Simple Anthropometric Indices are Useful for Predicting Non-alcoholic Fatty Liver Disease [NAFLD] in Asian Indians

The role of gut microbiota augmentation in managing non-alcoholic fatty liver disease: an in-depth umbrella review of meta-analyses with grade assessment

Background and aim

Currently, there are no authorized medications specifically for non-alcoholic fatty liver disease (NAFLD) treatment. Studies indicate that changes in gut microbiota can disturb intestinal balance and impair the immune system and metabolism, thereby elevating the risk of developing and exacerbating NAFLD. Despite some debate, the potential benefits of microbial therapies in managing NAFLD have been shown.

Methods

A systematic search was undertaken to identify meta-analyses of randomized controlled trials that explored the effects of microbial therapy on the NAFLD population. The goal was to synthesize the existing evidence-based knowledge in this field.

Results

The results revealed that probiotics played a significant role in various aspects, including a reduction in liver stiffness (MD: -0.38, 95% CI: [-0.49, -0.26]), hepatic steatosis (OR: 4.87, 95% CI: [1.85, 12.79]), decrease in body mass index (MD: -1.46, 95% CI: [-2.43, -0.48]), diminished waist circumference (MD: -1.81, 95% CI: [-3.18, -0.43]), lowered alanine aminotransferase levels (MD: -13.40, 95% CI: [-17.02, -9.77]), decreased aspartate aminotransferase levels (MD: -13.54, 95% CI: [-17.85, -9.22]), lowered total cholesterol levels (MD: -15.38, 95% CI: [-26.49, -4.26]), decreased fasting plasma glucose levels (MD: -4.98, 95% CI: [-9.94, -0.01]), reduced fasting insulin (MD: -1.32, 95% CI: [-2.42, -0.21]), and a decline in homeostatic model assessment of insulin resistance (MD: -0.42, 95% CI: [-0.72, -0.11]) (P<0.05).

Conclusion

Overall, the results demonstrated that gut microbiota interventions could ameliorate a wide range of indicators including glycemic profile, dyslipidemia, anthropometric indices, and liver injury, allowing them to be considered a promising treatment strategy.

Usefulness of Neck Circumference, Waist-to-Height Ratio and Waist-to-Hip Ratio in Predicting Non-Alcoholic Fatty Liver Disease in Saudi Population Without Type 2 Diabetes

Background

Early identification and treatment of non-alcoholic fatty liver disease (NAFLD) could reduce overall mortality. Anthropometric measurements offer a simple and cost-effective method to potentially improve early detection of NAFLD and prevent its complications. This study aims to estimate the prevalence of NAFLD using the fatty liver index (FLI) and evaluate the effectiveness of certain anthropometric measurements in predicting NAFLD as diagnosed by FLI.

Method

A cross-sectional analytical study was conducted with 1264 Saudi population without Type 2 diabetes mellitus (T2DM) non-alcoholic individuals at primary health care centers (PHCCs) in Jeddah city. Measurements included triglycerides, gamma-glutamyl transferase (GGT), glycated hemoglobin (HbA1c), and fasting plasma glucose (FPG). Measurements for neck circumference (NC), and calculations for weight-to-height ratio (WHtR) and weight-to-hip ratio (WHpR), along with FLI, were performed. NAFLD was identified in individuals with an FLI ⩾60. The receiver operating characteristic (ROC) curve analysis was utilized to assess the accuracy of WHtR, WHpR, and NC in detecting NAFLD, with Youden's index determining the optimal cutoff points for these 3 indices.

Result

The prevalence of NAFLD was found to be 30.9%. Among the markers, WHtR emerged as the most significant in indicating NAFLD, achieving an area under the curve (AUC) of 0.916; whereas NC and WHpR exhibited identical AUC values of 0.783. WHtR demonstrated superior diagnostic efficacy for identifying elevated FLI, with gender-specific cutoff values established at >0.57 for females and >0.61 for males. In all 3 markers, females exhibited higher sensitivity, specificity, and negative predictive value (NPV) compared to males.

Conclusion

WHtR could serve as a useful tool in the initial clinical screening for NAFLD among Saudi population without T2DM to identify those who may benefit from more comprehensive testing. Further local studies are warranted to confirm the levels of accuracy and the calculated cutoffs.

