Diabetes & Metabolism Journal

Brief Report

Epidemiology
Glycosylated Hemoglobin Threshold for Predicting Diabetes and Prediabetes from the Fifth Korea National Health and Nutrition Examination Survey: Sangmo Hong, Jun Goo Kang, Chul Sik Kim, Seong Jin Lee, Cheol-Young Park, Chang Beom Lee, Sung-Hee Ihm; Diabetes Metab J. 2016;40(2):167-170. Published online April 5, 2016; DOI: https://doi.org/10.4093/dmj.2016.40.2.167

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We aimed to estimate the threshold level of glycosylated hemoglobin (HbA1c) for the fasting plasma glucose of 100 and 126 mg/dL in the Korean adult population, using the 2011 Korea National Health and Nutrition Examination Survey. A total of 4,481 participants over 19 years of age without diabetic medications and conditions to influence the interpretation of HbA1c levels, such as anemia, renal insufficiency, liver cirrhosis, and cancers, were analyzed. A point-wise area under the receiver operating characteristic curve was used to estimate the optimal HbA1c cutoff value. A HbA1c threshold of 6.35% was optimal for predicting diabetes with a sensitivity of 86.9% and a specificity of 99.1%. Furthermore, the threshold of HbA1c was 5.65% for prediabetes, with a sensitivity of 69.3% and a specificity of 71%. Further prospective studies are needed to evaluate the HbA1c cutoff point for diagnosing prediabetes and diabetes in the Korean population.

Citations

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The Cutoff Value of HbA1c in Predicting Diabetes and Impaired Fasting Glucose
Seyoung Kwon, Youngak Na
The Korean Journal of Clinical Laboratory Science.2017; 49(2): 114. CrossRef
Cutoff Point of HbA1c for Diagnosis of Diabetes Mellitus in Chinese Individuals
Bing Wang, Ming-Chuan Liu, Xin-Yu Li, Xu-Han Liu, Qiu-Xia Feng, Lu Lu, Zhu Zhu, Ying-Shu Liu, Wei Zhao, Zheng-Nan Gao, Noel Christopher Barengo
PLOS ONE.2016; 11(11): e0166597. CrossRef

Original Articles

Is A1C Variability an Independent Predictor for the Progression of Atherosclerosis in Type 2 Diabetic Patients?: Chul Sik Kim, So Young Park, Sung Hoon Yu, Jun Goo Kang, Ohk Hyun Ryu, Seong Jin Lee, Eun Gyung Hong, Hyeon Kyu Kim, Doo-Man Kim, Jae Myung Yoo, Sung Hee Ihm, Moon Gi Choi, Hyung Joon Yoo; Korean Diabetes J. 2010;34(3):174-181. Published online June 30, 2010; DOI: https://doi.org/10.4093/kdj.2010.34.3.174

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Abstract PDF PubReader

Background

Little is known about the relative contribution of long-term glycemic variability to the risk of macrovascular complications in type 2 diabetes. This study was conducted to evaluate the effect of A1C variability on the progression of carotid artery intima-media thickness (IMT) in type 2 diabetic patients.

Methods

Among type 2 diabetic patients who visited Hallym University Sacred Heart Hospital from March 2007 to September 2009, 120 patients who had carotid artery IMT measured annually and A1C checked every three months for at least one year were analyzed. Individual A1C variability was defined as the standard deviation (SD) of five A1C levels taken every three months for approximately one year. Change in IMT was defined as an increase in IMT on follow-up measurement. The association between the SD of A1C and changes in IMT was evaluated.

Results

With greater A1C variability, there was a greater increase in the mean IMT (r = 0.350, P < 0.001) of the carotid artery. After adjusting for confounding factors that may influence IMT, A1C variability was significantly associated with the progression of IMT (r = 0.222, P = 0.034). However, the SD of A1C was not a significant independent risk factor for the progression of IMT in multiple regression analysis (β = 0.158, P = 0.093).

Conclusion

Higher A1C variability is associated with IMT progression in type 2 diabetic patients; however, it is not an independent predictor of IMT progression. Overall glycemic control is the most important factor in the progression of IMT.

