Diabetes association sets new a1c target for children with, Diabetes association sets new a1c target for children with type 1 diabetes .
Hemoglobin a1c measurement for the diagnosis of type 2, Position article and guidelines hemoglobin a1c measurement for the diagnosis of type 2 diabetes in children. Children with type 1 diabetes not meeting a1c targets, Less than a third of youth with type 1 diabetes cared for by endocrinologists are meeting recommended hemoglobin a1c targets, a large registry-based study found..
Hba1c to estimated average glucose (eag) calculator, Nathan dm, kuenen j, borg r, zheng h, schoenfeld d, heine rj. Shira Zelber-Sagi, RD, PhD, Head of Nutrition and Behavior Program, School of Public Health, the University of Haifa and the Tel-Aviv Medical Center, 6 Weizman Street, Tel-Aviv 64239, Israel.
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. AIM: To examine the association between non-alcoholic fatty liver disease (NAFLD) and general health perception. METHODS: This cross sectional and prospective follow-up study was performed on a cohort of a sub-sample of the first Israeli national health and nutrition examination survey, with no secondary liver disease or history of alcohol abuse. CONCLUSION: Fatty liver without clinically significant liver disease does not have independent impact on self-health perception. INTRODUCTIONNon-alcoholic fatty liver disease (NAFLD) is defined as fat accumulation in the liver, in the absence of significant alcohol intake.
Figure 2 Distribution of self-rated health perception among non-alcoholic fatty liver disease and normal liver groups among the entire population (A), subjects with body mass index 27 and below (n = 95) and subjects with body mass index above 27 (n = 112) (B).
Figure 3 Univariate and multivariate association between non-alcoholic fatty liver disease and "very good" health perception (A) by non-alcoholic fatty liver disease diagnosed with regular US compared to normal liver (B) by hepato-renal index level (per one unit increase in the index) [odds ratio (95%CI)]. Figure 4 Health perception by past and present diagnosis of fatty liver on ultrasound (never NAFLD n = 119, 1st US NAFLD n = 24, 2nd US NAFLD n = 28, both US NAFLD n = 42). Figure 5 Comparison between non-alcoholic fatty liver disease and normal liver groups in the distribution of frequency of family doctor visits (A) and in the distribution of frequency of specialty consultants (B).
DISCUSSIONNAFLD is emerging as a leading cause for chronic liver disease, cirrhosis and hepatocellular carcinoma[2], thus early diagnosis, life style modifications and treatment are essential. Presentation on theme: "Endocrine Pancreas Adipose hormores Diabetes mellitus and hypoglycemia ??.
Glucose transporters Active transport Facillitated transport Insulin sensitive Insulin insensitive Most tissues eg.
Adiponectin Energy metabolism Adiponectin level inversely correlate with adipose tissue percentage Impair adipocyte differentiation Increase energy expenditure Increase fatty acid ebeta- oxidation and reduce fat mass Inhibit hepatic gluconeogenesis Anti-inflammatory response Inversely correlate with inflammatory cytokines Suppress DM, obesity, atherosclerosis.
Central resistin nullifies central leptin action, induces hyperinsulinemia, and prevents obesity. Stacey M Lambeth, MD1, Trechelle Carson, MD1, Janae Lowe, MD1, Thiruvarangan Ramaraj, PhD2, Jonathan W. Association between type 2 diabetes (T2DM) and compositional changes inthe gut micro biota is established, however little is known about the dysbiosis in earlystages of Prediabetes (preDM).
Table 2: Relative abundance of taxonomies which demonstrated statistical significance after FDR adjustment. Table 3: Results of PERMANOVA and Mantel testscalculated using Bray-Curtis, unweighted UniFrac, and eighted UniFrac.
It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial.
