Transcript

1

Introduction

pÉÇÉåí~êó=äáÑÉëíóäÉë=ÅçìéäÉÇ=ïáíÜ=ÉñÅÉëëáîÉ=Å~äçêáÅ=áåí~âÉ=Ü~îÉ=ÄÉÉå=ã~àçê=ÇÉíÉêãáå~åíëíç=íÜÉ=ÉñéäçëáîÉ=áåÅêÉ~ëÉ=áå=íÜÉ=éêÉî~äÉåÅÉ=çÑ=çÄÉëáíó=~åÇ=íóéÉ=O=Çá~ÄÉíÉë=ãÉääáíìë=EqOajFKbåÇçÅêáåçäçÖáëíë= ~êÉ= ÉåÅçìåíÉêáåÖ= çå= ~= Ç~áäó= Ä~ëáë= é~íáÉåíë= ïáíÜ= çÄÉëáíóJêÉä~íÉÇÅçãéäáÅ~íáçåëI=ëìÅÜ=~ë=ãÉí~ÄçäáÅ=ëóåÇêçãÉ=EjÉípF=~åÇ=qOajK=qÜÉ=ÉéáÇÉãáÅ=çÑ=qOaj=Ü~ëÇêáîÉå= ÜÉ~äíÜ= Å~êÉ= éêçîáÇÉêë= íç= ÖáîÉ= áåÅêÉ~ëáåÖ= ~ííÉåíáçå= íç= íÜÉ= É~êäó= Çá~Öåçëáë= ~åÇíêÉ~íãÉåí=çÑ=Çá~ÄÉíáÅ=ÅçãéäáÅ~íáçåëK=eçïÉîÉêI=åçí=ìåíáä=êÉÅÉåíäó=Ü~ë=åçåJ~äÅçÜçäáÅ=Ñ~ííó=äáîÉêÇáëÉ~ëÉ=Ek^ciaF=ÄÉÉå=êÉÅçÖåáòÉÇ=~ë=~åçíÜÉê=Åçããçå=ÅçãéäáÅ~íáçå=çÑ=é~íáÉåíë=ïáíÜ=qOajíÜ~í=êÉèìáêÉë=ëéÉÅá~ä=~ííÉåíáçåK=oÉ~ëçåë=Ñçê=íÜáë=ã~ó=ÄÉ=êÉä~íÉÇ=íç=íÜÉ= ä~Åâ=çÑ=~ï~êÉåÉëë~Äçìí= íÜÉ= áåÅêÉ~ëÉÇ= ëìëÅÉéíáÄáäáíó= íç= Ñ~ííó= äáîÉê= ÇáëÉ~ëÉ= çÑ= é~íáÉåíë=ïáíÜ= qOajI= áåÜÉêÉåíÇáÑÑáÅìäíáÉë=áå=ã~âáåÖ=íÜÉ=Çá~Öåçëáë=~åÇ=áåÅçãéäÉíÉ=ìåÇÉêëí~åÇáåÖ=~Äçìí=íÜÉ=å~íìê~ä=ÜáëíçêóçÑ=íÜÉ=ÇáëÉ~ëÉK=qÜÉ=ã~å~ÖÉãÉåí=çÑ=é~íáÉåíë=ïáíÜ=k^cia=Ü~ë=íê~Çáíáçå~ääó=ÄÉäçåÖÉÇ=íç=íÜÉêÉ~äã=çÑ=ÜÉé~íçäçÖáëíëI=Äìí=êÉ~äáò~íáçå=íÜ~í=íÜÉ=ã~àçêáíó=çÑ=çÄÉëÉ=çê=qOaj=é~íáÉåíë=ã~ó=Ü~îÉ~= Ñ~ííó= äáîÉê= Ü~ë= ÄÉÅçãÉ= ~= åÉï= ~åÇ= ÅçåÅÉêåáåÖ= ãÉÇáÅ~ä= ÇáäÉãã~= Ñçê= éêáã~êó= Å~êÉéÜóëáÅá~åë= ~åÇ= ÉåÇçÅêáåçäçÖáëíëK= qÜáë= ÅÜ~éíÉê= ïáää= ÄêáÉÑäó= êÉîáÉï= çìê= ÅìêêÉåí= âåçïäÉÇÖÉ~Äçìí=k^cia=íêóáåÖ=íç=éáÉÅÉ=íçÖÉíÜÉê=çìê=áåÅçãéäÉíÉ=âåçïäÉÇÖÉ=çÑ=íÜÉ=ÇáëÉ~ëÉ=~åÇ=ïÉáÖÜíáåíç=íÜÉ=ÅçåíêçîÉêëó=çå=ïÜÉíÜÉê=íÜáë=ÅçåÇáíáçå=Å~êêáÉë=~å=áåÇÉéÉåÇÉåí=~åÇ=áåÜÉêÉåí=ÜÉ~äíÜêáëâ=çê=áí=áë=ëáãéäó=~å=ÉéáéÜÉåçãÉåçå=çÑ=~=ëí~íÉ=çÑ=áåëìäáå=êÉëáëí~åÅÉ=~åÇ=~Äåçêã~ä=ÖäìÅçëÉãÉí~ÄçäáëãK=

Non-alcoholic fatty liver disease (NAFLD) indiabetes: distraction or impending disaster?

Romina Lomonaco MD, Assistant Professor Division of Endocrinology, Diabetes and Metabolism, University of Florida,Gainesville, Florida, USA

Kenneth Cusi MD, Chief and Professor Division of Endocrinology, Diabetes and Metabolism, University of Florida,Gainesville, Florida and the Malcom Randall Veterans Affairs Medical Center(VAMC), Gainesville, Florida, USA

Chapter 21

Natural history

NAFLD and liver disease progression

k^cia= áë= ~= Åçããçå= Å~ìëÉ= çÑ= ÅÜêçåáÅ= äáîÉê= ÇáëÉ~ëÉI= ~åÇ= áíë= ïçêäÇïáÇÉ= éêÉî~äÉåÅÉÅçåíáåìÉë= íç= áåÅêÉ~ëÉ=ïáíÜ= íÜÉ= çÄÉëáíó= ÉéáÇÉãáÅ= NI= OK= iáîÉê= Ñ~í= ÇÉéçëáíáçå=ã~ó= ê~åÖÉ= ÑêçãëáãéäÉ=ëíÉ~íçëáë=íç=ëÉîÉêÉ=ëíÉ~íçÜÉé~íáíáë=ïáíÜ=ÜÉé~íçÅóíÉ=åÉÅêçëáëI=áåÑä~ãã~íáçå=~åÇ=î~êá~ÄäÉÇÉÖêÉÉë=çÑ=ÑáÄêçëáë=EåçåJ~äÅçÜçäáÅ=ëíÉ~íçÜÉé~íáíáë=çê=k^peFK=fí=áë=ÄÉäáÉîÉÇ=íÜ~í=áå=é~íáÉåíë=ïáíÜk^ciaI=úQMB=çê=ãçêÉ=ã~ó=Öç=çå=íç=ÇÉîÉäçé=k^pe=PJR EfffL_FI=~äíÜçìÖÜ=íÜÉ=å~íìê~ä=ÜáëíçêóçÑ=íÜÉ=ÇáëÉ~ëÉ=áë=åçí=ïÉää=Éëí~ÄäáëÜÉÇK=

píìÇáÉë=çå=íÜÉ=å~íìê~ä=Üáëíçêó=çÑ=k^cia=Ü~îÉ=ÄÉÉå=ÅÜ~ääÉåÖáåÖ=~ë=íÜÉó=êÉèìáêÉ=é~áêÉÇ=äáîÉêÄáçéëó=ë~ãéäÉëI=éçëëáÄäó=íÜÉ=ã~àçê=ÇÉíÉêãáå~åí=çÑ=íÜÉ=ëã~ää=å~íìêÉ=çÑ=íÜÉ=~î~áä~ÄäÉ=ëíìÇáÉëKaáÑÑáÅìäíáÉë=ïÜÉå=áåíÉêéêÉíáåÖ=íÜÉ=~î~áä~ÄäÉ=ëíìÇáÉë=áå=íÜÉ=k^cia=äáíÉê~íìêÉ=áåÅäìÇÉW=

� íÜÉ=áåÜÉêÉåí=ëÉäÉÅíáçå=Äá~ë=çÑ=ïçêâ=Ñêçã=íÉêíá~êó=ÜÉ~äíÜ=Å~êÉ=Ñ~ÅáäáíáÉëX=� î~êá~ÄäÉ=äÉåÖíÜ=çÑ=ÑçääçïJìé=~Åêçëë=ëíìÇáÉëX=� ÜáëíçäçÖáÅ~ä=áåíÉêéêÉí~íáçåI=ÄÉáåÖ=áåÜÉêÉåíäó=ÇáÑÑáÅìäí=~åÇ=~ÑÑÉÅíÉÇ=Äó=äáîÉê=Äáçéëó=ë~ãéäÉ

î~êá~Äáäáíó=~ë=ïÉää=~ë=êÉ~ÇáåÖ=ëí~åÇ~êÇáò~íáçå=~ãçåÖ=é~íÜçäçÖáëíë=~åÇ=ÄÉíïÉÉå=ãÉÇáÅ~äÅÉåíÉêëX=

� áåÅçãéäÉíÉ=áåÑçêã~íáçå=áå=éìÄäáëÜÉÇ=ëíìÇáÉë=~Äçìí=íÜÉ=~ëëçÅá~íÉÇ=ãÉí~ÄçäáÅ=êáëâ=Ñ~ÅíçêëÇìêáåÖ= ÑçääçïJìé= íÜ~í= äáâÉäó= áãé~Åí= ÇáëÉ~ëÉ= éêçÖêÉëëáçå= EáKÉK= ïÉáÖÜí= Ö~áåLçÄÉëáíóIÇÉîÉäçéãÉåí=çÑ=Çá~ÄÉíÉëI=Çá~ÄÉíÉë=ÅçåíêçäI=çíÜÉêFX=

� áåÅäìëáçå=çÑ=áåÇáîáÇì~äë=ïáíÜ=~Çî~åÅÉÇ=ÇáëÉ~ëÉ=EÅáêêÜçëáëF=~í=Ä~ëÉäáåÉX=~åÇ=� íÜÉ=êÉíêçëéÉÅíáîÉ=å~íìêÉ=çÑ=ãçëí=êÉéçêíëK=

aÉëéáíÉ=íÜÉëÉ=äáãáí~íáçåëI=íÜÉ=~î~áä~ÄäÉ=ëíìÇáÉë=Ü~îÉ=éêçîáÇÉÇ=ìëÉÑìä=áåëáÖÜíë=êÉÖ~êÇáåÖ=íÜÉéêçÖêÉëëáçå=~åÇ=éêçÖåçëáë=çÑ=íÜÉ=ÇáëÉ~ëÉK

q~ÄäÉ= N= ëìãã~êáòÉë= íÜÉ= ãçëí= êÉäÉî~åí= çÑ= íÜÉëÉ= ëíìÇáÉë= ~åÇ= ëìÖÖÉëíë= íÜ~í= k^pe=ã~óéêçÖêÉëë= íç= ~Çî~åÅÉÇ= ÑáÄêçëáë= áå= ~= ëáÖåáÑáÅ~åí= åìãÄÉê= çÑ= é~íáÉåíëK= fåÇÉÉÇI= k^pe= áë= åçïêÉÅçÖåáòÉÇ=~ë=~=ã~àçê=Å~ìëÉ=çÑ=ÅêóéíçÖÉåáÅ=ÅáêêÜçëáë=SJV=EffÄL_FK=få=ëíìÇáÉë=ïáíÜ=é~áêÉÇ=äáîÉêÄáçéëáÉë=ïáíÜ=P=óÉ~êë=çê=ãçêÉ=çÑ=ÑçääçïJìé=TI=NMJNPI=íÜÉ=çîÉê~ää=ê~íÉ=çÑ=éêçÖêÉëëáçå=çÑ=ÑáÄêçëáëï~ë=ÄÉíïÉÉå=OUB= íç=QNBK=^=åìãÄÉê=çÑ= Ñ~Åíçêë= ëÉÉã= áãéçêí~åí= çå=ÇÉíÉêãáåáåÖ=ÇáëÉ~ëÉéêçÖêÉëëáçåK=^ãçåÖ=íÜÉãI=ÇáëÉ~ëÉ=Çìê~íáçå= áë= íóéáÅ~ääó= íÜÉ=ãçëí=êÉäÉî~åí= Ñ~ÅíçêI=ïáíÜ=ãçêÉëÉîÉêÉ=ëíÉ~íçÜÉé~íáíáë=~åÇ= ÑáÄêçëáë= êÉéçêíÉÇ= áå=ëíìÇáÉë=ïáíÜ= äçåÖÉê= ÑçääçïJìé= TK=lÄÉëáíó= EçêïÉáÖÜí=Ö~áå=çîÉê=íáãÉFI=Çá~ÄÉíÉë=~í=Ä~ëÉäáåÉ=~åÇ=~Çî~åÅÉÇ=ÜÉé~íáÅ=ÑáÄêçëáë=çå=íÜÉ=áåáíá~ä=äáîÉêÄáçéëó= TI= NNJNP ïÉêÉ= ~ää= ÅçåëáëíÉåí= Ñ~Åíçêë= ~ëëçÅá~íÉÇ= ïáíÜ= ÇáëÉ~ëÉ= éêçÖêÉëëáçå= ~åÇ= éççêéêçÖåçëáë=Eff~L_FK=cçê=áåëí~åÅÉI=íÜÉ=êçäÉ=çÑ=ÇáëÉ~ëÉ=Çìê~íáçå=áë=áääìëíê~íÉÇ=áå=~=ëíìÇó=Äó=^Ç~ãëÉí=~ä NO íÜ~í=êÉéçêíÉÇ=íÜ~í=áå=é~íáÉåíë=ïáíÜ=k^pe=ÑçääçïÉÇ=ïáíÜ=é~áêÉÇ=äáîÉê=ÄáçéëáÉëI=ÇáëÉ~ëÉéêçÖêÉëëáçå=ï~ë= íïçJÑçäÇ=ÜáÖÜÉê= áÑ= ÑçääçïJìé=ï~ë=ÉñíÉåÇÉÇ= Ñçê=ìé= íç=Q=óÉ~êë=Åçãé~êÉÇ= íçëÜçêíÉê= éÉêáçÇë= çÑ= íáãÉK= få= íÜÉ= ïçêâ= Äó= bâëíÉÇí= Éí= ~ä TI= QNB= çÑ= é~íáÉåíë= Ü~Ç= ëáÖåë= çÑéêçÖêÉëëáîÉ=ÑáÄêçëáë=~ÑíÉê=~=ãÉ~å=ÑçääçïJìé=çÑ=NPKU=óÉ~êëK=^ÇÇáåÖ=ÅçãéäÉñáíó=íç=íÜÉ=áåÇáîáÇì~äêáëâ=~ëëÉëëãÉåí=~åÇ=ã~å~ÖÉãÉåí=çÑ=k^cia=áë=íÜÉ=çÄëÉêî~íáçå=íÜ~í=~=ëáÖåáÑáÅ~åí=ãáåçêáíó=çÑé~íáÉåíë=Ó=ìé=íç=NUB=áå=ëçãÉ=ëÉêáÉë=NMI=NO Ó=ã~ó=~Çî~åÅÉ=íç=ÅáêêÜçëáë=ïáíÜáå=àìëí=P=óÉ~êëK=

Evidence-based Management of Diabetes

2

aóëÑìåÅíáçå~ä=~ÇáéçëÉ=íáëëìÉI=~ë=çÄëÉêîÉÇ=áå=çÄÉëáíóI=áë=éÉêÜ~éë=íÜÉ=ëáåÖäÉ=ãçëí=áãéçêí~åíêáëâ= Ñ~Åíçê= Ñçê=éççê= äçåÖJíÉêã=çìíÅçãÉëK=jçëí=é~íáÉåíë=ìåÇÉêÖçáåÖ= äáîÉê= íê~åëéä~åí~íáçå= ÑçêÅêóéíçÖÉåáÅ=ÅáêêÜçëáë=~êÉ=çÄÉëÉ=~åÇ=íÜÉ=î~ëí=ã~àçêáíó=êÉéêÉëÉåí=Å~ëÉë=çÑ=ìåÇá~ÖåçëÉÇ=k^peKfå=íÜÉ=ëíìÇó=Äó=bâëíÉÇí=Éí=~ä TI=éêçÖêÉëëáçå=çÑ=äáîÉê=ÑáÄêçëáë=ï~ë=ãçëí=ëíêçåÖäó=~ëëçÅá~íÉÇ=ïáíÜëáÖåáÑáÅ~åí=ïÉáÖÜí=Ö~áå=E[RâÖF=~åÇ=áåëìäáå=êÉëáëí~åÅÉK=få=çìê=ÉñéÉêáÉåÅÉI=íÜÉ=ÇÉîÉäçéãÉåí=çÑäáîÉê=ÑáÄêçëáë=áë=ãçêÉ=ÇÉéÉåÇÉåí=çå=íÜÉ=ëÉîÉêáíó=çÑ=~ÇáéçëÉ=íáëëìÉ=ÇóëÑìåÅíáçå=~åÇ=éä~ëã~=ÑêÉÉÑ~ííó=~ÅáÇ=Ecc^F=ÅçåÅÉåíê~íáçå=íÜ~å=íÜÉ=ÇÉÖêÉÉ=çÑ=çÄÉëáíó=éÉê=ëÉK=içãçå~Åç=Éí=~ä NQ ÇáîáÇÉÇçÄÉëÉ= ëìÄàÉÅíë= áåíç= èì~êíáäÉë= çÑ= ~ÇáéçëÉ= íáëëìÉ= áåëìäáå= êÉëáëí~åÅÉ= EíÜÉ= éêçÇìÅí= çÑ= Ñ~ëíáåÖ

21 Non-alcoholic fatty liver disease (NAFLD) in diabetes: distraction or impending disaster?

3

Table 1. Natural history of NASH: disease progression in studies with paired liver biopsies.

^ìíÜçê=EóÉ~êF=

e~êêáëçå=Éí=~ä EOMMPF=

c~ëëáç=Éí=~ä EOMMQF=

iáåÇçê=Éí=~ä EOMMQF=

^Ç~ãë=Éí=~ä EOMMRF=

bâëíÉÇí=Éí=~ä EOMMSF=

tçåÖ=Éí=~ä EOMNMF=

p~åó~ä=Éí=~ä EOMNMF=

^pq=Z= ~ëé~êí~íÉ= ~ãáåçíê~åëÑÉê~ëÉX=^iq=Z= ~ä~åáåÉ= ~ãáåçíê~åëÑÉê~ëÉX=aj=Z=Çá~ÄÉíÉë=ãÉääáíìëX= fo=Z

áåëìäáå= êÉëáëí~åÅÉX=elj^=Z=eçãÉçëí~íáÅ=jçÇÉä=^ëëÉëëãÉåí= fåÇÉñX=ic^q=Z= äáîÉê= Ñ~íX=iaiJ`=Z= äçï

ÇÉåëáíó=äáéçéêçíÉáå=ÅÜçäÉëíÉêçä

G=mêçÖêÉëëáçå=íç=ÑáÄêçëáëæ jÉÇá~å˛ UU=çìí=çÑ=NOV=Ü~Ç=ÑçääçïJìé=Ç~í~=EÄìí=SU=Ü~Ç=~=ëÉÅçåÇ=äáîÉê=ÄáçéëóFI=~í=Ä~ëÉäáåÉ=çåäó=RRB=k^pe

EQ=çÑ=íÜÉã=Ü~Ç=ÅáêêÜçëáëFI=VB=ëíÉ~íçëáë=ïáíÜ=ìåëéÉÅáÑáÅ=áåÑä~ãã~íáçå=~åÇ=PSB=ëáãéäÉ=ëíÉ~íçëáë¬ ORB=ëíÉ~íçëáëI=QOB=ÄçêÇÉêäáåÉ=k^peI=PPB=k^pe

å=

OO=

OO=

NMT=

NMP=

SU�

RO¬

OQT=

cçääçïJìé

EãÉ~å=óÉ~êëF

RKT=

QKPæ �

OKM=

PKO=

NPKU=

PKM=

OKM=

aáëÉ~ëÉ

éêçÖêÉëëáçåG

POB=

POB=

ORB=

PTB=

QNB=

OUB=

NVB=

mêÉÇáÅíçêë

↑^pq

^iq=åçí=ìëÉÑìä

lÄÉëáíó

^pq=~åÇ=^iq=åçí=ìëÉÑìä

^iq=åçí=ìëÉÑìä

lÄÉëáíó

aj

↑^pqI=^iqajI=fo=EÄó=elj^F

ic q

^pqL^iq=ê~íáç=åçí=ìëÉÑìä

lÄÉëáíó

↑iaiJ`

^iq=åçí=ìëÉÑìä

éä~ëã~= cc^= ñ= Ñ~ëíáåÖ= éä~ëã~= áåëìäáå= ÅçåÅÉåíê~íáçåI= ~= î~äáÇ~íÉÇ= áåÇÉñ= çÑ= ~ÇáéçëÉ= íáëëìÉÇóëÑìåÅíáçå=áå=çÄÉëÉ=áåÇáîáÇì~äëF=~åÇ=êÉéçêíÉÇ=íÜ~í=íÜÉ=ëÉîÉêáíó=çÑ=ÜÉé~íáÅ=áåëìäáå=êÉëáëí~åÅÉI~íÜÉêçÖÉåáÅ=ÇóëäáéáÇÉãá~=~åÇ=çÑ=äáîÉê=ÑáÄêçëáë=çå=ÜáëíçäçÖó=ï~ë=åçí=ÇáêÉÅíäó=êÉä~íÉÇ=íç=_jf=çêîáëÅÉê~ä=Ñ~íI=Äìí=ê~íÜÉê=ÇáêÉÅíäó=éêçéçêíáçå~ä=íç=~ÇáéçëÉ=íáëëìÉ=áåëìäáå=êÉëáëí~åÅÉ=~åÇ=ÜÉé~íáÅäáéçíçñáÅáíóK

