Nonalcoholic fatty liver disease in Japanese junior high school students: its prevalence and relationship to lifestyle habits

Joint association of sleep quality and physical activity with metabolic dysfunction-associated fatty liver disease: a population-based cross-sectional study in Western China

BACKGROUND

Metabolic dysfunction-associated fatty liver disease (MAFLD) is a growing threat leading to substantial disease burden globally. Poor sleep and physical inactivity are common in modern societies and independently associated with MAFLD, however, their joint effects on MAFLD remains unclear.

METHODS

This population-based cross-sectional study was conducted in Xinjiang Uygur Autonomous Region, China, between July 2019 and September 2021. Self-reported sleep behaviors and physical activity (PA) were assessed using validated questionnaires. The primary outcome was radiological diagnosis of MAFLD.

RESULTS

Of the 10 089 participants aged 47.0 (9.1) years (51.6% men), 3854 (38.2%) individuals had MAFLD. Poor sleep quality and physical inactivity were independently and jointly associated with an increased prevalence of MAFLD, independent of traditional risk factors (P < 0.05). Compared to subjects with guideline-recommended moderate-to-vigorous PA (MVPA) and good sleep quality, individuals with no recommended MVPA and poor sleep had the highest possibility of MAFLD (odds ratio = 2.36, 95% confidence interval: 1.81 - 3.08). Enhancing sleep quality substantially attenuated MAFLD prevalence regardless of the volume of PA, whereas, engaging in PA well above current guidelines did not adequately counteract the adverse impacts of poor sleep on MAFLD.

CONCLUSIONS

Public health awareness and strategies concurrently targeting both sleep quality and PA should be encouraged to curb the climbing prevalence of MAFLD.

Enhanced non-alcoholic fatty liver detection: Computed tomography scan image analysis and noise reduction with morphological dilation

Non-alcoholic fatty liver disease (NAFLD) is characterized by accumulation of fat in the liver cells caused by means other than alcohol consumption. It is one of the most common chronic liver diseases worldwide and can lead to severe conditions, such as cirrhosis and liver cancer. NAFLD is often associated with other metabolic disorders, such as obesity and diabetes, and is closely related to lifestyle factors, such as diet and physical activity [1]. The diagnosis as well as management of NAFLD are complex and involve a multidisciplinary approach. The available treatment options include lifestyle modifications, pharmacological interventions, and in severe cases, liver transplantation. The increasing prevalence of NAFLD highlights the urgent requirement of effective prevention and management strategies. This disease is a growing health concern in India, given the rise in the incidence of obesity and diabetes. According to a study published in the Journal of Clinical and Experimental Hepatology in 2020, the prevalence of NAFLD in India is estimated to be between 9% and 32%. In accordance with the research population and diagnostic criteria employed, a study published in the Indian Journal of Gastroenterology in 2019 found that the prevalence of NAFLD in India ranged from 9.6% to 32.3% [2]. The same study also revealed that the prevalence of non-alcoholic steatohepatitis (NASH), a highly severe form of NAFLD, ranged from 1.5% to 8.4%. These statistics highlight the need for increased awareness and preventive measures to manage the growing burden of NAFLD in India.

Timing of energy intake and the therapeutic potential of intermittent fasting and time-restricted eating in NAFLD

Non-alcoholic fatty liver disease (NAFLD) represents a major public health concern and is associated with a substantial global burden of liver-related and cardiovascular-related morbidity and mortality. High total energy intake coupled with unhealthy consumption of ultra-processed foods and saturated fats have long been regarded as major dietary drivers of NAFLD. However, there is an accumulating body of evidence demonstrating that the timing of energy intake across a the day is also an important determinant of individual risk for NAFLD and associated metabolic conditions. This review summarises the available observational and epidemiological data describing associations between eating patterns and metabolic disease, including the negative effects of irregular meal patterns, skipping breakfast and night-time eating on liver health. We suggest that that these harmful behaviours deserve greater consideration in the risk stratification and management of patients with NAFLD particularly in a 24-hour society with continuous availability of food and with up to 20% of the population now engaged in shiftwork with mistimed eating patterns. We also draw on studies reporting the liver-specific impact of Ramadan, which represents a unique real-world opportunity to explore the physiological impact of fasting. By highlighting data from preclinical and pilot human studies, we present a further biological rationale for manipulating timing of energy intake to improve metabolic health and discuss how this may be mediated through restoration of natural circadian rhythms. Lastly, we comprehensively review the landscape of human trials of intermittent fasting and time-restricted eating in metabolic disease and offer a look to the future about how these dietary strategies may benefit patients with NAFLD and non-alcoholic steatohepatitis.

The burden and sexual dimorphism with nonalcoholic fatty liver disease in Asian children: A systematic review and meta-analysis

BACKGROUND

Despite substantial attention paid to the epidemic of nonalcoholic fatty liver disease (NAFLD) in adults, data on the burden and sexual dimorphism of NAFLD in Asian children have not yet been synthesized.

METHODS

We conducted a literature search of 735 references up to April 2021. Pooled analyses, stratified analyses and meta-regression were all performed.

RESULTS

Thirty-three study populations were finally included. Nine of them comprising 20 595 children showed an overall NAFLD prevalence of 5.53% (95% CI 3.46%-8.72%), in which, 36.64% (95% CI, 27.99%-46.26%) NAFLD subjects had elevated levels of ALT. The prevalence rate of NAFLD increased about 1.6-fold from 2004 to 2010 to the last decade. Male predominant trends were observed in paediatric NAFLD (boys: 8.18%, 95% CI 4.93%-13.26%; girls: 3.60%, 95% CI 1.60%-7.87%). Moreover, meta-analysis showed that after 10 years of age, boys were more prone to have NAFLD than girls (OR = 1.75; P = .0012). In addition, the pooled prevalence of NAFLD increased sequentially in normal-weight (1.49%, 95% CI 0.88%-2.51%, n = 2610), overweight (16.72%, 95% CI 7.07%-34.65%, n = 1265) and obese children (50.13%, 95% CI 41.99%-58.27%, n = 6434 individuals). After full covariate adjustment, the multivariate meta-regression also showed that boy percentage (P = .0396) and body mass index (P < .0001) were positively correlated with prevalent NAFLD.

