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As with many diseases, prevention strategies to tackle obesity – promoting healthy nutrition and exercise - are more cost-effective than the treatment routinely provided by health services. Programmes to encourage patients to control their conditions – some have shown positive results. Payment systems and diseases management programmes rewarding good outcomes and continuity of care. Placing community care at the centre of health systems to improve quality of diabetes care.
Science, Technology and Medicine open access publisher.Publish, read and share novel research. Franzese A, Vajro P, Argenziano A, Puzziello A, Iannucci MP, Saviano MC, Brunetti F, Rubino A. Manco M, Bedogni G, Marcellini M, Devito R, Ciampalini P, Sartorelli MR, Comparcola D, Piemonte F, Nobili V. D'Adamo E, Impicciatore M, Capanna R, Loredana Marcovecchio M, Masuccio FG, Chiarelli F, Mohn AA. Weiss R, Dufour S, Taksali SE, Tamborlane WV, Petersen KF, Bonadonna RC, Boselli L, Barbetta G, Allen K, Rife F, Savoye M, Dziura J, Sherwin R, Shulman GI, Caprio S. Taksali SE, Caprio S, Dziura J, Dufour S, Cali AM, Goodman TR, Papademetris X, Burgert TS, Pierpont BM, Savoye M, Shaw M, Seyal AA, Weiss R. Seppala-Lindroos A, Vehkavaara S, Hakkinen AM, Goto T, Westerbacka J, Sovijarvi A, Halavaara J, Yki-Jarvinen H. Petersen KF, Oral EA, Dufour S, Befroy D, Ariyan C, Yu C, Cline GW, DePaoli AM, Taylor SI, Gorden P, Shulman GI. Perseghin G, Mazzaferro V, Sereni LP, Regalia E, Benedini S, Bazzigaluppi E, Pulvirenti A, Leao AA, Calori G, Romito R, Baratti D, Luzi L.
Schwimmer JB, Celedon MA, Lavine JE, Salem R, Campbell N, Schork NJ, Shiehmorteza M, Yokoo T, Chavez A, Middleton MS, Sirlin CB.Heritability of nonalcoholic fatty liver disease. Romeo S, Kozlitina J, Xing C, Pertsemlidis A, Cox D, Pennacchio LA, Boerwinkle E, Cohen JC, Hobbs HH.
Santoro N, Kursawe R, D'Adamo E, Dykas DJ, Zhang CK, Bale AE, Cali AM, Narayan D, Shaw MM, Pierpont B, Savoye M, Lartaud D, Eldrich S, Cushman SW, Zhao H, Shulman GI, Caprio S.A Common Variant in the Patatin-Like Phopholipase 3 Gene (PNPLA3) is Associated with Fatty Liver Disease in Obese Children and Adolescents. Ekstedt M, Franzen LE, Mathiesen UL, Thorelius L, Holmqvist M, Bodemar G, Kechagias S.Long-term follow-up of patients with NAFLD and elevated liver enzymes. Solga S, Alkhuraishe AR, Clark JM, Torbenson M, Greenwald A, Diehl AM, Magnuson T.Dietary composition and nonalcoholic fatty liver disease. Bruce KD, Cagampang FR, Argenton M, Zhang J, Ethirajan PL, Burdge GC, Bateman AC, Clough GF, Poston L, Hanson MA, McConnell JM, Byrne CD.Maternal high-fat feeding primes steatohepatitis in adult mice offspring, involving mitochondrial dysfunction and altered lipogenesis gene expression. Wigg AJ, Roberts-Thomson IC, Dymock RB, McCarthy PJ, Grose RH, Cummins AG.The role of small intestinal bacterial overgrowth, intestinal permeability, endotoxaemia, and tumour necrosis factor alpha in the pathogenesis of non-alcoholic steatohepatitis.
Kang H, Greenson JK, Omo JT, Chao C, Peterman D, Anderson L, Foess-Wood L, Sherbondy MA, Conjeevaram HS.Metabolic syndrome is associated with greater histologic severity, higher carbohydrate, and lower fat diet in patients with NAFLD. D'Adamo E, Marcovecchio ML, Giannini C, Capanna R, Impicciatore M, Chiarelli F, Mohn A.The possible role of liver steatosis in defining metabolic syndrome in prepubertal children.
Lee TH, Kim WR, Benson JT, Therneau TM, Melton LJ 3rd.Serum aminotransferase activity and mortality risk in a United States community.
Pacifico L, Cantisani V, Ricci P, Osborn JF, Schiavo E, Anania C, Ferrara E, Dvisic G, Chiesa C.Nonalcoholic fatty liver disease and carotid atheroscelrosis in children.
While there are positive signs and progress on many fronts, it is clear that Australia is not healthy in every way, and there are some concerning patterns and trends. The rise in the proportion of Australians who are overweight or obese has occurred across virtually all ages. There is a relationship between socioeconomic status and obesity: people who live in the most disadvantaged areas are more likely to be obese than people in less disadvantaged areas.
National surveys show that the proportion of the population with diabetes more than doubled in Australia between 1989–90 and 2007–08. After adjusting for age differences, Aboriginal and Torres Strait Islander people were more than 3 times as likely as non-Indigenous Australians to report some form of diabetes. The prevalence of anxiety and affective disorders was highest for people aged 35–44, and more common among females. Sexually transmissible infections (STIs) are diseases that are spread through sexual contact. In 2011, there were about 80,800 chlamydia infections reported in Australia—a sixfold increase since notifications began in 1994. Notifications have increased for both males and females, although there were about 40% more notifications for females. End-stage kidney disease (ESKD) occurs when chronic kidney disease has advanced to the stage where the person’s only chance of survival is dialysis, or a kidney transplant. The total incidence rate of ESKD is 6 times as high among Aboriginal and Torres Strait Islander people as it is among non-Indigenous Australians, and Indigenous people are 8 times as likely to begin dialysis or receive a kidney transplant.
Australians living today experience relatively good oral health compared with those in the past. Higher income groups were also less likely to experience complete tooth loss, toothache and food avoidance, and to report discomfort with their appearance. National surveys show that vision and hearing disorders are some of the most common long-term conditions among Australians. Vision and hearing disorders are often linked to age, with older people more likely to be affected than younger people. Blood, organs and tissues can be donated to improve quality of life, and life expectancy, of people with a range of health conditions. While donor and transplant numbers are gradually increasing over time, the number of people on the transplant waiting list continues to exceed the number of available organs.
The rate of organ and tissue donation in Australia is also considered low by international standards. The amount of time it takes for a patient to see a health professional is important for the patient, the relevant health service, and governments. For elective surgery, the measure used in Australia is the median waiting time, that is, the middle value in the data arranged from lowest to highest number of days waited.
