41-year-old prediabetic woman with hypothyroidism
History of present illness: A 41-year-old woman presents with extreme lethargy, depression, and morbid obesity. She reports that her lethargy and depression have been present for six months, despite no major changes or life events, and notes that they are starting to significantly affect her daily life. Blood tests show the patient to be prediabetic, with all other tests normal. She reports trying several different low glycemic index diets with no success in relieving the lethargy. She notes wanting to lose weight but feeling overwhelmed every time she has tried.
Social history: Patient denies alcohol, tobacco and illicit drug use. She smokes medical marijuana once per week. She lives alone and has one mixed-breed dog. She works as a graphic designer.
Medication: Levothyroxine. Assorted herbal supplements as needed.
Allergies: Ragweed, grasses.
Past medical history: Maternal family history of breast cancer.
1. What diet would you recommend for this patient? Is there anything to avoid? Is there anything to intentionally consume?
2. What would be the pros and cons of starting this patient on daily metformin?
3. What lifestyle or other changes would you recommend for this patient?