Can modulation of gut microbiota affect anthropometric indices in patients with non-alcoholic fatty liver disease? An umbrella meta-analysis of randomized controlled trials

Background and aim

Modulating the gut microbiota population by administration of probiotics, prebiotics, and synbiotics has shown to have a variety of health benefits in different populations, particularly those with metabolic disorders. Although the promising effects of these compounds have been observed in the management of patients with non-alcoholic fatty liver disease (NAFLD), the exact effects and the mechanisms of action are yet to be understood. In the present study, we aimed to evaluate how gut microbiota modulation affects anthropometric indices of NAFLD patients to achieve a comprehensive summary of current evidence-based knowledge.

Methods

Two researchers independently searched international databases, including PubMed, Scopus, and Web of Science, from inception to June 2023. Meta-analysis studies that evaluated the effects of probiotics, prebiotics, and synbiotics on patients with NAFLD were entered into our umbrella review. The data regarding anthropometric indices, including body mass index, weight, waist circumference (WC), and waist-to-hip ratio (WHR), were extracted by the investigators. The authors used random effect model for conducting the meta-analysis. Subgroup analysis and sensitivity analysis were also performed.

Results

A total number of 13 studies were finally included in our study. Based on the final results, BMI was significantly decreased in NAFLD patients by modulation of gut microbiota [effect size (ES): -0.18, 05% CI: -0.25, -0.11, P<0.001]; however, no significant alteration was observed in weight and WC (ES: -1.72, 05% CI: -3.48, 0.03, P=0.055, and ES: -0.24, 05% CI: -0.75, 0.26, P=0.353, respectively). The results of subgroup analysis showed probiotics had the most substantial effect on decreasing BMI (ES: -0.77, 95% CI: -1.16, -0.38, P<0.001) followed by prebiotics (ES: -0.51, 95% CI: -0.76, -0.27, P<0.001) and synbiotics (ES: -0.12, 95% CI: -0.20, -0.04, P=0.001).

Conclusion

In conclusion, the present umbrella meta-analysis showed that although modulation of gut microbiota by administration of probiotics, prebiotics, and synbiotics had promising effects on BMI, no significant change was observed in the WC and weight of the patients. No sufficient data were available for other anthropometric indices including waist-to-hip ratio and waist-to-height ratio and future meta-analyses should be done in this regard.

New predictive models and indices for screening MAFLD in school-aged overweight/obese children

Currently, most predictions of metabolic-associated fatty liver disease (MAFLD) in school-aged children utilize indicators that usually predict nonalcoholic fatty liver disease (NAFLD). The present study aimed to develop new predictive models and predictors for children with MAFLD, which could enhance the feasibility of MAFLD screening programs in the future. A total of 331 school-aged overweight/obese children were recruited from six primary schools in Ningbo city, China. Hepatic steatosis and fibrosis were detected with controlled attenuation parameter (CAP) and liver stiffness measurement (LSM), respectively. Machine learning methods were adapted to build a set of variables to predict MAFLD in children. Then, the area under the curve (AUC) of multiple models and indices was compared to predict pediatric MAFLD. Compared with non-MAFLD children, children with MAFLD had more obvious metabolic disturbances, as they had higher anthropometric indicators, alanine aminotransferase, fasting plasma glucose, and inflammation indicators (white blood cell count, hemoglobin, neutrophil count) (all P < 0.05). The optimal variables for all subjects selected by random forest (RF) were alanine aminotransferase, uric acid, insulin, and BMI. The logistic regression (LR) model performed best, with AUC values of 0.758 for males and 0.642 for females in predicting MAFLD. LnAI-BMI, LnAI, and LnAL-WHtR were approving indices for predicting pediatric MAFLD in all participants, boys and girls individually.

CONCLUSIONS

This study developed LR models and sex-specific indices for predicting MAFLD in overweight/obese children that may be useful for widespread screening and identification of children at high risk of MAFLD for early treatment.

WHAT IS KNOWN

• Most of the indicators predicting pediatric MAFLD are derived from the predictive indicators for NAFLD, but the diagnostic criteria for MAFLD and NAFLD are not exactly the same. • The accuracy of predictors based on routine physical examination and blood biochemical indicators to diagnose MAFLD is limited.

WHAT IS NEW

• This study developed indicators based on routine examination parameters that have approving performance for MAFLD, with AUC values exceeding 0.70.

Waist to height ratio in nonalcoholic fatty liver disease - Systematic review and meta-analysis

BACKGROUND AND AIMS

Current nonalcoholic fatty liver disease (NAFLD) guidelines do not provide any recommendations regarding the waist-to-height ratio (WHtR), a simple obesity metric calculated by dividing waist circumference by height. Therefore, we performed a systematic review and meta-analysis aiming to evaluate WHtR in NAFLD.