CONCLUSIONS

In Asia, paediatric NAFLD is becoming prevalent over the recent decades, particularly among obese children and boys after 10 years old. The hormonal and chromosomal origins of paediatric NAFLD dimorphism need further investigation.

TUBB3 E410K Syndrome With Childhood-Onset Nonalcoholic Steatohepatitis

CONTEXT

Nonalcoholic fatty liver disease (NAFLD) is becoming a major issue worldwide, even in children. Multiple parallel hits hypothesis has been suggested as progress of NAFLD, but the mechanism of NAFLD is not completely understood. β-Tubulin is essential in mitoses, neuronal migration, and axon guidance during neuronal development. Pathogenic variants in the TUBB3 gene were shown to be associated with a wide spectrum of neurological abnormalities, but not accompanied by hepatic complications, such as NAFLD.

OBJECTIVE

This work aims to examine the association between TUBB3 mutation and nonalcoholic steatohepatitis (NASH).

METHODS

An 11-year-old girl has been followed up as having atypical Möbius syndrome since infancy, as she was born with bilateral ptosis, paralytic strabismus, and facial weakness. At age 7 years, she was diagnosed with TUBB3 E410K syndrome by whole-exome sequencing. At age 10 years, her blood examination revealed elevated liver transaminase levels, which persisted for almost 2 years. She underwent liver biopsy, the results of which were suggestive of NASH.

RESULTS

The expression of TUBB3 was absent, but that of tyrosine hydroxylase (TH) was present in the parenchymal nerve fibers of the liver. On the other hand, in comparison with an autopsy case of NASH and a normal control, these showed coexpression of TUBB3 and TH in the liver.

CONCLUSION

We report the first case of TUBB3 E410K syndrome accompanied by NASH. This case suggests that the TUBB3 mutation may be associated with the pathogenesis and progression of NASH in humans.

Prevalence and predictors of non-alcoholic fatty liver disease in tertiary care hospital of Taif, Saudi Arabia: A retrospective study

Background

The prevalence of nonalcoholic fatty liver disease (NAFLD) in Saudi Arabia is predicted to exceed 30% by 2030. NAFLD leads to liver fibrosis, thus increasing morbidity and health care burden. Obesity and diabetes have been strongly associated with NAFLD in different cities in Saudi Arabia.

Objectives

Therefore, we aim to determine the prevalence rate of NAFLD and specific risk factors for NAFLD among patients of tertiary care hospital of Taif city.

Material and methods

We retrospectively analyzed the medical records of patients for two years, between Feb 2017 and Feb 2019, (n = 100) referred to the hepatology clinic at King Abdulaziz Specialist Hospital in Taif. The diagnosis of NAFLD was based on the radiology report for patients who were aged >20 years old. Other parameters including fasting blood glucose (FBG), platelets count, alanine transaminase (ALT), aspartate transaminase (AST) and total bilirubin were statistically analyzed.

Results

We found that 40% (P < 0.05) of all patients had NAFLD. The results revealed that a significantly high number of patients with NAFLD have high FBG levels (75%, P < 0.0001) and total bilirubin (P < 0.05). Meanwhile, platelet count was significantly reduced in patients with NAFLD (P < 0.05).

Conclusion

NAFLD can be a serious health problem in the Taif region. In addition, high FBG is a significant specific risk factor for NAFLD. Health care providers should pay more attention to limiting the prevalence of NAFLD and its risk factors.

Effect of moderate exercises and curcumin on hepatic transcriptional factors associated with lipid metabolism and steatosis in elderly male rat

BACKGROUND AND PURPOSE

The specific molecular mediators involved in dyslipidemia in older people are not yet clearly understood. The current study was, thus, an attempt to investigate whether moderate aerobic exercises and curcumin administration alleviates the abnormalities caused by aging in the rats' liver.

EXPERIMENTAL APPROACH

Thirty-two eight-year-old young rats were classified into five groups, namely, young control, aged control, aged-curcumin, aged-exercise, and aged-curcumin-exercise co-treatment. The rats in the exercise groups were trained on an animal treadmill for 60 min/day five times per week for eight weeks.

FINDINGS/RESULTS

The results revealed a significant increase in FAT/CD36, PTP1B, significantly decreased HNF4α genes expression, increase in LDL and cholesterol in the aged group compared to the young control. Compared to those in the young control group, no significant changes in HDL and TG amounts in the aged control were observed. Moreover, compared to the young control, the aged group showed liver histological changes such as fibrosis and mild or grade 1 steatohepatitis. Moderate aerobic exercise and curcumin alone or in combination completely masked this effect.

CONCLUSION AND IMPLICATIONS

The findings revealed dyslipidemia and liver steatosis related to aging might be partly associated with changes in hepatic transcriptional factors which can be mitigated via moderate aerobic exercise and curcumin.

Composition of Dietary Fatty Acids and Health Risks in Japanese Youths

In the overall composition of dietary fatty acids (FAs), the quantity of each FA is interrelated with that of others. We examined the associations between dietary FA composition and cardiometabolic risk in Japanese youths. Risk factors (anthropometric characteristics, serum lipid and liver enzyme levels, and blood pressure) were measured in 5485 junior-high-school students. Dietary intake was assessed using a food frequency questionnaire. The mean saturated FA (SFA), monounsaturated FA (MUFA), omega-6 polyunsaturated FAs (PUFAs), and omega-3 PUFAs intake were 9.6%E, 10.3%E, 6.3%E, and 1.1%E, respectively. In compositional regression analysis controlled for confounders, a high intake of omega-6 PUFAs relative to others was associated with low low-density-lipoprotein cholesterol levels (LDL-C; p = 0.003), and relative SFA intake was associated with high levels of gamma-glutamyl transpeptidase (p = 0.019). Relative omega-3 PUFAs intake was associated with low blood pressure (p = 0.005–0.034) but had unfavorable effects on adiposity and alanine transaminase. Substitutional models showed similar results for omega-6 PUFAs on LDL-C, but MUFA had inconsistent effects on risk factors. The results from the compositional data analysis were consistent with previous studies and clinical practice/knowledge. Focusing on increasing omega-6 PUFAs in Japanese youths could have favorable consequences in the long term.

