk of major bleeding—primarily GI—and intracranial or ocular hemorrhage, among others. Given the narrow risk–benefit balance, routine use of ASA for primary prevention in diabetes is not justified. Cardiovascular and bleeding risks must be individually assessed. ASA may be considered in patients > 50 years with major CVD risk factors (family history of early CVD, smoking, dyslipidemia, hypertension, chronic kidney disease and/or albuminuria, or a positive non-invasive imaging test) if bleeding risk is low.
Recommendation #2Do not recommend routine use of nutritional supplements for glycemic control without individualized evaluation.
Source of evidenceClinical trials, systematic reviews, meta-analyses, scientific society recommendations.18–30
JustificationDietary supplements, as defined by Directive 2002/46/EC, are used to complement the diet. Their use is high among people with diabetes (∼60%), but evidence of benefit is limited. Their use is not recommended except in documented deficiencies. Substances such as cinnamon, chromium, berberine, or lipoic acid show some evidence but with methodological limitations. Vitamin D may reduce progression to type 2 diabetes. Metformin can induce vitamin B12 deficiency, which supports monitoring. Supplementation is indicated in pregnancy, lactation, disease-related malnutrition, or restrictive diets.
ObesityRecommendation #1Do not use so-called food intolerance tests to treat obesity or confirm suspected intolerances.
Source of evidenceScientific society recommendations.31–34
JustificationFood sensitivity tests should not be used to diagnose disease or guide dietary plans in patients with obesity due to lack of scientific basis and potential physical and psychological harm.
Recommendation #2Do not routinely use very-low-calorie diets for long-term obesity treatment.
Source of evidenceScientific society recommendations.35
JustificationVery-low-calorie diets are not recommended for long-term obesity treatment or without supervision by qualified health professionals.
NutritionRecommendation #1Do not use long-term enteral tube feeding as chronic treatment in people with advanced dementia.
Source of evidenceMeta-analyses, systematic reviews, clinical guidelines using GRADE methodology, and society recommendations.36–40
JustificationEnteral tube feeding does not improve quality of life or survival in advanced dementia but increases tube-related complications, pressure ulcers, and mortality compared with assisted or comfort oral feeding. Advanced dementia corresponds to GDS-FAST stage ≥ 7c.
Recommendation #2Do not require fasting from midnight for most patients undergoing scheduled major surgery.
Source of evidenceMeta-analyses and systematic reviews, systematic reviews of clinical guidelines, clinical guidelines, and scientific society recommendations.41–45
JustificationIt has not been demonstrated that ingesting clear liquids up to 2 h before elective major surgery increases the risk of aspiration, regurgitation, or complications vs traditional “nothing by mouth after midnight” policies. Clear liquids up to 2 h before surgery and light solids up to 6 h before surgery are safe in most patients, prevent loss of muscle mass and insulin resistance, and improve patients’ sense of well-being.
GonadsRecommendation #1Do not initiate testosterone replacement therapy in adolescents or young adults with Klinefelter syndrome (KS) and asymptomatic compensated hypogonadism.
Source of evidenceClinical practice guidelines using GRADE methodology, meta-analyses, systematic reviews, and randomized clinical trials.46–50
JustificationApproximately 60% of men with KS present with asymptomatic compensated hypogonadism (normal total testosterone with elevated luteinizing hormone in the absence of signs or symptoms of hypogonadism), and most complete puberty spontaneously. There is currently no evidence supporting initiation of testosterone replacement therapy in this context. The 2020 European Academy of Andrology clinical guideline for KS management recommends not initiating treatment in adolescents or young adults with asymptomatic compensated hypogonadism.
Recommendation #2Do not use ethinylestradiol as the estrogen of choice in hormone replacement therapy for Turner syndrome (TS).
Source of evidenceScientific society recommendations, clinical trials, systematic reviews, and meta-analyses.51–61
JustificationMost girls and women with TS will require hormone replacement therapy (HRT). TS is associated with higher rates of metabolic syndrome, obesity, hypertension, diabetes, and dyslipidemia, with cardiovascular disease being a leading cause of death. Therefore, prescribing an HRT regimen with the lowest possible cardiovascular risk is essential. Ethinylestradiol has a worse cardiovascular profile than 17β-estradiol (E2). For this reason, the 2023 clinical practice guideline for the care of girls and women with TS concludes that E2 is the estrogen of choice.
LipidsRecommendation #1Do not use fibrates with the primary goal of reducing cardiovascular risk.
Source of evidenceSystematic reviews, meta-analyses, clinical trials, and clinical practice guidelines.9,10,62–70
JustificationModerate hypertriglyceridemia (175–885 mg/dL) increases CVD risk. Fibrates are peroxisome proliferator-activated receptor-α (PPARα) agonists that reduce triglyceride levels, but their efficacy in reducing vascular risk is unproven. In the recent PROMINENT trial, adding pemafibrate to statin therapy in patients with type 2 diabetes and moderate hypertriglyceridemia had a neutral effect on CVD risk. Therefore, guidelines recommend reserving fibrates for prevention of pancreatitis in severe hypertriglyceridemia and discourage adding fibrates to statins for cardiovascular prevention.