The prevalence of "very good" self-reported health perception was lower among participants diagnosed with NAFLD compared to those without NAFLD. However, this study demonstrates that NAFLD diagnosis among a general population is not independently associated with lower general health perception nor is it associated with higher health care utilization. NAFLD is the most common chronic liver disorder globally[1], with a worldwide prevalence estimated from 6.3% to 33% and a median of 20%[2]. This micro biome involves approximately 100 trillion microbial organisms that inhabit and are believed to influence important physiological human processes[7,8]. Dysbiosis has been implicated in either the cause or the effect of localized disease such as dental caries, bacterial vaginosis, and inflammatory bowel disease; and systemic conditions such as obesity or allergies[8]. One study demonstrated that compositional changes in the intestinal micro biota were associated with T2DM compared to non-diabetic controls[16]. A preDM cohort of 200 participants was initially created in 2012–2014 from established patients attending a primary care clinic of the University of New Mexico Health Sciences Center. To assess the composition and diversity of the patients’ gut bacterial communities, we were able to use only 49 samples with intact and good quantity of DNA to conduct high-throughput sequencing of the V4 region of the 16S rRNA gene[20].
The closed reference-based OTU picking protocol was used along with other default parameters[22]. For assessment of micro biota, taxa were represented at a particular phylogenetic resolution (phylum, class and genus) that had a relative abundance of at least 0.1% in any of the three groups. Briefly, we recruited more female (n = 32) than male participants in the study cohort and more Caucasian white (n = 28) than Hispanics (n = 15) with three Native Americans and four others (participants didn’t identify the race or it was not listed).
Among these samples there were over 4000 different bacterial species, 440 different genera, 264 families, 90 classes, and 30 phyla. Based on Mantel test, we did not find a direct correlation between HbA1C level and dissimilarities in community composition (Table 3). The baseline characteristics of our study population show a significant difference between and among groups with regard to HbA1C, cholesterol, HDL, and LDL levels; however the remaining clinical parameters were not statistically different.
Chloracidobacteria was belongs to phylum Acidobacteria, which is known to inhabit soil globally[29], and has been found in small amounts on leaf salad vegetables[30]; however, it is not consistently reported in gut microbiome data. The increase in Collinsella in T2DM was a similar finding in[18], and has been associated with symptomatic atherosclerosis in other studies[32]. Non-significance in some of our results may have been related to a relatively small sample size or related to a small amount of lost data after rarefaction to 14900 OTUs. The known association between BMI, obesity and gut microbiome[11,12,31] could have affected the results, though our three groups had mean BMIs, which were not statistically different (Table 1).
The cost for clinical phenotyping and payments to participants was supported under a UNM Health Sciences Center-based Cardiovascular and Metabolic Diseases Signature Program. Cardona S, Eck A, Cassellas M, Gallart M, Alastrue C, Dore J, Azpiroz F, Roca J, Guarner F, Manichanh C. In 2009-2010 participants from the baseline survey were invited to participate in a follow-up survey. Recently, the prevalence of NAFLD was shown to be increasing in developing countries due to adoption of a Western lifestyle, the estimated prevalence of NAFLD varies from 20%-30% in Western countries to 5%-18% in Asia[3].NAFLD is associated with hepatic and extrahepatic morbidity. Perceived health status is a reflection of both physical and psychological self-perception and has a well-established association with adverse outcomes[31-33]. In 2012, it was estimated to cost the US $245 billion, accounting for both direct and indirect costs[1].
These organisms are thought to interact with their environment through quorum sensing, nutrient production, signaling pathway modulation, and gene transfer[8]. The effect of intestinal micro biota on whole-body metabolism and obesity began with studies in mice and quickly expanded to include humans[8]. This study demonstrated a significantly lower abundance of the phylum Firmicutesand class Clostridia, meanwhile a significantly higher abundance of class BetaProteobacteria[16]. The study presented in this article aims to answer a similar question: what is the composition of the gut micro biome belonging to preDM patients? For this pilot study a total of 71 willing and available participants were recalled from a Family Practice Clinic in Albuquerque, NM. In this approach sequence reads for each sample were clustered against a reference sequence collection and sequences < 97% similar to any reference sequence were excluded from downstream analyses.
