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Maleki Sedgi F, Mohammad Hosseiniazar M, Alizadeh M. The effects of replacing ghee with rapeseed oil on liver steatosis and enzymes, lipid profile, insulin resistance and anthropometric measurements in patients with non-alcoholic fatty liver disease: a randomised controlled clinical trial. Br J Nutr 2024; 131:1985-1996. [PMID: 38501177 DOI: 10.1017/s0007114524000564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
Non-alcoholic fatty liver disease (NAFLD), which is a prevalent hepatic condition worldwide, is expected to develop into the leading reason for end-stage fatty liver in the forthcoming decades. Incorporating rapeseed oil into a balanced diet may be beneficial in improving NAFLD. The goal of this trial was to evaluate the impact of substituting ghee with rapeseed oil on primary outcomes such as fatty liver and liver enzymes, as well as on secondary outcomes including glycaemic variables, lipid profile and anthropometric measurements in individuals with NAFLD. Over 12 weeks, 110 patients (seventy men and forty women; BMI (mean) 28·2 (sd 1·6 kg/m2); mean age 42 (sd 9·6) years), who daily consumed ghee, were assigned to the intervention or control group through random allocation. The intervention group was advised to substitute ghee with rapeseed oil in the same amount. The control group continued the consumption of ghee and was instructed to adhere to a healthy diet. Results showed a significant reduction in the steatosis in the intervention group in comparison with the control group (P < 0·001). However, a significant change in the levels of alanine aminotransferase (–14·4 μg/l), γ-glutamyl transferase (–1·8 μg/l), TAG (–39·7 mg/dl), total cholesterol (–17·2 mg/dl), LDL (–7·5 mg/dl), fasting blood glucose (–7·5 mg/dl), insulin (–3·05 mU/l), Homeostatic Model Assessment for Insulin Resistance (–0·9), Quantitative Insulin-Sensitivity Check Index (+0·01), weight (–4·3 kg), BMI (–0·04 kg/m2), waist (–5·6 cm) and waist:height ratio (–0·04) was seen in the intervention group. The consumption of rapeseed oil instead of ghee caused improvements in liver steatosis and enzymes, glycaemic variables and anthropometric measurements among individuals with NAFLD.
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Affiliation(s)
- Fatemeh Maleki Sedgi
- Student Research Committee, Urmia University of Medical Sciences, Urmia, Iran
- Department of Nutrition, School of Medicine, Urmia University of Medical Sciences, Urmia, Iran
| | | | - Mohammad Alizadeh
- Department of Nutrition, School of Medicine, Urmia University of Medical Sciences, Urmia, Iran
- Food and Beverages Safety Research Center, Urmia University of Medical Sciences, Urmia, Iran
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Matlock KA, Pérez-Escamilla R, Wagner J. Depression and Anxiety Mediate the Relationship between Discrimination and Well-Being in a Sample of Latinx Adults with Type 2 Diabetes: Results from a Dual Mediation Analysis. J Immigr Minor Health 2024; 26:453-460. [PMID: 38244119 PMCID: PMC11096199 DOI: 10.1007/s10903-024-01582-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2023] [Indexed: 01/22/2024]
Abstract
Latinxs experience greater risk for type 2 diabetes, discrimination, and poor mental health. The pathways linking these factors, however, are not well understood. This study tested whether depression and anxiety mediated the relationship between discrimination and well-being. Bootstrapped mediation tests were conducted using a sample of Latinx adults with type 2 diabetes (n = 121) and regression models adjusted for demographic and health covariates. Depression and anxiety fully and jointly mediated the effect of discrimination on well-being; everyday discrimination was linked to elevated symptoms of depression and anxiety which were, in turn, independently linked to reduced emotional well-being. Moreover, the effect size for the anxiety pathway (β=-0.13) was 60% larger than for depression (β=-0.08). Dual mediation suggests depression, and especially anxiety, may be important targets for interventions seeking to mitigate the deleterious effects of discrimination. Findings have important implications for psychotherapeutic treatments and public health policy.
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Affiliation(s)
- Kevin A Matlock
- Department of Psychiatry, University of Oxford, Oxford, UK.
- Worcester College, University of Oxford, Oxford, UK.