^å=~ëéÉÅí=çÑ= íÜÉëÉ=ëíìÇáÉë= íÜ~í= Ü~ë= áãéçêí~åí= ÅäáåáÅ~ä= áãéäáÅ~íáçåë= áë= íÜÉ=çîÉê~ää= ä~Åâ=çÑÅçêêÉä~íáçå=ÄÉíïÉÉå=éä~ëã~=~ãáåçíê~åëÑÉê~ëÉë=äÉîÉäë=~åÇ=ÅÜ~åÖÉë=áå=äáîÉê=ÑáÄêçëáë=çîÉê=íáãÉKtÜáäÉ= ëçãÉ= ëíìÇáÉë= Ü~îÉ= ÑçìåÇ= ~= ïÉ~â= ÅçêêÉä~íáçå= ÄÉíïÉÉå= äáîÉê= ÇáëÉ~ëÉ= ~åÇ= éä~ëã~~ãáåçíê~åëÑÉê~ëÉë=TI=NMI=ãçëí=ëíìÇáÉë=Ü~îÉ=åçí=ÑçìåÇ=íÜÉã=~äçåÉ=íç=ÄÉ=îÉêó=ìëÉÑìä=áå=éêÉÇáÅíáåÖÇáëÉ~ëÉ= ëÉîÉêáíó= çê= íêÉ~íãÉåí= êÉëéçåëÉ= NNJNPI= NRK= eçïÉîÉêI= áå= ÅçãÄáå~íáçå= ïáíÜ= ÅçããçåÅäáåáÅ~ä=êáëâ=Ñ~Åíçêë=ëìÅÜ=~ë=çÄÉëáíó=~åÇ=Çá~ÄÉíÉëI=~ë=ïÉää=~ë=äáîÉê=áã~ÖáåÖ=EáKÉK=ëíÉ~íçëáë=çåìäíê~ëçìåÇFI=íÜÉó=ã~ó=ÄÉ=ÜÉäéÑìä=Ñçê=~ëëÉëëáåÖ=êáëâ=çÑ=k^ciaK=cçê=áåëí~åÅÉI=ÉäÉî~íÉÇ=éä~ëã~~ãáåçíê~åëÑÉê~ëÉë= áå= íÜÉ= éêÉëÉåÅÉ= çÑ= ÄçíÜ= ÜáÖÜ= ÅÜçäÉëíÉêçä= ~åÇ= íêáÖäóÅÉêáÇÉë= EqdF= ï~ë~ëëçÅá~íÉÇ=ïáíÜ=k^cia= áå=UPB=çÑ=é~íáÉåíë= áå= íÜÉ=a~ää~ë=eÉ~êí=píìÇó= NSK= få= ëçãÉ=ëíìÇáÉëÉäÉî~íÉÇ= äáîÉê= ~ãáåçíê~åëÑÉê~ëÉë= ïÉêÉ= áåÇáÅ~íáîÉ= çÑ= ïçêëÉ= ÜÉé~íáÅ= áåëìäáå= êÉëáëí~åÅÉ= ~åÇçîÉê~ää=éêçÖåçëáë=áå=k^cia=NQI=NTK=qÜÉëÉ=~Äåçêã~äáíáÉëI=ÅçãÄáåÉÇ=ïáíÜ=ä~Äçê~íçêó=áåÇáÅ~íçêëçÑ= ~Çî~åÅÉÇ= äáîÉê= ÇáëÉ~ëÉ= EëìÅÜ= ~ë= éä~ëã~= äçï= éä~íÉäÉí= Åçìåí= ~åÇ= ÉäÉî~íÉÇ= ÄáäáêìÄáåFI= ~êÉÅäÉ~êäó=ìëÉÑìä=áåÇáÅ~íçêë=çÑ=~Çî~åÅÉÇ=äáîÉê=ÇáëÉ~ëÉ=Äìí=åçí=îÉêó=ëÉåëáíáîÉ=Ñçê=~å=É~êäó=Çá~ÖåçëáëKqÜÉ=íêìÉ=ÇáäÉãã~=áë=íÜÉ=Çá~Öåçëáë=çÑ=k^ciaI=~åÇ=áå=é~êíáÅìä~ê=çÑ=k^peI=áå=íÜÉ=É~êäó=ëí~ÖÉëçÑ=íÜÉ=ÇáëÉ~ëÉ=ïÜÉå=ãáäÇ=íç=ãçÇÉê~íÉ=äáîÉê=ÑáÄêçëáë=áë=éêÉëÉåíK=qÜáë=áë=~å=áãéçêí~åí=ÇáëíáåÅíáçåÄÉÅ~ìëÉ=äçåÖJíÉêã=éêçÖåçëáë=çÑ=äáîÉê=ÇáëÉ~ëÉ=ëÉÉãë=íç=Öç=Ü~åÇJáåJÜ~åÇ=ïáíÜ=íÜÉ=ÇÉîÉäçéãÉåíçÑ= ëíÉ~íçÜÉé~íáíáëI= ~åÇ= áå=é~êíáÅìä~êI= çÑ= ÑáÄêçëáëK= få= íÜáë= ëÉííáåÖI= äáîÉê= ÉåòóãÉë=Ü~îÉ=ÄÉÉå=çÑÇáë~ééçáåíáåÖ=Çá~ÖåçëíáÅ=î~äìÉ=NTJONI=~åÇ=ïÜÉå=ïáíÜáå=íÜÉ=åçêã~ä=ê~åÖÉI=çÑÑÉê=~=Ñ~äëÉ=ëÉåëÉ=çÑëÉÅìêáíóK=j~åó=êÉÅÉåí=ëíìÇáÉë=êÉéçêí=íÜÉ=éêÉëÉåÅÉ=çÑ=~Çî~åÅÉÇ=k^pe=ÉîÉå=ïáíÜ=åçêã~ä=äáîÉê~ãáåçíê~åëÑÉê~ëÉë=UI=NQI=OOI=OPI=Äìí=ã~ó=ìåÇÉêÉëíáã~íÉ= äáîÉê= Ñ~í=~ÅÅìãìä~íáçå= áå=é~íáÉåíë=ïáíÜqOaj=OQK=få=ëìãã~êóI=íÜÉëÉ=ÑáåÇáåÖë=Ü~îÉ=áãéçêí~åí=áãéäáÅ~íáçåë=áå=íÜÉ=Å~êÉ=çÑ=é~íáÉåíë=ïáíÜk^ciaK= ^äíÜçìÖÜ= íÜÉó= ÅçìäÇ= ÄÉ= áåÇáÅ~íáîÉ= çÑ= ëÉîÉêÉ= ãÉí~ÄçäáÅ= ÇáëÉ~ëÉ= ~åÇ= Ñ~ííó= äáîÉêáåÑáäíê~íáçåI=áåÅêÉ~ëÉÇ=äáîÉê=~ãáåçíê~åëÑÉê~ëÉë=~êÉ=éççê=ÖìáÇÉë=Ñçê=íÜÉ=çîÉê~ää=ã~å~ÖÉãÉåí=çÑé~íáÉåíë=ïáíÜ=k^cia=~åÇ=ÅìêêÉåíäó=çåäó=~=äáîÉê=Äáçéëó=Å~å=~ÅÅìê~íÉäó=ÇÉíÉêãáåÉ=íÜÉ=ëÉîÉêáíóçÑ=k^cia=~åÇ=åÉÉÇ=Ñçê=íêÉ~íãÉåíK=

NAFLD and long-term mortality

tÜÉíÜÉê= k^cia= áë= ~ëëçÅá~íÉÇ= ïáíÜ= ~å= áåÅêÉ~ëÉÇ= êáëâ= çÑ= éêÉã~íìêÉ= ÇÉ~íÜ= áë= ÜáÖÜäóÅçåíêçîÉêëá~äI= ~åÇ=~í= íÜÉ=éêÉëÉåí= íáãÉI=Ü~ë=åç=ÇÉÑáåáíáîÉ=~åëïÉêK=^Ö~áåI= ëíìÇáÉë=Ü~îÉ=ÄÉÉåéä~ÖìÉÇ= Äó= ëÜçêíÅçãáåÖë= ëìÅÜ= ~ë= ëã~ää= ë~ãéäÉ= ëáòÉI= é~íáÉåí= ëÉäÉÅíáçå= Äá~ëI= ä~Åâ= çÑëí~åÇ~êÇáòÉÇ=ÑçääçïJìé=~åÇ=íÜÉ=éêÉëÉåÅÉ=çÑ=çîÉêä~ééáåÖ=Å~êÇáçî~ëÅìä~ê=êáëâ=Ñ~Åíçêë=íóéáÅ~ä=çÑé~íáÉåíë=ïáíÜ=k^ciaK=få=ã~åó=ëíìÇáÉëI=~ÑíÉê=íÜÉ=áåáíá~ä=Ä~ëÉäáåÉ=Çá~Öåçëáë=çÑ=k^peI=åç=äáîÉêÄáçéëó=ÅçåÑáêãÉÇ=íÜÉ=ëÉîÉêáíó=çÑ=äáîÉê=ÇáëÉ~ëÉ=Eçê=áíë=êÉëçäìíáçåF=~í=íÜÉ=ÉåÇ=çÑ=íÜÉ=çÄëÉêî~íáçåéÉêáçÇK= qÜáë= áë= áãéçêí~åí= ÄÉÅ~ìëÉ= ~ë=ã~åó= ~ë=úNUJORB=çÑ= é~íáÉåíë= Ü~îÉ= áãéêçîÉãÉåí= çêêÉëçäìíáçå=çÑ=k^pe=çîÉê=íáãÉ=TI=ORJOTK=qÜìëI= áí=êÉã~áåë=ìåÅäÉ~ê=ïÜÉíÜÉê=íÜÉ=çîÉê~ää=ãçêí~äáíóêÉéçêíÉÇ=áå=íÜÉëÉ=ëíìÇáÉë=ï~ë=äáåâÉÇ=íç=äáîÉê=ÇáëÉ~ëÉ=çê=~ëëçÅá~íÉÇ=ãÉí~ÄçäáÅ=Ñ~ÅíçêëK=

Evidence-based Management of Diabetes

4

21 Non-alcoholic fatty liver disease (NAFLD) in diabetes: distraction or impending disaster?

5

Table 2. Long-term liver-related and overall mortality in middle-aged patients withNAFLD.

páãéäÉëíÉ~íçëáë

k^pe=

k^ciaJêÉä~íÉÇ=ÅáêêÜçëáë=

^ìíÜçê=

j~ííÉçåá=Éí=~ä ENVVVF=

bâëíÉÇí=Éí=~ä EOMMSF

o~Ñáè=Éí=~ä EOMMVF=

pçÇÉêÄÉêÖ=Éí=~ä EOMNMF=

a~ãJi~êëÉå=Éí=~ä EOMMVF=

qçí~äLãÉ~å=

j~ííÉçåá=Éí=~ä ENVVVF=

bâëíÉÇí=Éí=~ä EOMMSF=

o~Ñáè=Éí=~ä EOMMVF=

pçÇÉêÄÉêÖ=Éí=~ä EOMNMF=

bî~åë=Éí=~ä EOMMOF=

^Ç~ãë=Éí=~ä EOMMRF=

vçìåçëëá=Éí=~ä EOMNNF=

qçí~äLãÉ~å=

eìá=Éí=~ä EOMMPF=

p~åó~ä=Éí=~ä EOMMSF=

v~íëìàá=Éí=~ä EOMMVF=

_Ü~ä~=Éí=~ä EOMNNF=

qçí~äLãÉ~å=

å=

QV=

RU=

TQ=

ST=

NTM=

QNU

OV=

TN=

RT=

RN=

OS=

QV=

NPN=

PQV

OP=

NRO=

SU=

OQT=

QVM

cçääçïJìéEãÉ~åI=óêëF

V=

NQ=

NVG=

ON=

ON=

NT=

U=

NQ=

NVG=

ON=

V=

U=

NMG=

NN=

T=

NM=

R=

T=

T=

iáîÉêJêÉä~íÉÇãçêí~äáíó

OKMB=

MKMB=

OKTB=

PKMB=

MKSB=

NKTB=

NMKMB=

OKUB=

NTKRB=

RKVB=

ko=

UKNB=

NRKTB=

UKSB

ONKMB=

NQKRB=

TKPB=

RKTB=

NOKNB

lîÉê~ääãçêí~äáíó

PPKMB=

NOKNB=

RSKUB=

PQKPB=

OUKOB=

POKVB

PMKMB=

OSKUB=

SPKOB=

QTKNB=

NRKMB=

PRKMB=

ONKPB=

PQKNB

OSKMB=

NVKNB=

OTKVB=

NPKQB=

OQKPB

fåÅêÉ~ëÉÇjçêí~äáíó\=˛

vÉë

vÉë

vÉë

vÉë

vÉë

vÉë

ko

ko

ko

ko

vÉë

ko=Z=åçí=êÉéçêíÉDz tÜÉå=Åçãé~êÉÇ=íç=íÜÉ=ÖÉåÉê~ä=éçéìä~íáçå

G=jÉÇá~å

^ë=ëìãã~êáòÉÇ=áå=q~ÄäÉ=OI=äçåÖJíÉêã=äáîÉêJêÉä~íÉÇ=éêçÖåçëáë=áë=ÅäçëÉäó=ÅçêêÉä~íÉÇ=ïáíÜ=íÜÉëÉîÉêáíó=çÑ=ëíÉ~íçÜÉé~íáíáëI=~åÇ=áå=é~êíáÅìä~êI=çÑ=ÑáÄêçëáë=Eff~L_FK=pçãÉ=ëíìÇáÉë=Ü~îÉ=Ü~Ç=ÑçääçïJìéë=çÑ=úOM=óÉ~êë=ORI=OSI=OUK=m~íáÉåíë=ïáíÜ=ëáãéäÉ=EÚÄä~åÇÛF=ëíÉ~íçëáë=~ééÉ~ê=íç=Ü~îÉ=~=ÖççÇ=äçåÖJíÉêã=éêçÖåçëáëK=qÜÉó=ê~êÉäó=ÇáÉ=çÑ= äáîÉêJêÉä~íÉÇ=ÅçãéäáÅ~íáçåë=~åÇ=çîÉê~ää=ãçêí~äáíó=ÇçÉë=åçí~ééÉ~ê=íç=ÄÉ=áåÅêÉ~ëÉÇI=~äíÜçìÖÜ=çåäó=~=Ü~åÇÑìä=çÑ=ëíìÇáÉë=~êÉ=~î~áä~ÄäÉ=~åÇ=íÜÉó=Å~êêó=íÜÉäáãáí~íáçåë= ÇáëÅìëëÉÇ= ~ÄçîÉK= få= Åçåíê~ëíI= é~íáÉåíë= ïáíÜ= ëíÉ~íçÜÉé~íáíáë= Ek^peF= Ü~îÉ= ~å~ééêçñáã~íÉäó=íÜêÉÉJÑçäÇ=áåÅêÉ~ëÉ=áå=äáîÉêJêÉä~íÉÇ=ãçêí~äáíó=EPKSB=îëK=UKSBX=q~ÄäÉ=OF=TI=NOI=ORI=OSIOVJPNK pÉîÉê~ä=ëíìÇáÉë=TI=ORI=OSI Äìí=åçí=~ää=OVI=Ü~îÉ=ëìÖÖÉëíÉÇ=íÜ~í=é~íáÉåíë=ïáíÜ=k^pe=Ü~îÉ=~ÜáÖÜÉê=çîÉê~ää=ãçêí~äáíó=ê~íÉ=Åçãé~êÉÇ=íç=é~íáÉåíë=ïáíÜ=ëáãéäÉ=ëíÉ~íçëáëK=få=íÜÉ=ëíìÇó=ïáíÜ=íÜÉäçåÖÉëí=ÑçääçïJìé=EãÉ~å=Çìê~íáçå=çÑ=ON=óÉ~êëFI=pçÇÉêÄÉêÖ=Éí=~ä OS êÉéçêíÉÇ=~=ÅäÉ~ê=ÇáÑÑÉêÉåÅÉáå=íÜÉ=çîÉê~ää=ëìêîáî~ä=çÑ=ëìÄàÉÅíë=ïáíÜ=k^cia=ïÜÉå=ÇáîáÇÉÇ=~ãçåÖ=íÜçëÉ=ïáíÜ=çåäó=Ñ~ííó=äáîÉêçê=ëìÄàÉÅíë=ïáíÜ=Ñ~í=~åÇ=~åó=íóéÉ=çÑ=áåÑä~ãã~íáçåI=Ä~ääççåáåÖI=çê=ÑáÄêçëáë=EcáÖìêÉ=NFK=jçêí~äáíóï~ë=~äëç=ÜáÖÜÉê=ïÜÉå=é~íáÉåíë=ïáíÜ=ëíÉ~íçÜÉé~íáíáë= Ek^peF=ïÉêÉ=Åçãé~êÉÇ= íç=é~íáÉåíë=ïáíÜ

Evidence-based Management of Diabetes

6

Figure 1. Overall survival of subjects with NAFLD, divided among those with only fattyliver or subjects with fat and any type of inflammation, ballooning, or fibrosis. Adapted fromSoderberg C, et al 26. Reprinted with permission from John Wiley and Sons, © 2009.

låäó=äáîÉê=ëíÉ~íçëáë

píÉ~íçÜÉé~íáíáë=~åÇ=ÑáÄêçëáë

qáãÉ=EóÉ~êëF

MKMM

MKOR

MKRM

MKTR

NKMM

pìêîáîçê

M NM OM PM

ëáãéäÉ=ëíÉ~íçëáë= EQTKNB=îëK=PQKPBFK=bâëíÉÇí=Éí=~ä T ÑçìåÇ=åç= äáîÉêJêÉä~íÉÇ=ãçêí~äáíó=~ÑíÉê=NQóÉ~êë=çÑ=ÑçääçïJìé=áå=é~íáÉåíë=ïáíÜ=ëáãéäÉ=ëíÉ~íçëáë=Åçãé~êÉÇ=íç=OKUB=áå=é~íáÉåíë=ïáíÜ=k^pe~åÇ=~=OKRJÑçäÇ=áåÅêÉ~ëÉ=áå=çîÉê~ää=ãçêí~äáíóK=fÑ=íÜÉ=Ç~í~=çÑ=~ää=ëíìÇáÉë=áå=q~ÄäÉ=O=~êÉ=í~âÉå=íçÖÉíÜÉêIáí=~ééÉ~êë=íÜ~í=~ÑíÉê=NN=óÉ~êë=çÑ=ÑçääçïJìé=é~íáÉåíë=ïáíÜ=k^pe=ÉîÉå=Ü~îÉ=~=ïçêëÉ=éêçÖåçëáë=íÜ~åé~íáÉåíë=ïáíÜ= ëáãéäÉ= ëíÉ~íçëáë= ÑçääçïÉÇ= Ñçê= NT= óÉ~êëI=ïáíÜ= ~= ÑáîÉJÑçäÇ= áåÅêÉ~ëÉ= áå= äáîÉêJêÉä~íÉÇãçêí~äáíó=~åÇ=ÜáÖÜÉê=çîÉê~ää=ãçêí~äáíóK=tÜ~í=áë=ìåèìÉëíáçå~ÄäÉ=áë=íÜ~í=é~íáÉåíë=ïáíÜ=k^ciaJêÉä~íÉÇÅáêêÜçëáë=~êÉ=~í=~=ãìÅÜ=ÜáÖÜÉê= êáëâ=çÑ= äáîÉêJêÉä~íÉÇ=~åÇ=çîÉê~ää=ãçêí~äáíóI=ïáíÜ=RJNM=óÉ~êë= äáîÉêJêÉä~íÉÇ=ãçêí~äáíó=ÄÉáåÖ=~ë=ÜáÖÜ=~ë=NOKNB=~åÇ=çîÉê~ää=ãçêí~äáíó=OQKPB=POJPRK

NAFLD in patients with type 2 diabetes mellitus

få=íÜÉ=ä~ëí=ÇÉÅ~ÇÉI=~=åìãÄÉê=çÑ=ÉéáÇÉãáçäçÖáÅ~ä=~åÇ=ÅäáåáÅ~ä=íê~åëä~íáçå~ä=ëíìÇáÉë=Ü~îÉ=äÉÇíç=~å=áåÅêÉ~ëÉÇ=~ï~êÉåÉëë=~Äçìí=íÜÉ=ÅäçëÉ=äáåâ=ÄÉíïÉÉå=k^cia=~åÇ=qOajK=_çíÜ=ÅçåÇáíáçåëÑêÉèìÉåíäó= ÅçÉñáëí= ïáíÜ= ëÉîÉêÉ= ÜÉé~íáÅ= áåëìäáå= êÉëáëí~åÅÉ= éä~óáåÖ= ~= âÉó= êçäÉ= áå= íÜÉé~íÜçéÜóëáçäçÖó= çÑ= íÜÉ= ÇáëÉ~ëÉK= béáÇÉãáçäçÖáÅ~ä= ëíìÇáÉë= êÉîÉ~ä= íÜ~í= ÉäÉî~íÉÇ= éä~ëã~~ãáåçíê~åëÑÉê~ëÉ=äÉîÉäë=~êÉ=~ëëçÅá~íÉÇ=ïáíÜ=~=ÖêÉ~íÉê=êáëâ=çÑ=Ü~îáåÖ=Çá~ÄÉíÉë=PSJQNK=jçêÉçîÉêIÉîÉå= éä~ëã~= ~ä~åáåÉ= ~ãáåçíê~åëÑÉê~ëÉ= E^iqF= ïáíÜáå= íÜÉ= Úåçêã~äÛ= ê~åÖÉ= áë= ~ëëçÅá~íÉÇ= ïáíÜÜáÖÜÉê=Çá~ÄÉíÉë= áåÅáÇÉåÅÉI= áåÇÉéÉåÇÉåíäó=çÑ=Åä~ëëáÅ~ä=éêÉÇáÅíçêë= EáKÉK=_jfI=éä~ëã~=ÖäìÅçëÉäÉîÉäëI=éêÉëÉåÅÉ=çÑ= íÜÉ=jÉípF=PTI=QOI=QPK=qÜÉ=éêÉî~äÉåÅÉ=çÑ=~Äåçêã~ä=ÖäìÅçëÉ=ãÉí~Äçäáëã=áåé~íáÉåíë= ïáíÜ= k^cia= Ä~ëÉÇ= çåäó= çå= ëÉäÑJêÉéçêíÉÇ= Çá~Öåçëáë= çê= ~= Ñ~ëíáåÖ= éä~ëã~= ÖäìÅçëÉê~åÖÉë= ÄÉíïÉÉå= V= íç= PNB UI= QQI= QRK= eçïÉîÉêI= ïÜÉå= ëíìÇáÉë= Ü~îÉ= ëóëíÉã~íáÅ~ääó= ëÅêÉÉåÉÇé~íáÉåíë=ïáíÜ=k^cia= Ñçê= áãé~áêÉÇ=ÖäìÅçëÉ= íçäÉê~åÅÉ= EfdqF= çê= qOaj=ïáíÜ= ~å= çê~ä= ÖäìÅçëÉíçäÉê~åÅÉ=íÉëí=EldqqF=íÜÉ=íêìÉ=ê~íÉ=çÑ=~Äåçêã~ä=ÖäìÅçëÉ=ãÉí~Äçäáëã=áë=ãìÅÜ=ÜáÖÜÉêK=få=çìêÉñéÉêáÉåÅÉI=ïÜÉå=çÄÉëÉ=é~íáÉåíë=ÄÉäáÉîÉÇ= íç=Ü~îÉ=åçêã~ä=ÖäìÅçëÉ=ãÉí~Äçäáëã=EÄó=ÄçíÜ= íÜÉé~íáÉåí=~åÇ=éêáã~êó=Å~êÉ=éêçîáÇÉêF=~êÉ=ëóëíÉã~íáÅ~ääó=ëÅêÉÉåÉÇ=ïáíÜ=~å=ldqqI=íÜÉ=éêÉî~äÉåÅÉçÑ= éêÉÇá~ÄÉíÉë= Eáãé~áêÉÇ= Ñ~ëíáåÖ= ÖäìÅçëÉ= xfcdzI= fdqF= ~åÇ= åÉïäó= Çá~ÖåçëÉÇ= qOaj= áëÅçåëáÇÉê~Ääó=ÜáÖÜÉê=áå=é~íáÉåíë=ïáíÜ=k^cia=îÉêëìë=ã~íÅÜÉÇ=Åçåíêçäë=ïáíÜçìí=~=Ñ~ííó=äáîÉê=EUPBîëK=PUBI=éYMKMMNFK=m~íáÉåíë=ïáíÜ=k^cia=Ü~Ç=~å=~ééêçñáã~íÉäó=íÜêÉÉJÑçäÇ=ÜáÖÜÉê=ê~íÉ=çÑ=åÉïäóÇá~ÖåçëÉÇ=qOaj=QSK=lÑ=åçíÉI=íÜÉ=îÉêó=ÜáÖÜ=ê~íÉ=çÑ=~Äåçêã~ä=ÖäìÅçëÉ=ãÉí~Äçäáëã=áå=íÜáë=ÅçÜçêíï~ë= äáâÉäó= êÉä~íÉÇ= íç=~=ÜáÖÜ=éêÉî~äÉåÅÉ=çÑ=âåçïå=êáëâ= Ñ~Åíçêë= Ñçê= íÜÉ=ÇÉîÉäçéãÉåí=çÑ=qOajEëìÅÜ=~ë=ÜáÖÜ=ê~íÉë=çÑ=ëÉÇÉåí~êáëãI=çÄÉëáíó=~åÇ=eáëé~åáÅ=~åÅÉëíêóFI=Äìí=ëáãáä~ê=ÜáÖÜ=éêÉî~äÉåÅÉê~íÉë=çÑ=fdq=~åÇ=qOaj=Eê~åÖáåÖ=Ñêçã=PPB=íç=SOBF=Ü~îÉ=ÄÉÉå=êÉÅÉåíäó=êÉéçêíÉÇ=áå=ëíìÇáÉëÑêçã=`Üáå~=QTI=g~é~å=QU ~åÇ=áå=~=éêÉÇçãáå~åíäó=bìêçéÉ~å=éçéìä~íáçå=Ñêçã=^ìëíê~äá~=QVK=

tÜáäÉ=qOaj= áë=ãçêÉ=Åçããçå= áå=k^ciaI= íÜÉ=å~íìêÉ=çÑ= íÜáë= êÉä~íáçåëÜáé= áë= áåÅçãéäÉíÉäóìåÇÉêëíççÇ=~åÇ=áí=êÉã~áåë=íç=ÄÉ=Éëí~ÄäáëÜÉÇ=áÑ=ÜÉé~íáÅ=ëíÉ~íçëáë=éêÉÅÉÇÉë=íÜÉ=ÇÉîÉäçéãÉåíçÑ= ëíÉ~íçëáë= ~åÇ= ÇáêÉÅíäó= ÅçåíêáÄìíÉë= íç= íÜÉ= ÇÉîÉäçéãÉåí= çÑ= Çá~ÄÉíÉëI= çê= áë= ~å= ~ëëçÅá~íÉÇÅçåÇáíáçå=ãçêÉ=ÅäçëÉäó=ãáêêçêáåÖ=íÜÉ=ëí~íÉ=çÑ=áåëìäáå=êÉëáëí~åÅÉK=aÉÑÉÅíë=áå=~ÇáéçëÉ=íáëëìÉ=~êÉïÉää=Éëí~ÄäáëÜÉÇ= áå=çÄÉëáíó=~åÇ=qOaj=RMI=RNK=qÜÉ=é~íÜçÖÉåÉëáë=çÑ=k^cia= áå= íÜÉ=ëÉííáåÖ=çÑáåëìäáå=êÉëáëí~åÅÉ=áåîçäîÉë=~=ÅêçëëJí~äâ=ÄÉíïÉÉå=~ÇáéçëÉ=íáëëìÉ=~åÇ=í~êÖÉí=íáëëìÉë=ëìÅÜ=~ë=íÜÉäáîÉê=~åÇ=ëâÉäÉí~ä=ãìëÅäÉ RMI=ROK=lîÉêëìééäó=çÑ=ÑêÉÉ=Ñ~ííó=~ÅáÇë=Ecc^F=íç=íÜÉ=äáîÉê=Ñêçã=áåëìäáåêÉëáëí~åí=~ÇáéçëÉ=íáëëìÉ=~åÇ=~=ëí~íÉ=çÑ=äçÅ~ä=EÜÉé~íáÅF=~åÇ=ëóëíÉãáÅ=ÅÜêçåáÅ=áåÑä~ãã~íáçå=~êÉ~í= ÅÉåíÉê= ëí~ÖÉ= áå= íÜÉ= ÇÉîÉäçéãÉåí= çÑ= ëíÉ~íçëáë= ~åÇ= k^pe= NQI= NUI= RPI= RQK= få= íÜÉ= ëÉííáåÖ= çÑÉñÅÉëëáîÉ= cc^= ëìééäóI= ÄçíÜ= ÅÜêçåáÅ= ÜóéÉêÖäóÅÉãá~= ~åÇ= ÜóéÉêáåëìäáåÉãá~= éêçãçíÉ= ÜÉé~íáÅíêáÖäóÅÉêáÇÉ=ëóåíÜÉëáë=~åÇ=áåÅêÉ~ëÉ=íÜÉ=ëÉÅêÉíáçå=çÑ=siaiK=eçïÉîÉêI= áí=ãìëí=ÄÉ=êÉÅçÖåáòÉÇ