The relative abundances were compared across three groups using Kruskal-Wallis rank sum tests[26] and if significant, then pair wise comparison; p values were corrected using False Discovery Rate (FDR) to account for multiple comparisons. Mean relative abundance and standard deviation are represented for phyla, class, and genera (Supplemental Tables 2a-c). PreDM and T2DM patients had slightly lower Shannon diversity indices, but this was non-significant (Figure 2). Pseudonocardiaceae belongs to phylum Actinobacteria, which has been increased in obesity[31], but not consistently. This may be an indication that many of our T2DM subjects had co-morbid symptomatic atherosclerosis, which is expected in a diabetic population[1]. Diet is a known factor in development of one’s intestinal microbiome[35-37], and could have affected our results as well. 10-year follow-up of diabetes incidence and weight loss in the Diabetes Prevention Program Outcomes Study.
Pathophysiology of prediabetes and treatment implications for the prevention of type 2 diabetes mellitus. Compositional and Functional Features of the Gastrointestinal Microbiome and Their Effects on Human Health.

Ultra-high-throughput microbial community analysis on the Illumina HiSeq and MiSeq platforms.
An improved Greengenes taxonomy with explicit ranks for ecological and evolutionary analyses of bacteria and archaea. Microbial community resemblance methods differ in their ability to detect biologically relevant patterns. Acidobacteria form a coherent but highly diverse group within the bacterial domain: evidence from environmental genomics.
Culture dependent and independent analysis of bacterial communities associated with commercial salad leaf vegetables.
A marker of endotoxemia is associated with obesity and related metabolic disorders in apparently healthy Chinese.
Intestinal mucosal adherence and translocation of commensal bacteria at the early onset of type 2 diabetes: molecular mechanisms and probiotic treatment. Effect of probiotic administration on the intestinal microbiota, current knowledge and potential applications. On both baseline and follow-up surveys the data collected included: self-reported general health perception, physical activity habits, frequency of physician's visits, fatigue impact scale and abdominal ultrasound. Similar results were observed for the hepato-renal index; it was inversely associated with "very good" health perception but adjustment for BMI attenuated the association. These findings imply that in the general population, NAFLD is not considered a disease in the eyes of the NAFLD beholder, probably until an advanced stage. Moreover, patients with NAFLD have reduced survival compared with the general population, primarily due to cardiovascular disease followed by malignancy[4-7].
Similar results were observed for the hepato-renal index; it was inversely associated with "very good" health perception in the crude and in the age and gender adjusted model but not with further adjustment for BMI (Figure 3). There was no significant difference between subjects with and without NAFLD in the main reason for avoidance from physical activity (P = 0.163). Type 2 Diabetes Mellitus (T2DM) constitutes at least 90% of diabetes cases in the adult population[1].
The preDM state is associated with obesity, hypertension, and hypercholesterolemia and is considered a risk factor for both cardiovascular disease and T2DM[3].
Interestingly, the human micro biome has been shown to represent a pliable meta genome that varies from individual-to-individual, disease-to disease, and among anatomical locations within each individual[8,9]. Murine studies revealed a relative increase in phylaFirmicutes compared to Bacteroidetesin the intestines of obese mice[12], this was confirmed in some human studies[14], and not in others[11]. They also found that the ratio of PhylaBacteroidetes: Firmicutes was increased in T2DM and positively correlated with increasing plasma glucose on OGTT[16]. Information regarding pertinent medical history, demographics, current medications, diet, alcohol and tobacco use was obtained by means of a survey questionnaire administered by a member of the research team.
PCR product was quantified using the Pico Green dsDNAassay, and the samples’ bar-coded amplicons were combined in equimolar concentrations.
This approach implements reference based clustering using the UCLUST[23] algorithm and the Green genes[24] reference database that covers most of the organisms that are typically present in the human gut micro biome.
Principal Component Analysis (PCA) and Per Mutational Multivariate Analysis Of Variance (PERMANOVA) were used to analyze the relationship between overall micro biome composition and diagnosis group, and dissimilarities between composition and HbA1C were assessed using Mantel tests.