| | | | - Julie Wagner
- University of Connecticut Health Center, University of Connecticut, Farmington, CT, USA
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Wu Z, Huang K, Bao S, Zhang X, Li J, Kong W, Shi Y, Xie Y. The association of triglyceride-glucose-waist circumference with metabolic associated fatty liver disease and the severity of liver steatosis and fibrosis in American adults: a population-based study. Scand J Gastroenterol 2024; 59:561-569. [PMID: 38235548 DOI: 10.1080/00365521.2024.2305268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 01/08/2024] [Indexed: 01/19/2024]
Abstract
BACKGROUND The global obesity pandemic has led to an alarming rise in the prevalence of metabolic-associated fatty liver disease (MAFLD), making it a substantial clinical and economic burden on society. Early detection and effective treatment of MAFLD are imperative to mitigate its impact. METHODS This cross-sectional study was conducted involving 4634 adults from the National Health and Nutrition Examination Surveys (NHANES) 2017-2018 cycle. Transient elastography (TE) was used to diagnose MAFLD and assess the extent of liver steatosis and fibrosis. Multivariate logistic regression models were utilized to examine the association between the triglyceride and glucose index-waist circumference (TyG-WC) and the risk of MAFLD, liver fibrosis, and steatosis. RESULTS A positive association between TyG-WC and MAFLD persisted across all three models: model1: OR = 8.44, 95% CI: 6.85-10.38 (unadjusted), model2: OR = 8.28, 95% CI: 6.53-10.50 (partially adjusted), and model3: OR = 7.98, 95% CI: 4.11-15.46 (fully adjusted). Further investigation through interaction and stratified analysis revealed that this association was more pronounced in the non-obese and Non-Hispanic White persons groups. Moreover, a non-linear relationship analysis unveiled threshold and saturation effects between TyG-WC and MAFLD. Specifically, a TyG-WC value of approximately 600 may represent the threshold effect for MAFLD risk, while 1200 may signify the saturation effect of MAFLD risk. Finally, a robust correlation between TyG-WC and the severity of liver steatosis and fibrosis was found. CONCLUSIONS The findings suggest that the TyG-WC index exhibits excellent predictive value for MAFLD in the general American population.
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Affiliation(s)
- Zhouxiao Wu
- Health Science Center, Ningbo University, Ningbo, Zhejiang, China
- Department of Infectious Diseases, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
- Department of Hepatology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Kai Huang
- Department of General Medicine, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Sizeng Bao
- Department of Nephrology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Xiangyu Zhang
- Department of Nephrology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Jingwen Li
- Department of Infectious Diseases, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
- Department of Hepatology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Weiliang Kong
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Yanmei Shi
- Department of Infectious Diseases, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
- Department of Hepatology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
| | - Yilian Xie
- Department of Infectious Diseases, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
- Department of Hepatology, The First Affiliated Hospital of Ningbo University, Ningbo, Zhejiang, China
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Zhuo Y, He J, Wang L, Chow CB, Ho FK. Association between birth weight and insulin resistance in US adolescents: A retrospective cohort study exploring the role of concurrent body mass index. Nutr Metab Cardiovasc Dis 2024; 34:1061-1068. [PMID: 38331646 DOI: 10.1016/j.numecd.2023.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 11/22/2023] [Accepted: 11/27/2023] [Indexed: 02/10/2024]
Abstract
BACKGROUND AND AIMS This study aimed to investigate the association between birth weight (BW) and abnormal HOMA-IR in US adolescents aged 12-15 years. The role of concurrent body mass index (BMI) in adolescence was also examined. METHODS AND RESULTS This retrospective cohort study included 3429 participants from NHANES with data in 1999-2020. HOMA-IR ≥2.3 was considered abnormal. Participants were classified as low (LBW; <2.5 kg), normal (NBW; 2.5-4.0 kg), or high (HBW; >4.0 kg) BW. Logistic regression was used to explore the association between BW and HOMA-IR. Mediation analysis was used to examine whether BMI z-score in adolescence mediated the association between BW and HOMA-IR. Compared with those in NBW, the odds ratios (95 % CI) of abnormal HOMA-IR in LBW and HBW groups were 1.26 (0.99-1.60), and 0.62 (0.47-0.83) respectively. The association between BW and abnormal HOMA-IR was consistent in all subgroups with no significant interactions. Mediation analysis showed that BW is associated with lower risk of HOMA-IR directly, but with higher risk indirectly via BMI in adolescence. CONCLUSION There was a negative linear relationship between BW and the prevalence of abnormal HOMA-IR in adolescents aged 12-15 independent of concurrent BMI. Children who were born with LBW but had high BMI in adolescence were of particularly higher risk of insulin resistance.
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Affiliation(s)
- Yubo Zhuo
- Department of Pharmacy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Jieli He
- Department of Pharmacy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Liangbing Wang
- Department of Pediatrics, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Chun Bong Chow
- Department of Pediatrics, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Frederick K Ho
- School of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom.
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Ahmad AHM, Kamal Eldin F, Rashed MM. Efficacy of Perioperative Infusion of N(2)-L-alanyl-L-glutamine in Glycemic Control for Patients With Uncontrolled Diabetes Mellitus Presented for Urgent Coronary Artery Bypass Surgery: A Randomized Controlled Trial. J Cardiothorac Vasc Anesth 2023; 37:2289-2298. [PMID: 37537132 DOI: 10.1053/j.jvca.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 06/19/2023] [Accepted: 07/05/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVES To evaluate the efficacy of preoperative glutamine infusion in reducing insulin requirements in patients with uncontrolled type 2 diabetes, defined as glycated hemoglobin (HbA1c) >7%, undergoing urgent coronary artery bypass graft (CABG) surgery. DESIGN A randomized controlled trial. SETTING At Ain Shams University Hospital, Cardiothoracic Academy. PARTICIPANTS Ninety-three patients (of both sexes) with uncontrolled diabetes presenting for urgent CABG were categorized into 2 groups. INTERVENTIONS The dipeptiven group (n = 46) was given an infusion of dipeptiven 1.5 mL/kg body weight dissolved in normal saline (200 mL) over 3 hours before surgery. The control group (n = 47) received a normal saline infusion (200 mL). MEASUREMENTS AND MAIN RESULTS The dipeptiven group demonstrated statistically significant lower intraoperative (173.74 ± 19.97 mg/dL v 198.22 ±14.64 mg/dL) and postoperative (162.36 ±13.11 mg/dL v 176.13 ±14.86 mg/dL) mean blood glucose levels. In addition, dipeptiven infusion was found to reduce mean total insulin requirements intraoperatively by 3.64 ± 0.56 units/h and postoperatively by 37.109 ± 4.30 units/24 h in comparison to placebo (50.98 ± 16.55 units/24 h and 5.10 ± 2.28 units/h, respectively). CONCLUSION A preoperative infusion of dipeptiven can contribute to ameliorating stress hyperglycemia in uncontrolled diabetic patients undergoing urgent CABG.