Current status, problems, and perspectives of non-alcoholic fatty liver disease research

Non-alcoholic fatty liver disease (NAFLD) is a major chronic liver disease that can lead to liver cirrhosis, liver cancer, and ultimately death. NAFLD is pathologically classified as non-alcoholic fatty liver (NAFL) or non-alcoholic steatohepatitis (NASH) based on the existence of ballooned hepatocytes, although the states have been known to transform into each other. Moreover, since the detection of ballooned hepatocytes may be difficult with limited biopsied specimens, its clinical significance needs reconsideration. Repeated liver biopsy to assess histological NAFLD activity for therapeutic response is also impractical, creating the need for body fluid biomarkers and less invasive imaging modalities. Recent longitudinal observational studies have emphasized the importance of advanced fibrosis as a determinant of NAFLD outcome. Thus, identifying predictors of fibrosis progression and developing better screening methods will enable clinicians to isolate high-risk NAFLD patients requiring early intensive intervention. Despite the considerable heterogeneity of NAFLD with regard to underlying disease, patient age, and fibrosis stage, several clinical trials are underway to develop a first-in-class drug. In this review, we summarize the present status and future direction of NAFLD/NASH research towards solving unmet medical needs.

Prevalence and risk factors of elevated alanine aminotransferase among Korean adolescents: 2001-2014

BACKGROUND

An elevated alanine aminotransferase (ALT) level is a surrogate marker of non-alcoholic fatty liver disease (NAFLD), the most common liver disorder in adolescents. The majority of previous NAFLD studies in adolescents were performed in selected obese populations or had a cross-sectional design without a time-trend analysis. The purpose of this study was to estimate the prevalence and time trends of elevated ALT levels in a general adolescent population and to identify factors associated with ALT elevation.

METHODS

We analysed data of adolescent participants (aged 10-18 years) from the Korean National Health and Nutrition Examination Survey 2001-2014, a representative sample of the general population in South Korea. Suspected NAFLD was defined as ALT elevation (> 30 U/L) without hepatitis B surface antigen. In all statistical analyses, sampling weight- and design-based data were used.

RESULTS

ALT was elevated in 5.3% (standard error: 0.3%) of the study population of adolescent participants (N = 8455). No significant trends were found from 2001 to 2014 in the prevalence of elevated ALT among male and female adolescents. In multiple logistic regression analysis, elevated ALT was independently associated with sex (odds ratio [OR] male versus female 4.5; 95% CI, 3.3-6.2), obesity (OR 7.6; 95% CI, 5.3-11.0), and truncal obesity (OR 2.5; 95% CI, 1.8-3.5). Furthermore, male sex, obesity, truncal obesity and high household income level were associated with log-transformed ALT levels in multiple regression analysis.

CONCLUSIONS

In Korean adolescents of both genders, the prevalence of elevated ALT levels was stable from 2001 to 2014. This study has revealed that sex, obesity, truncal obesity and household income level are associated with ALT elevation in adolescents.

Emerging Gastrointestinal and Liver Diseases in Asia Pacific: Implications to Health Care in the Region (World Gastroenterology Organization: Asian Pacific Association of Gastroenterology Distinguished Global Lecture 2015)

Colorectal cancer (CRC), gastroesophageal reflux disease (GERD), inflammatory bowel disease (IBD), and nonalcoholic fatty liver disease are considered important emerging diseases in the Asia Pacific (AP) region. The incidence rate of CRC is the highest among gastrointestinal cancers in the region surpassing that of gastric cancer. However, population CRC screening is limited by availability of adequate health resources and financing. GERD is a highly prevalent disease in AP with the prevalence of GERD symptoms and reflux esophagitis reported to be increasing. The usage of proton pump inhibitors has also been reported to be high. The incidence and prevalence of IBD is not as high as in the west but is now an increasingly recognizable disease in the AP region. Being a complicated disease, IBD will pose a huge financial burden with the increasing use of expensive biological drugs. In tandem with the exponential increase in obesity and diabetes mellitus in AP, nonalcoholic fatty liver disease will become the most important liver disease in the region in the coming years. These emerging diseases reflect the continued fast-paced socioeconomic development in the region with marked lifestyle changes and increasing affluence.

What is the appropriate strategy for diagnosing NAFLD using ultrasonography in obese children?

BACKGROUND

The aim of this study is to identify obese children who are candidates for a potential diagnosis of non-alcoholic fatty liver disease (NAFLD).

METHODS

We enrolled 242 obese children (122 boys and 120 girls) aged 7-16 years who were examined with abdominal ultrasonography in our pediatric obesity clinic. We compared patients in the normal group with those in the NAFLD group (mild disease, moderate to severe disease) and identified the optimal anthropometric parameters among height, weight, body mass index (BMI), waist circumference, hip circumference, waist to height ratio (WHtR), and waist to hip ratio to predict NAFLD using a receiver operating characteristic curve analysis. We also investigated risk factors associated with NAFLD for the anthropometric parameters and the biochemical model using logistic regression.

RESULTS

The high- and low-risk groups for hepatic steatosis relative to a WHtR of 0.56 as the standard point showed significant differences in hepatic steatosis severity grade (P<0.001), BMI (P=0.004), hip circumference (P=0.090), aspartate aminotransferase (P<0.001), alanine aminotransferase (P<0.001), triglycerides (P=0.001), and the triglyceride to high-density lipoprotein (HDL) cholesterol ratio (P=0.006). Risk factors for hepatic steatosis on logistic regression analysis were male sex (odds ratio: 3.68, 95% confidence interval: 1.76-7.70), WHtR >0.56 (2.25, 1.05-4.81), and waist circumference >90th percentile (20.22, 9.21-44.36) in the anthropometric parameter model and elevated alanine aminotransferase levels (boys >25.8 U/L, girls >22.1 U/L) (6.93, 2.52-19.03), hypertriglyceridemia (>110 mg/dL) (3.80, 1.23-11.75), and triglyceride to HDL cholesterol ratio >3 (9.23, 2.95-8.83) in the biochemical parameter model.

CONCLUSION

A diagnostic approach to hepatic steatosis is recommended as part of the proper screening and stratification of risk factors in obese children. WHtR is a simple and convenient method of effectively identifying obese children who are candidates for hepatic steatosis screening.