For emergency department care in 2010–11, 70% of patients were seen within the recommended time for their triage category. Many aspects of health are related to how well-off people are financially: generally, with increasing social disadvantage comes less healthy lifestyles and poorer health. An example of a health behaviour with a strong relationship to socioeconomic status is tobacco smoking.
One interesting exception to this pattern of less healthy lifestyle with lower socioeconomic status is risky or high-risk alcohol use, which shows no particular pattern. Data snapshotIn the March 2010 quarter the unemployment rate for Pacific peoples was 14.4 percent, higher than for all ethnicities. Inadequate housing affects children more than adults, particularly children in low-income families, in larger families, rental dwellings, and more deprived neighbourhoods (Centre for Housing Research, 2010).
Social cohesion means cohesive community relationships with levels of participation in communal activities and public affairs, and a high number of community groups. A healthy diet is a key determinant of health outcomes and is particularly important for the growth and development of children and young people.Food choices are influenced by affordability as well as personal, family, and cultural preferences. Data snapshotThe National Children’s Nutrition Survey conducted in 2002 found that Pacific children were the least likely to bring their food from home to school, and most likely to buy it from a canteen, shop, or takeaway.Pacific children had a lower mean energy intake than Maori children (but higher than European children), and derived a higher portion of their energy intake from fat.
Physical activity is known to protect against obesity and cardiovascular disease, particularly in combination with a healthy diet (National Institute for Health and Clinical Excellence, 2010). Life at Faith City‘Life-changing’ is how participants have described the Life 12 Week Weight Loss Challenge run by Manukau’s Faith City Church.The first Life challenge was held late in 2010.
New Zealand has one of the highest obesity rates among OECD countries (Ministry of Social Development, 2009).
Smoking is the biggest single cause of preventable morbidity (the non-death impacts of disease) and mortality in OECD countries, including New Zealand, and is well recognised as the leading risk factor for many forms of cancer, respiratory disease, and cardiovascular disease in adults.
More Maori and Pacific peoples smoke (45 percent and 31 percent, respectively) compared with the total New Zealand population (20.7 percent) (Ministry of Health, 2008k).
Potentially hazardous drinking carries a high risk of damage to physical and mental health; including death and injury due to traffic accidents, drowning, suicide, and violence. Problem gambling can result in a range of negative effects for the gambler, their families, and the wider community. People’s beliefs and practices in relation to health and illness influence the ways they engage in health-promoting behaviours and access health services. Pacific peoples’ beliefs and practices may be different from mainstream understandings about health and illness. Access to timely and effective health care is an important determinant of health outcomes, for both death rates and the impact that chronic conditions have on Pacific peoples. Data snapshotImmunisation provides protection against a range of communicable diseases, and is considered to be one of the most cost-effective public health interventions. For the 12 months to October 2010, 89 percent of Pacific two-year-olds were fully immunised, compared with 87 percent of European two-year-olds. Screening identifies potential health problems at an early stage in people who do not show any symptoms. Breast and cervical cancer screening programmes have been effective in reducing mortality in the general population. The Primary Health Care Strategy (Ministry of Health, 2001b) established primary health organisations (PHOs) to provide structures for the local delivery of primary health-care services. The benefits of health care are dependent upon the quality of care received as well as accessibility of care.
The average time spent annually with GPs during visits is a key indicator of access and use of primary care. Secondary care includes services provided by specialists, as well as in-patient and out-patient care in public and private hospitals.
Health is strongly influenced by a broad range of cultural, social, economic, and environmental factors.
In addition, diabetics are prone to depression, making it difficult to follow treatment guidelines.
These have been introduced with some success in the Netherlands, France, Germany and the United Kingdom. Participants are agreeing to the Copenhagen Roadmap, an outcome document offering concrete suggestions for good practice in the management of chronic diseases. Loredana Marcovecchio1, 2, Tommaso de Giorgis1, 2, Valentina Chiavaroli1, 2, Cosimo Giannini1, 2, Francesco Chiarelli1, 2 and Angelika Mohn1, 2[1] Department of Pediatrics, University of Chieti, Chieti, Italy[2] Center of Excellence on Aging, "G.
The natural history of nonalcoholic fatty liver disease in children: a follow-up study for up to 20 years. Associations between liver histology and severity of the metabolic syndrome in subjects with nonalcoholic fatty liver disease. Alterations in fatty acid kinetics in obese adolescents with increased intrahepatic triglyceride content.
Ethnic differences in lipoprotein subclasses in obese adolescents: importance of liver and intraabdominal fat accretion. Central Role of Fatty Liver in the Pathogenesis of Insulin Resistance in Obese Adolescents. Metabolic syndrome in childhood from impaired carbohydrate metabolism to nonalcoholic fatty liver disease. Liver Biopsy versus Noninvasive Methods – Fibroscan and Fibrotest in the Diagnosis of Non-alcoholic Fatty Liver Disease: A Review of the Literature. Comparison of liver histology with ultrasonography in assessing diffuse parechymal liver disease. Waist circumference correlates with liver fibrosis in children with non-alcoholic steatohepatitis.
The spectrum of fatty liver in obese children and the relationship of serum aminotransferases to severity of steatosis.
Prediabetes in obese youth: a syndrome of impaired glucose tolerance, severe insulin resistance, and altered myocellular and abdominal fat partitioning. Low adiponectin levels in adolescent obesity: a marker of increased intramyocellular lipid accumulation. Unique effect of visceral fat on insulin sensitivity in obese Hispanic children with a family history of type 2 diabetes. Increased intrahepatic triglyceride is associated with peripheral insulin resistance: in vivo MR imaging and spectroscopy studies. Nonalcoholic fatty liver disease is associated with hepatic and skeletal muscle insulin resistance in overweight adolescents. Insulin resistance and whole body energy homeostasis in obese adolescents with fatty liver disease. Fat accumulation in the liver is associated with defects in insulin suppression of glucose production and serum free fatty acids independent of obesity in normal men. Leptin reverses insulin resistance and hepatic steatosis in patients with severe lipodystrophy. Contribution of reduced insulin sensitivity and secretion to the pathogenesis of hepatogenous diabetes: effect of liver transplantation. Defective insulin action on protein and glucose metabolism during chronic hyperinsulinemia in subjects with benign insulinoma. Insulin resistance in cirrhosis: prolonged reduction of hyperinsulinemia normalizes insulin sensitivity. Non-alcoholic fatty liver disease: the hepatic consequence of obesity and the metabolic syndrome. Fructose is associated with increased oxidative stress and elevated plasma triglycerides in children with nonalcoholic fatty liver disease. Increased intestinal permeability in obese mice: new evidence in the pathogenesis of nonalcoholic steatohepatitis. Association Between Metabolic Syndrome and Liver Histology Among Children With Nonalcoholic Fatty Liver Disease. Intima-media thickness of carotid artery and susceptibility to atherosclerosis in obese children with nonalcoholic fatty liver disease.