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Dashti F, Alavian SM, Sohrabpour AA, Mousavi SE, Keshavarz SA, Esmaillzadeh A. Effect of a moderately carbohydrate-restricted diet on liver enzymes, steatosis and fibrosis in normal-weight individuals with non-alcoholic fatty liver disease: study protocol for a parallel randomised controlled clinical trial. BMJ Open 2023; 13:e063988. [PMID: 37117000 PMCID: PMC10151946 DOI: 10.1136/bmjopen-2022-063988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/30/2023] Open
Abstract
INTRODUCTION Non-alcoholic fatty liver disease (NAFLD) is a hepatic condition that is considerably prevalent across the world. Dietary intakes, in which macronutrient composition is precisely planned, might be able to reduce inflammation, steatosis and fibrosis among patients with NAFLD. A moderately carbohydrate restricted diet with weight loss has been demonstrated to improve liver fat content among overweight or obese patients. However, there is no information about the appropriateness of such a restriction, without weight loss, in normal-weight patients. This randomised clinical trial will be aimed at assessing the effect of moderate carbohydrate restriction on liver enzymes, liver steatosis and fibrosis in normal-weight patients with NAFLD. METHODS AND ANALYSIS This randomised controlled clinical trial will be conducted to evaluate the impact of a moderately carbohydrate restricted diet on liver enzymes, steatosis and fibrosis in 52 eligible normal-weight individuals with NAFLD. Transient elastography and controlled attenuation parameter with FibroScan will be applied to diagnose NAFLD. After individual matching based on body mass index, age and sex, patients will be randomly assigned to receive a moderately carbohydrate restricted diet or an isocaloric diet without carbohydrate restriction for 12 weeks. The primary and secondary outcomes in this study will be liver function indices, including liver steatosis and fibrosis, metabolic parameters and anthropometric measures. All these variables will be assessed at study baseline and postintervention. ETHICS AND DISSEMINATION The present clinical trial study was accepted by the ethics committee of TUMS (Tehran University of Medical Sciences) (code: IR.TUMS.MEDICINE.REC.1400.116). TRIAL REGISTRATION NUMBER IRCT20210119050086N1.
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Affiliation(s)
- Fatemeh Dashti
- Department of Nutrition, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Seyed Moayed Alavian
- Baqiyatallah Research Center for Gasteroenterology and Liver Disease, Baqiyatallah University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Amir Ali Sohrabpour
- Department of Internal Medicine, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Sara Ebrahimi Mousavi
- Department of Clinical Nutrition, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
| | - Seyed-Ali Keshavarz
- Nutrition, Tehran Universirty of Medical Sciences, tehran, Iran, Islamic Republic of
| | - Ahmad Esmaillzadeh
- Department of Community Nutrition, Tehran University of Medical Sciences, Tehran, Iran (the Islamic Republic of)
- Department of Community Nutrition, Isfahan University of Medical Sciences, Isfahan, Iran (the Islamic Republic of)
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Xie Y, Kong W, Wang X, Wu Z. Association of glycated hemoglobin with non-alcoholic fatty liver disease patients and the severity of liver steatosis and fibrosis measured by transient elastography in adults without diabetes. BMC Endocr Disord 2022; 22:220. [PMID: 36045348 PMCID: PMC9434963 DOI: 10.1186/s12902-022-01134-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 08/16/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Type 2 diabetes mellitus (T2DM) is a well-known independent risk factor for non-alcoholic fatty liver disease (NAFLD). However, research exploring the association between blood glucose management and the risk of NAFLD status in subjects without diabetes was insufficient. This study aimed to explore the association of glycated hemoglobin (HbA1c) with NAFLD status and the severity of liver steatosis and fibrosis in non-diabetic people. METHODS A cross-sectional analysis was conducted on 2998 non-diabetic American adults using data from the National Health and Nutrition Examination Survey (NHANES) 2017-2018 cycle. We used multivariable logistic regression models to evaluate the association between HbA1c and NAFLD status and the severity of liver steatosis and fibrosis. Interaction and stratified analyses were additionally performed. RESULTS The multivariate regression analyses showed that HbA1c was associated independently with NAFLD status in all the models (model1: OR = 2.834, 95%CI: 2.321, 3.461; model 2: OR = 2.900, 95%CI: 2.312, 3.637 and model 3: OR = 1.664, 95%CI: 1.284, 2.156). We further performed the interaction and stratified analyses and discovered a significant interaction between HbA1c and BMI (Pinteraction < 0.05). Finally, a robust link was shown between HbA1c level and the severity of liver steatosis, which was mainly significant in the prediabetes group, while the correlation was not significant in HbA1c level and severity of liver fibrosis after controlling for all the potential confounders. CONCLUSIONS We concluded that HbA1c level was positively correlated to the risk of developing NAFLD in a large non-diabetic American population. Moreover, HbA1c level was associated with the severity of liver steatosis in subjects with prediabetes, suggesting that routine screening for HbA1c among individuals with prediabetes is necessary.
