In recent years, a strong link has been established between nonalcoholic fatty liver disease (NAFLD) and the pathogenesis of type 2 diabetes mellitus. The potential role of NAFLD in cardiovascular disease (CVD) has also attracted interest. Published studies have tended to use biochemical and imaging surrogate markers of NAFLD, such as elevated gamma glutamyl transpeptidase (GGT) and alanine aminotransferase (ALT) and fatty liver on ultrasound, when investigating associations with incident CVD events. Positive associations between both baseline GGT and temporal change in GGT, as well as cardiovascular events and cardiovascular mortality independent of alcohol intake, have been reported in several prospective studies. However, adjustment for confounders is often incomplete, and there is scant evidence of improvement in cardiovascular risk prediction beyond established risk scores when incorporating such data. There also appears to be a strong and underrecognized age interaction, with associations between GGT and incident coronary heart disease (CHD) being strong in young individuals but relatively weak in the elderly. By contrast, ALT appears to be only weakly associated with incident CHD and may exhibit a U-shaped association with total mortality. Finally, although some studies have linked imaging-defined and biopsy-confirmed NAFLD with CVD risk, the evidence is inconsistent, with few incident events and/or insufficient potential confounders. Conclusion: A diagnosis of NAFLD is insufficient to consider patients as being at high risk for CVD. The presence of NAFLD should be a clear indication for diabetes screening, but cardiovascular risk screening should be performed with the use of existing risk calculators and should be guided by established cardiovascular risk factors.

Smoking prevalence is generally high among Muslims. An awareness of their religious beliefs and rulings might increase the effectiveness of antismoking campaigns

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Aims/hypothesisThis study aimed to determine the extent to which increased insulin resistance and fasting glycaemia in South Asian men, compared with white European men, living in the UK, was due to lower cardiorespiratory fitness (maximal oxygen uptake []) and physical activity.MethodsOne hundred South Asian and 100 age- and BMI-matched European men without diagnosed diabetes, aged 40–70 years, had fasted blood taken for measurement of glucose concentration, HOMA-estimated insulin resistance (HOMAIR), plus other risk factors, and underwent assessment of physical activity (using accelerometry), , body size and composition, and demographic and other lifestyle factors. For 13 South Asian and one European man, HbA1c levels were >6.5% (>48 mmol/mol), indicating potential undiagnosed diabetes; these men were excluded from the analyses. Linear regression models were used to determine the extent to which body size and composition, fitness and physical activity variables explained differences in HOMAIR and fasting glucose between South Asian and European men.ResultsHOMAIR and fasting glucose were 67% (p < 0.001) and 3% (p < 0.018) higher, respectively, in South Asians than Europeans. Lower , lower physical activity and greater total adiposity in South Asians individually explained 68% (95% CI 45%, 91%), 29% (11%, 46%) and 52% (30%, 80%), respectively, and together explained 83% (50%, 119%) (all p < 0.001) of the ethnic difference in HOMAIR. Lower and greater total adiposity, respectively, explained 61% (9%, 111%) and 39% (9%, 76%) (combined effect 63% [8%, 115%]; all p < 0.05) of the ethnic difference in fasting glucose.Conclusions/interpretationLower cardiorespiratory fitness is a key factor associated with the excess insulin resistance and fasting glycaemia in middle-aged South Asian, compared with European, men living in the UK.Electronic supplementary materialThe online version of this article (doi:10.1007/s00125-013-2969-y) contains peer-reviewed but unedited supplementary material, which is available to authorised users.

Objective HbA1c levels are increasingly measured in screening for diabetes; we investigated whether HbA1c may simultaneously improve CVD risk assessment, using QRISK3, ACC/AHA and SCORE scoring systems. Research Design and Methods UK Biobank participants without baseline CVD or known diabetes (n=358,275) were included. Associations of HbA1c with CVD was assessed using Cox models adjusting for classical risk factors. Predictive utility was determined by the C-index and net reclassification index (NRI). A separate analysis was conducted in 16,619 participants with known baseline diabetes. Results Incident fatal or non-fatal CVD, as defined in the QRISK3 prediction model, occurred in 12,894 participants over 8.9 years. 3.3% (n=11,680) of participants had prediabetes (42.0-47.9mmol/mol (6.0 to 6.4%) and 0.7% (n=2579) undiagnosed diabetes (≥48.0mmol/mol;≥ 6.5%). In unadjusted models, compared with the reference group (<42.0 mmol/mol; <6.0%), those with prediabetes and undiagnosed diabetes were at higher CVD risk: HR 1.83 (95% CI 1.69-1.97) and 2.26 (95% CI 1.97-2.61), respectively. After adjustment for classical risk factors, these attenuated to HR 1.11 (95% CI 1.03-1.20) and 1.20 (1.04-1.38), respectively. Adding HbA1c to the QRISK3 CVD risk prediction model (C-index 0.7387) yielded a small improvement in discrimination (C-index +0.0004, 95% CI 0.0001, 0.0007). The NRI showed no improvement. Results were similar for models based on the ACC/AHA and SCORE risk models. Conclusion The near twofold higher unadjusted risk for CVD in prediabetes is driven mainly by abnormal levels of conventional CVD risk factors. Whilst HbA1c adds minimally to CV risk prediction, those with pre-diabetes should have their conventional CV risk factors appropriately measured and managed.

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International public health guidelines recommend that adults undertake at least 150 min.week−1 of moderate-intensity physical activity. However, the underpinning evidence has largely been obtained from studies of populations of white European descent. It is unclear whether these recommendations are appropriate for other ethnic groups, particularly South Asians, who have greater cardio-metabolic risk than white Europeans. The objective of our study was to determine the level of moderate-intensity physical activity required in South Asians adults to confer a similar cardio-metabolic risk profile to that observed in Europeans of similar age and body mass index (BMI) undertaking the currently recommended levels of 150 min.week−1. 148 South Asians and 163 white Europeans aged 18 to 70 years were recruited. Physical activity was measured objectively via vertical axis accelerations from hip-worn accelerometers. Factor analysis was used to summarize the measured risk biomarkers into a single underlying latent “factor” describing overall cardio-metabolic risk. Sex did not modify the association between physical activity and the cardio-metabolic risk factor, so data for both sexes were combined and models adjusted for age, sex, BMI and accelerometer wear time. We estimated that South Asian adults needed to undertake 232 (95% Confidence interval: 200 to 268) min.week−1 in order to obtain the same cardio-metabolic risk factor score as a white European undertaking 150 minutes of moderate-equivalent physical activity per week. The present findings suggest that South Asian men and women need to undertake ~230 minutes of moderate intensity physical activity per week. This equates to South Asians undertaking an extra 10–15 minutes of moderate intensity physical activity per day on top of existing recommendations.

Fasting in the Islamic month of Ramadan is obligatory for all sane, healthy adult Muslims. The length of the day varies significantly in temperate regions-typically lasting C 18 h during peak summer in the UK. The synodic nature of the Islamic calendar means that Ramadan migrates across all four seasons over an approximately 33-year cycle. Despite valid exemptions, there is an intense desire to fast during this month, even among those who are considered to be at high risk, including many individuals with diabetes mellitus. In this review we explore the current scientific and clinical evidence on fasting in patients with diabetes mellitus, focussing on type 2 diabetes mellitus and type 1 diabetes mellitus, with brief reviews on pregnancy, pancreatic diabetes, bariatric surgery, the elderly population and current practice guidelines. We also make recommendations on the management of diabetes patients during the month of Ramadan.