METHODS

We performed a systematic electronic search on PubMed, Embase, and Scopus, identifying observational studies assessing WHtR in NAFLD. QUADAS-2 tool was used to evaluate the quality of included studies. The two main statistical outcomes were the area under the curve (AUC) and the mean difference (MD).

RESULTS

We included a total of 27 studies in our quantitative and qualitative synthesis, with a total population of 93,536 individuals. WHtR was significantly higher in NAFLD patients compared to controls with an MD of 0.073 (95% CI 0.058 - 0.088). This was also confirmed after conducting a subgroup analysis according to the hepatic steatosis diagnosis method, for ultrasound (MD 0.066 [96% CI 0.051 - 0.081]) and transient elastography (MD 0.074 [96% CI 0.053 - 0.094]). Moreover, NAFLD male patients presented significantly lower WHtR compared to female patients (MD -0.022 [95% CI -0.041 - -0.004]). The AUC of WHtR for predicting NAFLD was 0.815 (95% CI 0.780 - 0.849).

CONCLUSIONS

WHtR is considerably higher in NAFLD patients compared to controls. Female NAFLD patients present higher WHtR compared to NAFLD male patients. In comparison to other presently suggested scores and markers, the WHtR's accuracy in predicting NAFLD is considered acceptable.

Anthropometric clinical indicators of visceral adiposity as predictors of nonalcoholic fatty liver disease

OBJECTIVE

This study aims to evaluate the role of anthropometric clinical indicators of visceral adiposity as predictors of NAFLD, identifying the cutoff points based on gender.

METHODS

This was a cross-sectional study conducted in patients with or without NAFLD. Waist circumference (WC), body mass index (BMI), waist-to-height ratio (WHtR), Conicity Index (C Index), and lipid accumulation product (LAP) were evaluated.

RESULTS

A total of 107 individuals were evaluated, of which 46.7% were diagnosed with NAFLD. Individuals with NAFLD presented higher values of WC, BMI, C Index, LAP, and WHtR when compared with those without NAFLD (p<0.05). For the total sample, the indicators WC, BMI, WHtR, LAP, and C Index had an area under the receiver operator characteristic curve (AUC) above 0.87, with no difference in the prediction of NAFLD in both sexes. WHtR (AUC=0.934) was the indicator of visceral adiposity with the best discriminatory power for NAFLD, followed by LAP (0.919), WC (0.912), C Index (0.907), and BMI (0.877).

CONCLUSIONS

The anthropometric clinical indicators of visceral adiposity showed high performance, especially the WHtR indicator, as NAFLD predictors.

Comparison of bioelectrical impedance analysis, mass index, and waist circumference in assessing risk for non-alcoholic steatohepatitis

OBJECTIVE

Non-alcoholic fatty liver disease is a leading cause of liver disease worldwide and includes nonalcoholic steatohepatitis (NASH), which can progress to cirrhosis. Because NASH is associated with obesity severity, routine evaluation of obesity/body fat in clinical settings may help detect patients at risk. The aim of this study was to determine whether assessing body fat by bioelectrical impedance analysis (BIA) is superior to body mass index (BMI) and waist circumference (WC) in assessing the risk for NASH.

METHODS

In this cross-sectional study, patients were recruited and gave consent from a local hospital. All had a liver biopsy. Measurements before the biopsy included BMI, WC, and BIA. BIA was used to measure percentage body fat and fat mass (kg). Based on histology, patients were grouped into one of three categories: simple steatosis (SS), NASH, or normal liver (NL).

RESULTS

Of the 139 participants who participated, 39 were classified as SS, 53 as NASH, and 47 as NL. Regardless of sex, patients with NASH had significantly higher BMI, WC, percentage body fat and fat mass than those with NL or SS. These four parameters were significantly positively correlated with liver histology measurements. In all patients, when controlling for sex and age we found that BMI, WC, and BIA were equal at predicting the presence of NASH (P = 0.0571).

CONCLUSION

All three methods, BIA, BMI, and WC, were comparable in assessing the risk for NASH. For practical purpose in clinical settings, using BMI is acceptable.

Body composition, phenotype and central obesity indices in Egyptian women with non-alcoholic fatty liver disease

OBJECTIVES

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease worldwide. The aim of this study is to investigate body composition and phenotype of Egyptian women with non-alcoholic fatty liver disease (NAFLD) and compare with those without and determine the optimal cut-off values of central obesity indices for predicting NAFLD.