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Affiliation(s)
- Yilian Xie
- Department of Infectious Diseases, Ningbo First Hospital, Ningbo, 315010, Zhejiang, China.
- Department of Hepatology, Ningbo First Hospital, Ningbo, 315010, Zhejiang, China.
| | - Weiliang Kong
- Department of Respiratory and Critical Care Medicine, Ningbo First Hospital, Ningbo, 315010, Zhejiang, China
| | - Xuepeng Wang
- Department of Infectious Diseases, Ningbo First Hospital, Ningbo, 315010, Zhejiang, China
- Department of Hepatology, Ningbo First Hospital, Ningbo, 315010, Zhejiang, China
| | - Zhouxiao Wu
- Department of Infectious Diseases, Ningbo First Hospital, Ningbo, 315010, Zhejiang, China
- Department of Hepatology, Ningbo First Hospital, Ningbo, 315010, Zhejiang, China
- School of Medicine, Ningbo University, Ningbo, China
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Ebrahimi-Mousavi S, Alavian SM, Sohrabpour AA, Dashti F, Djafarian K, Esmaillzadeh A. The effect of daily consumption of probiotic yogurt on liver enzymes, steatosis and fibrosis in patients with nonalcoholic fatty liver disease (NAFLD): study protocol for a randomized clinical trial. BMC Gastroenterol 2022; 22:102. [PMID: 35255811 PMCID: PMC8899796 DOI: 10.1186/s12876-022-02176-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 02/21/2022] [Indexed: 02/08/2023] Open
Abstract
Background Given the increasing prevalence of non-alcoholic fatty liver disease, it is necessary to find an easy and cost-effective method in its management and treatment. Probiotics are a group of living microorganisms that might affect NAFLD through the intestinal-liver axis. The present clinical trial aims to examine the effect of probiotic yogurt consumption on liver enzymes, steatosis and liver fibrosis in patients with NAFLD. Methods Sixty-eight patients with NAFLD will be recruited in this study. After block matching for sex, BMI and age, patients will be randomly assigned to receive 300 g/d probiotic yogurt containing 106 cfu/g of Lactobacillus acidophilus and Bifidobacterium lactis strains or 300 g/d plain yogurt daily for 12 weeks and those in the control group would receive similar amounts of plain yogurts. Weight, height, and waist circumference will be measured at study baseline and after the intervention. Biochemical indicators including plasma glucose, serum insulin, lipid profile, liver markers (ALT, AST and GGT) will be examined at study baseline and at the end of the trial. Insulin resistance and insulin sensitivity will be determined using the HOMA-IR and QUICKI equation. The degree of steatosis and hepatic fibrosis will also be assessed at the beginning and end of the intervention by the same gastroenterologist using elastography with fibroscan. Discussion Probiotics have been suggested as a new strategy in the management of NAFLD. Their effects might be mediated through intestinal microbiota modification and production of short-chain fatty acids. Consumption of probiotic-enriched foods, rather than their supplements, might be a cost-effective method for long-term use in these patients. In case of finding the beneficial effects of probiotic yogurt consumption in the current clinical trial, its inclusion in the dietary plan of NAFLD patients can be recommended. Trial registration This clinical trial was registered in Iranian Registry of Clinical Trials (www.irct.ir) at 2021-04-19 with code number of IRCT20210201050210N1.
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Affiliation(s)
- Sara Ebrahimi-Mousavi
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Moayed Alavian
- Baqiyatallah Research Center for Gastroenterology and Liver Disease, Baqyiatallah University of Medical Sciences, Tehran, Iran
| | - Amir Ali Sohrabpour
- The Liver, Pancreatic, and Biliary Disease Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Dashti
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Kurosh Djafarian
- Department of Clinical Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmad Esmaillzadeh
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, P.O. Box 14155-6117, Tehran, Iran. .,Obesity and Eating Habits Research Center, Endocrinology and Metabolism Molecular-Cellular Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran. .,Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran.