Targeting nuclear receptors for the treatment of fatty liver disease

Ligand-activated nuclear receptors, including peroxisome proliferator-activated receptor alpha (PPARα), pregnane X receptor, and constitutive androstane receptor, were first identified as key regulators of the responses against chemical toxicants. However, numerous studies using mouse disease models and human samples have revealed critical roles for these receptors and others, such as PPARβ/δ, PPARγ, farnesoid X receptor (FXR), and liver X receptor (LXR), in maintaining nutrient/energy homeostasis in part through modulation of the gut-liver-adipose axis. Recently, disorders associated with disrupted nutrient/energy homeostasis, e.g., obesity, metabolic syndrome, and non-alcoholic fatty liver disease (NAFLD), are increasing worldwide. Notably, in NAFLD, a progressive subtype exists, designated as non-alcoholic steatohepatitis (NASH) that is characterized by typical histological features resembling alcoholic steatohepatitis (ASH), and NASH/ASH are recognized as major causes of hepatitis virus-unrelated liver cirrhosis and hepatocellular carcinoma. Since hepatic steatosis is basically caused by an imbalance between fat/energy influx and utilization, abnormal signaling of these nuclear receptors contribute to the pathogenesis of fatty liver disease. Standard therapeutic interventions have not been fully established for fatty liver disease, but some new agents that activate or inhibit nuclear receptor signaling have shown promise as possible therapeutic targets. In this review, we summarize recent findings on the roles of nuclear receptors in fatty liver disease and discuss future perspectives to develop promising pharmacological strategies targeting nuclear receptors for NAFLD/NASH.

Association between endotoxemia and histological features of nonalcoholic fatty liver disease

AIM

To assess whether surrogate biomarkers of endotoxemia were correlated with the histological features of nonalcoholic fatty liver disease (NAFLD).

METHODS

One hundred twenty-six NAFLD patients who had undergone percutaneous liver biopsy were enrolled. Serum lipopolysaccharide (LPS)-binding protein (LBP) and anti-endotoxin core immunoglobulin G (EndoCab IgG) antibody concentrations at the time of liver biopsy were measured using the enzyme-linked immunosorbent assays to examine for relationships between biomarker levels and histological scores.

RESULTS

Serum LBP concentration was significantly increased in nonalcoholic steatohepatitis (NASH) patients as compared with nonalcoholic fatty liver (NAFL) subjects and was correlated with steatosis (r = 0.38, P < 0.0001) and ballooning scores (r = 0.23, P = 0.01), but not with the severity of lobular inflammation or fibrosis. Multivariate linear regression analysis revealed that LBP was associated with steatosis score and circulating C-reactive protein, aspartate aminotransferase, and fibrinogen levels. Serum EndoCab IgG concentration was comparable between NASH and NAFL patients. No meaningful correlations were detected between EndoCab IgG and histological findings.

CONCLUSION

LBP/EndoCab IgG were not correlated with lobular inflammation or fibrosis. More accurate LPS biomarkers are required to stringently assess the contribution of endotoxemia to conventional NASH.

Global Epidemiology of Nonalcoholic Fatty Liver Disease and Perspectives on US Minority Populations

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is a clinical syndrome predicted to be the next global epidemic affecting millions of people worldwide. The natural course of this disease including its subtype, non-alcoholic steatohepatitis (NASH), is not clearly defined especially in the African-American segment of the US population.

AIMS

To conduct a review of the global epidemiology of NAFLD with emphasis on US minority populations.

METHODS

A thorough search of evidence-based literature was conducted using the Pubmed database and commercial web sources such as Medscape and Google Scholar.

RESULTS

NAFLD and its subtype NASH are becoming the principal cause of chronic liver disease across the world. In the US, Hispanics are the most disproportionately affected ethnic group with hepatic steatosis, and elevated aminotransferase levels, whereas African-Americans are the least affected. Genetic disparities involved in lipid metabolism seem to be the leading explanation for the lowest incidence and prevalence of both NAFLD and NASH in African-Americans.

CONCLUSIONS

The unprecedented rise in the prevalence of NAFLD globally requires an initiation of population cohort studies with long-term follow-up to determine the incidence and natural history of NAFLD and its underrepresentation in African-Americans. Future studies should also focus on the delineation of the interplay between genetic and environmental factors that trigger the development of NAFLD and NASH.

Physical Activity Is Prospectively Associated With Adolescent Nonalcoholic Fatty Liver Disease

OBJECTIVES

The aim of the present study was to assess whether objectively measured physical activity at mean ages 12 and 14 years are prospectively associated with ultrasound scan liver fat and stiffness (alanine aminotransferase, aspartate aminotransferase [AST], and γ-glutamyl transferase [GGT]) assessed at mean age 17.8 years.

METHODS

Participants were from the Avon Longitudinal Study of Parents and Children. Total physical activity (counts per minute) and minutes of moderate to vigorous physical activity (MVPA) were measured using ActiGraph accelerometers at mean ages 12 and 14 years.

RESULTS

Greater total physical activity and MVPA at ages 12 and 14 years were associated with lower odds of liver fat and lower GGT levels at mean age 17.8 years, such as per 15-minute increase in daily MVPA at age 12 years, the confounder adjusted odds ratio of liver fat was 0.47 (95% confidence interval [CI] 0.27-0.84). Associations attenuated after additional adjustment for fat mass as a potential confounder (eg, per 15-minute increase in daily MVPA at age 12 years, the odds ratio of liver fat attenuated to 0.65 [95% CI 0.35-1.21]) or a potential mediator (eg, per 15-minute increase in daily MVPA at age 12 years the odds ratio of liver fat attenuated to 0.59 [95% CI 0.32-1.09]). Results did not further attenuate after additional adjustment for insulin resistance. There was some evidence that greater total physical activity and MVPA at age 12 years were associated with the higher AST levels.

CONCLUSIONS

Adolescents who were more active in childhood have lower odds of fatty liver and lower GGT levels. These findings are likely to be, at least in part, explained by adiposity.

Waist-to-height ratio is more closely associated with alanine aminotransferase levels than body mass index and waist circumference among population-based children: a cross-sectional study in Japan

BACKGROUND

An association between anthropometric measurements, including waist circumference (WC), and alanine aminotransferase (ALT) levels has been reported among adults. However, studies conducted among population-based elementary schoolchildren to date have been limited, especially in Japan, where the measurement of WC and blood collection are not usually performed in the annual health examination at elementary schools. The present study investigated the association between anthropometric measurements and ALT levels among population-based elementary schoolchildren in Japan.