These areas pose a challenge to our health system and suggest that there is premature death and disease that might otherwise be avoided. Comparisons among other developed countries show that Australia has the second highest rate of obesity for males and the fifth highest for females. In 2007–08, 1 in 4 adults and 1 in 12 children were obese; this equates to almost 3 million people.
It is caused either by the inability to produce insulin (a hormone produced by the pancreas to control blood glucose levels), or by the body not being able to use insulin effectively, or both. The latest estimates suggest that 898,800 people (4.1% of the population) have been diagnosed with diabetes at some time in their lives. A 2007 survey showed that 1 in 5 Australians had experienced a mental disorder in the previous 12 months. The prevalence of substance use disorders was highest for people aged 16–24, and more common among males. Diagnosis can be difficult as many STIs have no symptoms or have symptoms that are mild, despite serious complications that may develop later.
It affects 1 in 7 Australian adults to some degree and is often considered preventable because many of its risk factors (such as smoking and excess body weight) are modifiable.
At the end of 2009, about 18,300 people in Australia were receiving regular dialysis treatment or had a functioning kidney transplant—more than a sevenfold increase since 1977.
In 2007–08, 52% had a long-term vision disorder (such as long- and short-sightedness) and 13% had a long-term hearing disorder (such as complete or partial deafness).
Hence the number of people affected is expected to increase as the Australian population ages. A survey in 2009 found that 60% of people making a GP appointment for a matter they felt required urgent medical care were seen within 4 hours of making their appointment.
In 2010–11, the median waiting time was 36 days (meaning that 50% of patients had received their surgery within 36 days).
In 2010, 25% of people living in the most disadvantaged areas smoked tobacco, twice the rate of people living in the least disadvantaged areas. The quality of housing and household crowding are closely related to the risk of developing ARF, meningococcal disease, respiratory disease, and other infectious diseases.Due to their low income, many Pacific families live in less affluent communities. Healthier food options are often more expensive than those with high concentrations of fat and sugar, and those that are nutritionally limited.
Thirty-three mostly Pacific women completed the three-month course, which is designed for those who are very overweight and are keen to eat more healthily and be more active.Life involves training four times a week, sessions with a nutritionist and three weekend retreats to help address the psychological reasons behind obesity and unhealthy lifestyles. Obesity is associated with many adult health conditions such as cardiovascular disease, type 2 diabetes, cancer, and psychological and social problems (Ministry of Health, 2008e). Exposure to cigarette smoke (during a mother’s pregnancy and in childhood) is recognised as a major risk factor for sudden unexplained death in infancy syndrome and respiratory illness (Ministry of Health, 2005).Smoking is an important contributor to inequalities in life expectancy between ethnic groups. Alcohol problems are also associated with high-risk sexual behaviour and consequent problems.Fewer Pacific peoples drink alcohol than the general population.


Pacific peoples’ understandings tend to be characterised by a holistic perspective, where healthy and strong families are the basis for the well-being of individuals and communities. Suicide, for example, can be seen as the “ultimate rejection of one’s family” and a bereaved family can experience a “sense of failure to adequately care for and support the individual who is ill” (Beautrais et al, 2005).
In 2006, just over 90 percent of New Zealand infants were enrolled with Plunket, which provides clinical assessment, health promotion and parent education services. Screening improves health outcomes by offering effective interventions before diseases become advanced. An increase in the uptake of cervical screening and the introduction of the HPV vaccination programme in 2008 (which has reported high coverage among Pacific girls (Minister of Pacific Island Affairs, 2010) should contribute to lower incidence of, and deaths from, cervical cancer in the future.
The levels of coverage are below the target of 70 percent of all eligible women, but there has been a sustained increase in coverage for Pacific women.
Each PHO has an enrolled population, and is responsible for providing services to this population.In October 2007, nearly 100 percent of Pacific peoples were enrolled with a PHO6. The quality of health care is in part determined by interpersonal care; the interaction between health-care professionals and health-care users or their caregivers. The National Primary Medical Care Survey found that Pacific, Maori, and Asian people spent significantly less time with GPs, after controlling for a range of other variables. Secondary care services are normally accessed by referral from primary care or hospital emergency departments. In general, people with fewer socio-economic resources tend to have poorer health outcomes due to a combination of reduced material resources, greater exposure to health risks and behaviours, greater psychosocial stress, and reduced access to health services.Many Pacific peoples have not experienced success in the education system, and therefore tend to have lower incomes and live in communities with the fewest economic resources. The estimate of the socio -economic contribution is based on analysis undertaken in relation to the impact of socio-economic inequality on the difference between the Maori and the European or other ethnic group in the NZ Census-Mortality Study. That is, they were physically active for at least 30 minutes a day, for at least five days in the previous week. The survey uses AUDIT, which is a ten-item questionnaire covering alcohol consumption, abnormal drinking behaviour, and alcohol-related problems. This data is from the Enriched CBF Register produced by HealthPac at the Ministry of Health. Ultrasonography and liver enzymes levels at diagnosis and during follow-up in an Italian population.
Many experts are concerned about the effect rising obesity may have on our rates of diabetes, heart disease and other disorders, perhaps even on our life expectancy.
Type 1 diabetes results from the body’s own immune system damaging the pancreas so it can’t produce insulin, and the condition is not preventable. Overall, the most common types were anxiety disorders (14%), affective (mood) disorders (6%) and substance use disorders (5%). The rate of new cases of treated ESKD is projected to increase by 80% between 2009 and 2020.
When the adult population is divided into thirds by household income (adjusted for the size of the household), oral health improves as we move from the lowest income group to middle and highest incomes.
The majority (85%) of injuries were unintentional —they were not caused deliberately—however, many could have been prevented.
For those aged 65 and over, females are more likely to be hospitalised, due mainly to falls. For example, the proportion of Pacific households (with at least one Pacific adult) spending more than 30 percent of their income on housing was 33 percent in 2009, reflecting a steady increase from 23 percent in 2004 (Ministry of Social Development, 2010, p69).Students attending schools in communities with fewer economic resources tend to experience less education success than those in more affluent communities (Ministry of Social Development, 2009, p138).
The prevalence of factors associated with lower levels of well-being, such as widespread smoking, obesity, hazardous drinking, and non-casino gaming machines, is greater in these communities. Societies with diminished social cohesion have higher mortality rates and worse social outcomes than those with high levels of social cohesion (Stansfeld, 2006).Most Pacific communities have strong social connections, often centred on church and community activities. Affordability of food is a significant issue for Pacific households, who were the least likely to report that they could always eat properly. The training sessions include gym workouts, weights, running, boxing, aquarobics, and hill running.