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Eshghi F, Bakhshimoghaddam F, Rasmi Y, Alizadeh M. Effects of Resistant Starch Supplementation on Glucose Metabolism, Lipid Profile, Lipid Peroxidation Marker, and Oxidative Stress in Overweight and Obese Adults: Randomized, Double-Blind, Crossover Trial. Clin Nutr Res 2019; 8:318-328. [PMID: 31720257 PMCID: PMC6826060 DOI: 10.7762/cnr.2019.8.4.318] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 10/21/2019] [Accepted: 10/21/2019] [Indexed: 02/04/2023] Open
Abstract
Obesity is a substantial public health challenge across the globe. The use of resistant starch has been proposed as a probable management strategy for complications of obesity. We investigated the effects of resistant starch intake on lipid profiles, glucose metabolism, antioxidant status, lipid peroxidation marker, blood pressure, and anthropometric variables in subjects with overweight or obesity. In this 12-week, randomized, double-blind, placebo-controlled, 2 × 2 crossover trial, 21 Participants (mean age, 35 ± 7.0 years; body mass index, 32.4 ± 3.5 kg/m2) were given 13.5 g Hi-Maize 260 or placebo daily for 4 weeks, separated by a 4-week washout period. Changes in total antioxidant status (p = 0.04) and serum concentrations of insulin in 52.4% participants with insulin levels above 16 µIU/mL at the baseline (p = 0.04) were significantly different in the three phases. In addition, the mean of serum high-density lipoprotein cholesterol after the intervention was significantly higher than after baseline value (p = 0.04). We found no significant differences in serum concentrations of total cholesterol, triacylglycerol, low-density lipoprotein cholesterol, fasting blood sugar, insulin, homeostatic model assessment of insulin resistance, quantitative insulin sensitivity check index, superoxide dismutase activity, malondialdehyde, blood pressure, and anthropometric variables in the three phases of baseline, after intervention with resistant starch and after placebo. Resistant starch consumption improved serum insulin concentrations, lipid profiles, and antioxidant status in subjects with overweight or obesity.
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Affiliation(s)
- Fereshteh Eshghi
- Student Research Committee, Department of Nutrition, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran
| | - Farnush Bakhshimoghaddam
- Student Research Committee, Department of Nutrition, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran
| | - Yousef Rasmi
- Cellular and Molecular Research Center, Department of Clinical Biochemistry, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran
| | - Mohammad Alizadeh
- Department of Nutrition, Food and Beverages Safety Research Center, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran
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Whole-grain consumption and its effects on hepatic steatosis and liver enzymes in patients with non-alcoholic fatty liver disease: a randomised controlled clinical trial. Br J Nutr 2019; 123:328-336. [PMID: 31685037 DOI: 10.1017/s0007114519002769] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Non-alcoholic fatty liver disease (NAFLD) is a considerable challenge to public health across the globe. Whole grain is highly recommended as an inseparable part of a healthy diet and has been proposed as an effective way to manage NAFLD. The objective in the present study was to evaluate the effects of whole-grain consumption on hepatic steatosis and liver enzymes as primary outcomes in patients with NAFLD. Over the 12 weeks of this open-label, randomised controlled clinical trial, 112 patients (mean age 43 (sd 8·7) years; BMI 32·2 (sd 4·3) kg/m2) were randomly assigned to two groups to receive dietary advice, either to obtain at least half of their cereal servings each day from whole-grain foods or from usual cereals. By the end of the study, the grades of NAFLD showed a significant decrease in the intervention group (P < 0·001). In addition, a significant reduction in serum concentration of alanine aminotransferase (P < 0·001), aspartate aminotransferase (P < 0·001), γ-glutamyltransferase (P = 0·009), systolic blood pressure (P = 0·004) and diastolic blood pressure (P = 0·008) was observed in the intervention group compared with the control group. After adjusting, however, no significant differences were found between the two groups in terms of lipid profile, glycaemic status and anthropometric measurements. Overall, our study demonstrated that consumption of whole grains for 12 weeks had beneficial effects on hepatic steatosis and liver enzymes concentrations in patients with NAFLD.
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Jensen KG, Correll CU, Rudå D, Klauber DG, Decara MS, Fagerlund B, Jepsen JRM, Eriksson F, Fink-Jensen A, Pagsberg AK. Cardiometabolic Adverse Effects and Its Predictors in Children and Adolescents With First-Episode Psychosis During Treatment With Quetiapine-Extended Release Versus Aripiprazole: 12-Week Results From the Tolerance and Effect of Antipsychotics in Children and Adolescents With Psychosis (TEA) Trial. J Am Acad Child Adolesc Psychiatry 2019; 58:1062-1078. [PMID: 30858012 DOI: 10.1016/j.jaac.2019.01.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 01/15/2019] [Accepted: 03/01/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To investigate cardiometabolic effects and their predictors in youths with first-episode psychosis (FEP) treated with quetiapine-extended release (ER) versus aripiprazole. METHOD Youths with FEP who were 12 to 17 years of age were randomized to quetiapine-ER or aripiprazole in the 12-week, double-blinded, Tolerability and Efficacy of Antipsychotics (TEA) trial. Primary outcome was change in body weight; secondary outcomes were changes in body mass index (BMI) and waist circumference (WC), blood pressure (BP), heart rate, and lipid and glucose metabolism parameters. Possible predictors of cardiometabolic changes were examined. RESULTS Altogether, 113 patients (schizophrenia-spectrum disorders = 93%; age [mean ± SD] = 15.7 ± 1.4 years; male participants = 30.1%) were randomized to quetiapine-ER (n = 55) or aripiprazole (n = 58). Quetiapine-ER led to significant increases in body weight (4.88 kg, 95% CI = 3.92-5.83, p < .0001), BMI z-score (0.43, 95% CI = 0.33-0.53, p < .0001), and WC z-score (0.97, CI = 0.7-1.23, p < .0001). Changes were significantly smaller with aripiprazole (all between-group p values <.0001): body weight: 1.97 kg (CI = 0.97-2.97, p = .0001), BMI z-score: 0.10 (CI = -0.01 to 0.20, p = .0646), and WC z-score: 0.18 (CI = -0.09 to 0.45, p = .1968). Lipid and glucose metabolism parameters increased significantly at week 4 and week 12 only with quetiapine-ER (p range = 0.0001-0.037). Quetiapine-ER was associated with an increased occurrence of obesity, elevated blood lipids and hyperinsulinemia (p range = 0.004-0.039). Early weight gain, obesity, or type 2 diabetes in the family significantly predicted weight and BMI gain at week 12. CONCLUSION In youths with FEP, quetiapine-ER was associated with significantly greater weight gain and adverse changes in metabolic outcomes than was aripiprazole. Early weight gain must be addressed and family lifestyle factors taken into consideration when treating youths with antipsychotics. CLINICAL TRIAL REGISTRATION INFORMATION Tolerance and Effect of Antipsychotics in Children and Adolescents With Psychosis (TEA); https://clinicaltrials.gov; NCT01119014.
