���� JFIF  XX �� �� �     $.' ",#(7),01444'9=82<.342  2!!22222222222222222222222222222222222222222222222222�� ��" �� 4     ��   �� �,�PG"Z_�4�˷����kjز�Z�,F+��_z�,�© �����zh6�٨�ic�fu��� #ډb���_�N� ?� �wQ���5-�~�I���8��� �TK<5o�Iv-� ����k�_U_����� ~b�M��d��� �Ӝ�U�Hh��?]��E�w��Q���k�{��_}qFW7HTՑ��Y��F� ?_�'ϔ��_�Ջt� �=||I �� 6�έ"�����D���/[�k�9�� �Y�8 ds|\���Ҿp6�Ҵ���]��.����6� z<�v��@]�i% �� $j��~ �g��J>��no����pM[me�i$[�� �� s�o�ᘨ�˸ nɜG-�ĨU�ycP� 3.DB�li�;� �hj���x 7Z^�N�h��� ���N3u{�:j �x�힞��#M &��jL P@ _���� P�� &��o8 ������9 �����@Sz 6�t7#O�ߋ � s}Yf�T� ��lmr����Z)'N��k�۞p ����w\�T ȯ?�8` �O��i{wﭹW�[�r�� ��Q4F�׊�� �3m&L�=��h3� ���z~��#� \�l :�F,j@�� ʱ�wQT����8�"kJO��� 6�֚l���� }��� R�>ډK���]��y����&����p�}b�� ;N�1�m�r$� |��7�>e�@ B�TM*-i H��g�D�)� E�m�|�ؘbҗ�a ��Ҿ���� t4��� o���G��*oCN�rP���Q��@z,|?W[0 �����:�n,j WiE��W� �$~/�hp\��?��{(�0���+�Y8rΟ�+����>S-S�� ��VN;� }�s?.����� w �9��˟<���Mq4�Wv' ��{)0�1mB ��V����W[� ����8�/<� �%���wT^�5���b��)iM� p g�N�&ݝ� �VO~� q���u���9� ����!��J27��� �$ O-���! �: �%H��� ـ ����y�ΠM=t{!S�� oK8������ t<����è :a�� ����[���� �ա�H���~��w��Qz`�p o�^ �� ��Q��n�  �,uu�C� $ ^���,� �����8�#��:�6��e�|~� ��!�3� 3.�\0�� q��o�4`.|� ����y�Q�`~;�d�ׯ,��O�Zw�������`73�v�܋�< ���Ȏ�� ـ4k��5�K�a�u�=9Yd��$>x�A�&�� j0� ���vF��� Y� |�y��� ~�6�@c��1vOp �Ig�� ��4��l�OD� ��L����� R���c���j�_�uX 6��3?nk��Wy�f;^*B� ��@ �~a�`��Eu������ +� �� 6�L��.ü>��}y���}_�O�6�͐�:�Yr G�X��kG�� ���l^w�� �~㒶sy� �Iu�!� W ��X��N�7BV��O��!X�2����wvG�R�f�T#�����t�/?���%8�^�W�aT ��G�cL�M���I��(J����1~�8�?aT ���]����AS�E��(��*E}� 2�� #I/�׍qz��^t�̔��� b�Yz4x ���t�){ OH� �+(E��A&�N�������XT��o��"�XC�� '���)}�J�z�p� ��~5�}�^����+�6����w��c��Q�| Lp�d�H��}�(�.|����k��c4^� "�����Z?ȕ ��a< �L�!0 39C� �Eu� C�F�Ew�ç ;�n?�*o���B�8�bʝ���'#Rqf�� �M}7����]��� �s2tcS{�\icTx;�\��7K���P ���ʇ Z O-��~�� c>"��?�� �����P ��E��O�8��@�8��G��Q�g�a�Վ���󁶠 �䧘��_%#r�>� 1�z�a�� eb��qcP ѵ��n���#L��� =��׀t� L�7�` ��V��� A{�C:�g���e@ �w1 Xp 3�c3�ġ���� p��M"'-�@n4���fG� �B3�DJ�8[Jo�ߐ���gK)ƛ��$���� � ��8�3�����+���� �����6�ʻ���� ���S�kI�*KZlT _`�� �?��K� ���QK�d ����B`�s}�>���` ��*�>��,*@J�d�oF*� ���弝��O}�k��s��]��y�ߘ ��c1G�V���<=�7��7����6 �q�PT��tXԀ�!9*4�4Tހ 3XΛex�46�� �Y��D ����� �BdemDa����\�_l,� �G�/���֌7���Y�](�xTt^%�GE�����4�}bT ���ڹ�����; Y)���B�Q��u��>J/J � ⮶.�XԄ��j�ݳ� +E��d ��r�5�_D �1 �� o�� �B�x�΢�#� ��<��W�����8���R6�@ g�M�.��� dr�D��>(otU��@ x=��~v���2� ӣ�d�oBd ��3�eO�6�㣷�� ���ݜ 6��6Y��Qz`�� S��{���\P �~z m5{J/L��1������<�e�ͅPu� b�]�ϔ ���'�� ����f�b� Zpw��c`"��i���BD@:)ִ�:�]��h v�E� w���T�l ��P� ��"Ju�}��وV J��G6��. J/�Qgl߭�e�����@�z�Zev2u� )]կ��� ��7x�� �s�M�-<ɯ�c��r� v�����@��$�ޮ}lk���a�� �'����>x��O\�Z Fu>��� ��ck#��&:��`�$ �ai�>2Δ����l���oF[h� �lE�ܺ�Π k:)���` �� $[6�����9�����kOw�\|��� 8}������ބ:��񶐕� �I�A1/� =�2[�,�!��.}gN#�u����b ��� ~� �݊��}34q��� �d�E��L c��$ ��"�[q�U�硬g^��%B � z���r�p J�ru%v\h 1Y�ne` ǥ:g�� �pQM~�^� Xi� ��`S�:V2 9.�P���V� ?B�k�� AEvw%�_�9C�Q����wKekP ؠ�\� ;Io d�{ ߞo�c1eP��� �\� `����E=���@K<�Y�� �eڼ�J ���w����{av�F�'�M�@ /J��+9p ���|]���� �Iw &` ��8���& M�hg ��[�{ ��Xj�� %��Ӓ� $��(��� �ʹN��� <>�I���RY� ��K2�NPlL�ɀ )��&e� ���B+ь����( � �JTx ���_?EZ� }@ 6�U���뙢ط�z��dWI� n` D����噥�[��uV��"�G& Ú����2 g�}&m� �?ċ �"����Om#� ������� � ��{� ON��"S�X ��Ne��ysQ���@ Fn��Vg��� dX�~nj� ]J�<�K]: ��FW�� b�������62 �=��5f����JKw� �bf�X� 55��~J �%^� ���:�-�QIE��P��v�nZum� z � ~ə ���� ���ة����;�f��\v��� g�8�1��f2 4;�V���ǔ�)��� �9���1\�� c��v�/'Ƞ�w����� ��$�4�R-��t�� �� e�6�/�ġ �̕Ecy�J���u�B���<�W�ַ~�w[B1L۲�-JS΂�{���΃���� ��A��20�c# �� @    0!1@AP"#2Q`$3V�%45a6�FRUq���   � ���^7ׅ,$n� ������+��F�`��2X'��0vM��p�L=������ 5��8������u�p~���.�`r�����\��� O��,ư�0oS ��_�M�����l���4�kv\JSd���x���SW�<��Ae�IX����������$I���w�:S���y���›R��9�Q[���,�5�;�@]�%���u�@ *ro�lbI �� ��+���%m:�͇ZV�����u�̉����θau<�fc�.����{�4Ա� �Q����*�Sm��8\ujqs]{kN���)qO�y�_*dJ�b�7���yQqI&9�ԌK!�M}�R�;�� ����S�T���1���i[U�ɵz�]��U)V�S6���3$K{� ߊ<�(� E]Զ[ǼENg�����'�\?#)Dkf��J���o��v���'�%ƞ�&K�u� !��b�35LX�Ϸ��63$K�a�;�9>,R��W��3�3� d�JeTYE.Mϧ��-�o�j3+y��y^�c�������VO�9NV\nd�1 ��!͕_)a�v;����թ�M�lWR1��)El��P;��yوÏ�u 3�k�5Pr6<�⒲l�!˞*��u־�n�!�l:����UNW ��%��Chx8vL'��X�@��*��)���̮��ˍ��� � ��D-M�+J�U�kvK����+�x8��cY������?�Ԡ��~3mo��|�u@[XeY�C�\Kp�x8�oC�C�&����N�~3-H���� ��MX�s�u<`���~"WL��$8ξ��3���a�)|:@�m�\���^�`�@ҷ)�5p+��6���p�%i)P M���ngc�����#0Aruz���RL+xSS?���ʮ}()#�t��mˇ!��0}}y����<�e� �-ή�Ԩ��X������ MF���ԙ~l L.3���}�V뽺�v��� ��멬��Nl�)�2����^�Iq��a��M��qG��T�����c3#������3U�Ǎ���}��לS�|qa��ڃ�+���-��2�f����/��bz��ڐ�� �ݼ[2�ç����k�X�2�* �Z�d���J�G����M*9W���s{��w���T��x��y,�in�O�v��]���n����P�$� JB@=4�OTI�n��e�22a\����q�d���%�$��(���:���: /*�K[PR�fr\nڙdN���F�n�$�4� [�� U�zƶ����� �mʋ���,�ao�u 3�z� �x��Kn����\[��VFmbE;�_U��&V�Gg�]L�۪&#n%�$ɯ� dG���D�TI=�%+AB�Ru#��b4�1�»x�cs�YzڙJG��f��Il� �d�eF'T� iA��T���uC�$����Y��H?����[!G`}���ͪ� �纤Hv\������j�Ex�K���!���OiƸ�Yj�+u-<���'q����uN�*�r\��+�]���<�wOZ.fp�ێ��,-*)V?j-kÊ#�`�r��dV����(�ݽBk�����G�ƛk�QmUڗe��Z���f}|����8�8��a���i��3'J�����~G_�^���d�8w������ R�`(�~�.��u���l�s+g�bv���W���lGc}��u���afE~1�Ue������Z�0�8�=e�� f@/�jqEKQQ�J� �oN��J���W5~M>$6�Lt�;$ʳ{���^��6�{����v6���ķܰg�V�cnn �~z�x�«�,2�u�?cE+Ș�H؎�%�Za�)���X>uW�Tz�Nyo����s���FQƤ��$��*�&�LLXL)�1�" L��eO��ɟ�9=���:t��Z���c��Ž���Y?�ӭV�wv�~,Y��r�ۗ�|�y��GaF�����C�����.�+� ���v1���fήJ�����]�S��T��B��n5sW}y�$��~z�'�c ��8 ��� ,! �p��VN�S��N�N�q��y8z˱�A��4��*��'������2n<�s���^ǧ˭P�Jޮɏ�U�G�L�J�*#��<�V��t7�8����TĜ>��i}K%,���)[��z�21z ?