21 Non-alcoholic fatty liver disease (NAFLD) in diabetes: distraction or impending disaster?

7

íÜ~í=~äíÜçìÖÜ=ÇÉ=åçîç äáéçÖÉåÉëáë=EakiF=áë=áåÅêÉ~ëÉÇ=áå=k^ciaI=áí=ÅçåíêáÄìíÉë=äÉëë=íç=íÜÉ=íçí~äÜÉé~íáÅ=íêáÖäóÅÉêáÇÉ=éççä=EúOMJORBF=íÜ~å=Ñ~ííó=~ÅáÇë=Ñêçã=~ÇáéçëÉ=íáëëìÉ=EúSMBF=áå=k^cia=RRKlîÉêëÉÅêÉíáçå=çÑ=siai=ã~ó=ÄÉ=~å=~Ç~éí~íáçå=íç=éêÉîÉåí=ã~ëëáîÉ=ëíÉ~íçëáë=~åÇ=ã~ó=Éñéä~áå=ïÜóëç= ÑêÉèìÉåíäó=ÜáÖÜ=éä~ëã~= íêáÖäóÅÉêáÇÉëI= äçï=ÜáÖÜJÇÉåëáíó= äáéçéêçíÉáå= EeaiJ`FI=~åÇ= áåÅêÉ~ëÉÇÑçêã~íáçå=çÑ=ëã~ääI=ÇÉåëÉ=äçïJÇÉåëáíó=äáéçéêçíÉáå=EiaiJ`F=~êÉ=ëç=Åçããçå=áå=é~íáÉåíë=ïáíÜ=jÉípIqOaj=~åÇ=k^cia=QSI=RSK=få=é~íáÉåíë=ïáíÜ=ëíÉ~íçëáë=íÜÉêÉ=áë=~=Ñ~áäìêÉ=çÑ=áåëìäáå=íç=ëìééêÉëë=siaiëÉÅêÉíáçå=RTI=RU=~åÇ=ëÉÅêÉíáçå=ê~íÉë=çÑ= íÜÉ= äáéçéêçíÉáå= áåÅêÉ~ëÉ= áå=éêçéçêíáçå=íç= íÜÉ=ëÉîÉêáíó=çÑáåíê~ÜÉé~íáÅ=íêáÖäóÅÉêáÇÉ=~ÅÅìãìä~íáçå=RVK=oÉëáëí~åÅÉ=íç=áåëìäáåÛë=~Åíáçå=íç=ëìééêÉëë=ÖäìÅçëÉ=~åÇsiai=ëÉÅêÉíáçå=áå=é~íáÉåíë=ïáíÜ=qOaj=ã~ó=~ÅÅçìåí=Ñçê=íÜÉ=çÄëÉêî~íáçå=íÜ~í=Çá~ÄÉíÉë=Åçåíêçäã~ó=ÄÉ=ãçêÉ=ÇáÑÑáÅìäí= íç=~ÅÜáÉîÉ=~åÇ=êÉèìáêÉ=ÜáÖÜÉê= áåëìäáå=ÇçëÉë= áå=é~íáÉåíë=ïáíÜ=qOaj=~åÇk^cia=SMK=eçïÉîÉêI=ÜÉé~íáÅ=ëíÉ~íçëáë=ã~ó=ÄÉ=~ãÉäáçê~íÉÇ=~åÇ=éä~ëã~=íêáÖäóÅÉêáÇÉë=áãéêçîÉÇÄó=ÖççÇ=ÖäóÅÉãáÅ=Åçåíêçä=áå=é~íáÉåíë=ïáíÜ=qOaj=~åÇ=k^cia=E`ìëá=Éí=~äI=ìåéìÄäáëÜÉÇFK

qOaj= áë= ~äëç= ~ëëçÅá~íÉÇ= ïáíÜ= ïçêëÉ= äáîÉê= ÇáëÉ~ëÉ= ~äíÜçìÖÜ= íÜÉ= ìåÇÉêäóáåÖ= ãÉÅÜ~åáëãëêÉã~áå=ìåÅäÉ~ê=UI=RQK=cçê=áåëí~åÅÉI=áå=ÉéáÇÉãáçäçÖáÅ~ä=ëíìÇáÉë=qOaj=áë=~ëëçÅá~íÉÇ=ïáíÜ=~=íïçJ=íçÑçìêJÑçäÇ=áåÅêÉ~ëÉ=áå=~Çî~åÅÉÇ=äáîÉê=ÇáëÉ~ëÉ=PI=TI=ÅáêêÜçëáë=Q ~åÇ=ÜÉé~íçÅÉääìä~ê=Å~êÅáåçã~=QI=VI=SNISO EffÄL_FK= qÜÉ= éêÉëÉåÅÉ= çÑ= qOaj= áå= é~íáÉåíë=ïáíÜ=k^cia= áë= ~ëëçÅá~íÉÇ=ïáíÜ=ãçêÉ= ëÉîÉêÉÜÉé~íáÅ=~åÇ=~ÇáéçëÉ=íáëëìÉ=áåëìäáå=êÉëáëí~åÅÉ=NQI=NUI=QS ~åÇ=ãìÅÜ=ïçêëÉ=äáîÉê=ÜáëíçäçÖóI=áåÅäìÇáåÖÑêÉèìÉåíäó= ~Çî~åÅÉÇ= äáîÉê= ÑáÄêçëáë= çê= ÅáêêÜçëáë= OI= SJUI= NMI= NNI= NQI= NUI= OPI= QNI= QSI= SPK= eçïÉîÉêI= ïÉääJÅçåíêçääÉÇ=äçåÖJíÉêã=éêçëéÉÅíáîÉ=ëíìÇáÉë=çå=íÜÉ=å~íìê~ä=Üáëíçêó=çÑ=k^cia=áå=qOaj=~êÉ=ä~ÅâáåÖK=

få= ëìãã~êóI= íÜÉ= ~î~áä~ÄäÉ= ÉîáÇÉåÅÉ= Å~ääë= Ñçê= ÉåÇçÅêáåçäçÖáëíë= íç= ÄÉ= ~ï~êÉ= ~Äçìí= íÜÉéçëëáÄäÉ=êçäÉ=çÑ=k^cia=áå=é~íáÉåíë=ïáíÜ=qOajK=tÜáäÉ=íÜÉ=ÉîáÇÉåÅÉ= áë=ëíáää= äáãáíÉÇI=íÜÉ=Ç~í~êÉîáÉïÉÇ=ëìÖÖÉëíë=íÜ~í=íÜÉ=éêÉëÉåÅÉ=çÑ=k^cia=ã~ó=éä~ó=~=é~íÜçÖÉåáÅ=êçäÉI=çê=~í=äÉ~ëí=ÄÉ=~Ü~ääã~êâ=çÑI=ÑìíìêÉ=qOajK=fí=ã~ó=~äëç=áÇÉåíáÑó=~=ëìÄëÉí=çÑ=é~íáÉåíë=ïáíÜ=ãçêÉ=ëÉîÉêÉ=ÜÉé~íáÅáåëìäáå=êÉëáëí~åÅÉ=íÜ~í=~êÉ=ãçêÉ=éêçåÉ=íç=íÜÉ=ÇÉîÉäçéãÉåí=çÑ=ÇóëäáéáÇÉãá~=~åÇ=~í=êáëâ=çÑ=É~êäáÉêçê~ä=~ÖÉåí= Ñ~áäìêÉK=cáå~ääóI= íÜÉ=~ëëçÅá~íáçå=çÑ=qOaj=~åÇ=k^pe=éä~ÅÉë= íÜÉëÉ=é~íáÉåíë=~í=~åáåÅêÉ~ëÉÇ= êáëâ=çÑ= ëÉîÉêÉ= äáîÉê=ÇáëÉ~ëÉI= áåÅäìÇáåÖ=ÜÉé~íçÅÉääìä~ê= Å~êÅáåçã~K=q~âÉå= íçÖÉíÜÉêIíÜÉêÉ= áë=~=ÅçãéÉääáåÖ=åÉÉÇ=íç=ÇÉîÉäçé=åçåJáåî~ëáîÉ=ï~óë=íç=Éëí~ÄäáëÜ=~å=É~êäó=Çá~Öåçëáë=çÑk^pe=áå=é~íáÉåíë=ïáíÜ=qOajI=çê=áå=ëÉäÉÅíÉÇ=é~íáÉåíëI=éÉêÑçêã=~=äáîÉê=Äáçéëó=EáKÉK=íÜçëÉ=ïáíÜãçêÉ=êáëâ=Ñ~Åíçêë=Ñçê=k^peI=äáîÉê=~ãáåçíê~åëÑÉê~ëÉë=[íÜêÉÉJÑçäÇ=ìééÉê=äáãáí=çÑ=åçêã~äI=ÅäáåáÅ~äçê=áã~ÖáåÖ=ëìëéáÅáçå=çÑ=~Çî~åÅÉÇ=äáîÉê=ÇáëÉ~ëÉFK=

T2DM, NAFLD and cardiovascular disease (CVD)

tÜÉíÜÉê=íÜÉ=éêÉëÉåÅÉ=çÑ=k^cia=ÅçåÑÉêë=~å=áåÅêÉ~ëÉÇ=êáëâ=çÑ=`sa=ÄÉóçåÇ=íÜÉ=éêÉëÉåÅÉçÑ=íê~Çáíáçå~ä=êáëâ=Ñ~Åíçêë=áë=~å=~êÉ~=Ö~íÜÉêáåÖ=ëìÄëí~åíá~ä=~ííÉåíáçåK=píìÇáÉë=Ü~îÉ=êÉéçêíÉÇ=íÜ~íé~íáÉåíë=ïáíÜ=ÉäÉî~íÉÇ= äáîÉê= ~ãáåçíê~åëÑÉê~ëÉë=Ü~îÉ=~=ãìÅÜ=ÜáÖÜÉê=cê~ãáåÖÜ~ã= êáëâ= ëÅçêÉ~åÇLçê=Å~êÇáçî~ëÅìä~ê=ÉîÉåíë=Åçãé~êÉÇ=íç=íÜçëÉ=ïáíÜ=åçêã~ä=äáîÉê=~ãáåçíê~åëÑÉê~ëÉë QOI=SQJSSKqÜÉ=~ëëçÅá~íáçå=çÑ=k^cia=ïáíÜ=íÜÉ=jÉíp=Ü~ë=äÉÇ=íç=íÜÉ=ÅçååÉÅíáçå=ÄÉíïÉÉå=Ñ~ííó=äáîÉê=~åÇíÜÉ=ÇÉîÉäçéãÉåí=çÑ=`saK=qÜÉ=ëíìÇáÉë= äáåâáåÖ=`sa=ïáíÜ=k^cia=Å~å=ÄÉ=ÇáîáÇÉÇ= áåíç= íÜêÉÉã~àçê=Å~íÉÖçêáÉëW=

� ëã~ää=ëíìÇáÉë=ëìÖÖÉëíáåÖ=`sa=çÅÅìêë=ãçêÉ=Åçããçåäó=áå=íÜÉ=éêÉëÉåÅÉ=çÑ=k^pe=íÜ~å=áåíÜÉ=ÖÉåÉê~ä=éçéìä~íáçå=çê=ëìÄàÉÅíë=ïáíÜçìí=k^cia=TI=NOI=OUI=OVI=QNI=SSI=STX=

Evidence-based Management of Diabetes

8

� ÅêçëëJëÉÅíáçå~ä= ëíìÇáÉë= ïáíÜ= ëìêêçÖ~íÉ= ãÉ~ëìêÉë= çÑ= ~íÜÉêçëÅäÉêçëáë= áå= é~íáÉåíë= ïáíÜk^cia=Åçãé~êÉÇ=íç=ÅçåíêçäëX=~åÇ=

� äçåÖáíìÇáå~ä= ëíìÇáÉë= çÑ= Å~êÇáçî~ëÅìä~ê= ÉîÉåíë= áå= é~íáÉåíë= ïáíÜ= ~åÇ= ïáíÜçìí= k^cia= ~íÄ~ëÉäáåÉ=Eq~ÄäÉ=PFK=

21 Non-alcoholic fatty liver disease (NAFLD) in diabetes: distraction or impending disaster?

9

Table 3. Studies assessing cardiovascular burden in patients with and without NAFLD.

^ìíÜçê=EóÉ~êF=

sáää~åçî~=Éí=~ä EOMMRF=

_êÉ~=Éí=~ä EOMMRF=

sçäòâÉ=Éí=~ä EOMMRF=

q~êÖÜÉê=Éí=~ä EOMMSF=

jÅháããáÉ=Éí=~ä EOMMUF=

cê~Å~åò~åá=Éí=~ä EOMMUF=

mç~åí~=Éí=~ä EOMNNF=

jáêÄ~ÖÜÉêá=Éí=~ä EOMMTF=

q~êÖÜÉê=Éí=~ä EOMMRF=

e~ã~ÖìÅÜá=Éí=~ä EOMMTF=

pÅÜáåÇÜÉäã=Éí=~ä EOMMTF=

dçÉëëäáåÖ=Éí=~ä EOMMUF=

EåF=k^cia=

îëK=Åçåíêçäë

RO=îëK=OU=

QM=îëK=QM=

OVSN=îëK=NOSN=

UR=îëK=NSM=

NVO=îëK=QPN˛

NRM=îëK=ORM=

PU=îëK=NU˛

NRS=îëKNR=

OQU=îëK=QVS˛

OPN=îëK=VVM=

UUU=îëK=RRN=

ORNT=îëK=OVR=

aá~Öåçëáë=çÑ

k^cia=Äó=

iáîÉê=Äáçéëó=

rp=

rp=

iáîÉê=Äáçéëó=

`q=

rpGG=

rp=

rp=

rp=

rp=

^iq=

^pqI=^iq=

mêáã~êó=

ÉåÇéçáåí=

båÇçíÜÉäá~ä

ÑìåÅíáçåG=

`fjq=

`fjq=

`fjq=

`fjq=

`fjq=

`fjq=

`çêçå~êó

~åÖáçÖê~éÜó=

`s=ÉîÉåíë=

`s=ÉîÉåíë=

`s=ÉîÉåíë=

`s=ÉîÉåíë=

fåÅêÉ~ëÉÇ

`sa

vÉë=

vÉë=

vÉë=

vÉë=

kç=

vÉë=

vÉë=

vÉë=

vÉë

vÉë=

vÉë

^ÇàìëíÉÇ

`s=êáëâ=@

vÉë=

vÉë=

kç=

vÉë=

kç=

vÉë=

vÉë=

vÉë=

vÉë

rp=Z=ìäíê~ëçìåÇX=`q=Z=ÅçãéìíÉÇ=íçãçÖê~éÜóX=`fjq=Z=Å~êçíáÇ=~êíÉêó=áåíáã~JãÉÇá~=íÜáÅâåÉëëX=^iq=Z

~ä~åáåÉ=~ãáåçíê~åëÑÉê~ëÉX=^pqZ=~ëé~êí~íÉ=~ãáåçíê~åëÑÉê~ëÉ

@= ~êÇáçî~ëÅìä~ê=E`sF=êáëâ=~ÑíÉê=~ÇàìëíÉÇ=Ñçê=íê~Çáíáçå~ä=êáëâ=Ñ~Åíçêë=E~ÖÉI=ÖÉåÇÉêI=_jfI=qOajI=jÉípI=çíÜÉêF

G=jÉ~ëìêÉÇ=Äó=Äê~ÅÜá~ä=~êíÉêó=ÑäçïJãÉÇá~íÉÇ=î~ëçÇáä~íáçå

˛=^ää=é~íáÉåíë=Ü~Ç=qOaj

GG=RQ=é~íáÉåíë=Ü~Ç=äáîÉê=Äáçéëó

qÜÉ=ã~àçê=ïÉ~âåÉëëÉë=çÑ= íÜÉëÉ=ëíìÇáÉë=~êÉ= íÜÉ=Çá~Öåçëáë=çÑ= Ñ~ííó= äáîÉê=Äó=ìäíê~ëçìåÇI=~ê~íÜÉê=áåëÉåëáíáîÉ=íÉëí=ïáíÜ=ã~åó=Ñ~äëÉ=éçëáíáîÉë=~åÇ=Ñ~äëÉ=åÉÖ~íáîÉëI=~åÇ=íÜÉ=Ñ~Åí=íÜ~í=áå=ãçëíëíìÇáÉë=é~íáÉåíë=ïáíÜ=k^cia=íóéáÅ~ääó=~êÉ=ãçêÉ=çÄÉëÉI=Ü~îÉ=ãçêÉ=çÑíÉå=Çá~ÄÉíÉë=~åÇ=çîÉê~ääÜ~îÉ=~=ïçêëÉ=`s=êáëâ=éêçÑáäÉ=Åçãé~êÉÇ=íç=íÜÉ=ÅçåíêçäëK=qÜÉëÉ=ÇáÑÑÉêÉåÅÉë=ã~ó=çê=ã~ó=åçí=ÄÉ~ÄäÉ=íç=ÄÉ=Ñìääó=~ÅÅçìåíÉÇ=Ñçê=Äó=ãìäíáéäÉ=êÉÖêÉëëáçå=Eçê=çíÜÉêF=ëí~íáëíáÅ~ä=~å~äóëáëK=få=~åó=Å~ëÉI~ë=ÜáÖÜäáÖÜíÉÇ=áå=q~ÄäÉ=PI=ëÉîÉê~ä=ëíìÇáÉë=Ü~îÉ=ÑçìåÇ=íÜ~í=íÜÉ=éçëáíáîÉ=~ëëçÅá~íáçå=ïáíÜ=`saÇáë~ééÉ~êë=~ÑíÉê=~ÇàìëíáåÖ=Ñçê=íê~Çáíáçå~ä=êáëâ=Ñ~ÅíçêëK=

^ë=ãÉåíáçåÉÇ=áå=íÜÉ=ëÉÅíáçå=çå=å~íìê~ä=Üáëíçêó=çÑ=k^ciaI=ëÉêáÉë=Ü~îÉ=ÄÉÉå=ëã~ää=~åÇ=áåÖÉåÉê~ä= ÇáÇ= åçí= áåÅäìÇÉ= éêçéÉê= ÅçåíêçäëK= eçïÉîÉêI= íÜÉ= ~î~áä~ÄäÉ= äáíÉê~íìêÉ= ëìÖÖÉëíë= íÜ~ík^cia=Å~êêáÉë=~=ÜáÖÜÉê=êáëâ=çÑ=`saK=cçê=áåëí~åÅÉI=j~ííÉçåá=Éí=~ä OV ï~ë=~ãçåÖ=íÜÉ=Ñáêëí=íçêÉéçêí=áåÅêÉ~ëÉÇ=`s=ÉîÉåíë=áå=~=Öêçìé=çÑ=NPO=ÄáçéëóJéêçîÉå=k^cia=é~íáÉåíë=ÑçääçïÉÇ=Ñçêìé=íç=NU=óÉ~êëK=`çêçå~êó=~êíÉêó=ÇáëÉ~ëÉ=ï~ë=íÜÉ=ëÉÅçåÇ=Å~ìëÉ=çÑ=ãçêí~äáíó=~ÑíÉê=åÉçéä~ëãI~äíÜçìÖÜ= íÜÉêÉ=ïÉêÉ= ÑÉï=`s=ÉîÉåíëK=líÜÉêë= Ü~îÉ= ~êêáîÉÇ= ~í= ëáãáä~ê= ÑáåÇáåÖë= OUI= QNI= STI= SUK^Ç~ãë=Éí=~ä ST ÑçääçïÉÇ=QOM=é~íáÉåíë=ïáíÜ=k^cia=Ñêçã=läãëíÉÇ=`çìåíóI=jáååÉëçí~I=rp^IÄÉíïÉÉå=NVUM=~åÇ=OMMMK=jÉ~å=ÑçääçïJìé=ï~ë=TKS=óÉ~êë=~åÇ=NOKSB=ÇáÉÇK=pìêîáî~ä=áå=íÜÉk^cia=éçéìä~íáçå=ï~ë=ëáÖåáÑáÅ~åíäó= äçïÉê=Åçãé~êÉÇ= íç= íÜÉ=ÖÉåÉê~ä=éçéìä~íáçå=~åÇ= äáîÉêJêÉä~íÉÇ=ãçêí~äáíó=ï~ë=ÜáÖÜÉê=íÜ~å=áå=íÜÉ=ÖÉåÉê~ä=éçéìä~íáçå=EÜ~ò~êÇ=ê~íáç=çÑ=NKPQX=VRB=`fINKMMPJNKTSX= éZMKMPFI= Äìí= ~Ö~áåI= ÄçíÜ= ã~äáÖå~åÅáÉë= ~åÇ= Åçêçå~êó= ÜÉ~êí= ÇáëÉ~ëÉ= E`eaFïÉêÉ=íÜÉ=äÉ~ÇáåÖ=Å~ìëÉë=çÑ=ÇÉ~íÜK=oÉÅÉåí=êÉéçêíë=~ééÉ~ê=íç=ÅçáåÅáÇÉ=ïáíÜ=íÜÉ=çÄëÉêî~íáçåíÜ~í= k^cia= áåÅêÉ~ëÉë= `sa= ëÉîÉê~äJÑçäÇ= Eê~åÖáåÖ= Ñêçã= úíïçJ= íç= ÉáÖÜíJÑçäÇF= áå= íÜáëéçéìä~íáçå=QNI=SUK