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Affiliation(s)
- Karsten Gjessing Jensen
- Child and Adolescent Mental Health Center, Mental Health Services, Capital Region of Denmark, Copenhagen, Denmark, and the Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
| | - Christoph U Correll
- Hofstra Northwell School of Medicine and The Zucker Hillside Hospital, New York, NY, and the Charité Universitätsmedizin, Berlin, Germany
| | - Ditte Rudå
- Child and Adolescent Mental Health Center, Mental Health Services, Capital Region of Denmark, Copenhagen, Denmark, and the Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Dea Gowers Klauber
- Child and Adolescent Mental Health Center, Mental Health Services, Capital Region of Denmark, Copenhagen, Denmark, and the Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Marie Stentebjerg Decara
- Psychiatric Centre Copenhagen, Capital Region of Denmark, Copenhagen, Denmark, and the Laboratory of Neuropsychiatry, University of Copenhagen, Denmark
| | - Birgitte Fagerlund
- Lundbeck Foundation Center for Clinical Intervention and Neuropsychiatric Schizophrenia Research (CINS), and Center for Neuropsychiatric Schizophrenia Research (CNSR), Copenhagen University Hospital, Mental Health Services, Capital Region of Denmark
| | - Jens Richardt Møllegaard Jepsen
- Child and Adolescent Mental Health Center, Mental Health Services, Capital Region of Denmark, Copenhagen, Denmark, and the Faculty of Health and Medical Sciences, University of Copenhagen, Denmark; Lundbeck Foundation Center for Clinical Intervention and Neuropsychiatric Schizophrenia Research (CINS), and Center for Neuropsychiatric Schizophrenia Research (CNSR), Copenhagen University Hospital, Mental Health Services, Capital Region of Denmark
| | - Frank Eriksson
- Section of Biostatistics, University of Copenhagen, Denmark
| | - Anders Fink-Jensen
- Psychiatric Centre Copenhagen, Capital Region of Denmark, Copenhagen, Denmark, and the Laboratory of Neuropsychiatry, University of Copenhagen, Denmark
| | - Anne Katrine Pagsberg
- Child and Adolescent Mental Health Center, Mental Health Services, Capital Region of Denmark, Copenhagen, Denmark, and the Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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Bakhshimoghaddam F, Shateri K, Sina M, Hashemian M, Alizadeh M. Daily Consumption of Synbiotic Yogurt Decreases Liver Steatosis in Patients with Nonalcoholic Fatty Liver Disease: A Randomized Controlled Clinical Trial. J Nutr 2018; 148:1276-1284. [PMID: 29931231 DOI: 10.1093/jn/nxy088] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 04/20/2018] [Indexed: 12/13/2022] Open
Abstract
Background Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in developed and developing countries. The use of synbiotics has been proposed as a probable management strategy for patients with NAFLD. Objective We investigated the effects of synbiotic yogurt on hepatic steatosis and liver enzymes as primary outcomes and on oxidative stress markers, adipokine concentration, and gut peptide concentration as secondary outcomes in patients with NAFLD. Methods In this 24-wk, open-label, randomized controlled clinical trial, 102 patients [50 men and 52 women; mean age: 40 y; body mass index (in kg/m2) (mean ± SD): 31.2 ± 4.9] were randomly assigned to 3 groups, including 2 intervention groups and 1 control group. The intervention groups consumed 300 g synbiotic yogurt containing 108 colony-forming units Bifidobacterium animalis/mL and 1.5 g inulin or conventional yogurt daily and were advised to follow a healthy lifestyle (i.e., diet and exercise). The control group was advised to follow a healthy lifestyle alone. We evaluated differences between groups in liver function measures by using repeated-measures ANOVA, ANCOVA, and logistic regression. Results At the end of the study, the grades of NAFLD, as determined by ultrasonography, showed a significant decrease in the synbiotic group compared with the conventional and control groups (P < 0.001). The following significant mean ± SD decreases were seen in the synbiotic, conventional, and control groups, respectively: serum concentration of alanine aminotransferase (-14.5 ± 15.6 compared with 4.6 ± 15.4 and 3.1 ± 14.4 IU/L; P = 0.008), aspartate aminotransferase (-7.5 ± 6.1 compared with 3.0 ± 8.2 and 3.1 ± 5.7 IU/L; P < 0.001), alkaline phosphatase (-26.2 ± 16.8 compared with 3.4 ± 30.1 and 1.5 ± 31.9 IU/L; P = 0.024), and γ-glutamyltransferase (-6.0 ± 6.0 compared with 1.0 ± 6.4 and 7.6 ± 11.4 IU/L; P < 0.001). Conclusion Synbiotic yogurt consumption improved hepatic steatosis and liver enzyme concentrations in patients with NAFLD. This trial was registered at the Iranian Registry of Clinical Trials website (www.irct.ir) as IRCT2017020932417N2.