Citations

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Long-Term Risk of Cardiovascular Disease Among Type 2 Diabetes Patients According to Average and Visit-to-Visit Variations of HbA1c Levels During the First 3 Years of Diabetes Diagnosis
Hyunah Kim, Da Young Jung, Seung-Hwan Lee, Jae-Hyoung Cho, Hyeon Woo Yim, Hun-Sung Kim
Journal of Korean Medical Science.2023;[Epub] CrossRef
Association Between Long-Term Visit-to-Visit Hemoglobin A1c and Cardiovascular Risk in Type 2 Diabetes: The ACCORD Trial
Dan Huang, Yong-Quan Huang, Qun-Ying Zhang, Yan Cui, Tian-Yi Mu, Yin Huang
Frontiers in Cardiovascular Medicine.2021;[Epub] CrossRef
Association of Longitudinal Values of Glycated Hemoglobin With Cardiovascular Events in Patients With Type 2 Diabetes and Multivessel Coronary Artery Disease
Paulo Cury Rezende, Mark Andrew Hlatky, Whady Hueb, Rosa Maria Rahmi Garcia, Luciano da Silva Selistre, Eduardo Gomes Lima, Cibele Larrosa Garzillo, Thiago Luis Scudeler, Gustavo Andre Boeing Boros, Fernando Faglioni Ribas, Carlos Vicente Serrano, Jose An
JAMA Network Open.2020; 3(1): e1919666. CrossRef
Haemoglobin A1c variability as an independent correlate of atherosclerosis and cardiovascular disease in Chinese type 2 diabetes
Yifei Mo, Jian Zhou, Xiaojing Ma, Wei Zhu, Lei Zhang, Jie Li, Jingyi Lu, Cheng Hu, Yuqian Bao, Weiping Jia
Diabetes and Vascular Disease Research.2018; 15(5): 402. CrossRef
Relationship of HbA1c variability, absolute changes in HbA1c, and all-cause mortality in type 2 diabetes: a Danish population-based prospective observational study
Mette V Skriver, Annelli Sandbæk, Jette K Kristensen, Henrik Støvring
BMJ Open Diabetes Research & Care.2015; 3(1): e000060. CrossRef
Association between hemoglobin A1c variability and subclinical coronary atherosclerosis in subjects with type 2 diabetes
Hae Kyung Yang, Borami Kang, Seung-Hwan Lee, Kun-Ho Yoon, Byung-Hee Hwang, Kiyuk Chang, Kyungdo Han, Gunseog Kang, Jae Hyoung Cho
Journal of Diabetes and its Complications.2015; 29(6): 776. CrossRef
Glycated hemoglobin as a marker of subclinical atherosclerosis and cardiac remodeling among non-diabetic adults from the general population
Robin Haring, Sebastian E. Baumeister, Wolfgang Lieb, Bettina von Sarnowski, Henry Völzke, Stephan B. Felix, Matthias Nauck, Henri Wallaschofski
Diabetes Research and Clinical Practice.2014; 105(3): 416. CrossRef
HbA1c Variability and Micro- and Macrovascular Complications of Diabetes
Hae Kyung Yang, Seung-Hwan Lee
The Journal of Korean Diabetes.2014; 15(4): 202. CrossRef
HbA1c variability and the development of microalbuminuria in type 2 diabetes: Tsukuba Kawai Diabetes Registry 2
A. Sugawara, K. Kawai, S. Motohashi, K. Saito, S. Kodama, Y. Yachi, R. Hirasawa, H. Shimano, K. Yamazaki, H. Sone
Diabetologia.2012; 55(8): 2128. CrossRef

The Effect of alpha-Lipoic Acid on Proteinuria and Renal TGFbeta Expression in Obese Type 2 Diabetic Rat Model.: Seok Woo Kang, Seong Jin Lee, Dong Sun Kim, Tae Wha Kim; Korean Diabetes J. 2008;32(1):21-29. Published online February 1, 2008; DOI: https://doi.org/10.4093/kdj.2008.32.1.21