The five most abundant phyla identified were: Bacteroidetes, Firmicutes, Proteobacteria, Verrucomicrobia, and Actinobacteria (Figure 1, Supplemental Table 2a) which is consistent with previous findings[7-11].
We did not find an overall correlation between microbiome composition or diversity and HbA1C level.
The family of Enterobacteriaceae contains many gram-negative, pathogenic genera such as: Escherichia, Klebsiella, Yersinia, Citrobacter, Proteus, Shigella, Salmonella and Serratia. These participants reported whether they were vegetarian, lactose-free, or gluten-free, but other details of dietary habits were not explored. Fatty liver was diagnosed by abdominal ultrasonography using standardized criteria and the ratio between the median brightness level of the liver and the right kidney was calculated to determine the Hepato-Renal Index. In a Swedish cohort of NAFLD patients with a median follow-up of 27 years, 25% were diagnosed with cirrhosis and 14% with hepatocellular cancer[8]. Furthermore, naive (newly diagnosed) and previously diagnosed NAFLD patients (who already knew they have NAFLD) did not differ in their prevalence of "very good" health perception (Figure 4B). An unknown genus from familyPseudonocardiaceae was significantly present in preDM group compared to theothers (p = 0.04). This condition is considered to be a heterogeneous and multi factorial disease, influenced by both environmental and genetic factors[1]. Characterization of what is considered normal flora, has been undertaken for certain anatomical locations such as the skin, mouth, nasal cavities, vagina, and gastrointestinal tract[7,9]. When examining the function of the gut micro biome, studies have suggested an overall increased capacity for energy harvest from the diet in obese individuals[12,15].
Height, weight, waist circumference, and blood pressure were measured according to standard procedure. Sequencing was performed on an Illumina MiSeq instrument to produce 150 bp sequences at the University of Colorado at Boulder.
Three dissimilarity metrics were used: Bray-Curtis, unweighted UniFrac, and weighted UniFrac[27].
This indicates that there did not exist a particular pattern of bacterial abundance that associated with either HbA1C or diagnosis group.
Lipopolysaccharide (LPS), which is a cellular-membrane component of such gram-negative bacteria, is increased in both obese and T2DM subjects[33]; increased adherence of intestinal Escherichia coli (gram-negative) and a decrease in intestinal Bifidobacterium species are associated with increased serum LPS[34]. NAFLD patients do not usually present with symptoms directly attributable to their underlying liver disease[9]. However, controlling for BMI attenuated the association between both the presence of NAFLD and the amount of liver fat and self-reported health perception. T2DM continues to be a leading cause of renal failure, non-traumatic limb amputations, and blindness among adults[1].
Prevention of the transition to T2DM has been proven successful with weight loss, exercise programs, and pharmacologic agents such as Metformin[5]. Current micro biome techniques are based on sequencing of the bacterial 16S ribosomal RNA gene, phylogenetically identifying it, and quantifying the number of genes present[7]. They also identified groups of genes that were found to co-exist and were enriched in either T2DM or control subjects; for example, 337 genes belonging to the species Akkermansia muciniphila were enriched in T2DM, whereas 273 genes belonging to Haemophilus parainfluenzae were enriched in control subjects[17].
Because we obtained a variable number of sequences per sample ranging from 14,916 to 36,631 (Supplemental Table 1 for yield per sample after initial processes and closed-reference OTU picking), the sequence data were rarefied to 14,900 sequences per sample to account for this variation.
Phylum Synergistetes was significantly increased in T2DM compared to nonDM, however this was nominally significant after FDR correction (Table 2). However, there were many differences found in the individual relative abundances of specific taxa between the three groups. Qin, et al.[17] did find T2DM group with increased levels of Escherichia coli, but not others from the family of Enterobacteriaceae. Medications such as Metformin have been associated with a change in gut microbiome; specifically one study found that there was an increase in Firmicutes and decrease in Bacteroidetes in patients taking Metformin[38], the patients in this study were not questioned about Metformin specifically at the time of interview, but it can be assumed that some of the T2DM group was taking the medication, and possibly some of the preDM group as well. However, some patients report non-specific symptoms, including fatigue or malaise, daytime sleepiness and discomfort in the right upper abdominal quadrant[10].