METHODS

Subjects were fourth-grade schoolchildren (aged 9 or 10) from the town of Ina in Saitama Prefecture, Japan during 2004-2009. The height, weight, and WC of each subject were measured, and blood samples were drawn to measure ALT levels. Childhood overweight or obesity was defined according to the age- and sex-specific cut-off points proposed by the International Obesity Task Force. Spearman's correlation coefficients between anthropometric measurements (body mass index (BMI), WC, and waist-to-height ratio (WHtR)) and ALT levels were calculated.

RESULTS

Data from 2499 subjects (1293 boys and 1206 girls) were analyzed. BMI, WC, and WHtR were significantly positively correlated with ALT levels; the correlation coefficient of ALT levels with WHtR was higher than that with BMI and WC in boys and girls. In the analysis stratified by physique (non-overweight/obesity, overweight, or obesity), all anthropometric measurements were significantly positively correlated with ALT levels among boys, while only WHtR was significantly positively correlated with ALT levels among girls. Moreover, the correlation coefficient of ALT levels with WHtR was more pronounced than that with BMI and WC in the non-overweight/obesity group, in the overweight group, and in the obesity group for each sex.

CONCLUSIONS

The present study showed that WHtR was more closely associated with ALT levels than BMI and WC. Furthermore, only WHtR was significantly positively associated with ALT levels regardless of sex and physique. This study suggests that it is more useful to monitor WHtR than BMI and WC as a surrogate for ALT levels among population-based elementary schoolchildren.

Herbal medicines for fatty liver diseases

BACKGROUND

Fatty liver disease is potentially a reversible condition that may lead to end-stage liver disease. Since herbal medicines such as Crataegus pinnatifida and Salvia miltiorrhiza have increasingly been used in the management of fatty liver disease, a systematic review on herbal medicine for fatty liver disease is needed.

OBJECTIVES

To assess the beneficial and harmful effects of herbal medicines for people with alcoholic or non-alcoholic fatty liver disease.

SEARCH METHODS

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 3, 2012), MEDLINE, EMBASE, and Science Citation Index Expanded to 1 March 2012. We also searched the Chinese BioMedical Database, Traditional Chinese Medical Literature Analysis and Retrieval System, China National Knowledge Infrastructure, Chinese VIP Information, Chinese Academic Conference Papers Database and Chinese Dissertation Database, and the Allied and Complementary Medicine Database to 2 March 2012.

SELECTION CRITERIA

We included randomised clinical trials comparing herbal medicines with placebo, no treatment, a pharmacological intervention, or a non-pharmacological intervention such as diet or lifestyle, or Western interventions in participants with fatty liver disease.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data independently. We used the 'risk of bias' tool to assess the risk of bias of the included trials. We assessed the following domains: random sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting, and other sources of bias. We presented the effects estimates as risk ratios (RR) with 95% confidence intervals (CI) or as mean differences (MD) with 95% CI, depending on the variables of the outcome measures.

MAIN RESULTS

We included 77 randomised clinical trials, which included 6753 participants with fatty liver disease. The risks of bias (overestimation of benefits and underestimation of harms) was high in all trials. The mean sample size was 88 participants (ranging from 40 to 200 participants) per trial. Seventy-five different herbal medicine products were tested. Herbal medicines tested in the randomised trials included single-herb products (Gynostemma pentaphyllum, Panax notoginseng, and Prunus armeniaca), proprietary herbal medicines commercially available, and combination formulas prescribed by practitioners. The most commonly used herbs were Crataegus pinnatifida,Salvia miltiorrhiza,Alisma orientalis,Bupleurum Chinense,Cassia obtusifolia, Astragalus membranaceous, and Rheum palmatum. None of the trials reported death, hepatic-related morbidity, quality of life, or costs. A large number of trials reported positive effects on putative surrogate outcomes such as serum aspartate aminotransferase, alanine aminotransferase, glutamyltransferase, alkaline phosphatases, ultrasound, and computed tomography scan. Twenty-seven trials reported adverse effects and found no significant difference between herbal medicines versus control. However, the risk of bias of the included trials was high.The outcomes were ultrasound findings in 22 trials, liver computed tomography findings in eight trials, aspartate aminotransferase levels in 64 trials, alanine aminotransferase activity in 77 trials, and glutamyltransferase activities in 44 trials. Six herbal medicines showed statistically significant beneficial effects on ultrasound, four on liver computed tomography, 42 on aspartate aminotransferase activity, 49 on alanine aminotransferase activity, three on alkaline phosphatases activity, and 32 on glutamyltransferase activity compared with control interventions.

AUTHORS' CONCLUSIONS

Some herbal medicines seemed to have positive effects on aspartate aminotransferase, alanine aminotransferase, ultrasound, and computed tomography. We found no significant difference on adverse effects between herbal medicine and control groups. The findings are not conclusive due to the high risk of bias of the included trials and the limited number of trials testing individual herbal medicines. Accordingly, there is also high risk of random errors.

Role of physical activity in the treatment of nonalcoholic fatty liver disease in children and adolescents

Currently, nonalcoholic fatty liver disease (NAFLD) is the most frequent liver abnormality observed in obese children and adolescents. A strong body of evidence suggests that increased liver fat is significantly associated with visceral adiposity, metabolic syndrome, and insulin resistance in obese children and adolescents. Diet and exercise are generally recommended to treat obese youth with NAFLD as they do not carry side effects and confer multiple cardiometabolic benefits. Studies in adult populations report a beneficial effect of regular physical activity on reducing liver fat. In children and adolescents, available data show that weight loss induced by increasing physical activity and calorie restriction is beneficial to reduce liver fat and associated health risk factors such as insulin resistance and dyslipidemia. Currently, evidence regarding the independent effects of regular exercise alone (e.g., without calorie restriction) on NAFLD are unclear. Additionally, there is no data regarding the optimal exercise regimen (e.g., type, dose, intensity) that should be prescribed for reducing NAFLD in children and adolescents. The purpose of this review is to examine the role of physical activity on NAFLD in children and adolescents.