�N�i�n1?T�I�R#��m-�����������������1����lA�`��fT5+��ܐ�c�q՝��ʐ��,���3�f2U�եmab��#ŠdQ�y>\��)�SLY����w#��.���ʑ�f��� ,"+�w�~�N�'�c�O�3F�������N<���)j��&��,-� �љ���֊�_�zS���TǦ����w�>��?�������n��U仆�V���e�����0���$�C�d���rP �m�׈e�Xm�Vu� �L��.�bֹ��� �[Դaզ���*��\y�8�Է:�Ez\�0�Kq�C b��̘��cө���Q��=0Y��s�N��S.��� 3.���O�o:���#���v7�[#߫ ��5�܎�L���Er4���9n��COWlG�^��0k�%<���ZB���aB_���������'=��{i�v�l�$�uC���mƎҝ{�c㱼�y]���W�i ��ߧc��m�H� m�"�"�����;Y�ߝ�Z�Ǔ�����:S#��|}�y�,/k�Ld� TA�(�AI$+I3��;Y*���Z��}|��ӧO��d�v��..#:n��f>�>���ȶI�TX��� 8��y����"d�R�|�)0���=���n4��6ⲑ�+��r<�O�܂~zh�z����7ܓ�HH�Ga롏���nCo�>������a ���~]���R���̲c?�6(�q�;5%� |�uj�~z8R =X��I�V=�|{v�Gj\gc��q����z�؋%M�ߍ����1y��#��@f^���^�>N��� ��#x#۹��6�Y~�?�dfPO��{��P�4��V��u1E1J �*|���%�� �JN��`eWu�zk M6���q t[�� ��g�G���v��WIG��u_ft����5�j�"�Y�:T��ɐ���*�;� e5���4����q$C��2d�}���� _S�L#m�Yp��O�.�C�;��c����Hi#֩%+) �Ӎ��ƲV���SYź��g |���tj��3�8���r|���V��1#;.SQ�A[���S������#���`n�+���$��$ I �P\[�@�s��(�ED�z���P��])8�G#��0B��[ى��X�II�q<��9�~[Z멜�Z�⊔IWU&A>�P~�#��dp<�?����7���c��'~���5 ��+$���lx@�M�dm��n<=e�dyX��?{�|Aef ,|n3�<~z�ƃ�uۧ�����P��Y,�ӥQ�*g�#먙R�\���;T��i,��[9Qi歉����c>]9�� ��"�c��P�� �Md?٥��If�ت�u��k��/����F��9�c*9��Ǎ:�ØF���z�n*�@|I�ށ9����N3{'��[�'ͬ�Ҳ4��#}��!�V� Fu��,�,mTIk���v C�7v���B�6k�T9��1�*l� '~��ƞF��lU��'�M ����][ΩũJ_�{�i�I�n��$�� �L�� j��O�dx�����kza۪��#�E��Cl����x˘�o�����V���ɞ�ljr��)�/,�߬h�L��#��^��L�ф�,íMƁe�̩�NB�L�����iL����q�}��(��q��6IçJ$�W�E$��:������=#����(�K�B����zђ <��K(�N�۫K�w��^O{!����) �H���>x�������lx�?>Պ�+�>�W���,Ly!_�D���Ō�l���Q�!�[ �S����J��1��Ɛ�Y}��b,+�Lo�x�ɓ)����=�y�oh�@�꥟/��I��ѭ=��P�y9��� �ۍYӘ�e+�p�Jnϱ?V\SO%�(�t� ���=?MR�[Ș�����d�/ ��n�l��B�7j� ��!�;ӥ�/�[-���A�>� dN�sLj ��,ɪv��=1c�.SQ�O3�U���ƀ�ܽ�E����������̻��9G�ϷD�7(�}��Ävӌ\� y�_0[w ���<΍>����a_��[0+�L��F.�޺��f�>oN�T����q;���y\��bՃ��y�jH�<|q-eɏ�_?_9+P���Hp$�����[ux�K w�Mw��N�ی'$Y2�=��q���KB��P��~�� ����Yul:�[<����F1�2�O���5=d����]Y�sw:���Ϯ���E��j,_Q��X��z`H1,#II ��d�wr��P˂@�ZJV����y$�\y�{}��^~���[:N����ߌ�U�������O��d�����ؾe��${p>G��3c���Ė�lʌ�� ת��[��`ϱ�-W����dg�I��ig2��� ��}s ��ؤ(%#sS@���~���3�X�nRG�~\jc3�v��ӍL��M[JB�T��s3}��j�Nʖ��W����;7� �ç?=X�F=-�=����q�ߚ���#���='�c��7���ڑW�I(O+=:uxq�������������e2�zi+�kuG�R��������0�&e�n���iT^J����~\jy���p'dtG��s����O��3����9* �b#Ɋ�� p������[Bws�T�>d4�ۧs���nv�n���U���_�~,�v����ƜJ1��s�� �QIz�� )�(lv8M���U=�;����56��G���s#�K���MP�=��LvyGd��}�VwWBF�'�à �?MH�U�g2�� ����!�p�7Q��j��ڴ����=��j�u��� Jn�A s���uM������e��Ɔ�Ҕ�!) '��8Ϣ�ٔ� �ޝ(��Vp���צ֖d=�IC�J�Ǡ{q������kԭ�߸���i��@K����u�|�p=..�*+����x�����z[Aqġ#s2a�Ɗ���RR�)*HRsi�~�a &f��M��P����-K�L@��Z��Xy�'x�{}��Zm+���:�)�) IJ�-i�u���� ���ܒH��'� L(7�y�GӜq���� j��� 6ߌg1�g�o���,kر���tY�?W,���p���e���f�OQS��!K�۟cҒA�|ս�j�>��=⬒��˧L[�� �߿2JaB~R��u�:��Q�] �0H~���]�7��Ƽ�I���( }��cq '�ήET���q�?f�ab���ӥvr� �)o��-Q��_'����ᴎo��K������;��V���o��%���~OK ����*��b�f:���-ťIR��`B�5!RB@���ï�� �u �̯e\�_U�_������� g�ES��3������� QT��a�� ��x����U<~�c?�*�#]�MW,[8O�a�x��]�1bC|踤�P��lw5V%�)�{t�<��d��5���0i�XSU��m:��Z�┵�i�"��1�^B�-��P�hJ��&)O��*�D��c�W��vM��)����}���P��ܗ-q����\mmζZ-l@�}��a��E�6��F�@��&Sg@���ݚ�M����� ȹ 4����#p�\H����dYDo�H���"��\��..R�B�H�z_�/5˘����6��KhJR��P�mƶi�m���3� ,#c�co��q�a)*P t����R�m�k�7x�D�E�\Y�閣_X�<���~�)���c[[�BP����6�Yq���S��0����%_����;��Àv�~�| VS؇ ��'O0��F0��\���U�-�d@�����7�SJ*z��3n��y��P����O��������� m�~�P�3|Y��ʉr#�C�<�G~�.,! ���bqx���h~0=��!ǫ�jy����l� O,�[B��~��|9��ٱ����Xly�#�i�B��g%�S��������tˋ���e���ې��\[d�t)��.+u�|1 ������#�~Oj����hS�%��i.�~X���I�H�m��0n���c�1uE�q��cF�RF�o���7� �O�ꮧ� ���ۛ{��ʛi5�rw?׌#Qn�TW��~?y$��m\�\o����%W� ?=>S�N@�� �Ʈ���R����N�)�r"C�:��:����� �����#��qb��Y�. �6[��2K����2u�Ǧ�HYR��Q�MV��� �G�$��Q+.>�����nNH��q�^��� ����q��mM��V��D�+�-�#*�U�̒ ���p욳��u:�������IB���m� ��PV@O���r[b= �� ��1U�E��_Nm�yKbN�O���U�}�the�`�|6֮P>�\2�P�V���I�D�i�P�O;�9�r�mAHG�W�S]��J*�_�G��+kP�2����Ka�Z���H�'K�x�W�MZ%�O�YD�Rc+o��?�q��Ghm��d�S�oh�\�D�|:W������UA�Qc yT�q� �����~^�H��/��#p�CZ���T�I�1�ӏT����4��"�ČZ�����}��`w�#�*,ʹ�� ��0�i��課�Om�*�da��^gJ݅{���l�e9uF#T�ֲ��̲�ٞC"�q���ߍ ոޑ�o#�XZTp����@ o�8��(jd��xw�]�,f���`~� |,s��^����f�1���t��|��m�򸄭/ctr��5s��7�9Q�4�H1꠲BB@ l9@���C�����+�wp�xu�£Yc�9��?`@#�o�mH�s2��)�=��2�.�l����jg�9$�Y�S�%*L������R�Y������7Z���,*=�䷘$�������arm�o�ϰ���UW.|�r�uf����IGw�t����Zwo��~5 ��YյhO+=8fF�)�W�7�L9lM�̘·Y���֘YLf�큹�pRF���99.A �"wz��=E\Z���'a� 2��Ǚ�#;�'}�G���*��l��^"q��+2FQ� hj��kŦ��${���ޮ-�T�٭cf�|�3#~�RJ����t��$b�(R��(����r���dx� >U b�&9,>���%E\� Ά�e�$��'�q't��*�א���ެ�b��-|d���SB�O�O��$�R+�H�)�܎�K��1m`;�J�2�Y~9��O�g8=vqD`K[�F)k�[���1m޼c��n���]s�k�z$@��)!I �x՝"v��9=�ZA=`Ɠi �:�E��)` 7��vI��}d�YI�_ �o�:ob���o ���3Q��&D&�2=�� �Ά��;>�h����y.*ⅥS������Ӭ�+q&����j|UƧ��� �}���J0��WW< ۋS�)jQR�j���Ư��rN)�Gű�4Ѷ(�S)Ǣ�8��i��W52���No˓� ۍ%�5brOn�L�;�n��\G����=�^U�dI���8$�&���h��'���+�(������cȁ߫k�l��S^���cƗjԌE�ꭔ��gF���Ȓ��@���}O���*;e�v�WV���YJ\�]X'5��ղ�k�F��b 6R�o՜m��i N�i���� >J����?��lPm�U��}>_Z&�KK��q�r��I�D�Չ~�q�3fL�:S�e>���E���-G���{L�6p�e,8��������QI��h��a�Xa��U�A'���ʂ���s�+טIjP�-��y�8ۈZ?J$��W�P� ��R�s�]��|�l(�ԓ��sƊi��o(��S0 ��Y� 8�T97.�����WiL��c�~�dxc�E|�2!�X�K�Ƙਫ਼�$((�6�~|d9u+�qd�^3�89��Y�6L�.I�����?���iI�q���9�)O/뚅����O���X��X�V��ZF[�یgQ�L��K1���RҖr@v�#��X�l��F���Нy�S�8�7�kF!A��sM���^rkp�jP�DyS$N���q�� nxҍ!U�f�!eh�i�2�m ���`�Y�I�9r�6� �TF���C}/�y�^���Η���5d�'��9A-��J��>{�_l+�`��A���[�'��յ�ϛ#w:݅�%��X�}�&�PSt�Q�"�-��\縵�/����$Ɨh�Xb�*�y��BS����;W�ջ_mc�����vt?2}1�;qS�d�d~u:2k5�2�R�~�z+|HE!)