^ë=Å~å=ÄÉ=~ééêÉÅá~íÉÇ=áå=q~ÄäÉ=PI=éêÉîáçìë=ëíìÇáÉë=Ü~îÉ=ëìÖÖÉëíÉÇ=~=ÜáÖÜÉê=éêÉî~äÉåÅÉ=çÑÅçêçå~êóI=ÅÉêÉÄêçî~ëÅìä~ê=~åÇLçê=éÉêáéÜÉê~ä=î~ëÅìä~ê=ÇáëÉ~ëÉ=~ãçåÖ=é~íáÉåíë=ïáíÜ=k^ciaÅçãé~êÉÇ=ïáíÜ=íÜçëÉ=ïáíÜçìí=k^cia=ïÜÉå=Å~êÇáçî~ëÅìä~ê=ÄìêÇÉå=áë=ãÉ~ëìêÉÇ=Äó=ÇáÑÑÉêÉåíãÉíÜçÇë= EáKÉK= ÉåÇçíÜÉäá~ä= ÇóëÑìåÅíáçåI= Å~êçíáÇ= ~êíÉêó= áåíáã~JãÉÇá~= íÜáÅâåÉëë= x`fjqzI~åÖáçÖê~éÜóI=çíÜÉêFK=^=ëíìÇó=Äó=sáää~åçî~=Éí=~ä SV ÇÉãçåëíê~íÉÇ=~å=~ëëçÅá~íáçå=ÄÉíïÉÉå=Ñ~ííóäáîÉê=~åÇ=ÉåÇçíÜÉäá~ä=ÇóëÑìåÅíáçå=ãÉ~ëìêÉÇ=Äó=Äê~ÅÜá~ä=~êíÉêó= ÑäçïJãÉÇá~íÉÇ=î~ëçÇáä~íáçåI=~ã~êâÉê=çÑ=É~êäó=~íÜÉêçëÅäÉêçëáëI= áå=RO=é~íáÉåíë=ïáíÜ=k^cia=EPV=ïáíÜ=ÄáçéëóJéêçîÉå=k^peFÅçãé~êÉÇ= íç= é~íáÉåíë= ïáíÜçìí= k^ciaK= m~íáÉåíë= ïáíÜ= k^pe= ~äëç= Ü~Ç= ~= ÜáÖÜÉê= NMJóÉ~êéêçÄ~Äáäáíó=çÑ=`sa=ÉîÉåíë=Ä~ëÉÇ=çå=íÜÉ=cê~ãáåÖÜ~ã=êáëâ=ëÅçêÉK=líÜÉê=ëíìÇáÉë=Ü~îÉ=~äëç=ìëÉÇ`fjq= ~ë= ~= ã~êâÉê= çÑ= ~íÜÉêçëÅäÉêçíáÅ= ÄìêÇÉå= Eq~ÄäÉ= PFI= êÉéçêíáåÖ= íÜ~í= `fjq= áë= ã~êâÉÇäóáåÅêÉ~ëÉÇ= áå= é~íáÉåíë= ïáíÜ= k^cia= Åçãé~êÉÇ= íç= Åçåíêçä= ëìÄàÉÅíë= TMJTQK= eçïÉîÉêI= íÜÉ~ëëçÅá~íáçå=çÑ=k^cia=ïáíÜ=`sa=ÇáÇ=åçí=ÜçäÇ=áå=ëÉîÉê~ä=ëíìÇáÉë=ïÜÉå=~ÇàìëíÉÇ=Ñçê=íê~Çáíáçå~äêáëâ=Ñ~Åíçêë=çÑ=`sa=TNI=TOI=TRI=TS ~åÇ=êÉä~íáîÉäó=ÑÉï=ëíìÇáÉë=Ü~îÉ=êÉéçêíÉÇ=íÜ~í=íÜÉ=~ëëçÅá~íáçåçÑ= k^cia= ïáíÜ= `sa= éÉêëáëíë= EáKÉK= `fjq= ~åÇ= éä~èìÉ= éêÉî~äÉåÅÉF= áåÇÉéÉåÇÉåíäó= çÑ= íÜÉéêÉëÉåÅÉ= çÑ= ÅçãéçåÉåíë= çÑ= íÜÉ= jÉíp= SVI= TPI= TQI= TTK= cçê= áåëí~åÅÉI= áå= é~íáÉåíë= ïáíÜ= qOajIjÅháããáÉ=Éí=~ä TR ~åÇ=mç~åí~=Éí=~ä TS êÉéçêíÉÇ=íÜ~í=ÜÉé~íáÅ=ëíÉ~íçëáë=ï~ë=åçí=ÅçêêÉä~íÉÇ=ïáíÜ`fjqK=

píìÇáÉë=íÜ~í=Ü~îÉ=Éñ~ãáåÉÇ=íÜÉ=êáëâ=çÑ=`s=ÉîÉåíë=áå=é~íáÉåíë=ïáíÜ=k^cia=Ü~îÉ=êÉéçêíÉÇ=áåÖÉåÉê~ä= ~= ÜáÖÜÉê= êáëâ=çÑ= ~ääJÅ~ìëÉ=ãçêÄáÇáíó= ~åÇ=ãçêí~äáíó= êÉä~íÉÇ= íç=`sa= íÜ~å= íÜÉ=ÖÉåÉê~ä

Evidence-based Management of Diabetes

10

éçéìä~íáçå=Eq~ÄäÉ=PF=QOI=SRI=SVI=TNJTVK=^ë=ÇáëÅìëëÉÇ=É~êäáÉêI=~=åìãÄÉê=çÑ=êÉ~ëçåë=ã~ó=~ÅÅçìåí=ÑçêíÜáë=RMI=UMW=

� é~íáÉåíë=ïáíÜ=k^cia=~êÉ=çÑíÉå=ãçêÉ=áåëìäáåJêÉëáëí~åíX=� ÑêÉèìÉåíäó=Ü~îÉ=ÇóëäáéáÇÉãá~=ïáíÜ=ÉäÉî~íÉÇ=éä~ëã~=íêáÖäóÅÉêáÇÉë=~åÇ=äçï=eaiJ`X=� Ü~îÉ=ïçêëÉ=ëìÄÅäáåáÅ~ä=áåÑä~ãã~íáçåX=~åÇ=� ÄÉ=ÇáêÉÅíäó= ~ÑÑÉÅíÉÇ=Äó=cc^JáåÇìÅÉÇ=ÉåÇçíÜÉäá~ä= ÇóëÑìåÅíáçå=çê=ãóçÅ~êÇá~ä= äáéçíçñáÅáíó

EcáÖìêÉ=OFK=

låÉ=ëíìÇó=êÉéçêíÉÇ=íÜ~í=~ãçåÖ=ONMP=é~íáÉåíë=ïáíÜ=qOajI=RJóÉ~ê=åçåJÑ~í~ä=`eaI=áëÅÜÉãáÅëíêçâÉ=~åÇ=`s=ÇÉ~íÜ=çÅÅìêêÉÇ=ãçêÉ=ÑêÉèìÉåíäó=áå=é~íáÉåíë=ïáíÜ=k^cia=íÜ~å=íÜçëÉ=ïáíÜçìí=~Ñ~ííó=äáîÉê=ãÉ~ëìêÉÇ=Äó=ìäíê~ëçìåÇ=UNK=^ÇàìëíãÉåí=Ñçê=íê~Çáíáçå~ä=`s=êáëâ=Ñ~Åíçêë=~ííÉåì~íÉÇ=ÄìíÇáÇ=åçí=ÅçãéäÉíÉäó=~ÄçäáëÜ=íÜÉ=~ëëçÅá~íáçåK=pÉîÉê~ä=ëíìÇáÉë=ìëÉÇ=éä~ëã~=~ãáåçíê~åëÑÉê~ëÉë

21 Non-alcoholic fatty liver disease (NAFLD) in diabetes: distraction or impending disaster?

11

Figure 2. Dysfunctional adipose tissue leads to excessive free fatty acids (FFA) in theliver. This promotes triglyceride accumulation, hepatocyte lipotoxicity with necrosis,inflammation, and eventually disease progression to fibrosis, cirrhosis or hepatocellularcarcinoma. The metabolic consequences are hyperglycemia, hyperinsulinemia,dyslipidemia and subclinical inflammation, all leading to premature cardiovasculardisease. NAFLD: nonalcoholic fatty liver disease, NASH: nonalcoholic steatohepatitis,HDL-C: high-density lipoprotein cholesterol, sd LDL-C: small dense low-density lipoproteincholesterol.

E^iqF=~ë=~=ëìêêçÖ~íÉ=ã~êâÉê=çÑ=k^cia=QOI=SQJSSK=fç~ååçì=Éí=~ä SQ áå=~=ÅêçëëJëÉÅíáçå~ä=~å~äóëáëÑçìåÇ=~=ëíêçåÖ=ÅçêêÉä~íáçå=ÄÉíïÉÉå=ÉäÉî~íÉÇ=^iq=~åÇ=NMJóÉ~ê=êáëâ=çÑ=`ea=Éëíáã~íÉÇ=Äó=íÜÉcê~ãáåÖÜ~ã= êáëâ= ëÅçêÉ= ïáíÜ= ~= íÜêÉëÜçäÇ= Ñçê= áåÅêÉ~ëÉÇ= `s= êáëâ= ïáíÜ= ~å= ^iq= ÖêÉ~íÉê= íÜ~åQPfrLi=áå=ãÉå=~åÇ=PMfrLi=áå=ïçãÉåK=få=NQPV=é~íáÉåíë=Ñêçã=íÜÉ=eççêå=píìÇó=SRI=íÜÉ=éêÉÇáÅíáîÉî~äìÉ= çÑ= ÉäÉî~íÉÇ= ^iq= Ñçê=`ea= éÉêëáëíÉÇ= áåÇÉéÉåÇÉåí= çÑ= íÜÉ= éêÉëÉåÅÉ= çÑ=jÉíp= çê= çíÜÉêíê~Çáíáçå~ä=êáëâ=Ñ~ÅíçêëK=få=íÜÉ=cê~ãáåÖÜ~ã=lÑÑëéêáåÖ=eÉ~êí=píìÇó=QOI=íÜÉ=ÇÉîÉäçéãÉåí=çÑ=jÉíp~åÇ=Çá~ÄÉíÉë=ï~ë=ÅäçëÉäó=êÉä~íÉÇ=íç=íÜÉ=éêÉëÉåÅÉ=çÑ=ÉäÉî~íÉÇ=^iq=çîÉê=~=ÑçääçïJìé=éÉêáçÇ=çÑOM=óÉ~êëK=eçïÉîÉêI=ïÜáäÉ=`sa=ï~ë=áåÅêÉ~ëÉÇ=áå=~ÖÉLÖÉåÇÉêJ~ÇàìëíÉÇ=ãçÇÉäë=áå=é~íáÉåíë=ïáíÜk^ciaI= íÜáë= ~ëëçÅá~íáçå= ï~ë= åç= äçåÖÉê= ëáÖåáÑáÅ~åí= áå= ãìäíáî~êá~íÉJ~ÇàìëíÉÇ= ãçÇÉäë= íÜ~íáåÅäìÇÉÇ=Åä~ëëáÅ~ä=`s=êáëâ=Ñ~ÅíçêëK=

qÜìëI=~äíÜçìÖÜ=ãÉí~ÄçäáÅ=~åÇ=ÅäáåáÅ~ä=Ñ~Åíçêë=ïçìäÇ=ëìééçêí=íÜÉ=åçíáçå=íÜ~í=k^cia=Å~êêáÉë~å=áåÅêÉ~ëÉÇ=êáëâ=çÑ=`saI=íÜÉ=ÉîáÇÉåÅÉ=áë= áåÅçåÅäìëáîÉK=içåÖJíÉêã=éêçëéÉÅíáîÉ=ëíìÇáÉë=~êÉåÉÉÇÉÇ=íç=Ñìääó=Éëí~ÄäáëÜ=íÜÉ=å~íìêÉ=çÑ=íÜáë=~ëëçÅá~íáçåI=Äìí=áå=íÜÉ=ãÉ~åíáãÉI=ÅçåëáÇÉêáåÖ=íÜÉã~åó=éä~ìëáÄäÉ=é~íÜçÖÉåáÅ= äáåâë=ÄÉíïÉÉå=k^cia=~åÇ=~íÜÉêçÖÉåÉëáë= áå=qOajI=~ï~êÉåÉëë~åÇ=~ÖÖêÉëëáîÉ=íêÉ~íãÉåí=çÑ=`s=êáëâ=Ñ~Åíçêë=~ééÉ~êë=ï~êê~åíÉÇ=EfffL_FK

NAFLD: whom to screen and how to treat?

Diagnosis and screening

k^cia=áë=ãçëí=Åçããçåäó=Çá~ÖåçëÉÇ=Äó=~=ÅçãÄáå~íáçå=çÑ=ÅäáåáÅ~äI=ä~Äçê~íçêó=~åÇ=áã~ÖáåÖëíìÇáÉëK=^=ÖççÇ=ãÉÇáÅ~ä=Üáëíçêó=áë=áãéçêí~åí=íç=êìäÉ=çìí=çíÜÉê=Å~ìëÉë=çÑ=äáîÉê=ëíÉ~íçëáë=~åÇ=áíáë= ÉëëÉåíá~ä= íç= ÉñÅäìÇÉ= ëáÖåáÑáÅ~åí= ~äÅçÜçä= áåí~âÉK= tÜáäÉ= íÜÉ= Éñ~Åí= ÇÉÑáåáíáçå= çÑ= ÉñÅÉëëáîÉ~äÅçÜçä=Åçåëìãéíáçå=áå=é~íáÉåíë=ïáíÜ=k^cia=áë=ìåÅäÉ~êI=~äÅçÜçä=Åçåëìãéíáçå=ëÜçìäÇ=áÇÉ~ääóåçí= ÉñÅÉÉÇ= NR= Öê~ãë= éÉê= Ç~ó= E[NOçò= çÑ= ÄÉÉêI= [Rçò= çÑ= ïáåÉI= çê= [NKR= çÑ= ÇáëíáääÉÇ= ëéáêáíëFK^ÅÅÉéíÉÇ=ÅìíJçÑÑë=~êÉ=ÄÉëí=í~áäçêÉÇ=Äó=ÖÉåÇÉê=ïáíÜ=ëáÖåáÑáÅ~åí=~äÅçÜçä=Åçåëìãéíáçå=ÇÉÑáåÉÇìëì~ääó=~ë=[ON=Çêáåâë=éÉê=ïÉÉâ= áå=ãÉå=~åÇ=[NQ=Çêáåâë=éÉê=ïÉÉâ= áå=ïçãÉå=çîÉê=~=OJóÉ~êéÉêáçÇ= éêáçê= íç= Ä~ëÉäáåÉ= äáîÉê= ÜáëíçäçÖó= UOK= fí= áë= ~äëç= êÉÅçããÉåÇÉÇ= íÜ~í= ~= ëí~åÇ~êÇáòÉÇèìÉëíáçåå~áêÉ=ÄÉ=ìëÉÇ=EáKÉK=^rafq=èìÉëíáçåå~áêÉFK=

oçìíáåÉ=ëÅêÉÉåáåÖ=Ñçê=k^cia=Å~ååçí=ÄÉ=êÉÅçããÉåÇÉÇ=~í=íÜáë=íáãÉ=áå=~ää=çÄÉëÉ=é~íáÉåíëÖáîÉå=çìê=áåÅçãéäÉíÉ=ìåÇÉêëí~åÇáåÖ=~Äçìí=íÜÉ=å~íìê~ä=Üáëíçêó=çÑ=íÜÉ=ÇáëÉ~ëÉI=Ñ~Åíçêë=äÉ~ÇáåÖíç=ÇáëÉ~ëÉ=éêçÖêÉëëáçå= ~åÇ= íêÉ~íãÉåí= ÅÜçáÅÉë=ïáíÜçìí=ÇÉÑáåáíáîÉ= ÉåÇéçáåíëK=^í= íÜÉ=éêÉëÉåííáãÉI= ëÅêÉÉåáåÖ= ëÜçìäÇ= ÑçÅìë= çåäó= çå= íÜçëÉ= ~í= íÜÉ= ÜáÖÜÉëí= êáëâ= çÑ= Ü~îáåÖ= ëíÉ~íçÜÉé~íáíáëEk^peF=ìåíáä=~=ëáãéäÉI=åçåJáåî~ëáîÉ=ëÅêÉÉåáåÖ=íÉëí=ïáíÜ=~ÇÉèì~íÉ=ëÉåëáíáîáíó=~åÇ=ëéÉÅáÑáÅáíó=áë~î~áä~ÄäÉK= qÜÉëÉ= áåÅäìÇÉ= é~íáÉåíë=ïáíÜ= ëóãéíçãë= EáKÉK= êáÖÜí= ìééÉê= èì~Çê~åí= ÇáëÅçãÑçêíF= çê~Äåçêã~ä= äáîÉê=ÄáçÅÜÉãáëíêáÉë= Eáå=é~êíáÅìä~êI= ÉäÉî~íÉÇ=~ãáåçíê~åëÑÉê~ëÉëFK=m~íáÉåíë= áå=ïÜçãäáîÉê=ëíÉ~íçëáë=áë=~å=áåÅáÇÉåí~ä=ÑáåÇáåÖ=ÇÉíÉÅíÉÇ=çå=áã~ÖáåÖI=~êÉ=~ëóãéíçã~íáÅ=~åÇ=Ü~îÉ=åçêã~äéä~ëã~=~ãáåçíê~åëÑÉê~ëÉ= äÉîÉäëI=~= äáîÉê=Äáçéëó=~í= íÜÉ=ÅìêêÉåí= íáãÉ= áë=åçí= êÉÅçããÉåÇÉÇ= UOKeçïÉîÉêI= ~ë= çìíäáåÉÇ= É~êäáÉêI= éä~ëã~= ~ãáåçíê~åëÑÉê~ëÉ= äÉîÉäë= Ü~îÉ= ~= éççê= ëÉåëáíáîáíó= ~ë= ~ëÅêÉÉåáåÖ=íÉëí=~åÇ=~êÉ=çÑíÉå=ïáíÜáå=åçêã~ä=äáãáíë=áå=k^ciaLk^peK=tÜáäÉ=~=äáîÉê=ìäíê~ëçìåÇã~ó=~ëëáëí= áå= íÜÉ=Çá~ÖåçëáëI= áí= Å~ååçí=ÄÉ= êçìíáåÉäó= êÉÅçããÉåÇÉÇI=ÖáîÉå= áíë=Åçëí=~åÇ= ä~êÖÉåìãÄÉê=çÑ=é~íáÉåíë=ïáíÜ=jÉíp=çê=qOaj=~åÇ=k^ciaK=få=~ÇÇáíáçåI=áíë=ëÉåëáíáîáíó=áë=éççê=~í=äçïíç=ãçÇÉê~íÉ=ÇÉÖêÉÉë=çÑ=ëíÉ~íçëáë=~åÇ=áí=ÇÉÅêÉ~ëÉë=ÑìêíÜÉê=ïáíÜ=áåÅêÉ~ëáåÖ=ÅÉåíê~ä=~ÇáéçëáíóK

Evidence-based Management of Diabetes

12

^í=éêÉëÉåíI=ã~ÖåÉíáÅ=êÉëçå~åÅÉ=áã~ÖáåÖ=~åÇ=ëéÉÅíêçëÅçéó=EjopF=êÉã~áåë=íÜÉ=ÖçäÇ=ëí~åÇ~êÇÑçê=ãÉ~ëìêáåÖ=äáîÉê=íêáÖäóÅÉêáÇÉ=ÅçåíÉåí=Äìí=áë=~î~áä~ÄäÉ=çåäó=áå=~Å~ÇÉãáÅ=ÅÉåíÉêë=~ë=áí=êÉèìáêÉëëéÉÅá~äáòÉÇ= ëçÑíï~êÉ= ~åÇ= áåíÉêéêÉí~íáçå= áë= ä~Äçê= áåíÉåëáîÉK= eçïÉîÉêI= ïÜáäÉ= áí= Ü~ë= ~= ÅäçëÉÅçêêÉä~íáçå=ïáíÜ=äáîÉê=Ñ~í=ÅçåíÉåí=Éëíáã~íÉÇ=Ñêçã=äáîÉê=ÄáçéëáÉë=E`ìëá=Éí=~äI=ìåéìÄäáëÜÉÇF=áí=Ü~ë~=äçï=ëÉåëáíáîáíó=Ñçê=åÉÅêçáåÑä~ãã~íáçå=~åÇ=ÑáÄêçëáëK

råÑçêíìå~íÉäóI=åç=áã~ÖáåÖ=íÉÅÜåáèìÉ=Å~å=êÉéä~ÅÉ=~=äáîÉê=Äáçéëó=áå=ÅçåÑáêãáåÖ=íÜÉ=Çá~ÖåçëáëçÑ=k^peK=^= äáîÉê=Äáçéëó=ã~ó=ÄÉ=~=êÉ~ëçå~ÄäÉ=~ééêç~ÅÜ=íç=Çá~ÖåçëÉ=k^pe=~åÇ=ëí~ÖÉ=íÜÉÇáëÉ~ëÉ= EáKÉK= ëÉîÉêáíó= çÑ= ÑáÄêçëáëF= áå= áåÇáîáÇì~äë= ïÜç= ~êÉ= ~í= íÜÉ= ÜáÖÜÉëí= êáëâ= çÑ= ÇáëÉ~ëÉéêçÖêÉëëáçå=ëìÅÜ=~ë= áå=çÄÉëáíóI=jÉíp=~åÇLçê=qOajI=é~íáÉåíë=ïáíÜ=ëóãéíçãë=~åÇLçê= áå= íÜÉéêÉëÉåÅÉ= çÑ= ÉäÉî~íÉÇ= äáîÉê= ÉåòóãÉëI= ~åÇ= áÑ= íÜÉ= áåÑçêã~íáçå= çÄí~áåÉÇ= ïáää= éêçãéí= ~= ãçêÉ~ÖÖêÉëëáîÉ=íêÉ~íãÉåí=~ééêç~ÅÜK=qÜÉêÉ=~êÉ=íÜêÉÉ=ÖÉåÉê~ä=áåÇáÅ~íáçåë=Ñçê=äáîÉê=ÄáçéëóW=

� íç=ÅçåÑáêã=íÜÉ=Çá~Öåçëáë=~åÇ=Éëí~ÄäáëÜ=íÜÉ=éêÉëÉåÅÉ=çÑ=k^peX=� íç=ÇÉíÉêãáåÉ=íÜÉ=éêçÖåçëáë=Ä~ëÉÇ=çå=íÜÉ=ëÉîÉêáíó=çÑ=äáîÉê=ÑáÄêçëáëX=~åÇLçê=� áåÅäìëáçå=áåíç=~=ÅäáåáÅ~ä=íêá~ä=áå=~å=~Å~ÇÉãáÅ=ÅÉåíÉêK=

^=äáîÉê=Äáçéëó=ëÜçìäÇ=ÄÉ=ÅçåëáÇÉêÉÇ=çåäó=~ÑíÉê=~å=áåJÇÉéíÜ=ÇáëÅìëëáçå=ïáíÜ=íÜÉ=é~íáÉåí=~ÄçìííÜÉ=ÄÉåÉÑáíë=~åÇ=êáëâë=çÑ=íÜÉ=éêçÅÉÇìêÉK=få=ÅäáåáÅ~ä=éê~ÅíáÅÉ=áí=áë=ÇçåÉ=ìåÅçããçåäó=ÖáîÉå=íÜÉÜáÖÜ=éêÉî~äÉåÅÉ=çÑ=k^cia=~åÇ=íÜÉ=ä~Åâ=çÑ=ëéÉÅáÑáÅ=äçåÖJíÉêã=éÜ~êã~ÅçäçÖáÅ~ä=íÜÉê~éáÉëK=qÜáëï~íÅÜÑìä=ï~áíáåÖ=~ééêç~ÅÜ=ã~ó=ëççå=ÅÜ~åÖÉ=~ë=åÉï=ÉÑÑÉÅíáîÉ=íêÉ~íãÉåíë=ÉãÉêÖÉK=

cáå~ääóI= íÜÉêÉ= áë=~å=~ÅíáîÉ=ëÉ~êÅÜ=Ñçê=ëáãéäÉI=êÉäá~ÄäÉ=~åÇ=áåÉñéÉåëáîÉ=ï~óë=íç=ëÅêÉÉå=íÜÉä~êÖÉ=åìãÄÉê=çÑ=çÄÉëÉ=~åÇ=Çá~ÄÉíáÅ=é~íáÉåíë=íÜ~í=~êÉ=ÅìêêÉåíäó=ÄÉáåÖ=ãáëëÉÇ=ïáíÜ=k^cia=çêk^peK=bÑÑçêíë=áåÅäìÇÉ=íÜÉ=ìëÉ=çÑ=éä~ëã~=Äáçã~êâÉêë=~åÇ=åçîÉä=áã~ÖáåÖ=íÉÅÜåáèìÉë=ëìÅÜ=~ëíê~åëáÉåí=Éä~ëíçÖê~éÜó=UMI=UOK=tÜáäÉ=íÜÉëÉ=~ééêç~ÅÜÉë=~êÉ=éêçãáëáåÖ=íÜÉó=~ï~áí=ãçêÉ=ÇÉÑáåáíáîÉî~äáÇ~íáçå=ÄÉÑçêÉ=ÄÉáåÖ=êÉÅçããÉåÇÉÇ=áå=íÜÉ=êçìíáåÉ=ëÅêÉÉåáåÖ=çÑ=k^ciaK

Treatment

Lifestyle interventionfí= áë= ïÉää= âåçïå= íÜ~í= äáÑÉëíóäÉ= áåíÉêîÉåíáçåë= íÜ~í= êÉëìäí= áå= ïÉáÖÜí= äçëëI= ëìÅÜ= ~ë= ÇáÉí= ~åÇ

