Although nonalcoholic fatty liver disease (NAFLD) is associated with obesity, it can also occur in lean and metabolically normal individuals. Our aim was to determine the effect of different combinations of abdominal adiposity and overall adiposity on the mortality of NAFLD. The Third National Health and Nutrition Examination Survey with mortality data from the National Death Index were used. NAFLD was defined as steatosis without other liver diseases. Body composition was categorized according to waist circumference (WC) and body mass index (BMI). Obesity pattern was defined according to BMI (lean, overweight, and obese) and WC (normal and obese) using accepted definitions. The "metabolically abnormal" group had visceral obesity, insulin resistance, type 2 diabetes, hypertension, or hyperlipidemia. Of the 9,341 study individuals (47.9% male; 76.8% white), NAFLD was present in 3,140 (33.6%), of whom 0.6% had lean BMI and normal WC, and 1.7% had lean BMI and obese WC. The prevalence of metabolically normal NAFLD was 3.26% (95% confidence interval [CI]: 2.62%-3.90%), with most of these subjects having lean BMI (79.2%). During an average follow-up of 22.4 years, 24.1% of the subjects died from all causes. Among these deceased individuals, 41.7% had NAFLD at baseline. Causes of death were cardiovascular disease (24.8%), cancer-related (24.3%), type 2 diabetes-related (4.4%), and liver-related (1.7%). Individuals with NAFLD who were lean by BMI but obese by WC had higher risk of all-cause mortality. Individuals with NAFLD with normal BMI but obese WC had a higher risk of cardiovascular mortality (hazard ratio 2.63 [95% CI: 1.15-6.01]) as compared with overweight (by BMI) NAFLD with normal WC. Conclusion: The risk of mortality in NAFLD can be affected by the presence of visceral obesity, especially in the lean BMI group. These data have important management implications for patients with NAFLD.

Population-based studies that estimate awareness of nonalcoholic fatty liver disease (NAFLD) in the United States are scant. We aimed to understand public awareness of NAFLD and its temporal trends. Our study included 11,700 adults (18+ years old) from five National Health and Nutrition Examination Surveys (2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016). NAFLD was determined by the improved Fatty Liver Index for the multiethnic U.S. population (US-FLI) in the absence of secondary causes of liver disease. Overall prevalence of NAFLD, hepatitis C virus, and hepatitis B virus were 36.6%, 1.02% and 0.35%, respectively. From 2007-2008 to 2015-2016, awareness of liver disease among adults with NAFLD improved from 4.4% to 6.3% (trend P = 0.026) but 4 to 10 times lower than awareness about viral hepatitis. In 2015-2016, among adults with NAFLD, awareness of liver disease was lower among young adults (aged 18-29 years) compared with those aged ≥ 30 years (0% vs. 6.9%) and lower among non-Hispanic Blacks compared with other races (0.7% vs. 6.6%) (all P < 0.001). In multivariable analysis, young adults (adjusted odds ratio [aOR] = 0.29; confidence interval [CI] 0.10-0.87) and non-Hispanic Blacks (aOR = 0.43; CI 0.20-0.96) were negatively associated with awareness of liver disease among adults with NAFLD, whereas diabetes (aOR = 2.22; CI 1.37-3.58), advanced fibrosis (aOR = 2.34; CI 1.17-4.68), and a higher number of health care visits (aOR = 1.33; CI 1.15-1.50) were positively associated with awareness of liver disease. Nearly 96% of adults with NAFLD in the United States were unaware they had liver disease, especially among young adults and non-Hispanic Blacks. Findings indicate efforts are needed to improve awareness of NAFLD. (Hepatology Communications 2021;0:1-15).

Nonalcoholic fatty liver disease (NAFLD) is rapidly becoming the most common cause of chronic liver disease worldwide. This is primarily driven by the global epidemic of obesity and diabetes as well as the aging of the general population. Most of the epidemiology data of NAFLD for North America are published from studies originating in the United States (U.S.). The overall prevalence of NAFLD in the U.S. is estimated to be 24%. Hispanic Americans have a higher prevalence of NAFLD, whereas African Americans have a lower prevalence of NAFLD. The exact contributions of genetic and environmental factors on these differences in the prevalence rates have not been determined. From the spectrum of NAFLD, patients with non-alcoholic steatohepatitis (NASH) are at the highest risk of progression to cirrhosis and hepatocellular carcinoma (HCC). The most recent data regarding the progression of NASH suggest a complex pattern of progression and regression of fibrosis. Factors influencing the progression and regression of NASH have not been fully described. More research is needed to better understand NAFLD in Mexico and Canada.