�Ǟl��7`��0�<�,�2*���Hl-��x�^����'_TV�gZA�'j� ^�2Ϊ��N7t�����?w�� �x1��f��Iz�C-Ȗ��K�^q�;���-W�DvT�7��8�Z�������� hK�(P:��Q- �8�n�Z���܃e貾�<�1�YT<�,�����"�6{ / �?�͟��|1�:�#g��W�>$����d��J��d�B�� =��jf[��%rE^��il:��B���x���Sּ�1հ��,�=��*�7 fcG��#q� �eh?��2�7�����,�!7x��6�n�LC�4x��},Geǝ�tC.��vS �F�43��zz\��;QYC,6����~;RYS/6���|2���5���v��T��i����������mlv��������&� �nRh^ejR�LG�f���? �ۉҬܦƩ��|��Ȱ����>3����!v��i�ʯ�>�v��オ�X3e���_1z�Kȗ\<������!�8���V��]��?b�k41�Re��T�q��mz��TiOʦ�Z��Xq���L������q"+���2ۨ��8}�&N7XU7Ap�d�X��~�׿��&4e�o�F��� �H�� ��O���č�c�� 懴�6���͉��+)��v;j��ݷ�� �UV�� i��� j���Y9GdÒJ1��詞�����V?h��l�� ��l�cGs�ځ�������y�Ac���� �\V3�? �� ܙg�>qH�S,�E�W�[�㺨�uch�⍸�O�}���a��>�q�6�n6� ���N6�q�� ���� N    ! 1AQaq�0@����"2BRb�#Pr���3C`��Scst���$4D���%Td��  ? � ��N����a��3��m���C���w��������xA�m�q�m��� m������$����4n淿t'��C"w��zU=D�\R+w�p+Y�T�&�պ@��ƃ��3ޯ?�Aﶂ��aŘ���@-�����Q�=���9D��ռ�ѻ@��M�V��P��܅�G5�f�Y<�u=,EC)�<�Fy'�"�&�չ�X~f��l�KԆV��?�� �W�N����=(� �;���{�r����ٌ�Y���h{�١������jW����P���Tc�����X�K�r��}���w�R��%��?���E��m�� �Y�q|����\lEE4� ��r���}�lsI�Y������f�$�=�d�yO����p�����yBj8jU�o�/�S��?�U��*������ˍ�0����� �u�q�m [�?f����a�� )Q�>����6#������� ?����0UQ����,IX���(6ڵ[�DI�MNލ�c&���υ�j\��X�R|,4��� j������T�hA�e��^���d���b<����n�� �즇�=!���3�^�`j�h�ȓr��jẕ�c�,ٞX����-����a�ﶔ���#�$��]w�O��Ӫ�1y%��L�Y<�wg#�ǝ�̗`�x�xa�t�w��»1���o7o5��>�m뭛C���Uƃߜ}�C���y1Xνm�F8�jI���]����H���ۺиE@I�i;r�8ӭ���� V�F�Շ| ��&?�3|x�B�MuS�Ge�=Ӕ�#BE5G�� ���Y!z��_e��q�р/W>|-�Ci߇�t�1ޯќd�R3�u��g�=0 5��[?�#͏��q�cf���H��{ ?u�=?�?ǯ���}Z��z���hmΔ�BFTW�����<�q� (v� ��!��z���iW]*�J�V�z��gX֧A�q�&��/w���u�gYӘa���; �i=����g:��?2�dž6�ى�k�4�>�Pxs����}������G�9� �3 ���)gG�R<>r h�$��'nc�h�P��Bj��J�ҧH� -��N1���N��?��~��}-q!=��_2hc�M��l�vY%UE�@|�v����M2�.Y[|y�"Eï��K�ZF,�ɯ?,q�?v�M 80jx�"�;�9vk�����+ ֧�� �ȺU��?�%�vcV��mA�6��Qg^M��� �A}�3�nl� QRN�l8�kkn�'�����(��M�7m9و�q���%ޟ���*h$Zk"��$�9��: �?U8�Sl��,,|ɒ��xH(ѷ����Gn�/Q�4�P��G�%��Ա8�N��!� �&�7�;���eKM7�4��9R/%����l�c>�x;������>��C�:�����t��h?aKX�bhe�ᜋ^�$�Iհ �hr7%F$�E��Fd���t��5���+�(M6�t����Ü�UU|zW�=a�Ts�Tg������dqP�Q����b'�m���1{|Y����X�N��b �P~��F^F:����k6�"�j!�� �I�r�`��1&�-$�Bevk:y���#y w��I0��x��=D�4��tU���P�ZH��ڠ底taP��6����b>�xa� ���Q�#� WeF��ŮNj�p�J* mQ�N��� �*I�-*�ȩ�F�g�3 �5��V�ʊ�ɮ�a��5F���O@{���NX��?����H�]3��1�Ri_u��������ѕ�� ����0��� F��~��:60�p�͈�S��qX#a�5>���`�o&+�<2�D����: �������ڝ�$�nP���*)�N�|y�Ej�F�5ټ�e���ihy�Z �>���k�bH�a�v��h�-#���!�Po=@k̆IEN��@��}Ll?j�O������߭�ʞ���Q|A07x���wt!xf���I2?Z��<ץ�T���cU�j��]�� 陎Ltl �}5�ϓ��$�,��O�mˊ�;�@O��jE��j(�ا,��LX���LO���Ц�90�O �.����a��nA���7������j4 ��W��_ٓ���zW�jcB������y՗+EM�)d���N�g6�y1_x��p�$Lv :��9�"z��p���ʙ$��^��JԼ*�ϭ����o���=x�Lj�6�J��u82�A�H�3$�ٕ@�=Vv�]�'�qEz�;I˼��)��=��ɯ���x �/�W(V���p�����$ �m�������u�����񶤑Oqˎ�T����r��㠚x�sr�GC��byp�G��1ߠ�w e�8�$⿄����/�M{*}��W�]˷.�CK\�ުx���/$�WP w���r� |i���&�}�{�X� �>��$-��l���?-z���g����lΆ���(F���h�vS*���b���߲ڡn,|)mrH[���a�3�ר�[1��3o_�U�3�TC�$��(�=�)0�kgP���� ��u�^=��4 �WYCҸ:��vQ�ר�X�à��tk�m,�t*��^�,�}D*� �"(�I��9R����>`�`��[~Q]�#af��i6l��8���6�:,s�s�N6�j"�A4���IuQ��6E,�GnH��zS�HO�uk�5$�I�4��ؤ�Q9�@��C����wp �BGv[]�u�Ov��� 0I4���\��y�����Q�Ѹ��~>Z��8�T��a��q�ޣ;z��a���/��S��I:�ܫ_�|������>=Z����8:�S��U�I�J��"IY���8%b8���H��:�QO�6�;7�I�S��J��ҌAά3��>c���E+&jf$eC+�z�;��V����� �r���ʺ������my�e���aQ�f&��6�ND ��.:��NT�vm�<- u���ǝ\MvZY�N�NT��-A�>jr!S��n�O 1�3�Ns�%�3D@���`������ܟ 1�^c<���� �a�ɽ�̲�Xë#�w�|y�cW�=�9I*H8�p�^(4���՗�k��arOcW�tO�\�ƍR��8����'�K���I�Q�����?5�>[�}��yU�ײ -h��=��% q�ThG�2�)���"ו3]�!kB��*p�FDl�A���,�eEi�H�f�Ps�����5�H:�Փ~�H�0Dت�D�I����h�F3�������c��2���E��9�H��5�zԑ�ʚ�i�X�=:m�xg�hd(�v����׊�9iS��O��d@0ڽ���:�p�5�h-��t�&���X�q�ӕ,��ie�|���7A�2���O%P��E��htj��Y1��w�Ѓ!����  ���� ࢽ��My�7�\�a�@�ţ�J �4�Ȼ�F�@o�̒?4�wx��)��]�P��~�����u�����5�����7X ��9��^ܩ�U;Iꭆ 5 �������eK2�7(�{|��Y׎ �V��\"���Z�1� Z�����}��(�Ǝ"�1S���_�vE30>���p;� ΝD��%x�W�?W?v����o�^V�i�d��r[��/&>�~`�9Wh��y�;���R�� � ;;ɮT��?����r$�g1�K����A��C��c��K��l:�'��3 c�ﳯ*"t8�~l��)���m��+U,z��`( �>yJ�?����h>��]��v��ЍG*�{`��;y]��I�T� ;c��NU�fo¾h���/$���|NS���1�S�"�H��V���T���4��uhǜ�]�v;���5�͠x��'C\�SBpl���h}�N����� A�Bx���%��ޭ�l��/����T��w�ʽ]D�=����K���ž�r㻠l4�S�O?=�k �M:� ��c�C�a�#ha���)�ѐxc�s���gP�iG�� {+���x���Q���I= �� z��ԫ+ �8"�k�ñ�j=|����c ��y��CF��/ ��*9ж�h{ �?4�o� ��k�m�Q�N�x��;�Y��4膚�a�w?�6�> e]�����Q�r�:����g�,i"�����ԩA� *M�<�G��b�if��l^M��5� �Ҩ�{����6J��ZJ�����P�*�����Y���ݛu�_4�9�I8�7���������,^ToR���m4�H��?�N�S�ѕw��/S��甍�@�9H�S�T��t�ƻ���ʒU��*{Xs�@����f��� ��֒Li�K{H�w^���������Ϥm�tq���s� ���ք��f:��o~s��g�r��ט� �S�ѱC�e]�x���a��) ���(b-$(�j>�7q�B?ӕ�F��hV25r[7 Y� }L�R��}����*sg+��x�r�2�U=�*'WS��ZDW]�WǞ�<��叓���{�$�9Ou4��y�90-�1�'*D`�c�^o?(�9��u���ݐ��'PI&� f�Jݮ�������:wS����jfP1F:X �H�9dԯ�� �˝[�_54 �}*;@�ܨ�� ð�yn�T���?�ןd�#���4rG�ͨ��H�1�|-#���Mr�S3��G�3�����)�.᧏3v�z֑��r����$G"�`j �1t��x0<Ɔ�Wh6�y�6��,œ�Ga��gA����y��b��)� �h�D��ß�_�m��ü �gG;��e�v��ݝ�nQ� ��C����-�*��o���y�a��M��I�>�<���]obD��"�:���G�A��-\%LT�8���c�)��+y76���o�Q�#*{�(F�⽕�y����=���rW�\p���۩�c���A���^e6��K������ʐ�cVf5$�'->���ՉN"���F�"�UQ@�f��Gb~��#�&�M=��8�ט�JNu9��D��[̤�s�o�~��� ��� G��9T�tW^g5y$b��Y'��س�Ǵ�=��U-2 #�MC�t(�i� �lj�@Q 5�̣i�*�O����s�x�K�f��}\��M{E�V�{�υ��Ƈ�����);�H����I��fe�Lȣr�2��>��W� I�Ȃ6������i��k�� �5�YOxȺ����>��Y�f5'��|��H+��98pj�n�.O�y�������jY��~��i�w'������l�;�s�2��Y��:'lg�ꥴ)o#'Sa�a�K��Z� �m��}�`169�n���"���x��I ��*+� }F<��cГ���F�P�������ֹ*�PqX�x۩��,� ��N�� �4<-����%����:��7����W���u�`����� $�?