A study of patients more than 25 years of age with body mass index above 30, dyslipidemia, hypertension, and fasting glucose averaging 115 mg/ dL is performed. They have adipose tissue abnormalities including increased non-esterified fatty acid release, altered adipokines with decreased adiponectin, greater proinflammatory cytokine release, and diminished peroxisome proliferator-activated receptor gamma (PPARg) function. Which of the following is the best initial therapeutic intervention for these patients?
The findings are those of insulin resistance from obesity with metabolic syndrome. Insulin resistance drives beta-cell dysfunction, but other factors such as the TCF7L2 gene play a role in the eventual development of overt type 2 diabetes mellitus. Excess free fatty acids may stimulate cytokine release from beta cells to promote inflammation and islet cell dysfunction. Lifestyle modification with dietary modification for weight reduction coupled with increased exercise will aid in reversing the insulin resistance so that no drug therapy is needed to control hyperglycemia. Cushing syndrome may occur from ACTH-independent adrenal cortical lesions, such as primary hyperplasia, adenoma, or carcinoma, and lead to secondary diabetes from glucocorticoid-induced insulin resistance, but primary adrenal lesions are less common than metabolic syndrome from obesity alone, and the study patients lack additional features of Cushing syndrome such as hirsuitism, osteoporosis, and easy bruisability. The absolute decrease of insulin with type 1 diabetes mellitus must be treated with insulin injections. There is modest weight gain with hypothyroidism, but without abnormalities of adipocytes leading to insulin resistance. Liposuction is a plastic surgery technique used for body contouring, not weight reduction.
Adrenalectomy
Caloric restriction
Insulin injection
L-Thyroxine
Endocrine