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Affiliation(s)
- Farnush Bakhshimoghaddam
- Student Research Committee, Department of Nutrition, Food and Beverages Safety Research Center, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran
| | - Kamran Shateri
- Department of Gastroenterology, Food and Beverages Safety Research Center, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran
| | - Morad Sina
- Department of Radiology, Food and Beverages Safety Research Center, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran
| | - Maryam Hashemian
- Departments of Nutrition and Biochemistry, Faculty of Medicine, Sabzevar University of Medical Sciences, Sabzevar, Iran
- Departments of Biochemistry, Faculty of Medicine, Sabzevar University of Medical Sciences, Sabzevar, Iran
- Digestive Disease Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Alizadeh
- Department of Nutrition, Food and Beverages Safety Research Center, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran
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Study of serum visfatin level in patients with nonalcoholic fatty liver disease and its role in progression to nonalcoholic steatohepatitis. EGYPTIAN LIVER JOURNAL 2018. [DOI: 10.1097/01.elx.0000544522.99768.5b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Tučková D, Klugar M, Lasota T, Lasák J, Campbell JM, Munn Z. Alternative tests versus measurement of fasting plasma glucose and oral glucose tolerance test for diagnosis of pediatric type 2 pre-diabetes: a systematic review protocol. JBI DATABASE OF SYSTEMATIC REVIEWS AND IMPLEMENTATION REPORTS 2017; 15:2028-2032. [PMID: 28800051 DOI: 10.11124/jbisrir-2016-003205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
REVIEW QUESTION/OBJECTIVE The gold standard for the diagnosis of pre-diabetes is the measurement of fasting plasma glucose and the oral glucose tolerance test. The objective of this systematic review is to identify all alternative tests currently in use for the diagnosis of type 2 pre-diabetes mellitus in children and establish their accuracy relative to this gold standard.
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Affiliation(s)
- Dagmar Tučková
- 1The Czech Republic (Middle European) Centre for Evidence-Based Health Care: a Joanna Briggs Institute Centre of Excellence, Olomouc, Czech Republic 2Department of Social Medicine and Public Health, Faculty of Medicine and Dentistry, Palacký University, Olomouc, Czech Republic 3The Joanna Briggs Institute, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, Australia
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15
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Junge J, Engel C, Vogel M, Naumann S, Löffler M, Thiery J, Kratzsch J, Kiess W, Körner A. Neck circumference is similarly predicting for impairment of glucose tolerance as classic anthropometric parameters among healthy and obese children and adolescents. J Pediatr Endocrinol Metab 2017; 30:643-650. [PMID: 28489559 DOI: 10.1515/jpem-2017-0079] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 04/05/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND The objective of the study was to investigate the association of neck circumference (NC) to parameters of glucose homeostasis compared to classical anthropometric parameters of lean and obese children. METHODS Three dimensional (3D)-body scanning quantified anthropometric (height, weight, NC, hip/waist circumference, BMI) and metabolic parameters (fasting plasma glucose [FPG], insulin, HbA1c, oGTT, HOMA-IR) were determined cross-sectionally in 1542 participants (5-18 years). RESULTS NC was positively correlated with all metabolic parameters, except for FPG. For HbA1c there was only a modestly positive correlation. The associations between NC and glucose parameters were rather weak, while the correlation to insulin parameters were stronger. Overall the strongest association to glucose metabolism parameters was found for waist circumference (WC), except for FPG and 2h-postload glucose. In multiple linear regression analyses, NC provided additional benefit beyond classical anthropometric indices to describe impairment of glucose homeostasis. CONCLUSIONS We suggest that NC is comparable or additive to established anthropometric parameters but might not be superior to them. However NC is simple to measure, reproducible and may be considered in clinical practice as an additional measurement tool.
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Morandi A, Maffeis C. Predictors of metabolic risk in childhood obesity. Horm Res Paediatr 2015; 82:3-11. [PMID: 24923289 DOI: 10.1159/000362237] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Accepted: 03/14/2014] [Indexed: 11/19/2022] Open
Abstract
Most of the complications of juvenile obesity are due to metabolic disturbances induced by an excessive accumulation of fat which leads to chronic diseases like type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD). Finding effective ways of identifying obese paediatric patients who are at increased risk of developing cardiovascular and metabolic complications has been recognised to be a promising strategy to improve prevention of complications of early obesity. Moreover, correctly identifying obese children who are already affected by metabolic co-morbidities should be a clinical priority. According to the state of the art summarised in this review, traditional metabolic variables included in the definitions of metabolic syndrome (MS), pre-diabetes, non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steato-hepatitis and, in obese girls, the presence of polycystic ovary syndrome are the best available longitudinal predictors of CVD and T2DM among obese children and adolescents. In clinical practice, traditional metabolic variables included in the definitions of MS should be assessed in all obese children and adolescents; fasting metabolic variables have been proposed to identify obese patients likely to be affected by impaired glucose tolerance or T2DM, and ultrasound has proved to be a valid surrogate for biopsy in the diagnosis of NAFLD. Further large longitudinal and cross-sectional studies are needed to improve our chances of identifying obese youth at the highest metabolic risk.