�I��&����o��o��`v�>��P��"��l���4��5'�Z�gE���8���?��[�X�7(��.Q�-��*���ތL@̲����v��.5���[��=�t\+�CNܛ��,g�SQnH����}*F�G16���&:�t��4ُ"A��̣��$�b �|����#rs��a�����T�� ]�<�j��B S�('$�ɻ� �wP;�/�n��?�ݜ��x�F��yUn�~mL*-�������Xf�wd^�a�}��f�,=t�׵i�.2/wpN�Ep8�OР���•��R�FJ� 55TZ��T �ɭ�<��]��/�0�r�@�f��V��V����Nz�G��^���7hZi����k��3�,kN�e|�vg�1{9]_i��X5y7� 8e]�U����'�-2,���e"����]ot�I��Y_��n�(JҼ��1�O ]bXc���Nu�No��pS���Q_���_�?i�~�x h5d'�(qw52] ��'ޤ�q��o1�R!���`ywy�A4u���h<קy���\[~�4�\ X�Wt/� 6�����n�F�a8��f���z �3$�t(���q��q�x��^�XWeN'p<-v�!�{�(>ӽDP7��ո0�y)�e$ٕv�Ih'Q�EA�m*�H��RI��=:��� ���4牢) �%_iN�ݧ�l]� �Nt���G��H�L��� ɱ�g<���1V�,�J~�ٹ�"K��Q�� 9�HS�9�?@��k����r�;we݁�]I�!{ �@�G�[�"��`���J:�n]�{�cA�E����V��ʆ���#��U9�6����j�#Y�m\��q�e4h�B�7��C�������d<�?J����1g:ٳ���=Y���D�p�ц� ׈ǔ��1�]26؜oS�'��9�V�FVu�P�h�9�xc�oq�X��p�o�5��Ա5$�9W�V(�[Ak�aY錎qf;�'�[�|���b�6�Ck��)��#a#a˙��8���=äh�4��2��C��4tm^ �n'c� ��]GQ$[Wҿ��i���vN�{Fu ��1�gx��1┷���N�m��{j-,��x�� Ūm�ЧS�[�s���Gna���䑴�� x�p 8<������97�Q���ϴ�v�aϚG��Rt�Һ׈�f^\r��WH�JU�7Z���y)�vg=����n��4�_)y��D'y�6�]�c�5̪ �\� �PF�k����&�c;��cq�$~T�7j ���nç]�<�g ":�to�t}�159�<�/�8������m�b�K#g'I'.W����� 6��I/��>v��\�MN��g���m�A�yQL�4u�Lj�j9��#44�t��l^�}L����n��R��!��t��±]��r��h6ٍ>�yҏ�N��fU�� ���� Fm@�8}�/u��jb9������he:A�y�ծw��GpΧh�5����l}�3p468��)U��d��c����;Us/�֔�YX�1�O2��uq�s��`hwg�r~�{ R��mhN��؎*q 42�*th��>�#���E����#��Hv�O����q�}����� 6�e��\�,Wk�#���X��b>��p}�դ��3���T5��†��6��[��@ �P�y*n��|'f�֧>�lư΂�̺����SU�'*�q�p�_S�����M�� '��c�6��� ��m�� ySʨ;M��r���Ƌ�m�Kxo,���Gm�P��A�G�:��i��w�9�}M(�^�V��$ǒ�ѽ�9���|���� �a����J�SQ�a���r�B;����}���ٻ֢�2�%U���c�#�g���N�a�ݕ�'�v�[�OY'��3L�3�;,p�]@�S��{ls��X�'���c�jw� k'a�.��}�}&�� �dP�*�bK=ɍ!����;3n�gΊU�ߴmt�'*{,=SzfD� A��ko~�G�aoq�_mi}#�m�������P�Xhύ��� �mxǍ�΂���巿zf��Q���c���|kc�����?���W��Y�$���_Lv����l߶��c���`?����l�j�ݲˏ!V��6����U�Ђ(A���4y)H���p�Z_�x��>���e�� R��$�/�`^'3qˏ�-&Q�=?��CFVR �D�fV�9��{�8g�������n�h�(P"��6�[�D���< E�����~0<@�`�G�6����Hг�cc�� �c�K.5��D��d�B���`?�XQ��2��ٿyqo&+�1^� DW�0�ꊩ���G�#��Q�nL3��c���������/��x ��1�1 [y�x�პCW��C�c�UĨ80�m�e�4.{�m��u���I=��f�����0QRls9���f���������9���~f�����Ǩ��a�"@�8���ȁ�Q����#c�ic������G��$���G���r/$W�(��W���V�"��m�7�[m�A�m����bo��D� j����۳� l���^�k�h׽����� ��#� iXn�v��eT�k�a�^Y�4�BN�� ĕ�� 0    !01@Q"2AaPq3BR������ ? � ��@4�Q�����T3,���㺠�W�[=JK�Ϟ���2�r^7��vc�:�9 �E�ߴ�w�S#d���Ix��u��:��Hp��9E!�� V 2;73|F��9Y���*ʬ�F��D����u&���y؟��^EA��A��(ɩ���^��GV:ݜDy�`��Jr29ܾ�㝉��[���E;Fzx��YG��U�e�Y�C���� ����v-tx����I�sם�Ę�q��Eb�+P\ :>�i�C'�;�����k|z�رn�y]�#ǿb��Q��������w�����(�r|ӹs��[�D��2v-%��@;�8<a���[\o[ϧw��I!��*0�krs)�[�J9^��ʜ��p1)� "��/_>��o��<1����A�E�y^�C��`�x1'ܣn�p��s`l���fQ��):�l����b>�Me�jH^?�kl3(�z:���1ŠK&?Q�~�{�ٺ�h�y���/�[��V�|6��}�KbX����mn[-��7�5q�94�������dm���c^���h� X��5��<�eޘ>G���-�}�دB�ޟ� ��|�rt�M��V+�]�c?�-#ڛ��^ǂ}���Lkr���O��u�>�-D�ry� D?:ޞ�U��ǜ�7�V��?瓮�"�#���r��չģVR;�n���/_� ؉v�ݶe5d�b9��/O��009�G���5n�W����JpA�*�r9�>�1��.[t���s�F���nQ� V 77R�]�ɫ8����_0<՜�IF�u(v��4��F�k�3��E)��N:��yڮe��P�`�1}�$WS��J�SQ�N�j �ٺ��޵�#l���ј(�5=��5�lǏmoW�v-�1����v,W�mn��߀$x�<����v�j(����c]��@#��1������Ǔ���o'��u+����;G�#�޸��v-lη��/(`i⣍Pm^� ��ԯ̾9Z��F��������n��1��� ��]�[��)�'������ :�֪�W��FC����� �B9،!?���]��V��A�Վ�M��b�w��G F>_DȬ0¤�#�QR�[V��kz���m�w�"��9ZG�7'[��=�Q����j8R?�zf�\a�=��O�U����*oB�A�|G���2�54 �p��.w7� �� ��&������ξxGHp� B%��$g�����t�Џ򤵍z���HN�u�Я�-�'4��0�� ;_�� 3     !01"@AQa2Pq#3BR������ ? � �ʩca��en��^��8���<�u#��m*08r��y�N"�<�Ѳ0��@\�p��� �����Kv�D��J8�Fҽ� �f�Y��-m�ybX�NP����}�!*8t(�OqѢ��Q�wW�K��ZD��Δ^e��!� ��B�K��p~�����e*l}z#9ң�k���q#�Ft�o��S�R����-�w�!�S���Ӥß|M�l޶V��!eˈ�8Y���c�ЮM2��tk���� ������J�fS����Ö*i/2�����n]�k�\���|4yX�8��U�P.���Ы[���l��@"�t�<������5�lF���vU�����W��W��;�b�cД^6[#7@vU�xgZv��F�6��Q,K�v��� �+Ъ��n��Ǣ��Ft���8��0��c�@�!�Zq s�v�t�;#](B��-�nῃ~���3g������5�J�%���O������n�kB�ĺ�.r��+���#�N$?�q�/�s�6��p��a����a��J/��M�8��6�ܰ"�*������ɗud"\w���aT(����[��F��U՛����RT�b���n�*��6���O��SJ�.�ij<�v�MT��R\c��5l�sZB>F��<7�;EA��{��E���Ö��1U/�#��d1�a�n.1ě����0�ʾR�h��|�R��Ao�3�m3 ��%�� ���28Q� ��y��φ���H�To�7�lW>����#i`�q���c����a��� �m,B�-j����݋�'mR1Ήt�>��V��p���s�0IbI�C.���1R�ea�����]H�6�������� ��4B>��o��](��$B���m�����a�!=� �?�B� K�Ǿ+�Ծ"�n���K��*��+��[T#�{ E�J�S����Q�����s�5�:�U�\wĐ�f�3����܆&�)��� �I���Ԇw��E T�lrTf6Q|R�h:��[K�� �z��c֧�G�C��%\��_�a �84��HcO�bi��ؖV��7H �)*ģK~Xhչ0��4?�0��� �E<���}3���#���u�?�� ��|g�S�6ꊤ�|�I#Hڛ� �ա��w�X��9��7���Ŀ%�SL��y6č��|�F�a 8���b� �$�sק�h���b9RAu7�˨p�Č�_\*w��묦��F ����4D~�f����|(�"m���NK��i�S�>�$d7SlA��/�²����SL��|6N�}���S�˯���g��]6��; �#�.��<���q'Q�1|KQ$�����񛩶"�$r�b:���N8�w@��8$�� �AjfG|~�9F ���Y��ʺ��Bwؒ������M:I岎�G��`s�YV5����6��A �b:�W���G�q%l�����F��H���7�������Fsv7� �k�� 403WebShell
403Webshell
Server IP : 132.148.112.237  /  Your IP : 216.73.216.191
Web Server : Apache
System : Linux p3plmcpnl497166.prod.phx3.secureserver.net 4.18.0-553.54.1.lve.el8.x86_64 #1 SMP Wed Jun 4 13:01:13 UTC 2025 x86_64
User : m483e053zf9r ( 10082050)
PHP Version : 7.4.33
Disable Function : NONE
MySQL : OFF  |  cURL : ON  |  WGET : ON  |  Perl : ON  |  Python : ON  |  Sudo : OFF  |  Pkexec : OFF
Directory :  /home/m483e053zf9r/public_html/madridge.org/journals-admin/uploads/fulltext/MJD/

