Insulin resistance and adrenal incidentalomas: A bidirectional relationship

•Adrenal incidentalomas (AIs) have recently been on the rise.•This phenomenon could be highly associated with the respective rise in obesity.•Ιnsulin resistance, hyperinsulinemia and its anabolic effects on adrenal glands offer possible pathophysiological links.•Continuous headway in the field of radiology could very possibly be accountable too.•Reversly, patients with AIs and autonomous cortisol secretion may develop insulin resistance and obesity. An adrenal incidentaloma (AI) is an adrenal mass incidentally found via a radiological modality, independent of an endocrinological investigation. In this review, we aimed to investigate the possible reasons behind the increased frequency in AI detection, especially in ageing populations. The pathophysiological effects of insulin resistance (IR), hyperinsulinemia and various anabolic pathways are analyzed. In addition, we review data from studies indicating an increased incidence of adrenal adenomas and carcinomas in patients with type 2 diabetes mellitus (T2DM). The establishment of obesity as a global epidemic, with a higher prevalence in the female than in the male population, coincide with data regarding AIs and the conditions may share a pathophysiological basis. Furthermore, we discuss the bidirectional association of AIs with obesity, insulin resistance and T2DM, especially in patients with autonomous cortisol secretion. Lastly, as per the definition of an AI, we touch upon the evolution of radiological imaging as another possible cause of the rise in prevalence of AIs, especially concerning the greater use and precision of computed tomography (CT).