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Abstract PDF

BACKGROUND
It is well known that renal TGFbeta expression is related to the development of diabetic nephropathy. Alpha-lipoic acid (ALA), a potent antioxidant and cofactor of mitochondrial respiratory enzymes, can improve the insulin resistance and the vascular endothelial dysfunction, and suppresses the development of diabetic vascular complications. This study was undertaken to investigate whether ALA could reduce urinary protein excretion and renal TGFbeta protein expression in obese type 2 diabetes mellitus animal model, Otsuka Long-Evans Tokushima Fatty (OLETF) rat. METHODS: Obese 30 male OLETF rats were randomly divided to 3 groups at the age of 30 weeks. The rats in the Control group fed normal rat chow while the rats in the ALA group were fed with rat chow containing ALA (0.5% of food weight). Ten rats in the Pair-fed group were fed with normal rat chow, but were given the same amount of food as consumed by the ALA group. During 5 weeks of ALA feeding, food intake and body weight were checked in metabolic chamber. Blood glucose levels, HbA1c and urinary protein excretion were measured at 30 weeks and 35 weeks of age, and renal TGFbeta protein expression at 35 weeks of age was measured by Western blot and represented by relative unit (RU). Immunohistochemical staining for TGFbeta protein in renal tissue was also examined at 35 weeks of age. RESULTS: Food intake, body weight, blood glucose levels, HbA1c and urinary protein excretion among the Control, ALA and Pair-fed groups at 30 weeks of age were not different. At 35 weeks of age, food intake was significantly decreased in the ALA group than the Control group (Control group vs. ALA group, 27.7 +/- 1.1 g/day vs. 22.4 +/- 1.4 g/day, P < 0.001), and body weight was significantly decreased in the ALA group than the Control and Pair-fed groups (Control group: 694.4 +/- 10.3 g, ALA group: 600.4 +/- 7.4 g, Pair-fed group: 685.4 +/- 11.6 g, P < 0.001). Blood glucose levels were significantly decreased in the ALA group than the Control and Pair-fed groups (Control group: 157.7 +/- 4.6 mg/dL, ALA group: 130.7 +/- 4.8 mg/dL, Pair-fed group: 153.7 +/- 3.3 mg/dL, P < 0.001) although blood glucose levels from 30 weeks to 34 weeks of age and HbA1c at 35 weeks of age were not different among the groups. Urinary protein excretion and renal TGFbeta protein expression were significantly decreased in the ALA group than the Control and Pair-fed groups (urinary protein excretion, Control group: 5.033 +/- 0.254 mg/mgCr, ALA group: 3.633 +/- 0.303 mg/mgCr, Pair-fed group: 4.977 +/- 0.339 mg/mgCr, P < 0.001; renal TGFbeta protein expression, Control group: 7.09 +/- 0.17 RU, ALA group: 4.14 +/- 0.26 RU, Pair-fed group: 7.00 +/- 0.29 RU, P < 0.001). In the ALA group at 35 weeks of age, urinary protein excretion and renal TGFbeta protein expression were positively related in the Control, ALA and Pair-fed groups (Control group, r = 0.847, P = 0.002; ALA group, r = 0.954, P < 0.001; Pair-fed group, r = 0.858, P = 0.002). TGFbeta staining in glomeruli was observed in all groups but was decreased in the ALA group at 35 weeks of age. CONCLUSION: These results suggest that ALA may prevent the increase of food intake, body weight, blood glucose, urinary protein excretion and renal TGFbeta protein expression in obese type 2 diabetic rat model. The effect of ALA on diabetic nephropathy presented as proteinuria and renal TGFbeta expression in diabetic patients needs to be further clarified.

Citations

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Dietary alpha-lipoic acid boosts growth, immune-antioxidant traits, behavior, and transcriptomes of antioxidant, apoptosis, and immune-related genes to combat cold stress in Nile tilapia (Oreochromis niloticus)
Amany Behairy, Hanan A. Ghetas, Noura A. Abd-Allah, Walaa El-Houseiny, Ahmed H. Arisha, Mohamed M. M. Metwally, Basma A. Elshafey, Adham A. Al-Sagheer, Engy M. M. Mohamed
Aquaculture International.2024; 32(4): 4061. CrossRef

The Relationship of Family Support with Blood Glucose Control in Elderly Type 2 Diabetic Patients.: Eun Suk Kim, Seong Jin Lee, Ohk Hyun Ryu, Jee Youn Lee, Hyun Suk Yun, Moon Gi Choi; Korean Diabetes J. 2007;31(5):435-443. Published online September 1, 2007; DOI: https://doi.org/10.4093/jkda.2007.31.5.435