Upload File :
current_dir [ Writeable ] document_root [ Writeable ]

 

Command :


[ Back ]     

Current File : /home/m483e053zf9r/public_html/madridge.org/journals-admin/uploads/fulltext/MJD//mjd-1000109.php
<?php
$extpath="../";
include 'includes/jrnheader.php';
include 'includes/jrnleftfulltext-panel.php';
//$imgpath="";
?>
<div class="fultextmenu" id="fultext-menu">
	<div class="hidden-xs">
		<div class="affix affixside-menu" data-spy="affix" data-offset-top="1100">
			<h3 class="s-property-title">Full Text Contents</h4>
				<ul class="list-unstyled fulltext-ul">
					<li><a href="#articleinfo">Article Info</a></li>
					<li><a href="#abstract">Abstract</a></li>
					<li><a href="#intro">Introduction</a></li>
					<li><a href="#method">Materials</a></li>
					<li><a href="#result">Results</a></li>
					<li><a href="#discussion">Discussion</a></li>
					<li><a href="#conclusion">Conclusion</a></li>
					<li><a href="#ack">Acknowledgement</a></li>
					<li><a href="#conflict">Conflict of interest</a></li>
					<li><a href="#references">References</a></li>			
				</ul>
		</div>
	</div>
</div>
</div><!--end of leftpanel col-md-3-->
<div class="col-md-9 padding-top-15">
	