Disruption of phospholipid and bile acid homeostasis in mice with nonalcoholic steatohepatitis

Nonalcoholic steatohepatitis (NASH) is a progressive form of nonalcoholic fatty liver disease that can develop into cirrhosis, hepatic failure, and hepatocellular carcinoma. Although several metabolic pathways are disrupted and endogenous metabolites may change in NASH, the alterations in serum metabolites during NASH development remain unclear. To gain insight into the disease mechanism, serum metabolite changes were assessed using metabolomics with ultraperformance liquid chromatography-electrospray ionization-quadrupole time-of-flight mass spectrometry and a conventional mouse NASH model induced by a methionine- and choline-deficient (MCD) diet. Significant decreases in serum palmitoyl-, stearoyl-, and oleoyl-lysophosphatidylcholine (LPC) and marked increases in tauro-β-muricholate, taurocholate and 12-hydroxyeicosatetraenoic acid (12-HETE) were detected in mice with NASH. In agreement with these metabolite changes, hepatic mRNAs encoding enzymes and proteins involved in LPC degradation (lysophosphatidylcholine acyltransferase [Lpcat] 1-4), basolateral bile acid excretion (ATP-binding cassette subfamily C member [Abcc] 1/4/5 and organic solute transporter β), and 12-HETE synthesis (arachidonate 12-lipoxygenase) were significantly up-regulated. In contrast, the expression of solute carrier family 10 member 1 (Slc10a1) and solute carrier organic anion transporter family member (Slco) 1a1 and 1b2, responsible for transporting bile acids into hepatocytes, were markedly suppressed. Supplementation of the MCD diet with methionine revealed that the changes in serum metabolites and the related gene expression were derived from steatohepatitis, but not dietary choline deficiency or steatosis. Furthermore, tumor necrosis factor-α and transforming growth factor-β1 induced the expression of Lpcat2/4 and Abcc1/4 and down-regulated Slc10a1 and Slco1a1 in primary hepatocytes, suggesting an association between the changes in serum LPC and bile acids and proinflammatory cytokines. Finally, induction of hepatitis in ob/ob mice by D-galactosamine injection led to similar changes in serum metabolites and related gene expression.

CONCLUSION

Phospholipid and bile acid metabolism is disrupted in NASH, likely due to enhanced hepatic inflammatory signaling.

Epidemiology of a fast emerging disease in the Asia-Pacific region: non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is rapidly increasing in the Asia-Pacific and affects up to 30 % of the general population. In younger children, prevalence has been reported to be between 2.1 and 4.5 %. The prevalence of NAFLD increases with increasing age. NAFLD is more prevalent in men than women, but this trend fades in older age group. NAFLD is one of the most common causes of raised serum ALT levels and the latter is closely related to the presence of features of metabolic syndrome. NAFLD may contribute to metabolic syndrome in a similar way as visceral adiposity and can be an early predictor of metabolic disorders. NAFLD increases the risk of developing diabetes mellitus and is closely related to degree of glucose intolerance. A significant proportion of patients with NAFLD have impaired glucose tolerance or diabetes mellitus but with normal fasting blood glucose, highlighting the importance of oral glucose tolerance test in NAFLD patients with normal fasting blood glucose. Besides liver-related complications, NAFLD has been associated with cardiovascular complications, hyperuricemia, gout, chronic kidney disease, gallstone disease, colorectal adenomatous polyp, and polycystic ovarian syndrome. NAFLD seems to be related to host metabolic factors rather than viral factors and does not seem to affect severity of the liver disease in patients with chronic hepatitis B. On the other hand, hepatic steatosis may be related to both host metabolic and viral factors in patients with chronic hepatitis C and seems to adversely impact on the severity of liver disease and possibly response to antiviral therapy.

Clinical characteristics of young-onset ischemic colitis

BACKGROUND

Ischemic colitis (IC) typically develops in the elderly, where hypertension, cerebrocardiovascular disease, and past history of abdominal surgery are regarded as risk factors. Although there have been reports of younger patients with IC, its clinical features remain unclear.

AIM

The aim of this study was to clarify the clinical characteristics of IC in young adults.

METHODS

Three hundred fifty-nine patients were diagnosed as having IC at five hospitals across Nagano prefecture, Japan. Clinical data were compared between the young patient group [20-45 years, n = 53 (15%)] and the elderly patient group [>45 years, n = 306 (85%)], as well as with age- and gender-matched healthy individuals (n = 156).

RESULTS

The presence of a smoking habit and hyperuricemia were significantly higher in the young patient group compared with the elderly patient group (42 vs. 19%, P = 0.001 and 8 vs. 1%, P = 0.019, respectively), which was confirmed by multiple logistic regression analysis (P = 0.001, odds ratio 3.239 and P = 0.028, odds ratio 16.907, respectively). Additionally, multiple logistic regression analysis of the young IC patient group and age- and gender-matched healthy individuals demonstrated that these two factors were strongly associated with IC development (P = 0.008, odds ratio 2.49 for smoking habit and P = 0.039, odds ratio 6.37 for hyperuricemia).

CONCLUSIONS

High prevalences of a smoking habit and hyperuricemia are characteristic features of IC in the young adult population.

Hepatic steatosis and low cardiorespiratory fitness in youth with type 2 diabetes

The purpose of this study was to examine the association between cardiorespiratory fitness, ectopic triglyceride accumulation, and insulin sensitivity among youth with and without type 2 diabetes. Subjects included 137 youth ages 13-18 years including 27 with type 2 diabetes, 97 overweight normoglycemic controls, and 13 healthy weight normoglycemic controls. The primary outcome measure was cardiorespiratory fitness defined as peak oxygen uptake indexed to fat free mass. Secondary outcomes included liver and muscle triglyceride content determined by (1)H-magnetic resonance spectroscopy and insulin sensitivity determined by frequently sampled intravenous glucose tolerance test. Despite similar measures of adiposity, peak oxygen uptake was 11% lower (38.9 ± 7.9 vs. 43.9 ± 6.1 ml/kgFFM/min, P = 0.002) and hepatic triglyceride content was nearly threefold higher (14.4 vs. 5.7%, P = 0.001) in youth with type 2 diabetes relative to overweight controls. In all 137 youth, cardiorespiratory fitness was negatively associated with hepatic triglyceride content (r = -0.22, P = 0.02) and positively associated with insulin sensitivity (r = 0.29, P = 0.002) independent of total body and visceral fat mass. Hepatic triglyceride content was also negatively associated with insulin sensitivity (r = -0.35, P < 0.001), independent of adiposity, sex, age, and peak oxygen uptake. This study demonstrated that low cardiorespiratory fitness and elevated hepatic triglyceride content are features of type 2 diabetes in youth. Furthermore, cardiorespiratory fitness and hepatic triglyceride are associated with insulin sensitivity in youth. Taken together, these data suggest that cardiorespiratory fitness and hepatic steatosis are potential clinical biomarkers for type 2 diabetes among youth.

