Type 2 diabetes mellitus increases the risk of hepatic fibrosis in individuals with obesity and nonalcoholic fatty liver disease

Abstract

Objective This study assessed the impact of diabetes mellitus (DM) on nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) with advanced fibrosis prevalence in adults with overweight or obesity in the United States. Methods Participants (National Health and Nutrition Examination Survey [NHANES] 2015‐2016 database) included 834 middle‐aged patients with DM (21.7%) and 3,007 without DM (78.3%). NAFLD was defined by Fatty Liver Index (FLI) ≥ 60 or United States FLI (USFLI) ≥ 30. Moderate‐to‐high and high risk of advanced fibrosis was defined by fibrosis‐4 index (FIB‐4) ≥ 1.67 and ≥ 2.67, respectively, and NAFLD fibrosis scores > 0.676 also indicated a high risk. Results NAFLD prevalence increased with BMI. Steatosis was higher in individuals with overweight with DM versus without DM (USFLI ≥ 30: 48.3% vs. 17.4%; p < 0.01) and in individuals with obesity with DM versus without DM (USFLI ≥ 30: 79.9% vs. 57.6%; p < 0.01). DM significantly increased the proportion of individuals at moderate‐to‐high risk of fibrosis (FIB‐4 ≥ 1.67: 31.8% vs. 20.1%; p < 0.05). In the high risk of advanced fibrosis group (FIB‐4 ≥ 2.67), the risk almost doubled (3.8% vs. 7.1%). Among individuals with obesity, DM increased the proportion of adults with moderate and high risk of fibrosis by 1.8‐ and 2.5‐fold, respectively (p < 0.01 and p = 0.39, respectively, vs. without DM). Conclusions In this US cohort, DM modestly impacted steatosis, which was primarily obesity‐driven. DM added a significant risk of fibrosis to individuals with overweight or obesity, suggesting that screening is imperative in adults with DM.

The Association between Non-Alcoholic Fatty Liver Disease (NAFLD) and Advanced Fibrosis with Serological Vitamin B12 Markers: Results from the NHANES 1999–2004

“…The FLI had an AUC of 0.84, and the USFLI had an AUC of 0.80 to detect steatosis in the U.S. population [ 14 ]. We used a combination of these two indexes as previously described [ 44 ]. We performed a sensitivity analysis to test these patients and found that the association between RBC folate and NAFLD was stable whether FLI or USFLI was used ( Table S1 ).…”

Clinical Care Pathway for the Risk Stratification and Management of Patients With Nonalcoholic Fatty Liver Disease

“…Most patients screened in primary care will have a low risk of clinically significant liver fibrosis, defined as having a FIB-4 score <1.3, LSM <8.0 kPa by transient elastography, or a liver biopsy fibrosis stage of F0-F1 (Figure 3). 1,2,[50][51][52][53] We recommend therapeutic lifestyle interventions for these patients. Specific pharmacologic treatment targeting liver steatosis is not necessary in this lower-risk population.…”

“…Nearly 10% of patients screened based on Steps 1 to 4 will have a high risk of clinically significant liver fibrosis, defined as having a FIB-4 score >2.67, LSM >12.0 kPa by transient elastography, or a liver biopsy showing clinically significant liver fibrosis (Figure 3). 1,2,[50][51][52][53] We recommend that these patients be managed by a multidisciplinary team closely coordinated by a hepatologist who can monitor for cirrhosis, HCC, and other cirrhosis-related complications. In these patients, we recommend aggressive lifestyle changes aimed at long-term weight loss.…”

Nonalcoholic fatty liver disease in diabetes: Overlooked or just ignored?

“…TO THE EDITOR: We read with great interest the recently published Obesity article in which Barb et al (1) observed that prevalence of nonalcoholic fatty liver disease (NAFLD) in US participants was primarily driven by obesity and that people with diabetes had greater risk of NAFLD and advanced fibrosis. Indeed, 31.0% of those with obesity and diabetes had a fibrosis-4 index score indicating moderate-to-high risk, and 34.1% had an NAFLD fibrosis score (NFS) suggesting high risk of advanced fibrosis.…”