Cardiovascular disease (CVD) is an important cause of morbidity and mortality after liver transplantation (LT). Although LT is associated with dyslipidemia, particularly atherogenic lipoprotein subparticles, the impact of these subparticles on CVD‐related events is unknown. Therefore, the aim of the current study was to evaluate the impact of small dense (sdLDL‐C) low‐density lipoprotein (LDL) cholesterol (LDL‐C) on CVD events. Prospectively enrolled patients (N = 130) had detailed lipid profile consisting of traditional lipid parameters and sdLDL‐C and were followed for CVD events. The primary endpoint was a CVD composite consisting of myocardial infarction (MI), angina, need for coronary revascularization, and cardiac death. Mean age of the cohort was 58 ± 11 years, and the most common etiology of liver disease (LD) was hepatitis C virus (N = 48) and nonalcoholic steatohepatitis (N = 23). A total of 20 CVD events were noted after median follow‐up of 45 months. The baseline traditional profile was similar in patients with and without CVD events. A serum LDL‐C cutoff of 100 mg/dL was unable to identify individuals at risk of a CVD event (P = 0.86). In contrast, serum concentration of atherogenic sdLDL‐C >25 mg/dL was predictive of CVD events with a hazard ratio of 6.376 (95% confidence interval, 2.65, 15.34; P < 0.001). This relationship was independent of diabetes, hypertension, sex, ethnicity, LD, obesity, and statin use. Conclusion: sdLDL‐C independently predicted CVD events whereas LDL‐C did not. Thus, sdLDL‐C may provide a useful clinical tool in risk stratifying and managing patients after LT.

There is a paucity of recent data about the epidemiology and long‐term outcomes of nonalcoholic fatty liver disease (NAFLD) in the female population. Our aim was to assess the prevalence, risk factors, and mortality of NAFLD in female adults of the United States. Data from the National Health and Nutrition Examination Survey (NHANES) III and NHANES 1999‐2014 were used. NAFLD status was determined by the U.S. Fatty Liver Index (US‐FLI) in the absence of other liver diseases and excessive alcohol consumption. The prevalence rates, risk factors, and 5‐year all‐cause and cardiovascular mortality were determined in women with NAFLD. The most recent prevalence of NAFLD among female adults (2007‐2014) in the United States was 24.4% (95% confidence interval [CI], 22.48‐26.33). Prevalence was higher among women >44 years of age and those with body mass index ≥30 kg/m2. In addition, the average age of the female population with NAFLD has decreased over time. The fully adjusted odds ratios in women with NAFLD compared to those without NAFLD were 1.48 (95% CI, 1.20‐1.82) for cardiovascular disease (CVD), 1.89 (95% CI, 1.42‐2.52) for atherosclerotic cardiovascular disease (ASCVD) score ≥7.5%, and 1.76 (95% CI, 1.37‐2.25) for either CVD or ASCVD ≥7.5%. The 5‐year mortality for female adults with NAFLD was significantly higher than for those without NAFLD (adjusted hazard ratio, 1.48; 95% CI, 1.07‐2.05). Among women with NAFLD, those with ASCVD ≥7.5% had significantly higher 5‐year all‐cause mortality and CVD mortality. Conclusion: The prevalence of NAFLD in female NHANES participants from the United States has continued over recent years. In the female population with NAFLD, ASCVD ≥7.5% is an independent predictor of overall and cardiac‐specific mortality.

Understanding the burden of NAFLD among adolescents and young adults has become increasingly relevant. Our aim was to estimate the prevalence of NAFLD among adolescents and young adults in the United States. Data were obtained from National Health and Nutrition Examination Survey from 2007-2016. Adolescents and young adults aged 12 to 29 years were included. NAFLD was determined by the U.S. Fatty Liver Index in the absence of secondary causes of liver disease, and the differences in prevalence trends were analyzed based on age, gender, and race. Complete data were available for 4,654 adolescents and young adults (mean age 21 years; 50.9% male; 56.8% White, 20.9% Hispanic, and 13.3% Black). The overall prevalence of NAFLD among adolescents and young adults was 18.5%, ranging from 13.2% among early and middle adolescents (12-17 years) to 18.7% among late adolescents and young adults (18-24 years), to 24.0% among older young adults (25-30 years) (trend P < 0.001). The prevalence of NAFLD was higher for boys than for girls (aged 12-17: 15.1% vs. 11.3%; aged 18-24: 21.1% vs. 16.2%; aged 25-30: 28.7% vs. 19.2%, all P < 0.030). Among all age groups, Hispanics had a higher prevalence of NAFLD than Whites and Blacks (pairwise P < 0.001). Over the study time period, the prevalence of NAFLD among early and middle adolescents and young adults did not change (trend P > 0.80). In contrast, NAFLD prevalence among late adolescents increased (trend P = 0.018). In fact, White and Hispanic late adolescents were the drivers behind this increase in the prevalence of NAFLD. Conclusion: These data indicate an increasing trend in NAFLD prevalence among 18-24-year-olds. These data have important public health and policy implications. (Hepatology Communications 2021;0:1-13).

Lactobacilli are commensal anaerobic gram-positive rod organisms that are normal flora of the oral, genitourinary, and gastrointestinal tracts. Lactobacillus rhamnosus is now commonly found in probiotics. They are rarely pathogenic, but occasional cases of bacteremia and associated endocarditis have been noted in patients with pre-disposing factors. We describe a case of Lactobacillus endocarditis in an otherwise healthy patient with probiotic use and gingival laceration and present an accompanying discussion of the potential association of probiotic formulations containing lactobacilli and systemic infection.

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