Mechanisms and implications of age-related changes in the liver: nonalcoholic Fatty liver disease in the elderly

Nonalcoholic fatty liver disease (NAFLD) is hepatic steatosis associated with metabolic abnormalities such as overweight/central obesity, insulin resistance, type 2 diabetes (T2D), and dyslipidemia. NAFLD is becoming the most common liver disease in contemporary society, with the highest prevalence in those over 60 years. NAFLD pathology ranges from simple steatosis to a necroinflammatory fibrosing disorder called steatohepatitis (SH), the latter associated with high risk of developing cirrhosis, often occuring in the seventh to ninth decades of life. While the main health implications of NAFLD are increased risk of developing T2D, cardiovascular diseases, and common cancers, there is substantantially increased standardized mortality, and deaths from decompensated cirrhosis and hepatocellular carcinoma (HCC). Little is known about the interactive effects of ageing and NAFLD, with most studies focusing on the younger population. This paper summarises the epidemiology, pathogenesis, and clinical course of NAFLD, with particular attention to persons over age 60 years. An approach to the management of NASH and its complications in the elderly, will also be presented here.

NASH: A global health problem

Non-alcoholic fatty liver disease (NAFLD) is a major public health problem both in the Western world and in the East. This is mainly due to the high prevalence of the disease and its effects on the individual with NAFLD. In the USA, it is estimated that approximately a third of the general population has NAFLD. Increasing age, obesity and the presence of multiple features of metabolic syndrome, especially diabetes, are associated with a higher probability of having non-alcoholic steatohepatitis (NASH). In the individual with NAFLD, excess hepatic fat is associated with an increased risk of developing diabetes, hypertension, cardiovascular events, abnormal resting electrocardiography and endothelial dysfunction. These findings have been corroborated in studies in teenagers as well as adults. There is also an increase in cardiovascular mortality, especially in those with NASH. In addition, there is an increased risk of death from a variety of non-hepatocellular cancers. From a liver perspective, NAFLD is associated with a 15-20% risk of progression to cirrhosis. The disease progresses more rapidly in those with diabetes, increasing age and obesity. The PNPLA3 gene mutation at position 148 is associated with not only steatosis, but with the likelihood of having steatohepatitis and increased inflammation and fibrosis. Once cirrhosis develops, the liver disease decompensates at the rate of 3-4% per year. NASH-related cirrhosis is a risk factor for hepatocellular cancer. All of these factors indicate that NAFLD is a common condition that has significant adverse health consequences for those who are afflicted. It is therefore a major public health hazard throughout the world.

Clinical characteristics of de novo nonalcoholic fatty liver disease following pancreaticoduodenectomy

BACKGROUND

Hepatic steatosis may develop after pancreatic resection, but its clinicopathological features remain unclear. We explored the clinical characteristics of newly appearing nonalcoholic fatty liver disease (NAFLD) after pancreaticoduodenectomy (PD), designated as de novo NAFLD after PD.

METHODS

Of 83 patients who underwent PD between 2001 and 2006, the patients with regular alcohol consumption after PD (n = 3), those who were unavailable for regular abdominal computed tomography follow-up (n = 12), and those who died within 6 months of PD (n = 8) were excluded from the study. In the remaining 60 patients, the prevalence and clinical features of de novo NAFLD after PD were examined.

RESULTS

NAFLD developed after PD in 14 (23%) patients in our cohort. Liver biopsy was performed in 8 patients and all showed typical steatohepatitis. Compared with the patients who had conventional nonalcoholic steatohepatitis (NASH), patients with post-PD de novo NASH demonstrated significant decreases in body mass index and lower levels of serum albumin, cholesterol, apolipoprotein B, and homeostasis model assessment for insulin resistance. Multivariate logistic regression analysis revealed that pancreatic head cancer was associated with an increased risk of developing NAFLD after PD (odds ratio 12.0, 95% confidence interval 2.0-71.4, P = 0.006). Increased dosage of oral pancreatic enzymes significantly ameliorated the steatosis, as well as leading to the recovery of body weight loss and resolution of the biochemical abnormalities.

CONCLUSIONS

De novo NAFLD/NASH after PD is characterized by non-obesity and lack of hyperlipidemia and insulin resistance and is associated with pancreatic exocrine insufficiency. In such patients, intensifying pancreatic enzyme supplementation may be useful.

Iron load and liver enzymes in 10- and 13-year-olds

OBJECTIVES

Iron plays a pivotal role in adult steatosis, but its role in child and adolescent steatosis is unclear. We investigated the effect of dietary iron, serum iron, and ferritin on serum transaminases and γ-glutamyltransferase in 10- and 13-year-olds.

PATIENTS AND METHODS

The study included 4894 fifth and eighth graders enrolled between 2006 and 2009 in all schools in Shunan City, Japan. Multiple regression analyses were performed with adjustments for grade, sex, z score of the body mass index, serum lipids, plasma glucose, frequency of sports activities, having a single parent, number of siblings, tobacco smoking behavior, passive smoking at home, resident areas, and schools, using linear mixed models. In addition, we analyzed ferritin and insulin resistance in randomly selected subset of participants.

RESULTS

Dietary iron intake was positively associated with serum alanine aminotransferase levels (standardized coefficient β = 2.35, P = 0.019). Serum iron concentrations were associated with transaminase and γ-glutamyltransferase levels (β = 3.22, and 4.05, respectively, P < 0.01). In the subset of 421 subjects with further serum analysis, serum ferritin levels were significantly associated with serum enzyme levels (β = 2.43-3.35; P < 0.05) and showed significant odds ratio for the elevated alanine aminotransferase levels (1.05 for 1 SD with 95% confidence intervals 1.02-1.08). However, iron load did not show a positive association with insulin resistance.