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Abstract PDF

BACKGROUND
With the extension of human life span, the prevalence of diabetes in elderly population is increasing. The glycemic control is also important in elderly diabetics because the life expectancy in elderly is steadily increased. In this study, we investigated the role of family support on glycemic control in elderly type diabetic patients. METHODS: This study was conducted with 126 type 2 diabetic patients over 60 years of age who were enrolled between March and December, 2005. The data for glycemic control, family characteristics, and family support were collected by structured questionnaire, personal interview, and medical record review. We used total supportive index scores to evaluate family support. We evaluated the relationship between family support and glycemic control. RESULTS: Fasting plasma glucose was positively correlated with duration of diabetes (r = 0.277, P = 0.003). Postprandial 2 hour plasma glucose was negatively correlated with monthly incomes (r = -0.357, P = 0.002), assessment support (r = -0.201, P = 0.029). Hemoglobin A1c was positively correlated with duration with diabetes (r = 0.294, P = 0.002) and insulin use (r = 0.259, P = 0.004), but it was negatively correlated with diabetic self-management education (r = -0.190, P = 0.036). Adjusted for age, sex, duration of diabetes, and monthly incomes, there were no significant associations between glycemic control and family support. CONCLUSION: In this study, there were no significant associations between glycemic control and family support. More large prospective studies will be followed to exactly evaluate the role of family support in diabetic patients.

Citations

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The role of psychological insulin resistance in diabetes self‐care management
Ancho Lim, Youngshin Song
Nursing Open.2020; 7(3): 887. CrossRef
A Predictive Model of Health Outcomes for Young People with Type 2 Diabetes
Sun Young Jung, Sook Ja Lee, Sun Hee Kim, Kyung Mi Jung
Asian Nursing Research.2015; 9(1): 73. CrossRef
Factors Influencing Self-Care Behaviors Related to Insulin Therapy in Elders with Diabetes Mellitus
Na-Yeong Sohn, Jin-Hyang Yang
Journal of Korean Academy of Fundamentals of Nursing.2013; 20(1): 27. CrossRef
Perception of social support by individuals with diabetes mellitus and foot ulcers
Ana Laura Galhardo Figueira, Lílian Cristiane Gomes Villas Boas, Maria Cristina Foss de Freitas, Milton César Foss, Ana Emilia Pace
Acta Paulista de Enfermagem.2012; 25(spe1): 20. CrossRef
The impact of family support on metabolic control in patients with type 2 diabetes
Agata Matej-Butrym, Marek Butrym, Andrzej Jaroszyński
Zdrowie Publiczne.2012; 122(3): 265. CrossRef
Effects of Low Glycemic Index Nutrition Education on the Blood Glucose Control in Patients with Type 2 Diabetes Mellitus
Mi-Ja Kim, Sunja Kwon, Sun Yung Ly
The Korean Journal of Nutrition.2010; 43(1): 46. CrossRef
Relationships of family support, diet therapy practice and blood glucose control in typeII diabetic patients
Jeong-Ok Yun, Ki-Nam Kim
Nutrition Research and Practice.2009; 3(2): 141. CrossRef

Effects of Type 2 Diabetes Mellitus on Risk Factors of Acute Coronary Syndrome.: Hong Ju Moon, Jun Goo Kang, Min Ho Jo, Byung Wan Lee, Cheol Young Park, Seong Jin Lee, Eun Kyung Hong, Jae Myoung Yu, Doo Man Kim, Sung Hee Ihm, Hyun Kyu Kim, Chong Yun Rhim, Moon Gi Choi, Hyung Joon Yoo, Sung Woo Park; Korean Diabetes J. 2006;30(6):435-441. Published online November 1, 2006; DOI: https://doi.org/10.4093/jkda.2006.30.6.435

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BACKGROUND
Diabetes mellitus (DM) is equivalent as well a risk factor of cardiovascular disease. We analyzed the effects of DM on clinical risk factors of acute coronary syndrome by comparing DM group with Non-DM group. METHODS: A total of 847 (514 males and 333 females) patients with acute coronary syndrome was selected from 1664 patients who had undergone coronary angiography (CAG). These patients comprised 105 subjects with non-ST elevation myocardial infarction (MI), 313 with ST elevation MI and 429 with unstable angina. According to the presence of DM, we retrospectively reviewed the measured basic demographics, biochemical markers and coronary angiographic findings. RESULTS: In the multivariated analysis, history of hypertension (P = 0.001), C-reactive protein (CRP) level (P = 0.001) and triglyceride level (P = 0.018) were independent risk factors in type 2 diabetic group. Also the frequency of multiple coronary vessel disease was higher in DM group than non-DM group on the coronary angiographic finding CONCLUSIONS: Classic risk factors for acute coronary syndrome are strong predictors in patients with type 2 DM. Among these factors, the most important powerful risk factor is history of hypertension.