Obesity is primarily caused by poor nutrition and sedentary lifestyles (Ministry of Health, 2008e). Pacific peoples who drink alcohol are more likely to be New Zealand-born and young (Alcohol Advisory Council of New Zealand, 2009). Similarly, 7.6 percent of the Pacific population reported experiencing problems as the result of someone else’s gambling, double the number of adults in the total population who reported being affected by someone else’s gambling. Suicide prevention, support, and other interventions must therefore be tailored to work with and within existing beliefs and attitudes.Similarly, culturally-based attitudes towards sex mean that Pacific youth often have reduced access to information regarding sexual health.
It includes the provision of health education and prevention services, coordination and treatment of less serious illnesses, and referral to secondary care.Other than emergency departments, primary care services are the first step into the health system. Pacific infants (87.2 percent) were less likely than European, but more likely than Maori infants to be enrolled (Craig et al, 2007, p121).
Effective screening is dependent on well-structured and organised processes and the monitoring of indicators of process quality.
One of the providers, BreastScreen South, has reached the 70 percent target for both Maori women and Pacific women (National Screening Unit, nd, a).
For the overall population, the target coverage is 75 percent (Massey University, Centre for Public Health Research, 2008). Craig et al (2007) reported that Pacific children and young people had higher enrolment rates compared with non-Pacific people. Underlying good interpersonal skill are communication skills, the building of trust, understanding and empathy, the discussion and explanation of the patients’ symptoms, and involvement in decisions regarding management or treatment of a patient’s condition (Campbell, Roland, & Buetow, 2000). Overall, Pacific patients spent an average of 18.8 minutes less time annually with GPs than European patients.
Despite this, Pacific peoples are actively involved in their communities and have strong social and cultural resources with strong family ties, church affiliation, and community support. For example, 87% of people in the highest income group rate their oral health as good, very good or excellent, compared with 84% in the middle income group and 73% in the lowest income group. Falls and transportation (mostly motor vehicles) were common external causes of injury (49% of all hospitalised cases).
Pacific students tend to have poorer education outcomes than other students from the same communities. An individual’s identity and well-being are traditionally dependent on family heritage, connections, roles, and responsibilities.
They were also more likely (at nearly 50 percent) than Maori and Europeans to report sometimes running out of food due to lack of money (Ministry of Health, 2003).
Social interaction is one of the factors that promote participation in physical activity (De Bourdeauhuiji, 1998), which in turn encourages social cohesion and social well-being.Pacific children have relatively high levels of incidental physical activity (such as walking to school), although they participate less than other groups in organised leisure and sport. Day one of the challenge requires participants to push four-wheel drive vehicles around a carpark.Faith City project manager Essendon Tuitupou says women in last year’s challenge called it “life-changing”.
Smoking accounted for 37 percent of this loss for men and 13 percent of the loss for women (Ministry of Health, 2001a). However, the Youth 2007 Survey found that twice as many Pacific students are regular smokers compared with European students.Living in a house with a smoker influences children and young people to take up smoking, and contributes to respiratory and other childhood illnesses. Overall, those aged 35–44 years had the highest prevalence of problem gambling (Ministry of Health, 2008a). Parents are less available to provide advice, as it is considered culturally inappropriate for children to discuss sexual health with their parents. They are crucially important in identifying serious illnesses that are then managed in conjunction with secondary and tertiary services.
The results demonstrate that effective means are available to engage with Pacific peoples and deliver care services.
BreastScreen South used a communications campaign where Maori and Pacific women were the priority audience, as it was apparent they were groups who were less familiar with the service (National Screening Unit, nd, b). From 2011, the coverage target will be 80 percent (National Screening Unit nd, e).Since 2007, National Cervical Screening Programme communications campaigns have been particularly focused on encouraging more Maori and Pacific women to have regular smears (National Screening Unit nd, c). Fifteen percent of Pacific peoples were enrolled with a Pacific PHO and the remainder with a mainstream PHO (Ministry of Health, 2010c).
Improvements in the annual consultation rate coincide with the implementation of the Primary Health Care Strategy (Ministry of Health, 2001b) and the reduction in fees to access primary care.To access services, people must first be aware that the services are available and that they are needed. Only 21.2 percent of Pacific adults compared with 31 percent of non-Pacific adults used medical specialists in the previous 12 months. These community ties provide protection from some of the worst consequences of illness, and health services can be promoted to Pacific peoples through community organisations.Lower incomes mean that many of the conditions or factors that support good health, such as good nutrition and quality housing, are less accessible.
From this low base about 85 percent of Pacific peoples are sending remittances overseas (Money Pacific, 2010). More than half of people with the condition are from the less affluent E and FG quintiles, while only 11% are from the well-off AB quintile. Although there are limited long-term data on the natural history of NAFLD in children, NASH is increasingly diagnosed in obese children [4] and it may progress to cirrhosis even in this age group [2,5]. Type 2 diabetes—which accounts for 85–90% of all cases—is linked with lifestyle factors such as obesity, physical inactivity and unhealthy diet.
There were about 25,700 hospitalisations where the injury was self-inflicted and about 23,000 where it was inflicted by another person.
This is a result of a combination of factors, including lower levels of participation in early childhood education and teaching and learning practices throughout schooling that are less effective for Pacific students(Statistics NZ and Ministry of Pacific Island Affairs, 2010).Poor education reduces peoples’ employment opportunities. This reduces access to employment or education opportunities, community activities, and health care.
Having a strong sense of belonging seems to reduce the likelihood that an individual will consider or attempt suicide (Beautrais et al, 2005).In the 2006 Census, 83 percent of Pacific peoples stated they had at least one religion, compared with 61 percent of New Zealand overall.
The 2002 National Children’s Nutrition Survey found that Pacific children were more likely than European children to be the most active, and the least likely to be the least active.
In 2006, 48.1 percent of Pacific children under the age of 15 years lived in a household with a smoker (Craig et al, 2007, p165). Primary care services have historically been centred around GP and practice nurse services, but more recently these have been expanded to involve multi-disciplinary teams and a broader range of services. It was considered that this may reflect the difficulties of working through caregivers during the consultation, or generational or cultural differences (Davis et al, 2005). These findings are concerning given the documented high health needs of Pacific peoples, particularly the prevalence of chronic health conditions.Cultural competence is the ability of individuals and systems to understand and appreciate the differences and similarities within and among groups. Pacific peoples were even less likely to visit medical specialists when the specialist was located at a private facility. Pacific peoples experience greater exposure to risk factors such as smoking, alcohol, and poor nutrition, with Pacific youth being particularly at risk.
4 percent).For the 12-month period to October 2010, 89 percent of Pacific 2-year-olds were fully immunised, compared with 87 percent of European 2-year-olds. The 2006 Census of Population and Dwellings showed that 35 percent of Pacific peoples had no qualifications, compared with 25 percent of all New Zealanders.