We acknowledge that multicollinearity exists between NAFLD and obesity, the latter was associated with a lower health perception. It is a major contributor to both cardiovascular disease and stroke, and was reported as the seventh leading cause of death in the US in 2010[1]. Thus far, preDM is considered a multi factorial condition caused by genetic predisposition, increased insulin demand, and decreased pancreatic beta-cell mass[6]. The micro biome is currently being described in terms of richness and diversity, composition, and functionality[7-12]. A fasting blood sample was obtained from each subject by venipuncture for the determination of HbA1C, glucose, creatinine, albumin, total protein, uric acid, and lipids. The kidney phenotypes including UACR, uric acid, and creatinine were not different among or between the groups. Three classes out of 90 were identified as significantly different among the groups by Kruskal-Wallis (Table 2). This finding may indicate that there is not a specific gut pattern associated with glucose levels or the diabetic disease state; it may also mean that larger studies needed to see a consistent pattern.
The effects of probiotics are currently being researched, and so far have reported to have significant effects on metabolism and intestinal mucosal integrity[39]. Newly diagnosed (naive) and previously diagnosed (at the first survey, not naive) NAFLD patients did not differ in their self-health perception.
Fatigue is the most common symptom in NAFLD patients and leads to impaired quality of life[11]. However, we aimed to learn if NAFLD as a distinct entity is associated with a lower health perception and thus controlled for BMI.

This depth of sampling has been shown to be more than sufficient to make assessments of diversity and community composition diversity patterns across varied treatments[25]. Though nephropathy marked by albuminuria is a well-known complication of T2DM[28], non-difference in the UACR in our population, could be explained by the fact that 36% of T2DM group was taking an ACE inhibitor or angiotensin receptor blocker at the time of interview, which decreases the amount of albumin in the urine[28]. The presence of NAFLD at the first survey as compared to normal liver did not predict health perception deterioration at the 7 years follow-up. Lifestyle modification is the only established treatment in NAFLD, nevertheless, patients have low level of readiness for change and motivation to adopt a healthier lifestyle (particularly in the area of physical activity). To do that, we not only controlled for BMI in a multivariate analysis, but also stratified on it and in both cases it attenuated the association between the presence of NAFLD and self-reported health perception. All subjects provided a urine sample for the measurement of Urine Creatinine (UACR) and micro albumin as well as a stool sample for the study of intestinal micro biome. All patients participating in micro biome analysis were not actively taking antibiotics, nor had they taken any in the one month prior. In terms of health-services utilization, subjects diagnosed with NAFLD had a similar number of physician’s visits (general physicians and specialty consultants) as in the normal liver group. Furthermore, it was shown that the severity of liver disease or liver enzymes elevation, have almost no impact on motivation to change[12].To date, only a few studies examined quality of life parameters[13,14] or evaluated the utilization of health- care services among NAFLD patients[11,15]. Moreover, deterioration of "very good" health perception with time could not be predicted by NAFLD. Based on available research, the various functions of the intestinal micro biome are preserved despite a wide variety of species composition[9].
Eleven participants reported to be on anti-Gastro Esophageal Reflux Disease (GERD) medication and three reported to be taking probiotics. Parameters in the fatigue impact scale were equivalent between the NAFLD and the normal liver groups. Moreover, self-rated general health perception, a frequently assessed parameter in epidemiological research[16] and a powerful predictor for morbidity and mortality[17], has not been tested in NAFLD patients. This finding indicates that despite the multiple negative health outcomes of NAFLD, patients don’t feel or think of themselves as sick. Function is implied by characteristics of the species present, by meta genomic techniques that identify genes involved in functional pathways rather than by phylogeny, and by direct measurement of the byproducts of bacterial metabolism[9,11,13]. Clinical chemistry measurements were performed at the Tricore Reference Laboratories, Albuquerque, NM using clinical diagnostic assays certified by The Clinical Laboratory Improvement Amendments (CLIA) of the Centers for Medicare and Medicaid Services. An unknown genus from family Pseudonocardiaceae was significantly present in PreDM group compared to the others, whom had none detected (p = 0.04). Therefore, the current study was aimed to examine the association between NAFLD and general health perception along with fatigue and utilization of health-care services in a sample of a general population screened for NAFLD.MATERIALS AND METHODSStudy design and populationThis cross sectional and prospective follow-up study was performed on a cohort of a sub-sample of the first Israeli national health and nutrition examination survey (the MABAT Survey)[18].