Recommendation #2Do not diagnose statin intolerance after myalgias appear with the use of a single statin preparation.
Source of evidenceSystematic reviews, meta-analyses, clinical trials, and clinical practice guidelines.71–78
JustificationStatins have proven to reduce cardiovascular events, yet muscle symptoms often lead to discontinuation even though they are not always attributable to the drug. Diagnosing statin intolerance requires that adverse effects resolve upon discontinuation and recur after trying at least 2 different statins. In cases of severe symptoms or significant CPK elevation, the statin should be stopped and later re-introduced. A different statin at a low dose or low-frequency regimen may be attempted. In true intolerance, alternative therapies with proven cardiovascular benefit should be used.
LaboratoryRecommendation #1Routine measurement of 25-hydroxyvitamin D (vitamin D) in the general healthy population is not recommended, except when clearly indicated—even in situations such as adult or childhood obesity, dark skin, or pregnancy.
Recommendation #2Although routine monitoring of vitamin D concentrations is not recommended in most cases, it may be indicated in certain high-risk groups.
Source of evidenceClinical practice guidelines, consensus documents, and scientific society recommendations.79–84
JustificationThere is no evidence supporting universal measurement of 25-hydroxyvitamin D, and this practice carries significant economic burden. Therefore, screening for optimal vitamin D status should be avoided in the general population and reserved for specific situations or individuals with risk factors for deficiency.
Mineral metabolismRecommendation #1Do not screen for normocalcemic primary hyperparathyroidism (NPHPT) in the general population without evidence of bone or renal disease.
Source of evidenceRecommendations from clinical practice guidelines, expert consensus, and reviews.85–89
JustificationCohort studies of patients with normocalcemic primary hyperparathyroidism (NPHPT) typically include symptomatic individuals. Because of this peculiarity, the clinical significance of NPHPT as a biochemical finding in patients without renal or bone disease remanis unclear. Based on the premise that, with the information available today, the population that benefits from a diagnosis of NPHPT is that in which the biochemical abnormality is accompanied by target-organ involvement, it is in these cases where an active search for NPHPT should be undertaken.
Imaging in endocrinologyRecommendation #1Do not perform fine-needle aspiration (FNA) in hyperfunctioning and/or hypercaptant thyroid nodules on thyroid scintigraphy, except in exceptional cases.
Source of evidenceScientific society recommendations.90–93
JustificationFNA should not be performed in hyperfunctioning nodules because their benign nature is already established. Ultrasound criteria indicating FNA are unreliable in this context, cytological results may be altered due to hyperfunction, and unnecessary procedures may expose patients to greater iatrogenesis.
Recommendation #2Do not perform thyroid ultrasound in all patients with abnormal thyroid function tests if adequate palpation does not detect any abnormality.
Source of evidenceScientific society recommendations.92–99
JustificationThyroid ultrasound should not be ordered when thyroid functional disorders are present but cervical palpation is normal to avoid overdiagnosis of clinically insignificant thyroid nodules that may divert clinical focus and negatively affect the patient emotionally.
ConclusionsIn this 2nd edition, the Spanish Society of Endocrinology and Nutrition (SEEN) presents new recommendations to avoid low-value clinical practices in endocrinology and nutrition. This document, the result of collaborative work among various SEEN areas and working groups, provides guidance based on the best available evidence with the aim of optimizing care quality, minimizing unnecessary risks, and contributing to the sustainability of the health care system. Implementing these recommendations in daily clinical practice will improve the care of individuals with endocrine and nutritional disorders.
The full text of the document is available at: www.seen.es
Ethical considerationsAs this was a bibliographic review and coordination of working groups, approval by an ethics committee was not required. However, prior to drafting, the project was approved by the SEEN Executive Board.
FundingNone declared.
None declared.
The authors thank the coordinators of the SEEN knowledge areas in diabetes, obesity and nutrition, and the working groups on gonads, lipids and cardiovascular risk, laboratory, mineral and bone metabolism, and imaging for their collaboration in selecting authors and reviewing Recommendation texts, as well as the members of the SEEN Executive Board for their manuscript review.
President: Ignacio Bernabéu; First Vice President: Juan José Díez; Second Vice President: Gabriel Olveira; Treasurer: María Alba Galdón Sanz-Pastor; Secretary: Alberto Fernández Martínez; Board Members: Emma Anda Apiñaniz, Manuel Gahete Ortiz, Nuria Vilarrasa García, Julia Ocón Bretón, Juan José López Gómez, Beatriz Lardiés Sánchez, and Francisco Pita Gutiérrez.