Improvements in health can be achieved by improving educational performance and other social and economic circumstances. Pacific students express the importance of spiritual beliefs (57 percent) much more frequently than European students (20 percent) (Helu et al, 2009). The biggest thrill for me is when those ladies go away and continue with physical activity themselves.”Members of the group forged strong friendships and have continued to train together. Interestingly, the rate of parents ‘smoking at home’ was much lower than overall parental smoking rates, indicating that approximately half of Pacific families with smokers do not support smoking inside the house.Youth smoking rates are a key predictor of adult smoking behaviour, as taking up smoking early increases the risk of smoking-related diseases. Overall, Pacific adults experienced greater levels of harmful consequences subsequent to drinking and those who drank reported greater alcohol consumption (Huakau et al, 2005).According to the results of a 2003 Alcohol Advisory Council (ALAC) survey that looked at youth access to alcohol, Pacific young people are more likely to be non-drinkers compared with other ethnicities. Pacific young people are less likely to access sexual health services as they are concerned that others may find out (Ministry of Health, 2008i).
Programmes with a strong community-support focus, including provision of transport to attend appointments, have also had a positive effect on cervical screening participation rates.Cost is recognised as a continued barrier and the Ministry of Health supports subsidised cervical screening for groups where the uptake of screening services is lower (H Lewis, personal communication, October 2010). Similarly, medical insurance, which can allow more timely access to health care, is held by half as many Pacific (19 percent) as non-Pacific adults (38.
Exposure to these risk factors contributes to a greater incidence of chronic diseases (such as diabetes, stroke, and ischaemic heart disease) among Pacific peoples.
Several lines of evidence have shown that in obese children and adolescents excessive accumulation of IHTF is associated with important alterations in glucose, fatty acid (FA), lipoprotein metabolism and inflammation, suggesting that IHTF represents a strong risk factor for the development of the Metabolic Syndrome (MetS) and type 2 diabetes mellitus (T2D) [7-10].Although a multifactorial pathogenesis of NAFLD has been postulated [12-14], obesity and insulin resistance represent two important players in the development of the early stages of the disease [2,14].
The unemployment rate is higher for Pacific peoples (14.4 percent in the March 2010 quarter) than for any other ethnic group (Statistics NZ, 2010). This has been discussed in Education and Pacific peoples in New Zealand (Statistics NZ and Ministry of Pacific Island Affairs, 2010) and will be explored in a future report on economic development.
Voluntary work underpins a wide range of groups and organisations whose activities contribute to social well-being. The survey found that about two-thirds of Pacific young people (compared with just under half of young people overall) are non-drinkers (McMillen, Kalafatelis & De Bonnaire, 2004). Appropriate sexual and reproductive health information needs to be made available by alternative means.The relatively low success rate of smoking cessation programmes among Pacific peoples may be related to the belief, held by a relatively large number of Pacific smokers (24.
Cultural competence training of professionals improves patient satisfaction and the number of patients continuing with agreed medical care plans. 6 percent) (Ministry of Health, 2008a).‘Did-not-attend’ rates for out-patient appointments appear to be consistently higher among Pacific peoples.
Alcohol consumption is associated with a greater risk of injury through accidents and violence. Interestingly, although the insulin resistance state could explain the relationship between NAFLD and the development of metabolic alterations [10,15], the presence of liver steatosis is also an important marker of multiorgan insulin resistance [16], opening a debate as to whether hepatic steatosis is a consequence or cause of insulin resistance.
Since the March 2008 quarter, the rise in Pacific unemployment has been greater than the total rise in unemployment.
The General Social Survey 2008 showed that 42 percent of Pacific peoples had done voluntary work in the previous four weeks, significantly more than the mainly European ethnic group (Ministry of Social Development, 2010).The General Social Survey showed that 85 percent of Pacific peoples had at least weekly face to face contact with friends compared to 79 percent of the total population. This may be because Pacific children have higher rates of incidental activity, but lower rates of participation in organised leisure and sport, which is what SPARC measured.Research findings about adult levels of activity are mixed.
However, among young people who do drink, Pacific youth consumed, on average, 6.9 standard drinks. Those Pacific people who used face-to-face counselling services were experiencing more severe harm5 than those from other ethnic groups (Francis Group, 2009).
Pacific primary care providers deliver integrated services that include health promotion, primary care, secondary care, and social services. 4 percent), followed by lack of time, lack of availability of a suitable appointment, and not wanting to make a fuss. It impacts on the ability of an individual to communicate with health professionals, to discern what good advice is, and to translate this into action. The New Zealand Health Practitioners Competence Assurance Act 2004 requires professional bodies to ensure that set levels of cultural competence are met by practitioners (Tiatia, 2008). Addressing these risk factors will improve Pacific peoples’ health outcomes.People’s beliefs and practices in relation to health and illness influence their behaviour and how they access health services. Our figures show a 33% growth since 2007—and that’s just among people who know they have the condition. Therefore, it would be of paramount importance to identify children affected by NAFLD and to better understand the pathogenesis of this condition in order to prevent the development of the associated metabolic complications early in life.2.
Pacific peoples are over-represented in non-skilled and lower-skilled occupations (Ministry of Pacific Island Affairs, 2010). The Youth 2007 Survey found that 17 percent of Pacific youth had helped others in their community in the last 12 months, (Helu et al, 2009) compared with 14 percent of youth overall (Adolescent Health Research Group, 2008). The New Zealand Health Survey (Ministry of Health, nd, f) found that only about half of New Zealand’s total population, and slightly fewer Pacific peoples (46.1 percent), were sufficiently active to gain any health benefits3. Fonua Mo’ui grants are designed to improve Pacific peoples’ health by supporting initiatives that promote healthy eating and physical activity.
Since 1999, the number of smokers in the total New Zealand population has been trending down for all groups including Pacific boys and girls (Paynter, 2010).
Pacific smokers are also most likely to believe that smokers should be able to quit without the assistance of a programme (Ministry of Health, 2009a). They aim to provide services that incorporate Pacific cultural care and language components to ensure the services are more appropriate for, and responsive to, Pacific peoples. Pacific peoples were significantly more likely than non-Pacific people to cite cost as a reason for an unmet GP need. Those with limited health literacy have worse health status than those with adequate health literacy.
This applies to both nurses (Nursing Council of New Zealand, nd) and doctors (Medical Council of New Zealand, 2006). The higher rate among Pacific peoples may reflect the barriers Pacific peoples face in accessing services, including getting time off work, transport difficulties, cultural beliefs, and a lack of cultural responsiveness (Ministry of Health, 2008f).Surgical admissions (which tend to be elective rather than emergency) are lower for Pacific peoples. For example, attitudes to sexual health act as a barrier to Pacific peoples accessing sexual health services and protecting their sexual health. Obviously, this presents a growing challenge to Australia’s already stretched healthcare system.