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Affiliation(s)
- Anita Morandi
- Regional Centre for Pediatric Diabetes, Clinical Nutrition and Obesity, ULSS 20, and University of Verona, Verona, Italy
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17
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Aydin E, Ozkokeli M. Does homeostasis model assessment of insulin resistance have a predictive value for post-coronary artery bypass grafting surgery outcomes? Braz J Cardiovasc Surg 2014; 29:360-6. [PMID: 25372910 PMCID: PMC4412326 DOI: 10.5935/1678-9741.20140105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Accepted: 03/14/2014] [Indexed: 01/14/2023] Open
Abstract
Objective This study aims to investigate whether pre-operative Homeostasis Model Assessment
Insulin Resistance (HOMA-IR) value is a predictor in non-diabetic coronary artery
bypass grafting patients in combination with hemoglobin A1c, fasting blood glucose
and insulin levels. Methods Eighty one patients who were admitted to Cardiovascular Surgery Clinic at our
hospital between August 2012 and January 2013 with a coronary artery bypass
grafting indication were included. Patients were non-diabetic with <6.3%
hemoglobin A1c and were divided into two groups including treatment and control
groups according to normal insulin resistance (HOMA-IR<2.5, Group A; n=41) and
high insulin resistance (HOMA-IR>2.5, Group B; n=40), respectively.
Pre-operative fasting blood glucose and insulin were measured and serum chemistry
tests were performed. The Homeostasis Model Assessment Insulin Resistance values
were calculated. Statistical analysis was performed. Results There was a statistically significant difference in fasting blood glucose and
HOMA-IR values between the groups. Cross-clamping time, and cardiopulmonary bypass
time were longer in Group B, compared to Group A (P=0.043 and
P=0.031, respectively). Logistic regression analysis revealed
that hemoglobin A1c was not a reliable determinant factor alone for pre-operative
glucometabolic evaluation of non-diabetic patients. The risk factors of fasting
blood glucose and cardiopulmonary bypass time were more associated with high
Homeostasis Model Assessment Insulin Resistance levels. Conclusion Our study results suggest that preoperative screening of non-diabetic patients
with Homeostasis Model Assessment Insulin Resistance may improve both follow-up
visit schedule and short-term outcomes, and may be useful in risk stratification
of the high-risk population for impending health problems.
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Affiliation(s)
- Ebuzer Aydin
- Kartal Kosuyolu Training, Research Hospital Istanbul, Istanbul, Turkey
| | - Mehmet Ozkokeli
- Kartal Kosuyolu Training, Research Hospital Istanbul, Istanbul, Turkey
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Juarez DT, Demaris KM, Goo R, Mnatzaganian CL, Wong Smith H. Significance of HbA1c and its measurement in the diagnosis of diabetes mellitus: US experience. Diabetes Metab Syndr Obes 2014; 7:487-94. [PMID: 25349480 PMCID: PMC4208352 DOI: 10.2147/dmso.s39092] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The 2014 American Diabetes Association guidelines denote four means of diagnosing diabetes. The first of these is a glycosylated hemoglobin (HbA1c) >6.5%. This literature review summarizes studies (n=47) in the USA examining the significance, strengths, and limitations of using HbA1c as a diagnostic tool for diabetes, relative to other available means. Due to the relatively recent adoption of HbA1c as a diabetes mellitus diagnostic tool, a hybrid systematic, truncated review of the literature was implemented. Based on these studies, we conclude that HbA1c screening for diabetes has been found to be convenient and effective in diagnosing diabetes. HbA1c screening is particularly helpful in community-based and acute care settings where tests requiring fasting are not practical. Using HbA1c to diagnose diabetes also has some limitations. For instance, HbA1c testing may underestimate the prevalence of diabetes, particularly among whites. Because this bias differs by racial group, prevalence and resulting estimates of health disparities based on HbA1c screening differ from those based on other methods of diagnosis. In addition, existing evidence suggests that HbA1c screening may not be valid in certain subgroups, such as children, women with gestational diabetes, patients with human immunodeficiency virus, and those with prediabetes. Further guidelines are needed to clarify the appropriate use of HbA1c screening in these populations.
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Affiliation(s)
- Deborah Taira Juarez
- Daniel K Inouye College of Pharmacy, University of Hawaii at Hilo, Honolulu, HI, USA
- Correspondence: Deborah Taira Juarez, Daniel K Inouye College of Pharmacy, University of Hawaii at Hilo, 677 Ala Moana Boulevard, Suite 1025, Honolulu, HI 96813, USA, Email
| | - Kendra M Demaris
- Daniel K Inouye College of Pharmacy, University of Hawaii at Hilo, Honolulu, HI, USA
| | - Roy Goo
- Daniel K Inouye College of Pharmacy, University of Hawaii at Hilo, Honolulu, HI, USA
| | | | - Helen Wong Smith
- Daniel K Inouye College of Pharmacy, University of Hawaii at Hilo, Honolulu, HI, USA
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