ÉñÉêÅáëÉI=ÇÉÅêÉ~ëÉ=`sa=~åÇ=ÇÉä~ó=íÜÉ=ÇÉîÉäçéãÉåí=çÑ=qOaj=UPK=eçïÉîÉêI=íÜÉ=ãçëí=ÉÑÑÉÅíáîÉäáÑÉëíóäÉ= áåíÉêîÉåíáçå= áå=k^cia=êÉã~áåë=ìåÅäÉ~ê=ÄÉÅ~ìëÉ=íÜÉêÉ=~êÉ=åç=ä~êÖÉI= äçåÖJíÉêã=íêá~äëKtÉáÖÜí=äçëë=ÅäÉ~êäó=áãéêçîÉë=ÜÉé~íáÅ=ëíÉ~íçëáëK=lêäáëí~í=Å~å=Ñ~Åáäáí~íÉ=ïÉáÖÜí=äçëë=Äìí=ÇçÉë=åçíÜ~îÉ= ~å= áåíêáåëáÅ= ÉÑÑÉÅí= çå= äáîÉê= ÜáëíçäçÖó= áå=k^pe= UQI= URK= ^=≥TB=ïÉáÖÜí= äçëë=ïáíÜ= äáÑÉëíóäÉáåíÉêîÉåíáçå=EOMM=ãáåìíÉë=~=ïÉÉâ=çÑ=ãçÇÉê~íÉ=éÜóëáÅ~ä=~ÅíáîáíóF=Å~å=ëáÖåáÑáÅ~åíäó=áãéêçîÉ=äáîÉêëíÉ~íçëáëI=äçÄìä~ê=áåÑä~ãã~íáçå=~åÇ=Ä~ääççåáåÖI=Äìí=åçí=ÑáÄêçëáë=áå=çÄÉëÉ=é~íáÉåíë=ïáíÜ=ÄáçéëóJéêçîÉå=k^pe=USK=oÉÇìÅíáçå=áå=ëíÉ~íçëáë=ê~åÖáåÖ=ÄÉíïÉÉå=OMB=íç=UNB=EãÉ~ëìêÉÇ=Äó=íÜÉ=ÖçäÇJëí~åÇ~êÇ=jop=íÉÅÜåáèìÉF=Ü~ë=ÄÉÉå=êÉéçêíÉÇ= áå=ãìäíáéäÉ=ëíìÇáÉë=ÉáíÜÉê=Äó=ÇáÉí=~äçåÉ= UTJVM çêÅçãÄáåÉÇ=ïáíÜ=ÉñÉêÅáëÉ=UUI=VNJVQI=ÄÉáåÖ=éêçéçêíáçå~ä=íç=íÜÉ=áåíÉåëáíó=çÑ=íÜÉ=äáÑÉëíóäÉ=áåíÉêîÉåíáçåKeçïÉîÉêI=ÄÉÅ~ìëÉ=~=äáîÉê=Äáçéëó=ï~ë=åçí=ÇçåÉ=áå=íÜÉëÉ=ëíìÇáÉëI=íÜÉáê=áãé~Åí=çå=çíÜÉê=~ëéÉÅíëçÑ= äáîÉê= ÜáëíçäçÖó= êÉã~áå= íç=ÄÉ=Éëí~ÄäáëÜÉÇK= qÜÉ=çåäó= ëíìÇó= ìëáåÖ=ÄçíÜ= äáîÉê=jop=~åÇ= äáîÉêÄáçéëáÉë=áå=é~íáÉåíë=ïáíÜ=k^pe=êÉéçêíÉÇ=íÜ~í=ÇáÉí=éäìë=éáçÖäáí~òçåÉ=äÉÇ=íç=~=ROB=êÉÇìÅíáçå=áåäáîÉê=ëíÉ~íçëáë= íÜ~í=ÅçêêÉä~íÉÇ=ïáíÜ=~=RMB=ãÉ~å=ÇÉÅêÉ~ëÉ= áå=ëíÉ~íçëáëI=Ä~ääççåáåÖJåÉÅêçëáë

21 Non-alcoholic fatty liver disease (NAFLD) in diabetes: distraction or impending disaster?

13

~åÇ= áåÑä~ãã~íáçå= çå= äáîÉê= ÜáëíçäçÖó= VRK= oçìñJÉåJv= Ö~ëíêáÅ= Äóé~ëë= Eovd_F= çê= ä~é~êçëÅçéáÅ~Çàìëí~ÄäÉ= Ö~ëíêáÅ= Ä~åÇáåÖ= Ei^d_F= áãéêçîÉ= ãÉí~ÄçäáÅ= ~åÇ= ÜáëíçäçÖáÅ~ä= ~Äåçêã~äáíáÉë= áåk^peK=eçïÉîÉêI=ÅÜ~åÖÉë=áå=äáîÉê=ÑáÄêçëáë=Ü~îÉ=ÄÉÉå=ãìÅÜ=äÉëë=éêÉÇáÅí~ÄäÉ=~åÇ=ëçãÉ=ëíìÇáÉëêÉéçêí= íÜ~í= áí=ã~ó=ÉîÉå=ïçêëÉå= ÑçääçïáåÖ=Ä~êá~íêáÅ=ëìêÖÉêó= VSI=VTK=^î~áä~ÄäÉ=Ä~êá~íêáÅ=ëìêÖÉêóëíìÇáÉë=Ü~îÉ=ÄÉÉå=êÉíêçëéÉÅíáîÉ=~åÇ=éççêäó=ëí~åÇ~êÇáòÉÇ=áå=íÉêãë=çÑ=éêÉJ=~åÇ=éçëíJëìêÖáÅ~äÇáÉí~êó= éêçÅÉÇìêÉë= ~åÇ= ä~Åâ= çÑ= áåJÇÉéíÜ=ãÉí~ÄçäáÅ= íÉëíáåÖK= qÜÉêÉ= áë= ~å= ìêÖÉåí= åÉÉÇ= Ñçê= ~ÅçåíêçääÉÇI= äçåÖJíÉêã= Ä~êá~íêáÅ= ëìêÖÉêó= ëíìÇó= íç= íÉëí= íÜÉ= ÄÉëí= ~ééêç~ÅÜ= Ñçê= é~íáÉåíë= ïáíÜk^ciaK=

Pharmacological intervention^í=íÜÉ=éêÉëÉåí= íáãÉ=çåäó=îáí~ãáå=b=~åÇ=éáçÖäáí~òçåÉ=Ü~îÉ=éêçîÉå=ÉÑÑÉÅíáîÉ=~åÇ=ë~ÑÉ=Ñçê= íÜÉ

íêÉ~íãÉåí=çÑ=k^pe=áå=ëÜçêíJíÉêã=ëíìÇáÉë=ESJOQ=ãçåíÜëFK=eçï=îáí~ãáå=b=ÄÉåÉÑáíë=äáîÉê=ÜáëíçäçÖóáå=é~íáÉåíë=ïáíÜ=k^pe=áë=ìåâåçïå=Äìí=áí=~ééÉ~êë=íç=~ãÉäáçê~íÉ=çñáÇ~íáîÉ=ëíêÉëë=VUJNMMK=eçïÉîÉêIáíë=ÉÑÑáÅ~Åó=ï~ë=ÅçåÅäìëáîÉäó=ÇÉãçåëíê~íÉÇ=çåäó=áå=åçåJÇá~ÄÉíáÅ=ëìÄàÉÅíë=ïáíÜ=k^pe=OTK

máçÖäáí~òçåÉI=~å=~Öçåáëí=çÑ=mm^oγ ãçëí=~ÄìåÇ~åí= áå=~ÇáéçÅóíÉë=NMNI=NMOI= áãéêçîÉë=~ÇáéçëÉíáëëìÉLÜÉé~íáÅ=áåëìäáå=~Åíáçå=~åÇ=áãéêçîÉë=äáîÉê=ÜáëíçäçÖó=áå=é~íáÉåíë=ïáíÜ=k^pe=OI=NMPK=få=é~íáÉåíëïáíÜ= éêÉÇá~ÄÉíÉë= çê= qOaj= ~åÇ= k^peI= äáîÉê= ëíÉ~íçëáë= ÇÉÅêÉ~ëÉë= Äó= úRMB= ~åÇåÉÅêçáåÑä~ãã~íáçå=áãéêçîÉë=áå=URB=çÑ=ëìÄàÉÅíë=NMQK=qÜÉëÉ=êÉëìäíë=ïÉêÉ=ä~íÉê=ÅçåÑáêãÉÇ=áå=íïçê~åÇçãáòÉÇ=ÅçåíêçääÉÇ=íêá~äë=áå=é~íáÉåíë=ïáíÜ=k^pe=ïáíÜçìí=Çá~ÄÉíÉë=OTI=NMRI=~äíÜçìÖÜ=íÜÉ=êÉëìäíëïÉêÉ=äÉëë=áãéêÉëëáîÉ=éÉêÜ~éë=ÇìÉ=íç=íÜÉ=äçïÉê=ÇçëÉë=ìëÉÇ=EPMãÖ=éÉê=Ç~ó=îÉêëìë=QRãÖ=éÉêÇ~ó=Äó=_ÉäÑçêí=Éí=~ä NMQFK=qÜÉ=mfsbkp=ëíìÇó=OT ê~åÇçãáòÉÇ=OQT=é~íáÉåíë=íç=îáí~ãáå=b=EUMMfr=éÉêÇ~óFI=éáçÖäáí~òçåÉ=PMãÖLÇ~óI=çê=éä~ÅÉÄçK=qÜÉ=éêáã~êó=ÉåÇéçáåí=EÜáëíçäçÖáÅ~ä=áãéêçîÉãÉåí=áå=≥OÖê~ÇÉë= áå= íÜÉ= k^cia= ^Åíáîáíó= pÅçêÉ= ïáíÜ= ~í= äÉ~ëí= ~= NJéçáåí= áãéêçîÉãÉåí= áå= ÜÉé~íçÅÉääìä~êÄ~ääççåáåÖ=~åÇ=NJéçáåí=áå=ÉáíÜÉê=íÜÉ=äçÄìä~ê=áåÑä~ãã~íáçå=çê=ëíÉ~íçëáë=ëÅçêÉI=~åÇ=åç=áåÅêÉ~ëÉ=áåíÜÉ= ÑáÄêçëáë=ëÅçêÉF=ï~ë= êÉ~ÅÜÉÇ=Äó=QPBI=PQB=~åÇ=NUB=çÑ=é~íáÉåíë= íêÉ~íÉÇ=ïáíÜ=îáí~ãáå=bIéáçÖäáí~òçåÉ=çê=éä~ÅÉÄçI=êÉëéÉÅíáîÉäó=EëáÖåáÑáÅ~åí=~í=~=éZMKMQ=îÉêëìë=éä~ÅÉÄç=çåäó=Ñçê=îáí~ãáå=bFKeçïÉîÉêI=íïç=Ñ~Åíçêë=~ÑÑÉÅíÉÇ=íÜÉ=çìíÅçãÉ=çÑ=éáçÖäáí~òçåÉ=áå=íÜÉ=ëí~íáëíáÅ~ä=~å~äóëáëW=

� é~íáÉåíë=íÜ~í=ÇáÇ=åçí=Ü~îÉ=Ä~ääççåáåÖ=~í=Ä~ëÉäáåÉI=~=ÅçãéçåÉåí=çÑ=íÜÉ=éêáã~êó=ÜáëíçäçÖáÅ~äçìíÅçãÉI= ïÉêÉ= ÅçåëáÇÉêÉÇ= ~ë= åçåJêÉëéçåÇÉêë= ~åÇ= ãçêÉ= éÉçéäÉ= áå= íÜÉ= éáçÖäáí~òçåÉîÉêëìë=îáí~ãáå=b=~êã=ä~ÅâÉÇ=Ä~ääççåáåÖ=~í=ëíìÇó=Éåíêó=EOUB=îëK=NUBFX=~åÇ=

� é~íáÉåíë=íÜ~í=ÇáÇ=åçí=Ü~îÉ=íÜÉ=ëÉÅçåÇ=Äáçéëó=ïÉêÉ=~äëç=ÅçåëáÇÉêÉÇ=~ë=åçåJêÉëéçåÇÉêëK=

^Ö~áåI=ãçêÉ= é~íáÉåíë= áå= íÜÉ= éáçÖäáí~òçåÉ= ~êã= ÇáÇ= åçí= Ü~îÉ= ~= ëÉÅçåÇ= äáîÉê= Äáçéëó= ENPBîÉêëìë=RB=çå=îáí~ãáå=bFK=_çíÜ=íÜÉê~éáÉë=ïÉêÉ=Éèì~ääó=ÉÑÑÉÅíáîÉ=áå=ëìÄàÉÅíë=ïáíÜ=Ä~ääççåáåÖ=~íÄ~ëÉäáåÉI=íÜÉ=Ü~ääã~êâ=çÑ=k^pe=EéáçÖäáí~òçåÉW=ROBI=îáí~ãáå=bW=QTB=~åÇ=éä~ÅÉÄçW=OPBI=ÄçíÜëáÖåáÑáÅ~åíäó= ÄÉííÉê= îëK= éä~ÅÉÄçFK= _çíÜ= ~ÖÉåíë= ÇÉÅêÉ~ëÉÇ= ÜÉé~íáÅ= ëíÉ~íçëáë= EéZMKMMR= Ñçêîáí~ãáå=b=~åÇ=éYMKMMN=Ñçê=éáçÖäáí~òçåÉF=~åÇ=äçÄìä~ê=áåÑä~ãã~íáçå=EéZMKMO=Ñçê=îáí~ãáå=b=~åÇéZMKMMQ= Ñçê=éáçÖäáí~òçåÉFI=Äìí=ÇáÇ=åçí= ~äíÉê= äáîÉê= ÑáÄêçëáëK=oÉëçäìíáçå=çÑ=k^pe=çÅÅìêêÉÇ= áåPSB= çÑ= é~íáÉåíë= çå= îáí~ãáå= b= EéZMKMR= îëK= éä~ÅÉÄçFI= QTB= çå= éáçÖäáí~òçåÉ= EéZMKMMN= îëKéä~ÅÉÄçF=~åÇ=ONB=çå=éä~ÅÉÄçK=cáå~ääóI=áí=ãìëí=ÄÉ=âÉéí=áå=ãáåÇ=íÜ~í=íÜÉêÉ=áë=ëíáää=ÅçåÅÉêå=~ÄçìííÜÉ= äçåÖJíÉêã=ë~ÑÉíó= çÑ= éáçÖäáí~òçåÉ= êÉÖ~êÇáåÖ=ÜÉ~êí= Ñ~áäìêÉI= ÄçåÉ= äçëë= ~åÇ=Ää~ÇÇÉê= Å~åÅÉêEbìêçéÉ~å=jÉÇáÅáåÉë=^ÖÉåÅóI= gìåÉ=NRI=OMNNI= ÜííéWLLïïïKÉã~KÉìêçé~KÉìLÉã~F= NMSK=^í= íÜÉéêÉëÉåí= ãçãÉåíI= íÜÉ= ca^= êÉÅçããÉåÇë= ~îçáÇ~åÅÉ= çÑ= éáçÖäáí~òçåÉ= áÑ= ~= é~íáÉåí= Ü~ë= ~ÅíáîÉ

Evidence-based Management of Diabetes

14

Ää~ÇÇÉê=Å~åÅÉêI=~åÇ=Å~ìíáçå=áÑ=~=é~íáÉåí=Ü~ë=~=éêáçê=Üáëíçêó=çÑ=íÜÉ=ÇáëÉ~ëÉ=ìåíáä=ãçêÉ=ÇÉÑáåáíáîÉÇ~í~=ÄÉÅçãÉë= ~î~áä~ÄäÉK=eçïÉîÉêI= Å~êÇáçî~ëÅìä~ê= ÇáëÉ~ëÉ=Ü~ë=ÄÉÉå= êÉéçêíÉÇ= íç=ÇÉÅêÉ~ëÉïáíÜ=éáçÖäáí~òçåÉ=áå=é~íáÉåíë=ïáíÜ=qOaj=UMK=

líÜÉê= éÜ~êã~ÅçäçÖáÅ~ä= ~ÖÉåíë= ìëÉÇ= íç= íêÉ~í= qOaj= Ü~îÉ= ÄÉÉå= íêáÉÇ= áå= k^pe= ëìÅÜ= ~ëãÉíÑçêãáå= NMTI= NMU ~åÇ= áåÅêÉíáåJãáãÉíáÅë= ëìÅÜ= ~ë= ÉñÉå~íáÇÉ= NMVI= NNM çê= äáê~ÖäìíáÇÉ= NNNK= pÉîÉê~äìåÅçåíêçääÉÇ=íêá~äë=ïáíÜ=ãÉíÑçêãáå=RQI=NMPI=NNOJNNS=áå=é~íáÉåíë=ïáíÜ=k^cia=Ü~îÉ=ëÜçïå=~=êÉÇìÅíáçåáå=éä~ëã~=~ãáåçíê~åëÑÉê~ëÉë=Äìí=íÜÉ=ÄáÖì~åáÇÉ=ÇçÉë=åçí=áãéêçîÉ=äáîÉê=ÜáëíçäçÖó=NMPI=NNPI=NNRI=NNTKqÜÉ=áåÅêÉíáåJãáãÉíáÅë=ÉñÉå~íáÇÉ=~åÇ=äáê~ÖäìíáÇÉ=Ü~îÉ=ÖÉåÉê~íÉÇ=ëáÖåáÑáÅ~åí=áåíÉêÉëí=ÄÉÅ~ìëÉíÜÉó= áåÇìÅÉ= ïÉáÖÜí= äçëë= ~åÇ= ÉñÉåÇáåJQ= ~ãÉäáçê~íÉë= ÜÉé~íáÅ= áåëìäáå= êÉëáëí~åÅÉ= ~åÇíêáÖäóÅÉêáÇÉ= ~ÅÅìãìä~íáçå= áå= îáîç NNUK= jçêÉçîÉêI= dimJN= êÉÅÉéíçêë= ~êÉ= éêÉëÉåí= áå= Üìã~åÜÉé~íçÅóíÉë= NNVI= NOMK= bñÉå~íáÇÉ= Ü~ë= ÄÉÉå= êÉéçêíÉÇ= íç= áãéêçîÉ= ÜÉé~íáÅ= mm^oγLmm^oαÉñéêÉëëáçåI=^âí=~åÇ=^jmh=éÜçëéÜçêóä~íáçå= áå=ÜÉé~íçÅóíÉë=Ñêçã=é~íáÉåíë=ïáíÜ=k^pe=NNVKtÜáäÉ= ÄçíÜ= ~ÖÉåíë= ÉñÉå~íáÇÉ= NMVI= NNM ~åÇ= äáê~ÖäìíáÇÉ= NNN ~ééÉ~ê= éêçãáëáåÖI= ê~åÇçãáòÉÇIÅçåíêçääÉÇ=ëíìÇáÉë=ìëáåÖ=äáîÉê=ÜáëíçäçÖó=~ë=íÜÉ=ã~áå=ÉåÇéçáåí=~êÉ=åÉÉÇÉÇ=ÄÉÑçêÉ=íÜÉáê=ìëÉ=Å~åÄÉ=êÉÅçããÉåÇÉÇ=Ñçê=íÜÉ=íêÉ~íãÉåí=çÑ=k^peK=

Conclusions

NAFLD in T2DM: distraction or impending disaster?

cçê= ÇÉÅ~ÇÉëI= ~ííÉåíáçå= çÑ= íÜÉ= é~íáÉåí= ïáíÜ= qOaj= Ü~ë= ÑçÅìëÉÇ= çå= íÜÉ= Åçåíêçä= çÑÜóéÉêÖäóÅÉãá~=~åÇ=çÑ=êáëâ=Ñ~Åíçêë=~ëëçÅá~íÉÇ=ïáíÜ=ã~Åêçî~ëÅìä~ê=ÇáëÉ~ëÉK=qÜÉ=ÉéáÇÉãáÅ=çÑçÄÉëáíó=åçï=Ñ~ÅÉë=ÉåÇçÅêáåçäçÖáëíë=ïáíÜ=åÉï=ÅÜ~ääÉåÖÉëK=^ãçåÖ=íÜÉã=áë=íÜÉ=åÉÉÇ=íç=áÇÉåíáÑóÉ~êäó= ÅçãéäáÅ~íáçåë= êÉä~íÉÇ= íç= çÄÉëáíó= áå= íÜÉ= ëÉííáåÖ= çÑ= qOajK= få= íÜáë= ëÉåëÉI= k^cia= áë= ~Åçããçå=ÅçãéäáÅ~íáçå=çÑ=é~íáÉåíë=ïáíÜ=qOaj=íÜ~í=êÉèìáêÉë=ëéÉÅá~ä=~ííÉåíáçåK=eçïÉîÉêI=áí=ÇçÉëåçí=Ñáí=~ë=ëìÅÜ=áåíç=íÜÉ=íê~Çáíáçå~ä=êÉ~äã=çÑ=Çá~ÄÉíáÅ=ÅçãéäáÅ~íáçåë=EáKÉK=ãáÅêçJ=çê=ã~Åêçî~ëÅìä~êÇáëÉ~ëÉF= Äìí= ê~íÜÉê= áåíç= ~= åÉï= ÖÉåêÉ= çÑ= äáéçíçñáÅáíóJêÉä~íÉÇ= ÅçãéäáÅ~íáçåë= áå= Çá~ÄÉíÉëK`äáåáÅá~åë=áå=ÖÉåÉê~ä=~êÉ=ìåÅçãÑçêí~ÄäÉ=ïáíÜ=~=ÅçåÇáíáçå=íÜ~í=Å~ååçí=ÄÉ=Çá~ÖåçëÉÇ=çê=ÑçääçïÉÇïáíÜ=~=ÄäççÇ=íÉëíI=~åÇ=íÜ~í=íÜÉ=å~íìê~ä=Üáëíçêó=çÑ=íÜÉ=ÇáëÉ~ëÉ=áë=éççêäó=ìåÇÉêëíççÇK=eçïÉîÉêIíÜÉ=åÉÉÇ=Ñçê=ëéÉÅá~ä=~ííÉåíáçå=~Äçìí=k^cia=áå=qOaj=áë=Ä~ëÉÇ=çå=ëçãÉ=âÉó=ÑáåÇáåÖëW=

� êÉ~äáò~íáçå=íÜ~í=íÜÉ=ã~àçêáíó=çÑ=é~íáÉåíë=ïáíÜ=qOaj=E[TMBF=Ü~îÉ=~=Ñ~ííó=äáîÉê=~åÇ=~=ä~êÖÉéêçéçêíáçå=çÑ=íÜÉëÉ=Ü~îÉ=k^pe=E≥RMB\FX=

� ëÉîÉêÉ=ëíÉ~íçÜÉé~íáíáë=~åÇ=ÇáëÉ~ëÉ=éêçÖêÉëëáçå=çÅÅìêë=ãçêÉ=çÑíÉå=áå=qOajX=� ã~åó=ãÉÅÜ~åáëãë=~í=éä~ó=áå=k^cia=ëìÖÖÉëí=íÜ~í= áåÅêÉ~ëÉÇ=`sa=áë=~=êÉ~ä=éçëëáÄáäáíóI

~ÄçîÉ=~åÇ=ÄÉóçåÇ=íê~Çáíáçå~ä=êáëâ=Ñ~Åíçêë=áå=é~íáÉåíë=ïáíÜ=qOajX=� éáçÖäáí~òçåÉ=êÉã~áåë=~ë=íÜÉ=ãçëí=ÉÑÑÉÅíáîÉ=íêÉ~íãÉåí=Ñçê=k^pe=áå=é~íáÉåíë=ïáíÜ=qOaj=NMQK=

tÜáäÉ=äáÑÉëíóäÉ=áåíÉêîÉåíáçå=êÉã~áåë=íÜÉ=ÅçêåÉêëíçåÉ=çÑ=íêÉ~íãÉåí=Ñçê=k^cia=~åÇ=íÜÉ=äçåÖJíÉêã= ë~ÑÉíó= çÑ= qwaë= áë= ìåÇÉê= ÅäçëÉ= ëÅêìíáåóI= éáçÖäáí~òçåÉ= ïáää= ëççå= ÄÉ= ÖÉåÉêáÅ= áå= ã~åóÅçìåíêáÉëK=^=Çá~Öåçëáë=çÑ=k^pe=áå=~=é~íáÉåí=ïáíÜ=qOaj=ã~ó=ÉåÅçìê~ÖÉ=áíë=ìëÉ=~í=~å=É~êäáÉêëí~ÖÉ= ïáíÜáå= íÜÉ= Çá~ÄÉíÉë= íêÉ~íãÉåí= ~äÖçêáíÜã= íç= êÉîÉêëÉ= íÜÉ= ãÉí~ÄçäáÅ= ~åÇ= äáîÉêJëéÉÅáÑáÅ~Äåçêã~äáíáÉë=çÑ=íÜÉ=ÇáëÉ~ëÉK=