Evidence from previous recessions also suggests that unskilled workers are hit hardest in times of recession, when unemployment rates for unskilled workers increase more than those for skilled workers (Department of Labour, 2009).Figure 1 shows that approximately half of all Pacific children and young people live in a crowded house, a higher proportion than other ethnic groups.


Pacific peoples were the most sedentary group (undertaking less than 30 minutes of physical activity in the previous week) – 19. The Youth 2007 Survey found that Pacific students regularly smoked at twice the rate of European students, and that rates were highest among Samoan and Cook Island students (Helu et al, 2009).The 2006 Census showed that there are sub-group differences within the Pacific population.
The proportion of Pacific young people (32 percent) who reported ‘binge drinking’ at least once in the previous four weeks was slightly lower than European young people (Helu et al, 2009).Drinking alcohol at an early age is associated with greater adverse health outcomes (Odgers et al, 2008). These findings show that beliefs regarding the nature of nicotine addiction and cessation options need to be changed in order to increase the number of Pacific people who give up smoking. Access to care has been improved through lowering fees, providing local facilities, and giving nurses a greater role in primary care. Cost is also a factor in the collection of prescribed medications (Jatrana, Crampton, & Norris, 2010). Older people, those with more limited education, lower socio-economic groups, and those whose primary language is not local tend to have more limited levels of health literacy (Adams et al, 2009).
Access to coronary artery bypass grafts (CABG) operations, angioplasties, and major joint-replacement operations has improved (Ministry of Health, 2006b). Lack of knowledge of tobacco addiction and smoking cessation interventions may prevent Pacific peoples accessing cessation services and traditional respect for authority may prevent Pacific peoples demanding the best care within the health system.
A child growing up in an over-crowded house will be more susceptible to communicable diseases (Hawker, 2005) and over-crowding can have a detrimental effect on successful learning. It is estimated that three-quarters of Pacific peoples in New Zealand send money to family members in the Pacific region (Money Pacific, 2010).As well as building resilient and supportive communities, social connections also provide useful foundations for community health interventions. 4 percent – and were 40 percent more likely to be sedentary than the total New Zealand population. Drinking socially at an early age can cause increased short-term harm such as motor vehicle injuries and deaths, suicide, as well as longer-term harm from alcohol dependence, abuse, and related medical conditions (Alcohol Advisory Council of New Zealand, 2002).
Nicotine replacement therapies are considered ineffective by a large number of Pacific peoples, and a relatively low proportion of Pacific peoples in south Auckland made claims for subsidised nicotine replacement therapies.
Pacific providers have shown better results for the management of patients with long-term conditions than other providers (Ministry of Health, 2010c). The Adult Literacy and Life Skills Survey 2006 showed that, overall, the literacy of Pacific peoples was lower than other ethnic groups (Statistics NZ and Ministry of Pacific Island Affairs, 2010). Ambulatory-sensitive hospitalisations (ASH) are admissions that are potentially avoidable through primary care interventions.
While the number of admissions for coronary operations is low compared with the need experienced by Pacific peoples (Tukuitonga & Bindman, 2002), the inequalities in angioplasty operations are narrowing.
Although medical experts recommend specific lifestyle measures to control or even prevent type 2 diabetes, it seems that not everyone is listening. Liver biopsy allows an accurate assessment of histopatological findings, providing information on the type of NAFLD (simple steatosis or steatohepatitis) and the various degrees of hepatic fibrosis [20].
Projects that “create and reinforce strong social connections across Pacific communities” (Tait, 2008) provide useful foundations for effective public health action.
SPARC’s 2008 Active NZ Survey used the same criteria as the New Zealand Health Survey, and had similar findings. Tokelauans are the most likely to be regular smokers, followed by Cook Islanders (38 percent), Niueans (33 percent), Tongans (29 percent), and Samoans (28 percent).
Among young people, Cook Islanders are the heaviest drinkers with the most harmful drinking patterns, while Samoan men and women, and Tongan women are the least likely to drink (Ministry of Health, 2008i). Although more Pacific people are likely to smoke, 60 percent fewer Pacific people used nicotine replacement therapies compared with Europeans (Thornley, Jackson, Mcrobbie, Sinclair, & Smith, 2010). This may be due to a combination of factors, including poor communication of services by providers and difficulties managing the required application processes. Pacific peoples experience other factors that contribute to limited health literacy, such as lower socio-economic status and language difficulties.
Between 1999 and 2005, there was a larger growth in the number of Pacific peoples receiving angioplasties than in the number of non-Maori, non-Pacific peoples receiving angioplasties (Ministry of Health, 2006b).
However, the main limitation of the application of liver biopsy in the pediatric age group is due to the fact that it is an invasive procedure; thus, it is not considered as first line to screen the presence of liver disease [19,20]. For example, the success of initiatives such as the MeNZB and HPV vaccination campaigns in Pacific communities has been attributed to these strengths (F Tupu, personal communication, 2009; CBG Health Research Ltd, 2006). An ALAC study also found that Pacific young people, born and raised in New Zealand, consumed alcohol more frequently, pointing to the influence of acculturation factors (Alcohol Advisory Council of New Zealand, 2009). A Counties Manukau study of Pacific and Maori parents showed that these groups had a low awareness of other available cessation options (Glover & Cowie, 2010). For example, in education, difficulty with application processes was one of the main reasons identified for poor access to supplementary support (particularly when language is a barrier) (Clark et al, 2007; Rivers, 2005).
The incidence of ischaemic heart disease among Pacific peoples suggests that this group would have a greater need for angioplasties.
Although non-invasive methods, such as computer tomography, MRI, or ultrasonography are unable to distinguish between NASH and other forms of NAFLD [19,21], they have an acceptable sensitivity and specificity for the diagnosis of increased fat accumulation in the liver [21].
Smoking is particularly common for young Samoans and Cook Islanders, older men, Pacific-born men – particularly Tongan men, and younger New Zealand-born women, particularly Tokelauan and Cook Island women.Traditionally, Pacific men were more likely to be smokers than Pacific women. This clearly indicates that these groups of smokers need to be better informed.The traditional respect for authority figures in Pacific communities can make it more difficult for Pacific people to question their health professionals and demand more effective services (Statistics NZ and Ministry of Pacific Island Affairs, 2010).
Furthermore, ultrasound has been shown to have a good correlation with the histological findings of liver biopsy, particularly macrovescicular steatosis [22].
