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Clinical Gems

Our clinical gems come from the top selling medical books, and text books because knowledge is everything when it comes to diabetes.

International Textbook of Diabetes Mellitus, 4th Ed., Excerpt #106: Treatment of Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis Part 4

The role of statins in the primary and secondary prevention of CVD has been well established. Patients with NAFLD are believed to have increased cardiovascular risk and are logical candidates for their long-term use. In accordance with their higher cardiovascular risk, the use of statins should be encouraged in patients with NAFLD but their use has remained controversial in such patients, particularly in the setting of elevated liver enzymes. Recent practice guidelines on statin use in patients with NAFLD have clearly established that they are overall safe and that they do not carry a higher risk of liver toxicity.

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International Textbook of Diabetes Mellitus, 4th Ed., Excerpt #105: Treatment of Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis Part 3

Combined dietary intervention and exercise: The available information on the role of combined lifestyle interventions (hypocaloric diets plus exercise) in patients with NAFLD is much more extensive, with several randomized, controlled trials showing significant benefit with this comprehensive approach. Again, the overall reduction in liver fat reported in most of these trials has been strongly correlated with the amount of weight loss.

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International Textbook of Diabetes Mellitus, 4th Ed., Excerpt #104: Treatment of Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis Part 2

The effect of dietary intervention alone for the management of NAFLD and NASH has been evaluated extensively over the past 2–3 decades. These studies can be divided into two main types: those that have focused on weight reduction only, and clinical trials that have assessed the role of a particular dietary composition on hepatic steatosis.

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International Textbook of Diabetes Mellitus, 4th Ed., Excerpt #102: Pathogenesis of Nonalcoholic Fatty Liver Disease (NAFLD) Part 4

Hypertriglyceridemia and low HDL cholesterol, increased risk of type 2 diabetes: Under fasting conditions, the liver of subjects with NAFLD overproduces triglyceride-enriched VLDL particles despite hyperinsulinemia when compared to equally obese subjects without NAFLD. Insulin normally decreases production of VLDL by inhibiting adipose tissue lipolysis, and by directly suppressing hepatic production of VLDL.

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International Textbook of Diabetes Mellitus, 4th Ed., Excerpt #101: Pathogenesis of Nonalcoholic Fatty Liver Disease (NAFLD) Part 3

Cause of NAFLD: physical inactivity: Although physical training predominantly enhances muscle insulin sensitivity, cross-sectional epidemiologic data and studies on effects of physical training suggest that exercise may decrease liver fat even in the face of unchanged body weight [50]. In a cross-sectional study in 72,359 healthy Korean adults, subjects who were exercising regularly had a 28–53% lower risk of NAFLD across almost all BMI deciles.

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International Textbook of Diabetes Mellitus, 4th Ed., Excerpt #100: Pathogenesis of nonalcoholic fatty liver disease (NAFLD) Part 2

Cause of NAFLD: obesity and abnormalities in adipose tissue. Although both NAFLD and the MetS can occur in nonobese subjects, the prevalence of NAFLD is markedly increased in obesity as is that of the MetS. In the third National Health and Nutrition Examination Survey (NHANES), the prevalence of NAFLD averaged 7.5% and 6.7% in normal-weight men and women but was 57 and 44% in persons with a body mass index (BMI) greater than 35 kgm−2.

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International Textbook of Diabetes Mellitus, 4th Ed., Excerpt #99: Pathogenesis of nonalcoholic fatty liver disease (NAFLD) Part 1

NAFLD is defined as steatosis (greater than 5–10% of hepatocytes are fatty), which is not due to excess use of alcohol (defined in European and American guidelines as greater than 20 g of alcohol daily for women and greater than 30 g for men), or other conditions as determined by careful family and medical history, and laboratory tests to exclude at least steatosis due to viral and autoimmune causes and iron overload.

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International Textbook of Diabetes Mellitus, 4th Ed., Excerpt #98: Metabolomics: Applications in Type 2 Diabetes Mellitus and Insulin Resistance Part 4

Future directions and potential application of metabolite profiling in type 2 diabetes: metabolomics approaches have unmasked a variety of metabolic pathways influenced by T2DM or insulin resistance, moving the field of metabolic physiology beyond a “glucocentric” viewpoint of these conditions. However, a difficulty in interpretation is that the fasting concentration of a metabolite only reflects a single moment in time, and etiology or tissue origins of any metabolite differences across comparator groups requires further validation.

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