21 Non-alcoholic fatty liver disease (NAFLD) in diabetes: distraction or impending disaster?

15

få= ëìãã~êóI= ~äíÜçìÖÜ= çìê= ÅìêêÉåí= âåçïäÉÇÖÉ= ~Äçìí= k^cia= áë= áåÅçãéäÉíÉ= ~åÇ= ã~åó~ëéÉÅíë=êÉã~áå=ÅçåíêçîÉêëá~äI= áí= áë= äáâÉäó=íÜ~í=íÜáë=ÅçåÇáíáçå=Å~êêáÉë=~å=áåÜÉêÉåí=ÜÉ~äíÜ=êáëâ=íçã~åó=é~íáÉåíë=ïáíÜ=qOajK=låäó=çìê=~ï~êÉåÉëë=~åÇ=~=éêç~ÅíáîÉ=~ééêç~ÅÜ=áå=íÜÉ=Çá~Öåçëáë=~åÇíêÉ~íãÉåí=çÑ=k^cia=áå=qOaj=ã~ó=~îÉêí=~å=áãéÉåÇáåÖ=Çáë~ëíÉê=äççãáåÖ=çå=íÜÉ=ÜçêáòçåK=

Acknowledgement

qÜáë=ïçêâ=ï~ë=ëìééçêíÉÇ=Äó=íÜÉ=_ìêêçìÖÜë=tÉääÅçãÉ=cìåÇ=Eh`F=~åÇ=~=s^=jÉêáí=^ï~êÇ=ENfMN=`uMMMNSTJMNX=h`FX=~äëç=Äó=íÜÉ=sÉíÉê~åë=^ÑÑ~áêë=jÉÇáÅ~ä=oÉëÉ~êÅÜ=cìåÇ=~åÇ=Äó=^ï~êÇkìãÄÉê=ri=NooMORTST= Ñêçã= íÜÉ=k~íáçå~ä=`ÉåíÉê= Ñçê=oÉëÉ~êÅÜ=oÉëçìêÅÉëK= qÜÉ=ÅçåíÉåí= áëëçäÉäó=íÜÉ=êÉëéçåëáÄáäáíó=çÑ=íÜÉ=~ìíÜçêë=~åÇ=ÇçÉë=åçí=åÉÅÉëë~êáäó=êÉéêÉëÉåí=íÜÉ=çÑÑáÅá~ä=îáÉïë=çÑíÜÉ=k~íáçå~ä=`ÉåíÉê=Ñçê=oÉëÉ~êÅÜ=oÉëçìêÅÉë=çÑ=íÜÉ=k~íáçå~ä=fåëíáíìíÉë=çÑ=eÉ~äíÜK=

Evidence-based Management of Diabetes

16

Key points Evidence level

� k^cia=áë=íÜÉ=ãçëí=Åçããçå=Å~ìëÉ=çÑ=ÅÜêçåáÅ=äáîÉê=ÇáëÉ~ëÉ=~åÇ=~ëã~åó= ~ë= ≥QMB= çÑ= é~íáÉåíë= ïáíÜ= k^cia= Ü~îÉ= ëíÉ~íçÜÉé~íáíáëEk^peFK==k^pe=ã~ó=éêçÖêÉëë=íç=~Çî~åÅÉÇ=ÑáÄêçëáë=áå=~=ëáÖåáÑáÅ~åíåìãÄÉê=çÑ=é~íáÉåíë=~åÇ=áë=~=ã~àçê=Å~ìëÉ=çÑ=ÅêóéíçÖÉåáÅ=ÅáêêÜçëáëK

� lÄÉëáíó=~åÇ=Çá~ÄÉíÉë=EÄçíÜ=êÉä~íÉÇ=íç=ÇóëÑìåÅíáçå~ä=~ÇáéçëÉ=íáëëìÉ~åÇ= áåëìäáå= êÉëáëí~åÅÉFI= çê= íÜÉ= éêÉëÉåÅÉ= çÑ= ~Çî~åÅÉÇ= ÜÉé~íáÅÑáÄêçëáë= çå= ~= äáîÉê= ÄáçéëóI= ~êÉ= Ñ~Åíçêë= ~ëëçÅá~íÉÇ= ïáíÜ= k^peéêçÖêÉëëáçå=~åÇ=éççê=äçåÖJíÉêã=éêçÖåçëáëK

� tÜÉíÜÉê=k^cia=áë=~ëëçÅá~íÉÇ=ïáíÜ=~å=áåÅêÉ~ëÉÇ=êáëâ=çÑ=éêÉã~íìêÉÇÉ~íÜ= êÉã~áåë= ìåâåçïåK= bîáÇÉåÅÉ= ëìÖÖÉëíë= íÜ~í= é~íáÉåíë= ïáíÜk^pe= ~êÉ= ~í= áåÅêÉ~ëÉÇ= çÑ= äáîÉêJêÉä~íÉÇ= ãçêÄáÇáíó= ~åÇ= ãçêí~äáíóIä~êÖÉäó=~ëëçÅá~íÉÇ=ïáíÜ=íÜÉ=ëÉîÉêáíó=çÑ=äáîÉê=ÑáÄêçëáëK=

� qÜÉ=êÉä~íáçåëÜáé=ÄÉíïÉÉå=Çá~ÄÉíÉë=~åÇ=k^cia=áë=ÅçãéäÉñK==lÄÉëÉé~íáÉåíë= ïáíÜ= k^cia= ~êÉ= ~í= áåÅêÉ~ëÉÇ= êáëâ= çÑ= éêÉÇá~ÄÉíÉë= EfcdIfdqF=~åÇ=çÑ=åÉïäó=Çá~ÖåçëÉÇ=qOaj=Åçãé~êÉÇ=íç=é~íáÉåíë=ïáíÜçìík^ciaK=píêçåÖ=ÅçåëáÇÉê~íáçå=ëÜçìäÇ=ÄÉ=ÖáîÉå=íç=ëÅêÉÉå=é~íáÉåíëïáíÜ=k^cia=Ñçê=qOaj=íç=Éëí~ÄäáëÜ=~å=É~êäó=Çá~Öåçëáë=çÑ=Çá~ÄÉíÉë~åÇ=ÄÉÅ~ìëÉ=é~íáÉåíë=ïáíÜ=qOaj=~åÇ=k^pe=ÇÉîÉäçé=ïçêëÉ=äáîÉêÇáëÉ~ëÉ= ~åÇ= Ü~îÉ= ~= íïçJ= íç= ÑçìêJÑçäÇ= áåÅêÉ~ëÉ= áå= ~Çî~åÅÉÇ= äáîÉêÇáëÉ~ëÉI=ÅáêêÜçëáë=~åÇ=ÜÉé~íçÅÉääìä~ê=Å~êÅáåçã~K==

� qÜÉ=ãÉÅÜ~åáëãë=~í=éä~ó=áå=é~íáÉåíë=ïáíÜ=k^cia=ëìééçêí=íÜÉ=åçíáçåíÜ~í= íÜáë= ÅçåÇáíáçå= Å~êêáÉë= ~å= áåÅêÉ~ëÉÇ= êáëâ= çÑ= `saK= eçïÉîÉêÇáêÉÅí= íÜÉ= ÉîáÇÉåÅÉ= áë= ïÉ~â= ~åÇ= áåÅçåÅäìëáîÉK= içåÖJíÉêãéêçëéÉÅíáîÉ=ëíìÇáÉë=~êÉ=åÉÉÇÉÇ=íç=Ñìääó=Éëí~ÄäáëÜ=íÜÉ=å~íìêÉ=çÑ=íÜáë~ëëçÅá~íáçåI=Äìí=áå=íÜÉ=ãÉ~åíáãÉI=~ÖÖêÉëëáîÉ=íêÉ~íãÉåí=çÑ=`s=êáëâÑ~Åíçêë=~ééÉ~êë=ï~êê~åíÉÇ=áå=íÜáë=éçéìä~íáçåK

ffÄL_

ff~L_

ff~L_

ff~L_

fffL_

References

NK ^Ç~ãë=i^I=^åÖìäç=mK=oÉÅÉåí=ÅçåÅÉéíë=áå=åçåJ~äÅçÜçäáÅ=Ñ~ííó=äáîÉê=ÇáëÉ~ëÉK=aá~ÄÉí=jÉÇ OMMRX=OOW=NNOVJPPKOK jìëëç=dI=d~ãÄáåç=oI=`~ëë~ÇÉê=jK=kçåJ~äÅçÜçäáÅ=Ñ~ííó=äáîÉê=ÇáëÉ~ëÉ=Ñêçã=é~íÜçÖÉåÉëáë=íç=ã~å~ÖÉãÉåíW=~å

ìéÇ~íÉK=lÄÉë=oÉî OMNMX=NNW=QPMJQRKPK mçêÉé~=iI=o~ó=gdI=p~åÅÜÉòJoçãÉì=mI=Éí=~äK=kÉïäó=Çá~ÖåçëÉÇ=Çá~ÄÉíÉë=ãÉääáíìë=~ë=~=êáëâ=Ñ~Åíçê=Ñçê=ëÉêáçìë=äáîÉê

ÇáëÉ~ëÉK=`j^g OMNMX=NUOW=bROSJPNKQK pí~êäÉó= _nI= `~äÅ~Öåç= `gI= e~êêáëçå= p^K= kçå~äÅçÜçäáÅ= Ñ~ííó= äáîÉê= ÇáëÉ~ëÉ= ~åÇ= ÜÉé~íçÅÉääìä~ê= Å~êÅáåçã~W= ~

ïÉáÖÜíó=ÅçååÉÅíáçåK=eÉé~íçäçÖó OMNMX=RNW=NUOMJPOKRK `ä~êâ=gjI=_ê~åÅ~íá=ciI=aáÉÜä=^jK=kçå~äÅçÜçäáÅ=Ñ~ííó=äáîÉê=ÇáëÉ~ëÉK=d~ëíêçÉåíÉêçäçÖó OMMOX=NOOW=NSQVJRTKSK ^åÖìäç= mI= hÉ~ÅÜ= g`I=_~ííë= hmI= Éí= ~äK= fåÇÉéÉåÇÉåí= éêÉÇáÅíçêë= çÑ= äáîÉê= ÑáÄêçëáë= áå= é~íáÉåíë=ïáíÜ= åçå~äÅçÜçäáÅ

ëíÉ~íçÜÉé~íáíáëK=eÉé~íçäçÖó=NVVVX=PMW=NPRSJSOKTK bâëíÉÇí=jI=cê~åòÉå=ibI=j~íÜáÉëÉå=riI=Éí=~äK=içåÖJíÉêã=ÑçääçïJìé=çÑ=é~íáÉåíë=ïáíÜ=k^cia=~åÇ=ÉäÉî~íÉÇ=äáîÉê

ÉåòóãÉëK=eÉé~íçäçÖó OMMSX=QQW=USRJTPKUK kÉìëÅÜï~åÇÉêJqÉíêá=_^I=`ä~êâ=gjI=_~ëë=kjI=Éí=~äK=`äáåáÅ~äI=ä~Äçê~íçêó=~åÇ=ÜáëíçäçÖáÅ~ä=~ëëçÅá~íáçåë=áå=~Çìäíë

ïáíÜ=åçå~äÅçÜçäáÅ=Ñ~ííó=äáîÉê=ÇáëÉ~ëÉK=eÉé~íçäçÖó OMNMX=ROW=VNPJOQKVK t~åÖ=`I=t~åÖ=uI=dçåÖ=dI=Éí=~äK=fåÅêÉ~ëÉÇ=êáëâ=çÑ=ÜÉé~íçÅÉääìä~ê=Å~êÅáåçã~=áå=é~íáÉåíë=ïáíÜ=Çá~ÄÉíÉë=ãÉääáíìëW

~=ëóëíÉã~íáÅ=êÉîáÉï=~åÇ=ãÉí~J~å~äóëáë=çÑ=ÅçÜçêí=ëíìÇáÉëK=fåí=g=`~åÅÉê=OMNOX=NPMW=NSPVJQUKNMK e~êêáëçå= p^I= qçêÖÉêëçå= pI= e~ó~ëÜá= meK= qÜÉ= å~íìê~ä= Üáëíçêó= çÑ= åçå~äÅçÜçäáÅ= Ñ~ííó= äáîÉê= ÇáëÉ~ëÉW= ~= ÅäáåáÅ~ä

Üáëíçé~íÜçäçÖáÅ~ä=ëíìÇóK=^ã=g=d~ëíêçÉåíÉêçä=OMMPX=VUW=OMQOJTKNNK c~ëëáç=bI=^äî~êÉò=bI=açãáåÖìÉò=kI=Éí=~äK=k~íìê~ä=Üáëíçêó=çÑ=åçå~äÅçÜçäáÅ=ëíÉ~íçÜÉé~íáíáëW=~=äçåÖáíìÇáå~ä=ëíìÇó=çÑ

êÉéÉ~í=äáîÉê=ÄáçéëáÉëK=eÉé~íçäçÖó OMMQX=QMW=UOMJSKNOK ^Ç~ãë= i^I= p~åÇÉêëçå= pI= iáåÇçê= haI= Éí= ~äK= qÜÉ= ÜáëíçäçÖáÅ~ä= ÅçìêëÉ= çÑ= åçå~äÅçÜçäáÅ= Ñ~ííó= äáîÉê= ÇáëÉ~ëÉW= ~

äçåÖáíìÇáå~ä=ëíìÇó=çÑ=NMP=é~íáÉåíë=ïáíÜ=ëÉèìÉåíá~ä=äáîÉê=ÄáçéëáÉëK=g=eÉé~íçä OMMRX=QOW=NPOJUKNPK tçåÖ=stI=tçåÖ=diI=`Üçá=m`I=Éí=~äK=aáëÉ~ëÉ=éêçÖêÉëëáçå=çÑ=åçåJ~äÅçÜçäáÅ=Ñ~ííó=äáîÉê=ÇáëÉ~ëÉW=~=éêçëéÉÅíáîÉ

ëíìÇó=ïáíÜ=é~áêÉÇ=äáîÉê=ÄáçéëáÉë=~í=P=óÉ~êëK=dìí=OMNMX=RVW=VSVJTQKNQK içãçå~Åç= oI= lêíáòJiçéÉò= `I= lêë~â= _I= Éí= ~äK= bÑÑÉÅí= çÑ= ~ÇáéçëÉ= íáëëìÉ= áåëìäáå= êÉëáëí~åÅÉ= çå= ãÉí~ÄçäáÅ

é~ê~ãÉíÉêë=~åÇ=äáîÉê=ÜáëíçäçÖó=áå=çÄÉëÉ=é~íáÉåíë=ïáíÜ=k^ciaK=eÉé~íçäçÖó=OMNOX=RRW=NPUVJVTKNRK iáåÇçê= haI= hçïÇäÉó= hsI= eÉ~íÜÅçíÉ= bgI= Éí= ~äK= rêëçÇÉçñóÅÜçäáÅ= ~ÅáÇ= Ñçê= íêÉ~íãÉåí= çÑ= åçå~äÅçÜçäáÅ

ëíÉ~íçÜÉé~íáíáëW=êÉëìäíë=çÑ=~=ê~åÇçãáòÉÇ=íêá~äK=eÉé~íçäçÖó OMMQX=PVW=TTMJUKNSK _êçïåáåÖ=gaI=pòÅòÉé~åá~â=ipI=açÄÄáåë=oI=Éí=~äK=mêÉî~äÉåÅÉ=çÑ=ÜÉé~íáÅ=ëíÉ~íçëáë=áå=~å=ìêÄ~å=éçéìä~íáçå=áå=íÜÉ

råáíÉÇ=pí~íÉëW=áãé~Åí=çÑ=ÉíÜåáÅáíóK=eÉé~íçäçÖó OMMQX=QMW=NPUTJVRKNTK _çååÉí=cI=aìÅäìòÉ~ì=meI=d~ëí~äÇÉääá=^I=Éí=~äK=iáîÉê=ÉåòóãÉë=~êÉ=~ëëçÅá~íÉÇ=ïáíÜ=ÜÉé~íáÅ= áåëìäáå= êÉëáëí~åÅÉI

áåëìäáå=ëÉÅêÉíáçåI=~åÇ=ÖäìÅ~Öçå=ÅçåÅÉåíê~íáçå=áå=ÜÉ~äíÜó=ãÉå=~åÇ=ïçãÉåK=aá~ÄÉíÉë OMNNX=SMW=NSSMJTKNUK içãçå~Åç=oI=`ÜÉå=gI=`ìëá=hK=^å=ÉåÇçÅêáåÉ=éÉêëéÉÅíáîÉ=çÑ=åçå~äÅçÜçäáÅ=Ñ~ííó=äáîÉê=ÇáëÉ~ëÉ=Ek^ciaFK=qÜÉê=^Çî

båÇçÅêáåçä=jÉí~Ä OMNNX=OW=ONNJORKNVK mçóå~êÇ=qI=o~íòáì=sI=`Ü~êäçííÉ=cI=Éí=~äK=aá~ÖåçëíáÅ=î~äìÉ=çÑ=ÄáçÅÜÉãáÅ~ä=ã~êâÉêë=Ek~ëÜqÉëíF=Ñçê=íÜÉ=éêÉÇáÅíáçå

çÑ=åçå=~äÅçÜçäç=ëíÉ~íç=ÜÉé~íáíáë=áå=é~íáÉåíë=ïáíÜ=åçåJ~äÅçÜçäáÅ=Ñ~ííó=äáîÉê=ÇáëÉ~ëÉK=_j`=d~ëíêçÉåíÉêçä=OMMSX=SWPQK

OMK táÉÅâçïëâ~= ^I= jÅ`ìääçìÖÜ= ^gI= cÉäÇëíÉáå= ^bK= kçåáåî~ëáîÉ= Çá~Öåçëáë= ~åÇ= ãçåáíçêáåÖ= çÑ= åçå~äÅçÜçäáÅëíÉ~íçÜÉé~íáíáëW=éêÉëÉåí=~åÇ=ÑìíìêÉK=eÉé~íçäçÖó=OMMTX=QSW=RUOJVK

ONK _ÉÇçÖåá=dI=h~Üå=epI=_ÉääÉåí~åá=pI=Éí=~äK=^=ëáãéäÉ=áåÇÉñ=çÑ=äáéáÇ=çîÉê~ÅÅìãìä~íáçå=áë=~=ÖççÇ=ã~êâÉê=çÑ=äáîÉêëíÉ~íçëáëK=_j`=d~ëíêçÉåíÉêçä=OMNMX=NMW=VUK

OOK jçÑê~Ç=mI=`çåíçë=jgI=e~èìÉ=jI= Éí= ~äK=`äáåáÅ~ä= ~åÇ= ÜáëíçäçÖáÅ= ëéÉÅíêìã=çÑ= åçå~äÅçÜçäáÅ= Ñ~ííó= äáîÉê= ÇáëÉ~ëÉ~ëëçÅá~íÉÇ=ïáíÜ=åçêã~ä=^iq=î~äìÉëK eÉé~íçäçÖó OMMPX=PTW=NOUSJVOK

OPK pçêêÉåíáåç=mI=q~ê~åíáåç=dI=`çåÅ~=mI=Éí=~äK=páäÉåí=åçåJ~äÅçÜçäáÅ=Ñ~ííó=äáîÉê=ÇáëÉ~ëÉ=J=~=ÅäáåáÅ~äJÜáëíçäçÖáÅ~ä=ëíìÇóKg=eÉé~íçä=OMMQX=QNW=TRNJTK

OQK hçíêçåÉå= ^I= gììêáåÉå= iI= e~ââ~ê~áåÉå= ^I= Éí= ~äK= iáîÉê= Ñ~í= áë= áåÅêÉ~ëÉÇ= áå= íóéÉ= O= Çá~ÄÉíáÅ= é~íáÉåíë= ~åÇìåÇÉêÉëíáã~íÉÇ= Äó= ëÉêìã= ~ä~åáåÉ= ~ãáåçíê~åëÑÉê~ëÉ= Åçãé~êÉÇ= ïáíÜ= Éèì~ääó= çÄÉëÉ= åçåÇá~ÄÉíáÅ= ëìÄàÉÅíëKaá~ÄÉíÉë=`~êÉ=OMMUX=PNW=NSRJVK

ORK o~Ñáè=kI=_~á=`I=c~åÖ=vI=Éí=~äK=içåÖJíÉêã=ÑçääçïJìé=çÑ=é~íáÉåíë=ïáíÜ=åçå~äÅçÜçäáÅ=Ñ~ííó=äáîÉêK=`äáå=d~ëíêçÉåíÉêçäeÉé~íçä=OMMVX=TW=OPQJUK

OSK pçÇÉêÄÉêÖ=`I=pí~ä=mI=^ëâäáåÖ=gI=Éí=~äK=aÉÅêÉ~ëÉÇ=ëìêîáî~ä=çÑ=ëìÄàÉÅíë=ïáíÜ=ÉäÉî~íÉÇ=äáîÉê=ÑìåÅíáçå=íÉëíë=ÇìêáåÖ=~OUJóÉ~ê=ÑçääçïJìéK=eÉé~íçäçÖó=OMNMX=RNW=RVRJSMOK

21 Non-alcoholic fatty liver disease (NAFLD) in diabetes: distraction or impending disaster?

17

OTK p~åó~ä=^gI=`Ü~ä~ë~åá=kI=hçïÇäÉó=hsI=Éí=~äK=máçÖäáí~òçåÉI=îáí~ãáå=bI=çê=éä~ÅÉÄç=Ñçê=åçå~äÅçÜçäáÅ=ëíÉ~íçÜÉé~íáíáëKk=båÖä=g=jÉÇ OMNMX=PSOW=NSTRJURK

OUK a~ãJi~êëÉå=pI=_ÉÅâÉê=rI=cê~åòã~åå=j_I=Éí=~äK=cáå~ä= êÉëìäíë=çÑ=~= äçåÖJíÉêãI=ÅäáåáÅ~ä= ÑçääçïJìé= áå= Ñ~ííó= äáîÉêé~íáÉåíëK=pÅ~åÇ=g=d~ëíêçÉåíÉêçä OMMVX=QQW=NOPSJQPK

OVK j~ííÉçåá=`^I= vçìåçëëá= wjI=dê~ãäáÅÜ= qI= Éí= ~äK= kçå~äÅçÜçäáÅ= Ñ~ííó= äáîÉê= ÇáëÉ~ëÉW= ~= ëéÉÅíêìã= çÑ= ÅäáåáÅ~ä= ~åÇé~íÜçäçÖáÅ~ä=ëÉîÉêáíóK=d~ëíêçÉåíÉêçäçÖó NVVVX=NNSW=NQNPJVK

PMK bî~åë=`aI=láÉå=h^I=j~ÅpïÉÉå=okI=Éí= ~äK=kçåJ~äÅçÜçäáÅ= ëíÉ~íçÜÉé~íáíáëW= ~=Åçããçå=Å~ìëÉ=çÑ=éêçÖêÉëëáîÉÅÜêçåáÅ=äáîÉê=áåàìêó\=g=`äáå=m~íÜçä=OMMOX=RRW=SUVJVOK

PNK vçìåçëëá=wjI=píÉé~åçî~=jI=o~Ñáè=kI=Éí=~äK=m~íÜçäçÖáÅ=ÅêáíÉêá~=Ñçê=åçå~äÅçÜçäáÅ=ëíÉ~íçÜÉé~íáíáëW= áåíÉêéêçíçÅçä~ÖêÉÉãÉåí=~åÇ=~Äáäáíó=íç=éêÉÇáÅí=äáîÉêJêÉä~íÉÇ=ãçêí~äáíóK eÉé~íçäçÖó=OMNNX=RPW=NUTQJUOK

POK eìá=gjI=hÉåÅÜ=gdI=`Üáííìêá=pI=Éí=~äK=içåÖJíÉêã=çìíÅçãÉë=çÑ=ÅáêêÜçëáë=áå=åçå~äÅçÜçäáÅ=ëíÉ~íçÜÉé~íáíáë=Åçãé~êÉÇïáíÜ=ÜÉé~íáíáë=`K=eÉé~íçäçÖó OMMPX=PUW=QOMJTK

PPK p~åó~ä=^gI=`çäáå=_I=`~êçä=pI=Éí=~äK=páãáä~êáíáÉë=~åÇ=ÇáÑÑÉêÉåÅÉë=áå=çìíÅçãÉë=çÑ=ÅáêêÜçëáë=ÇìÉ=íç=åçå~äÅçÜçäáÅëíÉ~íçÜÉé~íáíáë=~åÇ=ÜÉé~íáíáë=`K=eÉé~íçäçÖó OMMSX=QPW=SUOJVK