This can lead to Pacific peoples being disempowered in the health system, not receiving services as needed, and therefore experiencing poorer outcomes. However, rates did decline for Pacific children aged 0-4 years (Ministry of Health, 2008c).There is some evidence that the delivery of effective health care to Pacific peoples is improving. In clinical practice, combining liver function tests, such as serum aminotransferases [18], with liver ultrasound represents a useful way of identifying the presence of liver steatosis in obese children. Between 2001 and 2007, the proportion of people with diabetes receiving an annual check through the Get Checked Programme has increased, including for Pacific peoples, who have higher coverage than other ethnic groups. In spite of the method used, it is clear that the prevalence of NAFDL is increasing in children and adolescence.
Prescription of statin medication also increased markedly for all ethnic groups, including Pacific peoples (Ministry of Health, 2008b).
This may be due to the fact that smoking was traditionally a male activity in the Pacific Islands. In a study of people with both type 1 and type 2 diabetes in Counties Manukau, access to tests and appropriate medication was consistent across ethnic groups (Smith et al, 2010). Pediatric NAFLD extends beyond North America according to centers in Europe, Asia, South America and Australia [2,3]. It appears Pacific women born in New Zealand have been influenced by local smoking behaviour.
A study of patients with type 2 diabetes in south and west Auckland showed Pacific peoples, who visited a regular GP, had a higher average number of consultations, equivalent frequency of testing, but worse glucose control. The prevalence of fatty liver in obese children in China, Italy, Japan, and the United States has been reported to be between 10% and 77% [2,3].
They were less likely to be on a statin, despite higher serum lipids compared with the total population (Robinson et al, 2006).Overall, Pacific peoples receive less effective care. Data derived from the National Health and Nutrition Examination Survey III (1988-1994) suggest that approximately 3% of adolescents present abnormal serum aminotransferase values [26]. Access to care and the quality of care is improving but outcomes are not equivalent to other ethnic groups. Moreover, studies from autopsies of 742 children (ages 2–19 years) reported fatty liver prevalence at 9.6%, and in obese children this rate increased to an alarming 38% [25]. The reasons for this are complicated, and seem to include a combination of late presentation, receiving appropriate medication and treatment less often, and less effective ongoing management.
This is influenced by the cultural attitudes and expectations of both Pacific peoples and those in the health system, and by levels of financial resources. Improved cultural competence of services will improve the quality of consultations and services, promote improved health-care delivery, and improve health outcomes. The prevalence of NAFLD is around 30% in children with a Tanner pubertal stage I, significantly lower when compared to that found in the pubertal age [28].Alarming data come from our study population of prepubertal Caucasian obese children [29]. Out of 100 severely obese prepubertal children, liver steatosis was found in 52% and was equally distributed between the two sexes [29]. Insulin resistance and central obesityThe “two-hit” model proposes that fat accumulation in the hepatocytes is a prerequisite for a second hit that induces fibrosis and inflammation [30]. Fat accumulation in the liver is likely to result from insulin resistance and concomitant impairment of fatty acid (FA) metabolism within liver, skeletal muscle and adipose tissue [31]. Insulin resistance seems to be responsible for abnormalities in lipid storage and lipolysis in insulin-sensitive tissues, leading to an increased fatty acids flux from adipose tissue to the liver and subsequent accumulation of triglycerides in the hepatocytes [31].
In particular, steatosis develops when the rate of FA input (uptake and synthesis with subsequent esterification to triglycerides (TG)) is greater than the rate of FA output (oxidation and secretion) [11]. Several studies [32,33] have demonstrated that obese adolescents presenting increased intramyocellular lipid content (IMCL) [32] and visceral fat and decreased subcutaneous fat deposition are more likely to develop insulin resistance.There is extensive evidence indicating that central obesity is associated with an impaired insulin action in obese pediatric populations.
Although controversy remains regarding the contribution of visceral and subcutaneous fat to the development of insulin resistance [33], a previous study by Cruz et al. Insulin resistance and fatty liver disease: Which comes first?Despite the demonstrated relationship between IMCL, visceral fat and metabolic dysfunction, the ectopic fat deposition in the liver is emerging as the most important marker of insulin resistance in adults [15] as well as in obese pediatric population [36]. In healthy nondiabetic humans the correlation between the IHTF content and peripheral insulin resistance was much stronger than the correlation with intramyocellular lipid content, visceral fat content or subcutaneous fat content [37]. The relationship between liver steatosis and insulin resistance has been clearly demonstrated in children [36,29]. In our cross sectional study, we evaluated insulin resistance indexes between obese prepubertal children with and without liver steatosis; furthermore insulin resistance indexes were compared to values of normal weight children.
Our results showed that children with NAFLD not only presented severe obesity but also an increased degree of insulin resistance when compared to the sex- and age-matched normal weight children [29].The relationship between insulin resistance and fatty liver disease is not only related to the presence of liver steatosis, but also to the degree of fatty liver. In particular, adiponectin, the most abundant secretory protein produced by adipose tissue, is closely related with insulin action. Plasma adiponectin concentrations are inversely associated with hepatic steatosis and metabolic complications [37,38].Although these findings support the central role of insulin resistance in the development of fatty liver, several studies have demonstrated that the presence of liver steatosis is an important marker of multiorgan insulin resistance, independently of BMI, percent body fat, and visceral fat mass [11,15,36].
In particular, NAFLD has been found to be associated with insulin resistance in liver (impaired suppression of insulin-mediated glucose production) [39,40], skeletal muscle (reduced insulin stimulated glucose uptake) [40] and adipose tissue (decrease inhibition of lipolysis by insulin) [41] in obese children and adolescents, independently of adiposity.Recently, Caprio et al. These results suggest that the liver has a central role in the complex phenotype of the insulin resistance state in obese adolescents with fatty liver. Although it is clear that there is an important correlation between insulin resistance and hepatic steatosis, the mechanisms responsible for the interrelationships between fatty liver disease and insulin resistance are not clearly understood. In fact, it remains unclear whether hepatic steatosis is a consequence or the primary event leading to hepatic and subsequently peripheral insulin resistance.
60-80% of patients with liver cirrhosis are glucose intolerant and in 10-15% diabetes occurs relatively rapidly (over a period of 5 years). Diabetes complicating liver cirrhosis, also known as hepatogenous diabetes, and the common form of T2D are the results of a marked reduction in insulin action and a ?-cell secretion defect that is not able to compensate the severity of insulin resistance [43,44]. The important role of peripheral insulin resistance in the glucose tolerance of cirrhosis has been highlighted by the observation that liver transplantation, when the dosage of immunosuppressive agents was reduce and corticosteroids withdrawn, was able to restore normal insulin sensitivity not only in the liver but also at the level of the skeletal muscle and adipose tissue and normalizes glucose tolerance in most patients with diabetes [43,44].The mechanism by which IHTF has an important systemic consequence to adversely affect insulin sensitivity is unknown. However, it has been proposed that fatty liver might interfere with insulin degradation [45]; the resultant hyperinsulinemia may potentially be able to impair insulin action in peripheral tissues, as shown in benign insulinoma induced hyperinsulinemia [43,44,46].