Citations

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Gender-Based Differences in the Management and Prognosis of Acute Coronary Syndrome in Korea
Hee Tae Yu, Kwang Joon Kim, Woo-Dae Bang, Chang-Myung Oh, Ji-Yong Jang, Sung-Soo Cho, Jung-Sun Kim, Young-Guk Ko, Donghoon Choi, Myeong-Ki Hong, Yangsoo Jang
Yonsei Medical Journal.2011; 52(4): 562. CrossRef

Clinical Characteristics and Analysis of Risk Factor for Gastroesophageal Reflux Disease in Diabetic Patient.: Kwang Hyuk Park, Seong Bo Yoon, Min Ho Jo, Eon Kyung Hong, Seong Jin Lee, In Kyung Jeong, Chul Young Park, Ki Won Oh, Hyun Kyu Kim, Jac Myoung Yu, Doo Man Kim, Sung Hee Lim, Moon Ki Choi, Hyung Jun Yoo, Sung Woo Park, Heung Young Oh, Jin Bae Kim, Il Hyun Baek, Myung Seok Lee; Korean Diabetes J. 2005;29(4):358-366. Published online July 1, 2005

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Abstract PDF: BACKGROUND
A high prevalence of gastroesophageal reflux disease(GERD) has been reported in diabetic patient. However, the exact mechanisms of GERD in diabetic patient have not been described. In several studies, diabetic neuropathy and dysfunction of the autonomic nervous system have been suggested as risk factors of GERD. However, there have been no studies on the exact prevalence or risk factors of GERD in Korean diabetic patients. Therefore, the prevalence of GERD in Korean diabetics patients was examined, and the risk factors for GERD, the differences in symptoms between GERD and non-GERD patients, and the degree of symptom relief after treatment were also analyzed. METHODS: A total of 310 diabetic patients, who underwent an upper gastroendoscopy due to diverse gastrointestinal symptoms, between April 2001 and November 2003, were enrolled. The diagnostic criteria or GERD included the upper gastroendoscopic view, which was analyzed using the scale of 'The Los Angeles Classification of Esophagus' from grades A to D. The prevalence and symptoms of GERD patients and the variable risk factors, such as blood glucose level, smoking and diabetic neuropathy, were examined. RESULTS: 1) There was an 18.4% prevalence of GERD in diabetic patients. 2) The clinical characteristics, including sex, age and serum lipid level, of the GERD group were not significantly different to those of the control group. However, the duration of smoking, the fasting and postprandial 2-hour serum glucose levels, and the diabetic neuropathy significantly affected GERD, 3) The main symptoms of the GERD group were dyspepsia(47.4%) and heart burn(26.3%). 4) The degree of subjective symptom relief in the GERD group after treatment with the proton pump inhibitor, pantoprazole(40mg), was remarkably lower than in the control group for approximately 1 month. CONCLUSION: In this study, the prevalence of GERD in diabetic patient was higher than that found in the general population which suggests that GERD in diabetic patient was due to a poorly controlled serum glucose level and diabetic neuropathy. The chief complaints pertaining to gastrointestinal symptoms in both study groups were non-specific. However, the recovery from symptoms in the GERD group was lower than the control group following drug therapy. The causes of the lower response rate in the GERD group will need to be examined in further studies.

The Influence of Metabolic Syndrome on the Intima-Medial Thickness and Cardiovascular Risk Factors in Type 2 Diabetes.: Kwang Pyo Son, Young Je Chae, Tae Yu Lee, In Kyung Jeong, Mina Hur, Gu Young Jo, Young Lee, Seong Jin Lee, Chul Young Park, Ki Won Oh, Eon Kyung Hong, Hyun Kyu Kim, Jae Myoung Yu, Doo Man Kim, Sung Hee Lim, Moon Ki Choi, Hyung Jun Yoo, Sung Woo Park; Korean Diabetes J. 2004;28(5):392-406. Published online October 1, 2004