Functional pathways being studied include nutrient metabolism and harvest, immuno modulation, and inflammation[8,10].
First, the NAFLD patients do not utilize more health services as measured by physician visits. Second, even though time spent in leisure time physical activity was lower among NAFLD subjects compared to normal liver controls, fatigue as an explanation for lack of physical activity was evenly reported between the groups.
Genus Bulleidia was present in T2DM while it was absent in the other groups, which lost significance after correction. No difference was observed between subjects that participated in the follow-up study compared to those who did not participate in any demographic, anthropometric or biochemical parameters as previously reported[19]. To avoid report bias, the participants were informed on their US and blood tests results only after filling in the questionnaires.Fatigue was assessed by the fatigue impact scale (FIS)[21], including 7 questions regarding alertness, decreased work volume, less motivation for physical effort, difficulties in decision making or in thinking process and decreased activity[21]. Similarly, according to the OECD cross-country comparisons of perceived good health status, in the vast majority of participating countries, men were more likely than women to report good health, and health perception tended to worsen with age[38].As opposed to the scant data regarding health perception, fatigue is more extensively investigated among NAFLD patients. In a cohort from Newcastle (United Kingdom) 44% of NAFLD patients experienced significant fatigue which was not correlated to thyroid function[39], insulin resistance or severity of liver disease[13]. Fatigue as a reason for physical inactivity was assessed by multi-choice question that evaluated the reasons for physical inactivity.Self-reported general health perception was estimated with one simple question that was highly validated as an indication to general health status and is commonly used in surveys worldwide[17,22,23]. Fatigue (assessed with FIS) among NAFLD patients was also significantly higher compared with age and sex matched controls[11,13].
The fatigue in NAFLD can be explained by lower blood pressure and autonomic dysfunction, but it may also be that relative hypotension is secondary to fatigue, reflecting the decreased amount of physical activity undertaken by patients who perceive themselves as fatigued[11,14]. Another explanation is excessive daytime sleepiness, the cardinal symptom of obstructive sleep apnea (OSA), commonly associated with obesity and NAFLD. Ultrasonography was performed in all subjects both at baseline and at follow up with the same equipment (EUB-8500 scanner Hitachi Medical Corporation, Tokyo, Japan) and by the same experienced radiologist (Webb M) as previously described[26-28]. OSA is well correlated with insulin resistance, but the correlation to NAFLD is debatable[40,41]. The radiologist was blinded to the laboratory values and medical history of the participants. However, in a prospective cohort study, moderate to severe liver steatosis was associated with more severe obstructive sleep apnea. Continuous positive airway pressure (CPAP) therapy for 3 years partially reversed these changes in the majority of patients[42]. The ratio between the median brightness level of the liver and the right kidney was calculated to determine the Hepato-Renal Index (HRI). In the current study the NAFLD subjects were sampled from the general population and not from a selected population of a liver clinic at a medical center.If indeed fatigue is comparable among NAFLD and normal liver subjects, why do NAFLD subjects exercise less than normal liver subjects? Continuous variables are presented as mean ± SD, while categorical variables are presented in percentage.
Univariate analyses were used for the comparison of variable’s distribution between the study groups.
In a 5-year population-based follow-up study in Germany, the presence of NAFLD, defined by both presence of a hyperechogenic pattern of the liver and elevated serum alanine aminotransferase (ALT) levels, was associated with a 26% increase of overall health care costs, after controlling for co-morbidities[45].
