Although few patients in this cohort had liver

biopsy, cirrhosis was found in 12% of patients with abnormal OGTT and 4% of those with normal glucose tolerance. These two studies concur with previous studies showing that one-third to one-half of NAFLD patients had undiagnosed diabetes and impaired glucose tolerance.11 Thus, the number needed to screen for OGTT to detect abnormal glucose regulation is only 2 to 3. Even in NAFLD patients with normal fasting glucose, the number needed to screen is less than 5. In cross-sectional and longitudinal studies, post-challenge hyperglycemia appears to be associated with adverse clinical outcomes. In a study of 1040 patients JQ1 chemical structure undergoing coronary angiogram, impaired glucose tolerance or diabetes by OGTT was associated this website with cardiovascular events (defined as a composite of vascular deaths, non-fatal myocardial infarctions, non-fatal strokes, percutaneous coronary interventions, bypass graftings, and revascularizations of non-coronary arteries) at a mean follow-up of 3.8 years.12 In another histological cohort, impaired glucose tolerance and diabetes were also associated with advanced liver fibrosis or cirrhosis.11

While it is unclear if post-challenge hyperglycemia itself contributes to the pathogenesis of these clinical complications, OGTT may help clinicians to identify high-risk patients for more intensive monitoring and treatment. At present, lifestyle changes and insulin sensitizers have been shown to be useful in the treatment of impaired glucose tolerance or pre-diabetes. In the landmark Diabetes Prevention Program Study, 3234 patients with elevated fasting or post-challenge plasma glucose were randomized to placebo, metformin, or a lifestyle-modification

program.13 While both treatments prevented the progression to DNA ligase diabetes, it was remarkable that lifestyle modification achieved even lower incidence of diabetes than metformin treatment. This highlights the importance of lifestyle intervention in patients with metabolic disorders. Recently, randomized controlled trials have confirmed that lifestyle modification is effective in reducing hepatic fat in NAFLD patients.14 The full extent of benefits will become clearer when larger clinical trials are completed. Do we have new markers to replace OGTT? Although clinicians commonly use glycosylated hemoglobin levels to monitor glycemic control of patients with diabetes, the test has limited sensitivity and specificity in diagnosing impaired glucose tolerance. Besides, the tests for glycosylated hemoglobin have not been fully standardized, making comparison among different centers difficult. Lately, a number of adipocyte-secreted proteins, collectively known as adipokines, have been shown to have various effects on insulin sensitivity and inflammation.