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Abstract PDF: BACKGROUND
Metabolic syndrome (MS) is usually present in type 2 DM (T2DM), and it is associated with atherosclerosis. The aim of this study is to exam the influence of MS on the intima-medial thickness(IMT) and the cardiovascular risk factors for type 2 diabetic patients. SUBJECTS AND METHODS: A cross sectional study was performed on 82 patients with Type 2 diabetes mellitus (DM) and 84 healthy controls. MS was defined according to the NCEP-ATP III criteria. Those subjects with any history of cerebro vascular accident, ischemic heart disease or acute inflammation were excluded. The cardiovascular risk factors (hsCRP, lipid profile, homocysteine, and uric acid), the status of glucose metabolism (HbA1c, fasting glucose, insulin, and HOMA-IR), the diabetic microvascular complications and the IMT at both common carotid arteries were measured. RESULTS: 1) For patients with T2DM, the levels of waist circumference, blood pressure, TG (1.7+/-1.4 vs 2.2+/-1.4 mmol/L), HDL-C (1.5+/-0.4 vs. 1.3+/-0.3 mmol/L), LDL-C (2.7+/-0.7 vs 3.1+/-0.9 mmol/L), TC/HDL-C (3.5 vs. 41), log of (hsCRP) (-0.11+/-0.4 vs 0.17+/-0.4), mean carotid IMT (0.63+/-0.12 vs. 0.74+/-0.12 mm) and max IMT (0.68+/-0.14 vs. 0.86+/-0.15 mm) were significantly different from the healthy control group. 2) The prevalence of MS in the T2DM groups was 64%. However, a decrease of the waist circumference, as measured by the modified Asian criteria, increased the crude prevalence of MS by up to 75%. 3) Diabetic patients with MS had a higher incidence of hypertension, a lower level of HDL-C, and higher levels of waist circumference, HOMA-IR, TG, and TC/HDL-C, a greater extent of microvasculopathy, an increased log (hsCRP), homocysteine, and carotid IMT than did diabetic patients without MS. 4) Among the component of MS, the presence of hypertriglyceridemia had an influence on the IMT mean and max. 5) The carotid IMT of patients with DM correlated with age, homocysteine, log (hsCRP), and uric acid on univariate analysis, and age and homocysteine we found to be independent risk factors of carotid IMT on multivariated analysis. CONCLUSION: Metabolic syndrome in subjects with glucose intolerance increases the risk of atherosclerosis.

Effects of High Fat Diet on Lipolysis in Skeletal Muscle and Adipose Tissue in Rats.: Chul Hee Kim, Yun Ey Chung, Seong Jin Lee, Joong Yeol Park, Sung Kwan Hong, Hong Kyu Kim, Kyo Il Suh, Ki Up Lee; Korean Diabetes J. 2000;24(6):641-651. Published online January 1, 2001

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Abstract PDF: BACKGROUND
It has been hypothesized that increased fat oxidation reduces glucose utilization in skeletal muscle, and is responsible for the insulin resistance associated with obesity or high-fat feeding. In contrast, there have been reports that fat oxidation capacity was decreased in skeletal muscles from insulin resistant subjects. This study was undertaken to examine whether insulin resistance in high- fat fed rats is associated with increased lipolysis in skeletal muscle and adipose tissue. METHODS: Two groups of Sprague-Dawley rats were fed either high-fat or low-fat diets for 4 weeks. Lipolysis in skeletal muscle and adipose tissue was determined by measurement of interstitial glycerol concentrations by a microdialysis method in basal and hyperinsulinemic-euglycemic clamp conditions. RESULTS: In basal state, plasma glycerol levels and interstitial glycerol concen trations of skeletal muscle, and adipose tissue were lower in high-fat fed than in low-fat fed rats. The degree of suppression of glycerol release by the hyperinsulinemia was smaller in the high-fat diet than in the low-fat diet group. However, plasma and interstitial glycerol concentrations during the hyperinsul inemic euglycemic clamps were also lower in the high-fat diet group. CONCLUSION: Lipolysis was decreased in skeletal muscle and adipose tissue of insulin resistant, high-fat fed rats. These results support the idea that limited fat oxidation capacity resulting in lipid accumulation in tissues, rather than increased fat oxida tion per se, is responsible for the insulin resistance associated with high-fat feeding.

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