To test differences in continuous variables between two groups the independent samples t-test (for normally distributed variables) or the Mann-Whitney U test (if non-parametric tests were required) were performed. The current study results are inconsistent with the limited literature, perhaps since the NAFLD subjects in this study were sampled from the general population, most of them having liver enzymes within the normal range, thus it is very likely that their NAFLD is at a less progressive and symptomatic state compared with NAFLD patients referred for treatment at a medical center which have higher risk for having NASH.In this study, the utilization of health services was not increased among the NAFLD diagnosed subjects.
To test differences in continuous variables between more than two groups the One-Way ANOVA was performed. This finding combined with the equivalent health perception might point towards lack of awareness and understanding that NAFLD is in fact a progressive disease that requires a closer medical surveillance.
The misperception of NAFLD as a non-significant disease may also be attributed to the way the health practitioners perceive NAFLD, perhaps not as a disease in itself with potentially severe outcomes, and as a consequence the information they provide to patients and their disease management. Several studies have demonstrated that hepatogastroenterologists[46], primary care practitioners[47] and hospital non-hepatologists specialists[48] do consider NAFLD as a disease and major health problem and follow NAFLD patients, but it is still unclear how firm is the message provided to the patients.How can this obstacle to patient care be overcome? Furthermore, general practitioners and hepatologists treating NAFLD patients should provide information and refer the patients to appropriate resources about NAFLD implications and treatment and have training in behavioral therapy. Similarly to the treatment approach of other chronic diseases, healthcare providers need to talk with their NAFLD patients more about the broader picture of complications; hepatocellular cancer, increased risk of diabetes, heart attack or stroke, with the message that risk reduction is possible[50]. First, the diagnosis of NAFLD was established by using noninvasive methods of abdominal US and HRI and the histologic diagnosis of inflammation and fibrosis could not be obtained in a sample of the general population. However, with regard to the diagnosis of steatosis, using abdominal US is the most common and acceptable first-line screening procedure for NAFLD in clinical practice and in epidemiological studies[20,52,53].Second, as mentioned above, the NAFLD subjects were sampled from the general population, thus our sample may not represent the more severe forms of the disease.
There were no significant age and gender differences between subjects with and without NAFLD.
Last, the utilization of health services was self-reported instead of objectively measured and thus prone to a report bias that may have weakened the observed associations.In conclusion, NAFLD diagnosis among a general population is not independently associated with lower general health perception nor is it associated with higher health care utilization. BMI, waist circumference (women and men), serum ALT, blood glucose, serum insulin, HbA1C and triglyceride levels were all significantly higher in the NAFLD group (Table 1).
It is the most common chronic liver disorder globally with significant hepatic and extrahepatic morbidity. Moreover, patients with NAFLD have reduced survival compared with the general population, primarily due to cardiovascular disease followed by malignancy.Research frontiersIn recent years there is overwhelming evidence that NAFLD is a major public health concern.
However, self-rated general health perception, a frequently assessed parameter in epidemiological research and a powerful predictor for morbidity and mortality, has not been tested in NAFLD patients.Innovations and breakthroughsThis study demonstrates that NAFLD diagnosis among a general population is not independently associated with lower general health perception nor is it associated with higher health care utilization.
These findings imply that in the general population, NAFLD is not considered a disease in the eyes of the NAFLD beholder, probably until the advanced stage.ApplicationsMore efforts should be directed to establish the acknowledgment of NAFLD as an independent clinical entity with a potentially progressive course. Such a firm and clear message from the treating physician to the patients may promote motivation and adherence to lifestyle changes and a wiser health care utilization for a closer medical surveillance.TerminologySelf-reported general health perception was estimated with one simple question that was highly validated as an indication to general health status and is commonly used in surveys worldwide. The brightness level for each organ is recorded and the ratio between the median brightness level of the liver and the right kidney cortex is calculated to determine the HRI.Peer-reviewThis is a cross sectional study aimed at evaluating the self-rated general health perception in a cohort of 213 subjects form a health survey in Israel. The article is generally well-written and has scientific value, given the high prevalence of NAFLD and the potential implications of its findings in formulating health care policies.

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