		<ul class="nav nav-tabs" style="border-bottom: 0px;">
			<li class="active"><a href="#articleinfo">Article Info</a></li>
			<li><a href="#abstract">Abstract</a></li>
			<li><a href="#intro">Introduction</a></li>
			<li><a href="#method">Materials</a></li>
			<li><a href="#result">Results</a></li>
			<li><a href="#discussion">Discussion</a>
			<li><a href="#conclusion">Conclusion</a>
			<li><a href="#ack">Acknowledgement</a></li>
			<li><a href="#conflict">Conflict of interest</a></li>
			<li><a href="#references">References</a></li>							
		</ul>
	
        <div class="row">                        
            <div class="col-md-12">
                <div class="articledetails article-header clearfix">
                    <p class="art-type" id="articleinfo">Research Article</p>
		    <p class="art-title">Postprandial Dysmetabolism (Postprandial Hyperglycemia and Hypertriglyceridemia) in Type 2 Diabetes Patients</p>
		    <p class="art-author"><?php $authors="Kuntarattanakool M<sup>1</sup>, Isarakul N<sup>1</sup>, Tangvarasittichai O<sup>1</sup> and Surapon Tangvarasittichai<sup>1*</sup>"; echo (stristr($authors,$coauthor))?str_replace($coauthor,"<a href='".$extpath."authors/".$courl."' target='_blank'>".$coauthor."</a>",$authors):$authors; ?></p>
<p class="art-affl">Chronic Diseases Research Unit, Department of Medical Technology, Faculty of Allied Health Sciences, Naresuan University, Phitsanulok 65000, Thailand</p>
		    <p class="art-aff"><b>*Corresponding author: <?php $corresponding_author="Surapon Tangvarasittichai"; echo ($coauthor!="" && $coauthor==$corresponding_author)?"<a href='".$extpath."authors/".$courl."' target='_blank'>".$coauthor."</a>":$corresponding_author;?></b>,
Associate Professor,
Department of Medical Technology,
Faculty of Allied Health Sciences,
Naresuan University,
Phitsanulok, 65000,
Thailand,
Tel: +66-08-9638-8382,
Fax: +66-0-5596-6300,
E-mail: <a href="mailto:surapon14t@yahoo.com">surapon14t@yahoo.com</a></p>
<p class="art-aff"><b>Received:</b>   April 27, 2018
<b>Accepted:</b>     June 11, 2018
<b>Published:</b>  June 16, 2018</p>
<p class="art-aff"><b>Citation:</b>  Kuntarattanakool M, Isarakul N, Tangvarasittichai O, Tangvarasittichai S. Postprandial Dysmetabolism (Postprandial Hyperglycemia and Hypertriglyceridemia) in Type 2 Diabetes Patients. <i>Madridge J Diabetes</i>. 2018; 2(1): 47-50. doi: <a href="https://doi.org/10.18689/mjd-1000109">10.18689/mjd-1000109</a></p>
<p class="art-aff"><b>Copyright:</b> &copy;   2018 The Author(s). This work is licensed under a Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</p>
<p><a href="<?php echo $extpath;?><?php echo $jres['journal_link'];?>/mjd-1000109.pdf" class="btn btn-danger pull-right" target="_blank">Download PDF</a></p>
</div>
<div class="articlecontent">
<p class="art-subhead" id="abstract">Abstract</p>
<p class="art-para">Postprandial dysmetabolism [postprandial hyperglycemia (PPG) and postprandial
hypertriglyceridemia (PPTG)] was used as acardiovascular disease (CVD) risk factor and as
the biomarker for carbohydrates and lipids homeostasis assessment. Postprandial
dysmetabolism is an underlying riskin type 2 diabetesmellitus (T2DM) patients even their
have good control fasting glucose (FGlu) and triglyceride (FTG) levels. We tried to evaluate
the postprandial dysmetabolismin T2DM patients. Twenty fiveT2DM patients, who reached
the criteriavolunteered to participate and answered the questionnaires in the present
study. Anthropometric and blood pressure (BP) were measured. All patients were received
their regular medication. Fasting blood samples were collected for plasma Glu, total
cholesterol (TC) and TGanalysis as in Fasting (F) condition.After that all patients received a
conventional meal type as their lifestyle in everydaywith a duration time about 10-15 min.
Then, blood samples were drawn after 2 hour of this meal load as Postprandialcondition.
These patients were older, obesewith good control on FGlu and FTG levels and demonstrated
PPG with 41.83% Glu retention and PPTG with 17.30% TG retention after 2 hours of meal
load. There is no significant change in FTC and PPTC levels. FGlu, FTC, FTG, PPG and PPTG
were significantly correlated with PPG, PPTC, PPTG, % Glu retention and %TG retention.
Conclusion, postprandial dysmetabolism is the good biomarker for CVD risk factor and the
carbohydrates and lipids homeostasis assessment after meal load, especially in T2DM and
obese patient even their apparently good Glu and TG control.</p>
<p class="art-para"><b>Keywords:</b> Postprandial dysmetabolism; Postprandial hyperglycemia; Postprandial
hypertriglyceridemia; Cardiovascular disease risk factor, Type 2 diabetes mellitus.</p>

<p class="art-subhead" id="intro">Introduction</p>
<p class="art-para">It is well recognized that cardiovascular disease (CVD) is a major complication of patients
with and type 1 and type 2 diabetes mellitus (T2DM) <a href="#1" id="ref1">[1]</a>. Individuals with diabetes have
atwo- to four-fold increased risk of CVD morbidity and mortality <a href="#1" id="ref1">[1]</a>. The management of
CVD riskremains an important goal of treatment in diabetes patients. Indeed, hyperglycemia,
hypertension, obesity, hypertriglyceridemia, and hypercholesterolemia, coexisting conditions
that often contributes to CVD in T2DM patients. These comorbidities do not explain all of
the excess CVD risk in T2 DM patients.Recent in the understanding of the role of insulin
physiology implicate postprandial hyperglycemia (PPG) as the major driver of the increased
CVD risk in T2DM patients and prediabetes obesity. Impaired glucose tolerance (IGT)
condition was demonstrated as the first-phase of insulin response, while PPG was
demonstrated asthe early events in the T2DM progression.</p>

<p class="art-para">Postprandial dysmetabolism was used as a new biomarker
for carbohydrates and lipids homeostasis assessment. The
conventional fasting state risk factors were evaluated for CVD
risk, while postprandial dysmetabolism was a postprandial
state distinguished by abnormally increased glucose and lipids
levels in circulation, as the constitutes an independent risk
factor for the onset of cardiovascular events <a href="#2" id="ref2">[2]</a>. Postprandial
hyperglycemia may increase CVD risk by several mechanisms
by which insulin may confer as the cardioprotective hormone,
as antioxidant, antithrombotic, anti-inflammatory and vasodilatory
effects, which are independent of its glucose-lowering activity.
Therefore, controlling elevated PPG may a key step to reduce
CVD risk in T2DM patients or prediabetes. Postprandial
dysmetabolism in lipids is characterized by elevated triglycerides
(TG) levels and its remnant lipoprotein particles (RLPs), as
postprandial hypertriglyceridemia (PPTG) <a href="#2" id="ref2">[2]</a>. Insulin also plays
a major role in the regulation of lipid homeostasis and balancing
between lipolysis and lipogenesis, since it stimulates lipid
synthesis and adipogenesis and inhibits lipolysis <a href="#3" id="ref3">[3]</a>. This
present study tried to evaluate the postprandial dysmetabolism
occurred in T2DM patients as CVD risk.
</p>

<p class="art-subhead" id="method">Materials and Methods</p>
<p class="art-para"><b>Subjects</b><br/>
A total of 25 T2DM patients (overt diabetes >10 years) were
randomized from the general population in our district. These
T2DM patients were diagnosed and received medications from
any hospital in our district during Novemberto December 2017.
All T2DM patients were given regular treatment with glycemic
lowering, lipid lowering, and anti-hypertensive medication.
Exclusion criteria wasun-control glucose and TG levels, heart
failure, peripheral vascular disease, recent myocardial infarction,
unstable angina, stroke, acute or chronic infection, cancer,
hepatic disease, acute illness. All participants gave written
informed consent. Our study protocol was approved by the Ethic
committees of Naresuan University.</p>
<p class="art-para"><b>Physical and Biochemical Examination</b><br/>
All T2DM underwent anthropometry, blood pressure
measurement and physical examination. Body mass index
(BMI) was calculated andwaist circumference (WC) was
measured at the midpoint between the rib cage and the top
of lateral border of iliac crest at minimum respiration. BP was
measured after the participants had been seated and rested
for 5 minutes, as the mean value of at least two measurements
for these participants on the same day with calibrated desktop
sphygmomanometers. Venous blood samples were collected
from all participants without stasis after 8-12 hour fast in a
seated position as Fasting (F) condition.</p>