This hyperinsulinemia-induced mechanism may be justified also based on the finding of the reverse experiment: when the prolonged infusion of octreotide was administered to extremely insulin-resistant cirrhotic individuals, the correlation of hyperinsulinemia was paralleled by the restoration of normal insulin sensitivity [43,47]. Although these data showed a clear possibility that intrahepatic fat accumulation plays a key role in the onset of insulin resistance and insulin resistance syndrome, longitudinal data are needed in order to clarify which abnormality comes first. In particular, obese prepubertal children with liver steatosis presented decreased RAGEs levels compared with children without liver disease, underling that oxidative stress could play a role even in the early stages of the disease [48]. Genetic and environmental factors associated with fatty liver diseaseSeveral genetic and environmental factors are likely responsible for NAFLD and its progression from simple steatosis to NASH. In fact, although the development of NAFLD is strongly linked to obesity and insulin resistance, there are obese individuals who do not have NAFLD, and since NAFLD can occur in normal-weight individuals with normal metabolic profile, thus multiple genetic and environmental factors should be involved in its development [49]. Initial evidence for a genetic component of NAFLD comes from ethnic variation in NAFLD prevalence [50]. Children from certain ethnicities are predisposed to NAFLD, primarily Hispanics, Asians and Native Americans [25,50].
Furthermore, a familial aggregation study of fatty liver in overweight children with and without NAFLD found that fatty liver is a highly heritable trait. Family members of children with biopsy-proven NAFLD and overweight children without NAFLD were evaluated by magnetic resonance imaging (MRI). Fatty liver was identified in 17% of siblings and 37% of parents of overweight children without NAFLD and in 59% of siblings and 78% of parents of children with NAFLD [51].Interestingly, Romeo et al.
The authors demonstrated that the patatin-like phospholipase domain containing protein 3 (also known as adiponutrin) gene was strongly associated with IHTF content in adults [52].These findings have been recently supported by Santoro et al. By genotyping the PNLPA3 SNP in a multiethnic group of 85 obese youths, the authors found that the PNPLA3 rs738409 SNP gene confers susceptibility to hepatic steatosis.Nutrition and physical activity are important environmental factors that determine risk in NAFLD.
Excess food intake and lack of exercise contribute to weight gain, which has been shown to contribute to the progression of liver fibrosis in patients with NAFLD [54].
Specific dietary factors may also play either protective or antagonistic roles in the development and progression of NAFLD. An increased consumption of meat and soft drinks and low consumption of fish were found to be associated with NAFLD cases compared with controls [49]. Furthermore, low intakes of polyunsaturated fatty acid (PUFA) and high intakes of saturated fat and cholesterol were also shown to be associated with NAFLD [49].
Other studies have shown higher-carbohydrate and lower-fat diets to be associated with more progressive disease [49,55]. Notably, very recent animal data have shown that in both mice [49,56] and non-human primates [49] exposure to a maternal high-fat diet leads to a disturbing development and progression of NAFLD in the offspring.It has been proposed that increase consumption of fructose in soft drinks and fruit drinks may have a role in the pathogenesis of NAFLD [2]. In one study, children with biopsy-proven NAFLD were shown to have significantly elevated plasma TG levels and oxidative stress levels after consumption of fructose as compared with glucose [57]. However, children without NAFLD were found to have no differences in TG or oxidative stress levels following the consumption of glucose compared with fructose [2].Small intestinal bacterial overgrowth may be an additional environmental factor involved in NAFLD pathogenesis, and dietary supplements such as probiotics could have a beneficial effect [49].
Evidences from animal studies have shown that small intestinal bacterial overgrowth increases gut permeability leading to portal endotoxaemia and increased circulating inflammatory cytokines, both of which have been implicated in the progression of NAFLD [58,59]. NAFLD and metabolic complicationsNAFLD is nowadays considered the hepatic manifestation of the MetS in adults as well as in children [60].
This is not surprising since NAFLD is closely associated with obesity, insulin resistance, and alterations in glucose and lipid metabolism [44].The association between NAFLD and MetS has been clearly demonstrated by Burgert et al. After adjusting for potential confounders, rising ALT levels were associated with deterioration in insulin sensitivity and glucose tolerance, as well as increasing FFA and TG levels. Furthermore, increased hepatic fat accumulation was found in 32% of obese adolescents and was associated with decreased insulin sensitivity and increased lipid levels and visceral fat [61]. These results demonstrate that in obese children and adolescents, hepatic fat accumulation is associated with insulin resistance, dyslipidemia and altered glucose metabolism. In addition, a diagnosis of MetS was predictive of steatosis severity, NASH, hepatocellular ballooning and NAFLD pattern [63].
In a recent study by our group [64], we assessed the role of liver steatosis in defining MetS in prepubertal children. The prevalence of the MetS was around 14% and increased to 20% when liver steatosis was included as an additional diagnostic criterion. In fact, paralleling the severity of hepatic steatosis, there was a significant decrease in insulin sensitivity and impairment in ?-cell function, as indicated by the fall in the disposition index (DI). Furthermore, paralleling the severity of fatty liver, there was a significant increase in the prevalence of MetS, suggesting that hepatic steatosis may probably be a predictive factor of MetS in children [36].The important role of intrahepatic fat content in the development of metabolic complications in obese subject has been recently underlined by Fabbrini et al. The authors showed that in adults with high IHTF insulin action in liver, skeletal muscle and adipose tissue was impaired and hepatic VLDL-TG secretion rate was increased. In contrast, they were not able to observe these metabolic alterations in subjects with high visceral fat volume and matched for IHTF. NAFLD and cardiovascular diseaseRecent evidences suggests that individuals with NAFLD are also at high risk for coronary heart disease [3,43]. In adults, elevated serum ALT have been associated with increased risk of cardiovascular and all cause mortality (in addition to liver mortality) [3,65].A study in Turkish children [66] showed that carotid artery intima-media thickness is significantly higher in obese children with fatty liver than in obese children without fatty liver or normal weight control. However, given the lack of long-term longitudinal cohort studies in pediatric fatty liver disease, the relationship between the natural history of the disease and the actual risk for future cardiac events is unclear. ConclusionsThe prevalence of fatty liver disease is increasing in obese children and adolescence. Although the exact pathogenetic mechanism is still unclear, there is an urgent need to screen obese children for this pathology.



Ordin m.92 din 17 septembrie 2008
Treatment for diabetes in homeopathy 6x
Pw50 vitesse
Pathophysiological basis of the symptoms and signs of uncontrolled diabetes mellitus


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