PQK v~íëìàá= pI= e~ëÜáãçíç= bI= qçÄ~êá= jI= Éí= ~äK= `äáåáÅ~ä= ÑÉ~íìêÉë= ~åÇ= çìíÅçãÉë= çÑ= ÅáêêÜçëáë= ÇìÉ= íç= åçåJ~äÅçÜçäáÅëíÉ~íçÜÉé~íáíáë=Åçãé~êÉÇ=ïáíÜ=ÅáêêÜçëáë=Å~ìëÉÇ=Äó=ÅÜêçåáÅ=ÜÉé~íáíáë=`K=g=d~ëíêçÉåíÉêçä=eÉé~íçä=OMMVX=OQW=OQUJRQK

PRK _Ü~ä~= kI= ^åÖìäç= mI= î~å= ÇÉê= mççêíÉå= aI= Éí= ~äK= qÜÉ= å~íìê~ä= Üáëíçêó= çÑ= åçå~äÅçÜçäáÅ= Ñ~ííó= äáîÉê= ÇáëÉ~ëÉ= ïáíÜ~Çî~åÅÉÇ=ÑáÄêçëáë=çê=ÅáêêÜçëáëW=~å=áåíÉêå~íáçå~ä=Åçää~Äçê~íáîÉ=ëíìÇóK=eÉé~íçäçÖó OMNNX=RQW=NOMUJNSK

PSK sçò~êçî~=_I=píÉÑ~å=kI=iáåÇë~ó=opI=Éí=~äK=eáÖÜ=~ä~åáåÉ=~ãáåçíê~åëÑÉê~ëÉ=áë=~ëëçÅá~íÉÇ=ïáíÜ=ÇÉÅêÉ~ëÉÇ=ÜÉé~íáÅáåëìäáå=ëÉåëáíáîáíó=~åÇ=éêÉÇáÅíë=íÜÉ=ÇÉîÉäçéãÉåí=çÑ=íóéÉ=O=Çá~ÄÉíÉëK=aá~ÄÉíÉë OMMOX=RNW=NUUVJVRK

PTK p~íí~ê=kI=pÅÜÉêÄ~âçî~=lI=cçêÇ=fI=Éí=~äK=bäÉî~íÉÇ=~ä~åáåÉ=~ãáåçíê~åëÑÉê~ëÉ=éêÉÇáÅíë=åÉïJçåëÉí=íóéÉ=O=Çá~ÄÉíÉëáåÇÉéÉåÇÉåíäó=çÑ=Åä~ëëáÅ~ä= êáëâ= Ñ~ÅíçêëI=ãÉí~ÄçäáÅ=ëóåÇêçãÉI=~åÇ=`JêÉ~ÅíáîÉ=éêçíÉáå= áå= íÜÉ=ïÉëí=çÑ=pÅçíä~åÇÅçêçå~êó=éêÉîÉåíáçå=ëíìÇóK=aá~ÄÉíÉë OMMQX=RPW=OURRJSMK

PUK e~åäÉó=^gI=táääá~ãë=hI=cÉëí~=^I=Éí=~äK=bäÉî~íáçåë=áå=ã~êâÉêë=çÑ=äáîÉê=áåàìêó=~åÇ=êáëâ=çÑ=íóéÉ=O=Çá~ÄÉíÉëW=íÜÉ=áåëìäáåêÉëáëí~åÅÉ=~íÜÉêçëÅäÉêçëáë=ëíìÇóK=aá~ÄÉíÉë OMMQX=RPW=OSOPJPOK

PVK t~åå~ãÉíÜÉÉ=pdI=pÜ~éÉê=^dI=iÉååçå=iI=Éí=~äK=eÉé~íáÅ=ÉåòóãÉëI=íÜÉ=ãÉí~ÄçäáÅ=ëóåÇêçãÉI=~åÇ=íÜÉ=êáëâ=çÑíóéÉ=O=Çá~ÄÉíÉë=áå=çäÇÉê=ãÉåK=aá~ÄÉíÉë=`~êÉ=OMMRX=OUW=OVNPJUK

QMK jçå~ãá=jI=_~êÇáåá=dI= i~ã~åå~=`I= Éí= ~äK= iáîÉê= ÉåòóãÉë= ~åÇ= êáëâ= çÑ= Çá~ÄÉíÉë= ~åÇ= Å~êÇáçî~ëÅìä~ê= ÇáëÉ~ëÉWêÉëìäíë=çÑ=íÜÉ=cáêÉåòÉ=_~Öåç=~=oáéçäá=Ecf_^oF=ëíìÇóK jÉí~Äçäáëã OMMUX=RTW=PUTJVOK

QNK ^Ç~ãë=i^I=e~êãëÉå=pI=pí=p~ìîÉê=giI=Éí=~äK=kçå~äÅçÜçäáÅ= Ñ~ííó= äáîÉê=ÇáëÉ~ëÉ= áåÅêÉ~ëÉë=êáëâ=çÑ=ÇÉ~íÜ=~ãçåÖé~íáÉåíë=ïáíÜ=Çá~ÄÉíÉëW=~=ÅçããìåáíóJÄ~ëÉÇ=ÅçÜçêí=ëíìÇóK=^ã=g=d~ëíêçÉåíÉêçä OMNMX=NMRW=NRSTJTPK

QOK dçÉëëäáåÖ=tI=j~ëë~êç=gjI=s~ë~å=opI=Éí=~äK=^ãáåçíê~åëÑÉê~ëÉ=äÉîÉäë=~åÇ=OMJóÉ~ê=êáëâ=çÑ=ãÉí~ÄçäáÅ=ëóåÇêçãÉIÇá~ÄÉíÉëI=~åÇ=Å~êÇáçî~ëÅìä~ê=ÇáëÉ~ëÉK d~ëíêçÉåíÉêçäçÖó=OMMUX=NPRW=NVPRJQQI=NVQQ=ÉNK

QPK pÜäçã~á=^I=h~êáî=oI=iÉëÜåç=jI=Éí=~äK=i~êÖÉJëÅ~äÉ=éçéìä~íáçå=~å~äóëáë=êÉîÉ~äë=~å=ÉñíêÉãÉäó= äçï=íÜêÉëÜçäÇ=ÑçêÚåçåJÜÉ~äíÜóÛ= ~ä~åáåÉ= ~ãáåçíê~åëÑÉê~ëÉ= íÜ~í= éêÉÇáÅíë= Çá~ÄÉíÉë= ãÉääáíìëK= g= d~ëíêçÉåíÉêçä= eÉé~íçä= OMNMX= ORWNSUTJVNK

QQK pìåÖ=h`I=háã=peK= fåíÉêêÉä~íáçåëÜáé=ÄÉíïÉÉå= Ñ~ííó= äáîÉê=~åÇ= áåëìäáå= êÉëáëí~åÅÉ= áå= íÜÉ=ÇÉîÉäçéãÉåí=çÑ= íóéÉ=OÇá~ÄÉíÉëK=g=`äáå=båÇçÅêáåçä=jÉí~Ä OMNNX=VSW=NMVPJTK

QRK háãìê~= vI= eóçÖç= eI= fëÜáíçÄá= qI= Éí= ~äK= mçëíéê~åÇá~ä= áåëìäáå= ëÉÅêÉíáçå= é~ííÉêå= áë= ~ëëçÅá~íÉÇ= ïáíÜ= ÜáëíçäçÖáÅ~äëÉîÉêáíó= áå= åçåJ~äÅçÜçäáÅ= Ñ~ííó= äáîÉê= ÇáëÉ~ëÉ= é~íáÉåíë=ïáíÜçìí= éêáçê= âåçïå= Çá~ÄÉíÉë=ãÉääáíìëK= g=d~ëíêçÉåíÉêçäeÉé~íçä OMNNX=OSW=RNTJOOK

QSK lêíáòJiçéÉò=`I=içãçå~Åç=oI=lêë~â=_I=Éí=~äK=mêÉî~äÉåÅÉ=çÑ=éêÉÇá~ÄÉíÉë=~åÇ=Çá~ÄÉíÉë=~åÇ=ãÉí~ÄçäáÅ=éêçÑáäÉ=çÑé~íáÉåíë=ïáíÜ=åçå~äÅçÜçäáÅ=Ñ~ííó=äáîÉê=ÇáëÉ~ëÉ=Ek^ciaFK=aá~ÄÉíÉë=`~êÉ OMNOX=PRW=UTPJUK

QTK tçåÖ= stpI= eìá= ^vI= që~åÖ= pt`I= Éí= ~äK= mêÉî~äÉåÅÉ= çÑ= ìåÇá~ÖåçëÉÇ= Çá~ÄÉíÉë= ~åÇ= éçëíÅÜ~ääÉåÖÉÜóéÉêÖäóÅ~Éãá~=áå=`ÜáåÉëÉ=é~íáÉåíë=ïáíÜ=åçåJ~äÅçÜçäáÅ=Ñ~ííó=äáîÉê=ÇáëÉ~ëÉK=^äáãÉåí=mÜ~êã~Åçä=qÜÉê=OMMSX=OQWNONRJOOK

QUK háãìê~= vI= eóçÖç= eI= fëÜáíçÄá= qI= Éí= ~äK= mçëíéê~åÇá~ä= áåëìäáå= ëÉÅêÉíáçå= é~ííÉêå= áë= ~ëëçÅá~íÉÇ= ïáíÜ= ÜáëíçäçÖáÅ~äëÉîÉêáíó= áå= åçåJ~äÅçÜçäáÅ= Ñ~ííó= äáîÉê= ÇáëÉ~ëÉ= é~íáÉåíë=ïáíÜçìí= éêáçê= âåçïå= Çá~ÄÉíÉë=ãÉääáíìëK= g=d~ëíêçÉåíÉêçäeÉé~íçä=OMNNX=OSW=RNTJOOK

QVK j~åÅÜ~å~ó~âÉ=gI=`Üáííìêá=pI=kçä~åæ=`I=Éí=~äK=mçëíéê~åÇá~ä=ÜóéÉêáåëìäáåÉãá~=áë=ìåáîÉêë~ä=áå=åçåJÇá~ÄÉíáÅ=é~íáÉåíëïáíÜ=åçå~äÅçÜçäáÅ=Ñ~ííó=äáîÉê=ÇáëÉ~ëÉK=g=d~ëíêçÉåíÉêçä=eÉé~íçä OMNNX=OSW=RNMJSK

RMK `ìëá=hK=qÜÉ=êçäÉ=çÑ=~ÇáéçëÉ=íáëëìÉ=~åÇ=äáéçíçñáÅáíó=áå=íÜÉ=é~íÜçÖÉåÉëáë=çÑ=íóéÉ=O=Çá~ÄÉíÉëK=`ìêê=aá~Ä=oÉé OMNMXNMW=PMSJNRK

Evidence-based Management of Diabetes

18

RNK _çòòÉííç=iI=mêáåëíÉê=^I=j~åÅáåá=jI=Éí=~äK=iáîÉê=Ñ~í=áå=çÄÉëáíóW=êçäÉ=çÑ=íóéÉ=O=Çá~ÄÉíÉë=ãÉääáíìë=~åÇ=~ÇáéçëÉ=íáëëìÉÇáëíêáÄìíáçåK=bìê=g=`äáå=fåîÉëí=OMNNX=QNW=PVJQQK

ROK kÉìëÅÜï~åÇÉêJqÉíêá=_^K=eÉé~íáÅ=äáéçíçñáÅáíó=~åÇ=íÜÉ=é~íÜçÖÉåÉëáë=çÑ=åçå~äÅçÜçäáÅ=ëíÉ~íçÜÉé~íáíáëW=íÜÉ=ÅÉåíê~äêçäÉ=çÑ=åçåíêáÖäóÅÉêáÇÉ=Ñ~ííó=~ÅáÇ=ãÉí~ÄçäáíÉëK=eÉé~íçäçÖó OMNMX=ROW=TTQJUUK

RPK pãáíÜ=_tI=^Ç~ãë=i^K=kçå~äÅçÜçäáÅ=Ñ~ííó=äáîÉê=ÇáëÉ~ëÉ=~åÇ=Çá~ÄÉíÉë=ãÉääáíìëW=é~íÜçÖÉåÉëáë=~åÇ=íêÉ~íãÉåíK=k~íoÉî=båÇçÅêáåçä OMNNX=TW=QRSJSRK

RQK `ìëá=hK=kçå~äÅçÜçäáÅ=Ñ~ííó=äáîÉê=ÇáëÉ~ëÉ=áå=íóéÉ=O=Çá~ÄÉíÉë=ãÉääáíìëK=`ìêê=léáå=båÇçÅêáåçä=aá~ÄÉíÉë=lÄÉë=OMMVXNSW=NQNJVK

RRK açååÉääó= hiI= pãáíÜ= `fI= pÅÜï~êòÉåÄÉêÖ= pgI= Éí= ~äK= pçìêÅÉë= çÑ= Ñ~ííó= ~ÅáÇë= ëíçêÉÇ= áå= äáîÉê= ~åÇ= ëÉÅêÉíÉÇ= îá~äáéçéêçíÉáåë=áå=é~íáÉåíë=ïáíÜ=åçå~äÅçÜçäáÅ=Ñ~ííó=äáîÉê=ÇáëÉ~ëÉK g=`äáå=fåîÉëí OMMRX=NNRW=NPQPJRNK

RSK ^ÇáÉäë=jI=q~ëâáåÉå=joI=_çêÉå=gK=c~ííó=äáîÉêI=áåëìäáå=êÉëáëí~åÅÉI=~åÇ=ÇóëäáéáÇÉãá~K=`ìêê=aá~Ä=oÉé OMMUX=UW=SMJQK

RTK ^ÇáÉäë=jI=q~ëâáåÉå=jI=m~Åâ~êÇ=`I=Éí=~äK=lîÉêéêçÇìÅíáçå=çÑ=ä~êÖÉ=siai=é~êíáÅäÉë=áë=ÇêáîÉå=Äó=áåÅêÉ~ëÉÇ=äáîÉê=Ñ~íÅçåíÉåí=áå=ã~åK=aá~ÄÉíçäçÖá~ OMMSX=QVW=TRRJSRK

RUK ^ÇáÉäë=jI=tÉëíÉêÄ~Åâ~=gI=pçêçJm~~îçåÉå=^I=Éí=~äK=^ÅìíÉ=ëìééêÉëëáçå=çÑ=siaiN=ëÉÅêÉíáçå=ê~íÉ=Äó= áåëìäáå= áë~ëëçÅá~íÉÇ=ïáíÜ=ÜÉé~íáÅ=Ñ~í=ÅçåíÉåí=~åÇ=áåëìäáå=êÉëáëí~åÅÉK=aá~ÄÉíçäçÖá~ OMMTX=RMW=OPRSJSRK

RVK c~ÄÄêáåá= bI= j~Öâçë= cI= jçÜ~ããÉÇ= _pI= Éí= ~äK= fåíê~ÜÉé~íáÅ= Ñ~íI= åçí= îáëÅÉê~ä= Ñ~íI= áë= äáåâÉÇ= ïáíÜ= ãÉí~ÄçäáÅÅçãéäáÅ~íáçåë=çÑ=çÄÉëáíóK=mêçÅ=k~íä=^Å~Ç=pÅá=rp^=OMMVX=NMSW=NRQPMJRK

SMK oóóëó=iI=e~ââáåÉå=^jI=dçíç=qI=Éí=~äK=eÉé~íáÅ=Ñ~í=ÅçåíÉåí=~åÇ=áåëìäáå=~Åíáçå=çå=ÑêÉÉ=Ñ~ííó=~ÅáÇë=~åÇ=ÖäìÅçëÉãÉí~Äçäáëã=ê~íÜÉê=íÜ~å=áåëìäáå=~Äëçêéíáçå=~êÉ=~ëëçÅá~íÉÇ=ïáíÜ=áåëìäáå=êÉèìáêÉãÉåíë=ÇìêáåÖ=áåëìäáå=íÜÉê~éó=áå=íóéÉO=Çá~ÄÉíáÅ=é~íáÉåíëK=aá~ÄÉíÉë OMMMX=QVW=TQVJRUK

SNK a~îáä~=g^I=jçêÖ~å=olI=pÜ~áÄ=vI=Éí=~äK=aá~ÄÉíÉë=áåÅêÉ~ëÉë=íÜÉ=êáëâ=çÑ=ÜÉé~íçÅÉääìä~ê=Å~êÅáåçã~=áå=íÜÉ=råáíÉÇpí~íÉëW=~=éçéìä~íáçåJÄ~ëÉÇ=Å~ëÉ=Åçåíêçä=ëíìÇóK=dìí OMMRX=RQW=RPPJVK

SOK páÇÇáèìÉ= ^I= hçïÇäÉó= hsK= fåëìäáå= êÉëáëí~åÅÉ= ~åÇ= çíÜÉê= ãÉí~ÄçäáÅ= êáëâ= Ñ~Åíçêë= áå= íÜÉ= é~íÜçÖÉåÉëáë= çÑÜÉé~íçÅÉääìä~ê=Å~êÅáåçã~K=`äáå=iáîÉê=aáë OMNNX=NRW=OUNJVSI=îááJñK

SPK vçìåçëëá=wjI=dê~ãäáÅÜ=qI=j~ííÉçåá=`^I=Éí=~äK=kçå~äÅçÜçäáÅ=Ñ~ííó=äáîÉê=ÇáëÉ~ëÉ=áå=é~íáÉåíë=ïáíÜ=íóéÉ=O=Çá~ÄÉíÉëK`äáå=d~ëíêçÉåíÉêçä=eÉé~íçä=OMMQX=OW=OSOJRK

SQK fç~ååçì=dkI=_çóâç=bgI=iÉÉ=pmK=qÜÉ=éêÉî~äÉåÅÉ=~åÇ=éêÉÇáÅíçêë=çÑ=ÉäÉî~íÉÇ=ëÉêìã=~ãáåçíê~åëÑÉê~ëÉ=~Åíáîáíó=áåíÜÉ=råáíÉÇ=pí~íÉë=áå=NVVVJOMMOK ^ã=g=d~ëíêçÉåíÉêçä=OMMSX=NMNW=TSJUOK

SRK pÅÜáåÇÜÉäã=ohI=aÉââÉê=gjI=káàéÉäë=dI=Éí=~äK=^ä~åáåÉ=~ãáåçíê~åëÑÉê~ëÉ=éêÉÇáÅíë=Åçêçå~êó=ÜÉ~êí=ÇáëÉ~ëÉ=ÉîÉåíëW~=NMJóÉ~ê=ÑçääçïJìé=çÑ=íÜÉ=eççêå=píìÇóK=^íÜÉêçëÅäÉêçëáë OMMTX=NVNW=PVNJSK

SSK låÖ=gmI=máííë=^I=vçìåçëëá=wjK=fåÅêÉ~ëÉÇ=çîÉê~ää=ãçêí~äáíó=~åÇ=äáîÉêJêÉä~íÉÇ=ãçêí~äáíó=áå=åçåJ~äÅçÜçäáÅ=Ñ~ííó=äáîÉêÇáëÉ~ëÉK=g=eÉé~íçä OMMUX=QVW=SMUJNOK

STK ^Ç~ãë=i^I=ióãé=gcI=pí=p~ìîÉê=gI=Éí=~äK=qÜÉ=å~íìê~ä=Üáëíçêó=çÑ=åçå~äÅçÜçäáÅ= Ñ~ííó= äáîÉê=ÇáëÉ~ëÉW=~=éçéìä~íáçåJÄ~ëÉÇ=ÅçÜçêí=ëíìÇóK=d~ëíêçÉåíÉêçäçÖó=OMMRX=NOVW=NNPJONK

SUK aìåå=tI=uì=oI=táåÖ~êÇ=aiI=Éí=~äK=pìëéÉÅíÉÇ=åçå~äÅçÜçäáÅ=Ñ~ííó=äáîÉê=ÇáëÉ~ëÉ=~åÇ=ãçêí~äáíó=êáëâ=áå=~=éçéìä~íáçåJÄ~ëÉÇ=ÅçÜçêí=ëíìÇóK=^ã=g=d~ëíêçÉåíÉêçä OMMUX=NMPW=OOSPJTNK

SVK sáää~åçî~= kI= jçëÅ~íáÉääç= pI= o~ãáääá= pI= Éí= ~äK= båÇçíÜÉäá~ä= ÇóëÑìåÅíáçå= ~åÇ= Å~êÇáçî~ëÅìä~ê= êáëâ= éêçÑáäÉ= áååçå~äÅçÜçäáÅ=Ñ~ííó=äáîÉê=ÇáëÉ~ëÉK=eÉé~íçäçÖó OMMRX=QOW=QTPJUMK

TMK q~êÖÜÉê= dI= _Éêíçäáåá= iI= m~Ççî~åá= oI= Éí= ~äK= oÉä~íáçå= çÑ= åçå~äÅçÜçäáÅ= ÜÉé~íáÅ= ëíÉ~íçëáë= íç= É~êäó= Å~êçíáÇ~íÜÉêçëÅäÉêçëáë=áå=ÜÉ~äíÜó=ãÉåW=êçäÉ=çÑ=îáëÅÉê~ä=Ñ~í=~ÅÅìãìä~íáçåK=aá~ÄÉíÉë=`~êÉ OMMQX=OTW=OQVUJRMMK

TNK _êÉ~=^I=jçëèìÉê~=aI=j~êíáå=bI=Éí=~äK=kçå~äÅçÜçäáÅ=Ñ~ííó=äáîÉê=ÇáëÉ~ëÉ=áë=~ëëçÅá~íÉÇ=ïáíÜ=Å~êçíáÇ=~íÜÉêçëÅäÉêçëáëW~=Å~ëÉJÅçåíêçä=ëíìÇóK=^êíÉêáçëÅäÉê=qÜêçãÄ=s~ëÅ=_áçä OMMRX=ORW=NMQRJRMK

TOK sçäòâÉ=eI= oçÄáåëçå=ajI= häÉáåÉ= sI= Éí= ~äK= eÉé~íáÅ= ëíÉ~íçëáë= áë= ~ëëçÅá~íÉÇ=ïáíÜ= ~å= áåÅêÉ~ëÉÇ= êáëâ= çÑ= Å~êçíáÇ~íÜÉêçëÅäÉêçëáëK=tçêäÇ=g=d~ëíêçÉåíÉêçä OMMRX=NNW=NUQUJRPK

TPK q~êÖÜÉê=dI=_Éêíçäáåá=iI=m~Ççî~åá=oI=Éí=~äK=oÉä~íáçåë=ÄÉíïÉÉå=Å~êçíáÇ=~êíÉêó=ï~ää=íÜáÅâåÉëë=~åÇ=äáîÉê=ÜáëíçäçÖó=áåëìÄàÉÅíë=ïáíÜ=åçå~äÅçÜçäáÅ=Ñ~ííó=äáîÉê=ÇáëÉ~ëÉK=aá~ÄÉíÉë=`~êÉ OMMSX=OVW=NPORJPMK

TQK cê~Å~åò~åá= ^iI=_ìêÇáÅâ= iI=o~ëÉääá= pI= Éí= ~äK=`~êçíáÇ= ~êíÉêó= áåíáã~JãÉÇá~= íÜáÅâåÉëë= áå= åçå~äÅçÜçäáÅ= Ñ~ííó= äáîÉêÇáëÉ~ëÉK=^ã=g=jÉÇ=OMMUX=NONW=TOJUK

TRK jÅháããáÉ=oiI=a~åáÉä=hoI=`~êê=ggI=Éí=~äK=eÉé~íáÅ=ëíÉ~íçëáë=~åÇ=ëìÄÅäáåáÅ~ä=Å~êÇáçî~ëÅìä~ê=ÇáëÉ~ëÉ=áå=~=ÅçÜçêíÉåêáÅÜÉÇ=Ñçê=íóéÉ=O=Çá~ÄÉíÉëW=íÜÉ=aá~ÄÉíÉë=eÉ~êí=píìÇóK=^ã=g=d~ëíêçÉåíÉêçä=OMMUX=NMPW=PMOVJPRK

TSK mç~åí~=ifI=^äÄì=^I=cçÇçê=aK=^ëëçÅá~íáçå=ÄÉíïÉÉå=Ñ~ííó=äáîÉê=ÇáëÉ~ëÉ=~åÇ=Å~êçíáÇ=~íÜÉêçëÅäÉêçëáë=áå=é~íáÉåíë=ïáíÜìåÅçãéäáÅ~íÉÇ=íóéÉ=O=Çá~ÄÉíÉë=ãÉääáíìëK jÉÇ=räíê~ëçå OMNNX=NPW=ONRJVK