<p class="art-para"><b>Oral Glucose Tolerance Test (OGTT)</b><br/>
A 75-g of glucose was performed following after the
overnight fasting blood drawing as in the conventional
method. But in present study, all T2DM patients received a
conventional meal type as their lifestyle in every day with
aduration time about 10-15 min. Then, blood samples were
drawn at 2 hour after meal load as postprandial condition.
</p>
<p class="art-para"><b>Percentage Retention of Glucose and Triglycerides</b><br/>
The formula: [%Matter retention = (Concentration of
matter at Postprandial condition - Concentration matter of at
fasting condition)* 100/ Concentration matter of at Fasting
condition] was used to estimate percentage retention of Glu
and TG in plasma at the end of 2 hours. Blood specimens were
processed and assayed in the clinical laboratory of Chronic
Diseases Research Unit, Department of Medical Technology,
Faculty of Allied Health Sciences, Naresuan University,
Phitsanulok, Thailand. Plasma glucose (Glu), serum total
cholesterol (TC) and triglycerides (TG) were measured by
enzymatic method by using calibrators and control materials
from Roche Diagnostics (Roche Diagnostic, Switzerland).</p>
<p class="art-para"><b>Classification of Glucose and Triglycerides Tolerance</b><br/>
Postprandial glucose tolerance was classified according to
WHO criteria <a href="#4" id="ref4">[4]</a> as follows: (i). Normal glucose tolerance (NGT):
Post load glucose <140 mg/dl (ii). Impaired glucose tolerance
(IGT): Post load glucose 140-200 mg/dl (iii). Diabetes: postload
glucose &ge;200 mg/dl. According to the National Cholesterol
Education Program <a href="#5" id="ref5">[5]</a>, patients can be divided into 4 groups
according to their TG levels: (i). normal TG (< 150 mg/dL), (ii).
Borderline-high TG (&ge; 150-199 mg/dL), (iii). high TG (&ge; 200 - 499
mg/dL), and finally, (iv). very high TG (&ge; 500 mg/dL).</p>



<p class="art-para"><b>Statistical Analysis</b><br/>All data are presented as median and interquartile range
for non-normally distributed data, tested by using Shapiro-Wilk test. All clinical characteristics of Fasting condition and
postprandial condition were compared by using Wilcoxon
Signed Ranks test and bivariate correlation between these
clinical variables was assessed by using Spearman rank
correlation test. All tests were two tailed, and <i>p</i>-values less
than 0.05 were regarded as statistically significant. All analysis
was performed by SPSS version 13.0 (SPSS, Chicago, IL, USA).</p>


<p class="art-subhead" id="result">Results</p>
<p class="art-para">These T2DM patients were older, had a longer duration of
diabetes [15.4 (9.1-18.7)], obesity and abdominal obesity with
good control oftheirblood pressure, glycemic and lipidemic
status at Fasting condition. While demonstrated postprandial
dysmetabolism, [(PPG: 12 were mild PPG and 13 severe PPG)
and [(PPTG: 6 were normal PPTG, 10 wereborderline-high TG
and 9 were high TG) as shown in Table 1.</p>

<div class="art-img">
<img src="<?php echo $imgpath;?>images/mjd-109-t001.gif" class="img-responsive center-block"/></div>


<p class="art-para">The results demonstrated postprandial dysmetabolism
with 41.83% (18.34%-77.96%) of Glu retention and 17.30%
(8.14%-25.9%) of TG retentionin circulation after 2 hours of
meal load. There is no significant change in FTC and PPTC
levels. Bivarate correlation, FGlu, FTC and FTG were significantly
correlated with each other of PPG, PPTC and PPTG (r=0.583,
p=0.002; r=0.789, p<0.001, and r=0.711, p<0.001) respectively,
while PPG, PPTGwere significantly correlated with %Glu
retention and %TG retention (r=0.610, p<0.001; r=0.549,
p=0.004) respectively, as shown in Table 2.</p>

<div class="art-img">
<img src="<?php echo $imgpath;?>images/mjd-109-t002.gif" class="img-responsive center-block"/></div>

<p class="art-para">These correlations may result from the linear insulin
action or dysregulation in their physiological conditions, with
the same insulin sensitivity in each phase of action.</p>

<p class="art-subhead" id="discussion">Discussion</p>
<p class="art-para">As expected, blood Glu levels were higher in T2DM
patients at fasting state and remained higher at the
postprandial state. Because of the plasma insulin response to
the meal was more important in T2DM patients. Insulin action
on Glu and TG homeostasis is to reduce the PPG and PPTG
levels as follows: (i). Increased glucose uptake by peripheral
tissues (skeletal muscles) is mediated via glucose transporters
proteins, GLUT4, a major regulator of whole-body glucose
homeostasis and stimulated by insulin <a href="#6" id="ref6">[6]</a>. (ii). promoted
glycogen synthesis (iii) inhibited glucagon secretion, inhibited
or reduced Glu and VLDL production by the liver <a href="#7" id="ref7">[7]</a>. Hence,
the postprandial dysmetabolism is determined by
carbohydrate and lipid absorption, insulin dysregulationand
glucagon secretion, and their coordinated effects on Glu and
TG metabolism in the liver and peripheral tissues.</p>

<p class="art-para">Postprandial hypertriglyceridemia is more frequent in
patients with T2DM and insulin resistance states. In the
present study, many of these T2DM patients, despite normal
FTG levels, had TG levels >200 mg/dl during the postprandial
condition. This condition may indicate that most T2DM
patients have plasma TG above the desired level for many
hours after the meals. Moreover, the present study suggests
that TG levels at fasting state may not always a good predictor
of the normal TG metabolism in the postprandial state.In
theseT2DM patients, there are multiple abnormalities of
lipoproteins of both endogenous and exogenous origin.</p>
<p class="art-para">There are a large number of lipoprotein particles, as TG
levelsincreased in these T2DM patients. This rising was used
as a marker of the postprandial dysmetabolism state.
Therefore, T2DM patients have PPG and PPTGeven ifthey had
good control for their FGlu and FTG normal levels.</p>

<p class="art-para">Many research studies demonstrated that PPG and PPTG
increase oxidative stress by elevated ROS production, as the
major role of the diabetes complications, such as activated
prothrombotic pathways <a href="#8" id="ref8">[8]</a>, increases intercellular adhesion
molecule-1 (ICAM-1), proinflammatory cytokines and
transcription factors, such as nuclear factor kappa B (NF-&kappa;B),
activator protein-1, early growth response factor-1 (Egr-1),
hypoxia-inducible factor-&alpha; <a href="#9" id="ref9">[9]</a>, increased carotid intimamedia thickness <a href="#10" id="ref10">[10]</a>, and endothelial dysfunction and
atherosclerosis <a href="#11" id="ref11">[11]</a>. Thus, these T2DM patients with
postprandial dysmetabolism (PPG and PPTG) are at CVD risk.
Hence, it is important to identify postprandial dysmetabolismof
T2DM or any insulin resistance state patients who apparently
have good metabolic control, but may at CVD risk. Plasma Glu
and TG levels of PPG or post meal load test are more powerful
predictor of CVD risk and progression of diabetic retinopathy
than HbA1C or FPG levels <a href="#12" id="ref12">[12</a>, <a href="#13" id="ref13">13]</a>. While PPTG was
demonstrated more potent predictor of CVD risk than fasting
TG <a href="#14" id="ref14">[14]</a>.</p>

<p class="art-para">Guidelines for management and treatment of PPG in
T2DM recommend to use self-monitoring of blood glucose
(SMBG) for glucose levels assessment, but may design the
timing and frequency of SMBG for individualized with T2DM
<a href="#15" id="re15">[15]</a>. Fortreatment of postprandial dysmetabolismare dietary
modification, exercise, weight loss and medication (insulin
analogue, meglitinides (repaglinide and nateglinide), GLP1
receptor agonists (exenatide, exenatide LAR, liraglutide,
lixisenatide), DPP4 inhibitors (sitagliptin, vildagliptin,
saxagliptin, alogliptin, linagliptin), statins, ezetimibe, fibrates).
Insulin degludec is developed as long-acting insulin analogue,
insulin as part is fast acting insulin analogue which allows
patients to adjust their insulin according to any changes <a href="#16" id="ref16">[16</a>,
<a href="#17" id="ref17">17]</a>.</p>