CONCLUSIONS

Although an effect size for iron is small in regression analyses, iron is implicated in increased transaminase levels in prepubertal and pubertal children.

Nonalcoholic fatty liver disease and nonalcoholic steatohepatitis in Japan

During the past 20 to 30 years, the frequency of patients presenting with nonalcoholic fatty liver diseases (NAFLD) has increased gradually in Japan in proportion to the increase in the population with life-style related diseases. We describe here the current status of the clinical and basic aspects of research into NAFLD in Japan. The increase in the incidence of life-style-related diseases has resulted in an increase in NAFLD throughout the past 20 to 30 years. The rate of obesity in the population is not high compared to western countries but the incidence of NAFLD is similar to those countries. In 2008 we started a nationwide study of NAFLD which has been supported by the Ministry of Labor and Welfare Japan. In this project, we planned to investigate the epidemiology, genetic backgrounds and biochemical markers, and liver injury in patients with diabetes mellitus (DM) and hepatocellular carcinoma in NASH, and treatment of NASH. Approximately 20 to 25% of DM patients showed NAFLD in which the prevalence of NASH might be more than 30 to 40%. Fortunately, we have been able to obtain very interesting results from our group studies, including single necleotide polymorphisms (SNPs) which will be published in the near future.

Prevalence, gender, ethnic variations, and prognosis of NASH

We provide an update review on the prevalence, gender, ethnic variations, and prognosis of nonalcoholic steatohepatitis (NASH). According to annual health checks, 9-30% of Japanese adults have nonalcoholic fatty liver disease (NAFLD) by ultrasonography (US) and prevalence of NASH is estimated to be 1-3%. These conditions are strongly associated with the presence of obesity and lifestyle-related diseases. NAFLD and NASH exhibit age and gender differences in both prevalence and severity. Among younger patients, these conditions are more common in men (2-3 times); however, after 60 years of age, the prevalence of NASH is higher in women. According to a systemic analysis of histological findings for NASH, 37.6% of patients had progressive fibrosis, 20.8% improved, and 41.6% remained stable over a mean duration of follow-up of 5.3 years. Age and presence of inflammation on initial biopsy were independent predictors of progression to advanced fibrosis. The frequencies of development of cirrhosis in NASH are 5-25% during around 7-year follow-up periods. Survival in NASH is lower than the expected survival of the matched general population due to the higher prevalence of cardiovascular and liver-related death. In patients with cirrhotic NASH, hepatocellular carcinoma (HCC) and liver failure are the main causes of morbidity and mortality (5-year cumulative HCC development rate 11.3%, 5-year survival rate 75.2%, respectively). The cumulative rate of recurrence of HCC at 5 years was 72.5%. Regular screening for complications of liver cirrhosis and HCC is extremely important for cirrhotic NASH patients.

Comparison of routine blood parameters and blood biochemical parameters between patients with alcoholic and non-alcoholic fatty liver disease

AIM: To compare routine blood parameters and blood biochemical parameters between patients with alcoholic fatty liver disease (AFLD) and non-alcoholic fatty liver disease (NAFLD).

METHODS: A total of 1 203 subjects, who underwent physical examination, including measurement of abdominal circumference and blood pressure, routine blood examination, biochemical examination and two-dimensional ultrasound, were included in this study. Of these subjects, 509 (415 men and 94 women) were diagnosed with fatty liver disease (FLD) and 694 (446 men and 248 women) without FLD by two-dimensional ultrasound. According to the Guidelines for the Diagnosis and Treatment of Alcoholic Liver Disease, subjects with FLD were divided into two groups: AFLD group (n = 106, 105 men and 1 woman) and NAFLD group (n = 403, 310 men and 93 women).

RESULTS: Subjects with FLD had a younger mean age and a higher BMI than subjects without FLD (P = 0.011 and 0.000, respectively). WBC, RBC, HGB, ALT, AST, GGT, ALB, TG, TC, LDL-C, FBG, UA (P < 0.001 for all), ALP (P = 0.015), TP (P = 0.026), AST/PLT ratio (P = 0.001), AST/ALT ratio (P < 0.001), and GGT/PLT ratio (P < 0.001) were higher and HDL-C, AST/GGT ratio, and TBIL/GGT ratio (P < 0.001 for all) were lower in subjects with FLD than in those without FLD. Subjects with AFLD had a younger mean age (P < 0.001), a higher HGB, GGT, ALB, UA (P < 0.001 for all), TG, AST, RBC, ALT (P = 0.007, 0.005, 0.011 and 0.027, respectively), AST/PLT ratio, AST/ALT ratio, and GGT/PLT ratio (P = 0.012, 0.014 and 0.002, respectively), and a lower UREA, AST/GGT ratio and TBIL/GGT ratio (P < 0.001 for all) than those with NAFLD.

CONCLUSION: Routine blood examination and blood biochemical examination are useful in distinguishing patients with and without FLD as well as those with AFLD and NAFLD.

Association between serum uric acid levels and cardiometabolic risk factors among Japanese junior high school students

BACKGROUND

The present study was designed to examine whether serum uric acid (SUA) levels were associated with cardiometabolic risk factors and to determine optimal cut-offs for SUA to identify multiple risk factors among Japanese junior high school students.

METHODS AND RESULTS

A total of 958 students (518 boys and 440 girls, aged 12.1-15.0 years) who were enrolled between April 2005 and June 2008 were divided into 4 groups according to SUA quartiles. Compared with the lowest quartile of SUA, prevalence of abdominal obesity, hypertension, and dyslipidemia was significantly increased in the highest quartile in boys and that of abdominal obesity was increased in the highest quartile in girls. The adjusted odds ratios (95% confidence interval) of the highest quartile of SUA for 2 or more cardiometabolic risk factors were 2.59 (1.16-5.79) for boys and 1.54 (0.43-5.56) for girls. Receiver operating characteristic curve analysis demonstrated that the most appropriate cut-offs for SUA to identify multiple cardiometabolic risk factors were 6.4 mg/dl for boys and 4.9 mg/dl for girls.

CONCLUSIONS

SUA was strongly associated with the prevalence of cardiometabolic risk factors among male Japanese junior high school students. The present study may provide insights into the role of SUA in the school screening system for the development of educational programs on prevention of lifestyle-related diseases among school children.