21 Non-alcoholic fatty liver disease (NAFLD) in diabetes: distraction or impending disaster?

19

TTK jáêÄ~ÖÜÉêá=p^I=o~ëÜáÇá=^I=^ÄÇá=pI=Éí=~äK=iáîÉêW=~å=~ä~êã=Ñçê=íÜÉ=ÜÉ~êí\=iáîÉê=fåí OMMTX=OTW=UVNJQKTUK q~êÖÜÉê=dI=_Éêíçäáåá=iI=mçäá=cI=Éí=~äK=kçå~äÅçÜçäáÅ= Ñ~ííó= äáîÉê=ÇáëÉ~ëÉ=~åÇ=êáëâ=çÑ= ÑìíìêÉ=Å~êÇáçî~ëÅìä~ê=ÉîÉåíë

~ãçåÖ=íóéÉ=O=Çá~ÄÉíáÅ=é~íáÉåíëK aá~ÄÉíÉë OMMRX=RQW=PRQNJSKTVK e~ã~ÖìÅÜá= jK= kçå~äÅçÜçäáÅ= Ñ~ííó= äáîÉê= ÇáëÉ~ëÉ= áë= ~= åçîÉä= éêÉÇáÅíçê= çÑ= Å~êÇáçî~ëÅìä~ê= ÇáëÉ~ëÉK= tçêäÇ= g

d~ëíêçÉåíÉêçä OMMTX=NPW=NRTVJUQKUMK `ìëá=hK=oçäÉ=çÑ=çÄÉëáíó=~åÇ=äáéçíçñáÅáíó=áå=íÜÉ=ÇÉîÉäçéãÉåí=çÑ=åçå~äÅçÜçäáÅ=ëíÉ~íçÜÉé~íáíáëW=é~íÜçéÜóëáçäçÖó=~åÇ

ÅäáåáÅ~ä=áãéäáÅ~íáçåëK=d~ëíêçÉåíÉêçäçÖó OMNOX=NQOW=TNNJORKUNK q~êÖÜÉê=dI=_Éêíçäáåá=iI=m~Ççî~åá=oI=Éí=~äK=mêÉî~äÉåÅÉ=çÑ=åçå~äÅçÜçäáÅ=Ñ~ííó=äáîÉê=ÇáëÉ~ëÉ=~åÇ=áíë=~ëëçÅá~íáçå=ïáíÜ

Å~êÇáçî~ëÅìä~ê=ÇáëÉ~ëÉ=~ãçåÖ=íóéÉ=O=Çá~ÄÉíáÅ=é~íáÉåíëK=aá~ÄÉíÉë=`~êÉ=OMMTX=PMW=NONOJUKUOK `Ü~ä~ë~åá=kI=vçìåçëëá=wI=i~îáåÉ=gbI=Éí=~äK=qÜÉ=Çá~Öåçëáë=~åÇ=ã~å~ÖÉãÉåí=çÑ=åçåJ~äÅçÜçäáÅ=Ñ~ííó=äáîÉê=ÇáëÉ~ëÉW

mê~ÅíáÅÉ= ÖìáÇÉäáåÉ= Äó= íÜÉ= ^ãÉêáÅ~å= ^ëëçÅá~íáçå= Ñçê= íÜÉ= píìÇó= çÑ= iáîÉê= aáëÉ~ëÉëI= ^ãÉêáÅ~å= `çääÉÖÉ= çÑd~ëíêçÉåíÉêçäçÖóI= ~åÇ= íÜÉ= ^ãÉêáÅ~å= d~ëíêçÉåíÉêçäçÖáÅ~ä= ^ëëçÅá~íáçåK= eÉé~íçäçÖó OMNOX= ÇçáWNMKNMMOLÜÉéKORTSOK

UPK _ìÅÜ~å~å=q^K=EeçïF=`~å=ïÉ=éêÉîÉåí=íóéÉ=O=Çá~ÄÉíÉë\=aá~ÄÉíÉë=OMMTX=RSW=NRMOJTKUQK e~êêáëçå=pI=_êìåí=bI=cÉÅÜí=tI=Éí=~äK=lêäáëí~í=Ñçê=çîÉêïÉáÖÜí=ëìÄàÉÅíë=ïáíÜ=åçå~äÅçÜçäáÅ=ëíÉ~íçÜÉé~íáíáë=Ek^peFW

~=ê~åÇçãáòÉÇ=éêçëéÉÅíáîÉ=íêá~äK=eÉé~íçäçÖó OMMVX=QVW=UMJSKURK wÉäÄÉêJp~Öá=pI=hÉëëäÉê=^I=_ê~òçïëâó=bI=Éí=~äK=^=ÇçìÄäÉJÄäáåÇ=ê~åÇçãáòÉÇ=éä~ÅÉÄçJÅçåíêçääÉÇ=íêá~ä=çÑ=çêäáëí~í=Ñçê

íÜÉ=íêÉ~íãÉåí=çÑ=åçå~äÅçÜçäáÅ=Ñ~ííó=äáîÉê=ÇáëÉ~ëÉK=`äáå=d~ëíêçÉåíÉêçä=eÉé~íçä=OMMSX=QW=SPVJQQKUSK mêçãê~í=hI=häÉáåÉê=abI=káÉãÉáÉê=ejI=Éí=~äK=o~åÇçãáòÉÇ=ÅçåíêçääÉÇ=íêá~ä=íÉëíáåÖ=íÜÉ=ÉÑÑÉÅíë=çÑ=ïÉáÖÜí=äçëë=çå

åçå~äÅçÜçäáÅ=ëíÉ~íçÜÉé~íáíáëK=eÉé~íçäçÖó OMNMX=RNW=NONJVKUTK háêâ=bI=oÉÉÇë=aI=cáåÅâ=_I=Éí=~äK=aáÉí~êó=Ñ~í=~åÇ=Å~êÄçÜóÇê~íÉë=ÇáÑÑÉêÉåíá~ääó=~äíÉê=áåëìäáå=ëÉåëáíáîáíó=ÇìêáåÖ=Å~äçêáÅ

êÉëíêáÅíáçåK=d~ëíêçÉåíÉêçäçÖó OMMVX=NPSW=NRROJSMKUUK h~åí~êíòáë= hI= qÜ~ãÉê= `I= mÉíÉê= ^I= Éí= ~äK= eáÖÜ= Å~êÇáçêÉëéáê~íçêó= ÑáíåÉëë= áë= ~å= áåÇÉéÉåÇÉåí= éêÉÇáÅíçê= çÑ= íÜÉ

êÉÇìÅíáçå=áå=äáîÉê=Ñ~í=ÇìêáåÖ=~=äáÑÉëíóäÉ=áåíÉêîÉåíáçå=áå=åçåJ~äÅçÜçäáÅ=Ñ~ííó=äáîÉê=ÇáëÉ~ëÉK=dìí OMMVX=RUW=NOUNJUKUVK tÉëíÉêÄ~Åâ~=gI=i~ããá=hI=e~ââáåÉå=^JjI=Éí=~äK=aáÉí~êó=Ñ~í=ÅçåíÉåí=ãçÇáÑáÉë=äáîÉê=Ñ~í=áå=çîÉêïÉáÖÜí=åçåÇá~ÄÉíáÅ

ëìÄàÉÅíëK=g=`äáå=båÇçÅêáåçä=jÉí~Ä OMMRX=VMW=OUMQJVKVMK mÉíÉêëÉå=hcI=aìÑçìê=pI=_ÉÑêçó=aI=Éí=~äK=oÉîÉêë~ä=çÑ=åçå~äÅçÜçäáÅ=ÜÉé~íáÅ=ëíÉ~íçëáëI=ÜÉé~íáÅ=áåëìäáå=êÉëáëí~åÅÉI

~åÇ=ÜóéÉêÖäóÅÉãá~=Äó=ãçÇÉê~íÉ=ïÉáÖÜí=êÉÇìÅíáçå=áå=é~íáÉåíë=ïáíÜ=íóéÉ=O=Çá~ÄÉíÉëK=aá~ÄÉíÉë OMMRX=RQW=SMPJUKVNK i~òç=jI=pçäÖ~=pI=eçêëâ~=^I=Éí=~äK=bÑÑÉÅí=çÑ=~=NOJãçåíÜ=áåíÉåëáîÉ=äáÑÉëíóäÉ=áåíÉêîÉåíáçå=çå=ÜÉé~íáÅ=ëíÉ~íçëáë=áå

~Çìäíë=ïáíÜ=íóéÉ=O=Çá~ÄÉíÉëK=aá~ÄÉíÉë=`~êÉ OMNMX=PPW=ONRSJSPKVOK qÜ~ãÉê=`I=j~ÅÜ~åå=gI=píÉÑ~å=kI=Éí=~äK=eáÖÜ=îáëÅÉê~ä=Ñ~í=ã~ëë=~åÇ=ÜáÖÜ=äáîÉê=Ñ~í=~êÉ=~ëëçÅá~íÉÇ=ïáíÜ=êÉëáëí~åÅÉ

íç=äáÑÉëíóäÉ=áåíÉêîÉåíáçåK=lÄÉëáíó OMMTX=NRW=RPNJUKVPK pÅÜ~ÑÉê=pI=h~åí~êíòáë=hI=j~ÅÜ~åå= gI= Éí= ~äK= iáÑÉëíóäÉ= áåíÉêîÉåíáçå= áå= áåÇáîáÇì~äë=ïáíÜ= åçêã~ä= îÉêëìë= áãé~áêÉÇ

ÖäìÅçëÉ=íçäÉê~åÅÉK=bìê=g=`äáå=fåîÉëí OMMTX=PTW=RPRJQPKVQK q~ãìê~=vI=q~å~â~=vI=p~íç=cI=Éí=~äK=bÑÑÉÅíë=çÑ=ÇáÉí=~åÇ=ÉñÉêÅáëÉ=çå=ãìëÅäÉ=~åÇ=äáîÉê=áåíê~ÅÉääìä~ê=äáéáÇ=ÅçåíÉåíë

~åÇ=áåëìäáå=ëÉåëáíáîáíó=áå=íóéÉ=O=Çá~ÄÉíáÅ=é~íáÉåíëK=g=`äáå=båÇç=jÉí~Ä OMMRX=VMW=PNVNJSKVRK _ÉäÑçêí=oI=e~êêáëçå=p^I=_êçïå=hI=Éí=~äK=^=éä~ÅÉÄçJÅçåíêçääÉÇ=íêá~ä=çÑ=éáçÖäáí~òçåÉ=áå=ëìÄàÉÅíë=ïáíÜ=åçå~äÅçÜçäáÅ

ëíÉ~íçÜÉé~íáíáëK=k=båÖä=g=jÉÇ OMMSX=PRRW=OOVTJPMTKVSK j~íÜìêáå=mI=eçääÉÄÉÅèìÉ=^I=^êå~äëíÉÉå=iI=Éí=~äK=mêçëéÉÅíáîÉ=ëíìÇó=çÑ=íÜÉ=äçåÖJíÉêã=ÉÑÑÉÅíë=çÑ=Ä~êá~íêáÅ=ëìêÖÉêó

çå=äáîÉê=áåàìêó=áå=é~íáÉåíë=ïáíÜçìí=~Çî~åÅÉÇ=ÇáëÉ~ëÉK=d~ëíêçÉåíÉêçäçÖó OMMVX=NPTW=RPOJQMKVTK `ëÉåÇÉë=^I=pãçâ=dI=_ìêÖçë=^jK=eáëíçäçÖáÅ~ä=ÑáåÇáåÖë=áå=íÜÉ=äáîÉê=ÄÉÑçêÉ=~åÇ=~ÑíÉê=Ö~ëíêáÅ=Äóé~ëëK=lÄÉë=pìêÖ

OMMSX=NSW=SMTJNNKVUK _ìÖá~åÉëá= bI=dÉåíáäÅçêÉ=bI=j~åáåá=oI= Éí= ~äK=^= ê~åÇçãáòÉÇ= ÅçåíêçääÉÇ= íêá~ä= çÑ=ãÉíÑçêãáå= îÉêëìë= îáí~ãáå=b= çê

éêÉëÅêáéíáîÉ=ÇáÉí=áå=åçå~äÅçÜçäáÅ=Ñ~ííó=äáîÉê=ÇáëÉ~ëÉK=^ã=g=d~ëíêçÉåíÉêçä OMMRX=NMMW=NMUOJVMKVVK p~åó~ä=^gI=jçÑê~Ç=mpI=`çåíçë=jgI=Éí=~äK=^=éáäçí=ëíìÇó=çÑ=îáí~ãáå=b=îÉêëìë=îáí~ãáå=b=~åÇ=éáçÖäáí~òçåÉ=Ñçê=íÜÉ

íêÉ~íãÉåí=çÑ=åçå~äÅçÜçäáÅ=ëíÉ~íçÜÉé~íáíáëK=`äáå=d~ëíêçÉåíÉêçä=eÉé~íçä=OMMQX=OW=NNMTJNRKNMMK e~êêáëçå=p^I=qçêÖÉêëçå=pI=e~ó~ëÜá=mI=Éí=~äK=sáí~ãáå=b=~åÇ=îáí~ãáå=`=íêÉ~íãÉåí=áãéêçîÉë=ÑáÄêçëáë=áå=é~íáÉåíë=ïáíÜ

åçå~äÅçÜçäáÅ=ëíÉ~íçÜÉé~íáíáëK=^ã=g=d~ëíêçÉåíÉêçä OMMPX=VUW=OQURJVMKNMNK läÉÑëâó=gI=dä~ëë=`K=j~ÅêçéÜ~ÖÉëI=áåÑä~ãã~íáçåI=~åÇ=áåëìäáå=êÉëáëí~åÅÉK=^åå=oÉî=mÜóëáçä=OMNMX=TOW=ONVJQSKNMOK _çÖ~Åâ~= fI= uáÉ=eI=_ê~ó=d^I= Éí= ~äK= qÜÉ= ÉÑÑÉÅí= çÑ= éáçÖäáí~òçåÉ=çå=éÉêçñáëçãÉ=éêçäáÑÉê~íçêJ~Åíáî~íÉÇ= êÉÅÉéíçêJ

Ö~ãã~=í~êÖÉí=ÖÉåÉë=êÉä~íÉÇ=íç=äáéáÇ=ëíçê~ÖÉ=áå=îáîçK=aá~ÄÉíÉë=`~êÉ OMMQX=OTW=NSSMJTKNMPK o~âçëâá=jI= páåÖ~ä= ^I= oçÖÉêë=jI= Éí= ~äK=jÉí~J~å~äóëáëW= áåëìäáå= ëÉåëáíáòÉêë= Ñçê= íÜÉ= íêÉ~íãÉåí= çÑ= åçåJ~äÅçÜçäáÅ

ëíÉ~íçÜÉé~íáíáëK=^äáãÉåí=mÜ~êã~Åçä=qÜÉê=OMNMX=POW=NONNJONK

Evidence-based Management of Diabetes

20

NMQK _ÉäÑçêí=oI=e~êêáëçå=p^I=_êçïå=hI=Éí=~äK=^=éä~ÅÉÄçJÅçåíêçääÉÇ=íêá~ä=çÑ=éáçÖäáí~òçåÉ=áå=ëìÄàÉÅíë=ïáíÜ=åçå~äÅçÜçäáÅëíÉ~íçÜÉé~íáíáëK=k=båÖä=g=jÉÇ=OMMSX=PRRW=OOVTJPMTK

NMRK ^áíÜ~ä=dmI= qÜçã~ë= g^I= h~óÉ= msI= Éí= ~äK o~åÇçãáòÉÇI= éä~ÅÉÄçJÅçåíêçääÉÇ= íêá~ä= çÑ= éáçÖäáí~òçåÉ= áå= åçåÇá~ÄÉíáÅëìÄàÉÅíë=ïáíÜ=åçå~äÅçÜçäáÅ=ëíÉ~íçÜÉé~íáíáëK d~ëíêçÉåíÉêçäçÖó=OMMUX=NPRW=NNTSJUQK

NMSK iÉïáë=gaI=cÉêê~ê~=^I=mÉåÖ=qI=Éí=~äK=oáëâ=çÑ=Ää~ÇÇÉê=Å~åÅÉê=~ãçåÖ=Çá~ÄÉíáÅ=é~íáÉåíë=íêÉ~íÉÇ=ïáíÜ=éáçÖäáí~òçåÉWáåíÉêáã=êÉéçêí=çÑ=~=äçåÖáíìÇáå~ä=ÅçÜçêí=ëíìÇóK=aá~ÄÉíÉë=`~êÉ OMNNX=PQW=VNSJOOK

NMTK `ìëá=hI=aÉcêçåòç=oK=jÉíÑçêãáåW=~=êÉîáÉï=çÑ=áíë=ãÉí~ÄçäáÅ=ÉÑÑÉÅíëK=aá~ÄÉíÉë=oÉîáÉïë=NVVUX=SW=UVJNPNKNMUK `ìëá=hI=`çåëçäá=^I=aÉcêçåòç=oK=jÉí~ÄçäáÅ=ÉÑÑÉÅíë=çÑ=ãÉíÑçêãáå=çå=ÖäìÅçëÉ=~åÇ=ä~Åí~íÉ=ãÉí~Äçäáëã=áå=kfaajK

g=`äáå=båÇç=jÉí~Ä=NVVSX=UNW=QMRVJSTKNMVK hÉååó= moI= _ê~Çó=abI= qçêêÉë=ajI= Éí= ~äK= bñÉå~íáÇÉ= áå= íÜÉ= íêÉ~íãÉåí= çÑ= Çá~ÄÉíáÅ= é~íáÉåíë=ïáíÜ= åçåJ~äÅçÜçäáÅ

ëíÉ~íçÜÉé~íáíáëW=~=Å~ëÉ=ëÉêáÉëK ^ã=g=d~ëíêçÉåíÉêçä=OMNMX=NMRW=OTMTJVKNNMK häçåçÑÑ=a`I=_ìëÉ=g_I=káÉäëÉå=iiI=Éí=~äK=bñÉå~íáÇÉ=ÉÑÑÉÅíë=çå=Çá~ÄÉíÉëI=çÄÉëáíóI=Å~êÇáçî~ëÅìä~ê=êáëâ=Ñ~Åíçêë=~åÇ

ÜÉé~íáÅ=Äáçã~êâÉêë=áå=é~íáÉåíë=ïáíÜ=íóéÉ=O=Çá~ÄÉíÉë=íêÉ~íÉÇ=Ñçê=~í=äÉ~ëí=P=óÉ~êëK=`ìêê=jÉÇ=oÉë=léáå=OMMUX=OQWOTRJUSK

NNNK gÉåÇäÉ= gI= k~ìÅâ= j^I= j~ííÜÉïë= aoI= Éí= ~äK=tÉáÖÜí= äçëë= ïáíÜ= äáê~ÖäìíáÇÉI= ~= çåÅÉJÇ~áäó= Üìã~å= ÖäìÅ~ÖçåJäáâÉéÉéíáÇÉJN=~å~äçÖìÉ=Ñçê=íóéÉ=O=Çá~ÄÉíÉë=íêÉ~íãÉåí=~ë=ãçåçíÜÉê~éó=çê=~ÇÇÉÇ=íç=ãÉíÑçêãáåI=áë=éêáã~êáäó=~ë=~=êÉëìäíçÑ=~=êÉÇìÅíáçå=áå=Ñ~í=íáëëìÉK=aá~ÄÉíÉë=lÄÉë=jÉí~Ä=OMMVX=NNW=NNSPJTOK

NNOK o~íòáì= sI= `~äÇïÉää= pI= kÉìëÅÜï~åÇÉêJqÉíêá= _^K= qÜÉê~éÉìíáÅ= íêá~äë= áå= åçå~äÅçÜçäáÅ= ëíÉ~íçÜÉé~íáíáëW= áåëìäáåëÉåëáíáòÉêë=~åÇ=êÉä~íÉÇ=ãÉíÜçÇçäçÖáÅ~ä=áëëìÉëK=eÉé~íçäçÖó OMNMX=ROW=OOMSJNRK

NNPK jìëëç= dI= d~ãÄáåç= oI= `~ëë~ÇÉê= jI= Éí= ~äK= ^= ãÉí~J~å~äóëáë= çÑ= ê~åÇçãáòÉÇ= íêá~äë= Ñçê= íÜÉ= íêÉ~íãÉåí= çÑåçå~äÅçÜçäáÅ=Ñ~ííó=äáîÉê=ÇáëÉ~ëÉK=eÉé~íçäçÖó=OMNMX=ROW=TVJNMQK

NNQK ^äá=oI=`ìëá=hK=kÉï=Çá~ÖåçëíáÅ=~åÇ=íêÉ~íãÉåí=~ééêç~ÅÜÉë=áå=åçåJ~äÅçÜçäáÅ=Ñ~ííó=äáîÉê=ÇáëÉ~ëÉ=Ek^ciaFK= åå=jÉÇOMMVX=QNW=OSRJTUK

NNRK iççãÄ~=oI=iìíÅÜã~å=dI=häÉáåÉê=aI=Éí=~äK=`äáåáÅ~ä=íêá~äW=éáäçí=ëíìÇó=çÑ=ãÉíÑçêãáå=Ñçê=íÜÉ=íêÉ~íãÉåí=çÑ=åçå~äÅçÜçäáÅëíÉ~íçÜÉé~íáíáëK=^äáãÉåí=mÜ~êã~Åçä=qÜÉê=OMMVX=OVW=NTOJUOK

NNSK aìëÉà~=^I=a~ë=^I=aÜáã~å=ohI=Éí=~äK=jÉíÑçêãáå=áë=ÉÑÑÉÅíáîÉ=áå=~ÅÜáÉîáåÖ=ÄáçÅÜÉãáÅ~ä=êÉëéçåëÉ=áå=é~íáÉåíë=ïáíÜåçå~äÅçÜçäáÅ=Ñ~ííó=äáîÉê=ÇáëÉ~ëÉ=Ek^ciaF=åçí=êÉëéçåÇáåÖ=íç=äáÑÉëíóäÉ=áåíÉêîÉåíáçåëK=^åå=eÉé~íçä=OMMTX=SW=OOOJSK

NNTK e~ìâÉä~åÇ= gI=hçåçéëâá= wI=bÖÖÉëÄ›=eI= Éí= ~äK=jÉíÑçêãáå= áå= é~íáÉåíë=ïáíÜ= åçåJ~äÅçÜçäáÅ= Ñ~ííó= äáîÉê= ÇáëÉ~ëÉW= ~ê~åÇçãáòÉÇI=ÅçåíêçääÉÇ=íêá~äK=pÅ~åÇ=g=d~ëíêçÉåíÉêçä OMMVX=QQW=URPJSMK

NNUK aáåÖ= uI= p~ñÉå~=khI= iáå= pI= Éí= ~äK= bñÉåÇáåJQI= ~= ÖäìÅ~ÖçåJäáâÉ= éêçíÉáåJN= EdimJNF= êÉÅÉéíçê= ~ÖçåáëíI= êÉîÉêëÉëÜÉé~íáÅ=ëíÉ~íçëáë=áå=çÄLçÄ=ãáÅÉK eÉé~íçäçÖó OMMSX=QPW=NTPJUNK

NNVK pîÉÖäá~íáJ_~êçåá=dI=p~ÅÅçã~ååç=pI=oóÅÜäáÅâá=`I=Éí=~äK=däìÅ~ÖçåJäáâÉ=éÉéíáÇÉJN=êÉÅÉéíçê=~Åíáî~íáçå=ëíáãìä~íÉëÜÉé~íáÅ= äáéáÇ= çñáÇ~íáçå= ~åÇ= êÉëíçêÉë= ÜÉé~íáÅ= ëáÖå~ääáåÖ= ~äíÉê~íáçå= áåÇìÅÉÇ= Äó= ~= ÜáÖÜJÑ~í= ÇáÉí= áå= åçå~äÅçÜçäáÅëíÉ~íçÜÉé~íáíáëK=iáîÉê=fåí OMNNX=PNW=NOURJVTK

NOMK dìéí~=k^I=jÉääë=gI=aìåÜ~ã=ojI=Éí=~äK=däìÅ~ÖçåJäáâÉ=éÉéíáÇÉJN=êÉÅÉéíçê=áë=éêÉëÉåí=çå=Üìã~å=ÜÉé~íçÅóíÉë=~åÇÜ~ë= ~= ÇáêÉÅí= êçäÉ= áå= ÇÉÅêÉ~ëáåÖ= ÜÉé~íáÅ= ëíÉ~íçëáë= áå= îáíêç Äó= ãçÇìä~íáåÖ= ÉäÉãÉåíë= çÑ= íÜÉ= áåëìäáå= ëáÖå~äáåÖé~íÜï~óK=eÉé~íçäçÖó OMNMX=RNW=NRUQJVOK

21 Non-alcoholic fatty liver disease (NAFLD) in diabetes: distraction or impending disaster?

21

Evidence-based Management of Diabetes

22


Recommended