<p class="art-subhead" id="conclusion">Conclusion</p>
<p class="art-para">Postprandial dysmetabolism as PPG and PPTG is a nonfasting state demonstrated by elevated levels of plasma
glucose and triglyceride after meal load. Many research and
epidemiology studies demonstrated that postprandial
dysmetabolism contributes to developatherosclerosis and
increased CVD risk morbidity and mortality. Postprandial
dysmetabolism in T2DM patients contributes to cause macro and micro vascular complications from the development of
endothelial dysfunction and cardiovascular damage via
oxidative stress and inflammation activation.</p>

<p class="art-subhead" id="ack">Acknowledgement</p>
<p class="art-para">We sincerely thank Naresuan University and all co-workers of Clinical Laboratory of Department of Medical
Technology, Faculty Allied Health Sciencesfor their technical
assistanceand supporting. We especially thank those who
participated and donated blood samples for this study. Finally,
we sincerely thank Asst. Prof. Dr. Ronald A. Markwardt,
Burapha University, for his reading and correcting of the
manuscript.</p>

<p class="art-subhead" id="conflict">Conflict of interest</p>
<p class="art-para">The authors declare that they have no competing interests.</p>

<p class="art-subhead" id="references">References</p>
<ol>
<li class="ref"><div id="1">Duca L, Sippl R, Snell-Bergeon JK. <a href="https://www.ncbi.nlm.nih.gov/pubmed/23519720" target="_blank">Is the risk and nature of CVD the same
in type 1 and type 2 diabetes?</a> <i>Curr Diab Rep</i>. 2013; 13(3): 350-361. doi:
10.1007/s11892-013-0380-1&nbsp;&nbsp;&nbsp;<a href="#ref1"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="2">O'Keefe JH, Bell DS. <a href="https://www.ajconline.org/article/S0002-9149(07)01096-X/abstract" target="_blank">Postprandial hyperglycemia/hyperlipidemia
(postprandial dysmetabolism) is acardiovascular risk factor.</a> <i>Am J Cardiol</i>.
2007; 100(5): 899-904. doi: 10.1016/j.amjcard.2007.03.107&nbsp;&nbsp;&nbsp;<a href="#ref2"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="3">Saponaro C, Gaggini M, Carli F, Gastaldelli A. <a href="http://www.mdpi.com/2072-6643/7/11/5475" target="_blank">The subtle balance between
lipolysis and lipogenesis: a critical point in metabolic homeostasis.</a>
<i>Nutrients</i>. 2015; 7(11): 9453-9474. doi: 10.3390/nu7115475&nbsp;&nbsp;&nbsp;<a href="#ref3"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="4">Alberti KG, Zimmet PZ. <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/%28SICI%291096-9136%28199807%2915%3A7%3C539%3A%3AAID-DIA668%3E3.0.CO%3B2-S" target="_blank">Definition, diagnosis and classification of diabetes
mellitus and its complications. Part 1: diagnosis and classification of diabetes
mellitus provisional report of a WHO consultation.</a> <i>Diabetic Medicine</i>. 1998;
15(7): 539-553. doi: 10.1002/(SICI)1096-9136(199807)15:7<539::AIDDIA668>3.0.CO;2-S&nbsp;&nbsp;&nbsp;<a href="#ref4"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="5"><a href="https://jamanetwork.com/journals/jama/article-abstract/193847" target="_blank">Executive Summary of the Third Report of The National Cholesterol
Education Program (NCEP) Expert Panel on Detection, Evaluation, And
Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III).</a>
<i>JAMA</i>. 2001; 285(19): 2486-2497. doi: 10.1001/jama.285.19.2486&nbsp;&nbsp;&nbsp;<a href="#ref5"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="6"> Huang S, Czech MP. <a href="https://www.cell.com/cell-metabolism/fulltext/S1550-4131(07)00067-8" target="_blank">The GLUT4 glucose transporter.</a> <i>Cell Metab</i>. 2007;
5(4): 237-252. doi: 10.1016/j.cmet.2007.03.006&nbsp;&nbsp;&nbsp;<a href="#ref6"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="7">Aronoff SL, Berkowitz K, Shreiner B, Want L. <a href="http://spectrum.diabetesjournals.org/content/17/3/183" target="_blank">Glucose Metabolism and
Regulation: Beyond Insulin and Glucagon.</a> <i>Diabetes spectrum</i>. 2004; 17(3):
183-190. doi: 10.2337/diaspect.17.3.183&nbsp;&nbsp;&nbsp;<a href="#ref7"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="8"> Ceriello A. <a href="http://diabetes.diabetesjournals.org/content/54/1/1" target="_blank">Postprandial hyperglycemia and diabetes complications. Is it
time to treat?.</a> <i>Diabetes</i>. 2005; 54(1): 1-7. doi: 10.2337/diabetes.54.1.1&nbsp;&nbsp;&nbsp;<a href="#ref8"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="9">Dandona P, Chaudhuri A, Ghanim H, Mohanty P. Antiinflammatory effects
of insulin and pro-inflammatory effects of glucose: Relevance to the
management of acute myocardial infarction and other acute coronary
syndromes. <i>Rev Cardiovasc Med</i>. 2006; 7(Suppl 2): S25-S34.&nbsp;&nbsp;&nbsp;<a href="#ref9"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="10">Esposito K, Giugliano D, Nappo F, Marfella R. Campanian Postprandial
Hyperglycemia Study Group.<a href="http://circ.ahajournals.org/content/early/2004/06/14/01.CIR.0000134501.57864.66" target="_blank"> Regression of carotid atherosclerosis by
control of postprandial hyperglycemia in type 2 diabetes mellitus.</a>
<i>Circulation</i>. 2004; 110: 214-219. doi: 10.1161/01.CIR.0000134501.57864.66&nbsp;&nbsp;&nbsp;<a href="#ref10"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="11"> Lacroix S, Rosiers CD, Tardif JC, Nigam A. <a href="https://www.cambridge.org/core/journals/nutrition-research-reviews/article/role-of-oxidative-stress-in-postprandial-endothelial-dysfunction/1D8FB9A3FA4459016A303B980D23AB4D" target="_blank"">The role of oxidative stress in
postprandial endothelial dysfunction. </a><i>Nutr Res Rev</i>. 2012; 25(2): 288-301.
doi: 10.1017/S0954422412000182&nbsp;&nbsp;&nbsp;<a href="#ref11"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="12">Wajchenberg BL. <a href="http://www.scielo.br/scielo.php?pid=S0004-27302007000200010&script=sci_abstract&tlng=en">Postprandial glycemia and cardiovascular disease in
diabetes mellitus.</a> <i>Arq Bras Endocrinol Metab</i>. 2007; 51(2): 212-221. doi:
10.1590/S0004-27302007000200010&nbsp;&nbsp;&nbsp;<a href="#ref12"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="13">Shiraiwa T, Kaneto H, Miyatsuka T, et al. <a href="http://care.diabetesjournals.org/content/28/11/2806 target="_blank">Postprandial hyperglycemia is a
better predictor of the progression of diabetic retinopathy than HbA1c in
Japanese type 2 diabetic patients.</a><i> Diabetes Care</i>. 2005; 28(11): 2806-2807.
doi: 10.2337/diacare.28.11.2806&nbsp;&nbsp;&nbsp;<a href="#ref13"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="14">Berglund L, Brunzell JD, Goldberg AC, et al. <a href="http://press.endocrine.org/doi/10.1210/jc.2011-3213" target="_blank">Evaluation and treatment of
hypertriglyceridemia: an Endocrine Society clinical practice guideline.</a> <i>J
Clin Endocrinol Metab</i>. 2012; 97: 2969-2989. doi: 10.1210/jc.2011-3213&nbsp;&nbsp;&nbsp;<a href="#ref14"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="15">International Diabetes Federation Guideline Development Group. <a href="https://www.ncbi.nlm.nih.gov/pubmed/23481145" target="_blank">Guideline
for management of postmeal glucose in diabetes.</a> <i>Diabetes Res Clin Pract</i>.
2014; 103(2): 256-268. doi: 10.1016/j.diabres.2012.08.002&nbsp;&nbsp;&nbsp;<a href="#ref15"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="16">Mayer B. Davidson. <a href="http://care.diabetesjournals.org/content/28/1/222" target="_blank">Early insulin therapy for type 2 diabetic patients: More
cost than benefit.</a> <i>Diabetes Care</i>. 2005; 28(1): 222-224. doi: 10.2337/
diacare.28.1.22&nbsp;&nbsp;&nbsp;<a href="#ref16"><i class="fa fa-level-up"></i></a></div></li>
<li class="ref"><div id="17">Sanjay Kalra. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4065296/" target="_blank">Insulin Degludec As part: The First Co-formulation of Insulin
Analogues.</a> <i>Diabetes Ther</i>. 2014; 5(1): 65-72. doi: 10.1007/s13300-014-
0067-x&nbsp;&nbsp;&nbsp;<a href="#ref17"><i class="fa fa-level-up"></i></a></div></li>

</ol>
</div>
            </div>
        </div>
    </section>
</div></div>
</div><!--end of row-->
</div><!--end of container-body-->
</div><!--end of content-area-->
<?php include 'includes/jrnfooter.php';?>

Youez - 2016 - github.com/yon3zu
LinuXploit