METHODS

The study included 100 women with NAFLD and 100 age and sex matched healthy controls without NAFLD. All women were subjected to ultrasonography examination. Anthropometric measurements included weight, height, waist circumference (WC), hip circumference (HC) and skinfolds thickness were assessed for all participants. Body fat % was evaluated by Tanita body composition analyzer. Body mass index (BMI), WC / height ratio (WHtR), WC / HC ratio (WHR) and visceral adiposity index (VAI) were calculated. Receiver-operating characteristic (ROC) curve was used to determine the optimal cut-off values.

RESULTS

Data showed significant higher levels of WHtR, WHR, BMI, sum of skinfolds, body fat %, serum fasting blood lipids and glucose in NAFLD women compared to group of patients without NAFLD. The area under curve (AUC) was 0.920 for VIA, 0.883 for WHtR and 0.647 for WHR. The optimal cutoff value of VAI was 3.66, of WHtR was 0.66 and WHR was 0.84. All values showed high sensitivity and specificity values.

CONCLUSION

NAFLD women were obese, had excess subcutaneous fat and body fat ratio. Central obesity indices are closely associated with the presence of NAFLD in Egyptian women and might be responsible for its development. Visceral adiposity index had superior diagnostic performance.

Estimation of visceral fat is useful for the diagnosis of significant fibrosis in patients with non-alcoholic fatty liver disease

BACKGROUND

Obesity is a risk factor for non-alcoholic fatty liver disease (NAFLD), although obese patients with NAFLD do not always develop significant fibrosis. The distribution of body fat could predict the risk of NAFLD progression. 

AIM

To investigate the role of bioelectrical impedance-estimated visceral fat (VF) in assessing NAFLD severity.

METHODS

In this cross-sectional study, patients with biopsy-proven NAFLD were prospectively included. All patients underwent anthropometric evaluation, blood tests and bioelectrical impedance analysis.

RESULTS

Between 2017 and 2020, 119 patients were included [66.4% male, 56 years (SD 10.7), 62.2% obese, 61.3% with metabolic syndrome]. Sixty of them (50.4%) showed significant fibrosis (≥ F2) in liver biopsy. Age, VF and metabolic syndrome were associated with significant fibrosis (61 years vs 52 years, 16.4 vs 13.1, 73.3% vs 49.2%, respectively; P < 0.001 for all). In the multivariate analysis, VF and age were independently associated with significant fibrosis (VF, OR: 1.11, 95%CI: 1.02-1.22, P = 0.02; age, OR: 1.08, 95%CI: 1.03-1.12, P < 0.01). A model including these variables showed and area under the receiver operating characteristic curve (AUROC) of 0.75, which was not inferior to transient elastography or NAFLD fibrosis score AUROCs. We developed a nomogram including age and VF for assessing significant fibrosis in routine practice.

CONCLUSION

VF is a surrogate marker of liver fibrosis in patients with NAFLD. Bioelectrical impedance analysis is an inexpensive and simple method that can be combined with age to guide patient referral when other resources may be unavailable.

Development and validation of screening scores of non-alcoholic fatty liver disease in middle-aged and elderly Chinese

AIM

Non-alcoholic fatty liver disease (NAFLD) is one of the most common causes of chronic liver disease and also closely related to cardiometabolic disease. Its prevalence was estimated at over one-fourth in the general population in China. We aimed to develop effective score tools for detecting NAFLD.

METHODS

A total of 17,212 participants aged 45-70 years old were surveyed in Shanghai between 2013 and 2014, and 13,293 participants were included in this analysis. All participants were randomly classified into the exploratory group or the validation group. Candidate categorical variables were selected using a logistic regression model. The score points were generated according to the β-coefficients.

RESULTS

We developed the Shanghai Nicheng NAFLD Score I (SHNC NAFLD Score I), which included body mass index and waist circumference with an area under the receiver-operating characteristic curve (AUC) of 0.802 (95% CI 0.792-0.811) in the exploratory group and 0.802 (95% CI 0.793-0.812) in the validation group. We further developed the SHNC NAFLD Score II by adding fasting plasma glucose, triglyceride, and alanine aminotransferase/aspartate aminotransferase ratio to the SHNC NAFLD Score I, achieving an AUC of 0.852 (95% CI 0.843-0.861) in the exploratory group and 0.843 (95% CI 0.834-0.852) in the validation group. The two score tools also performed well in subjects with normal alanine aminotransferase (ALT) levels.

CONCLUSIONS

Based on anthropometric and clinical categorical variables, our two scores are effective tools for detecting NAFLD in both this southern Chinese population and their subpopulation with normal ALT levels.

Gender-specific differences in clinical and metabolic variables associated with NAFLD in a Mexican pediatric population

INTRODUCTION AND OBJECTIVES

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease in children and it is more prevalent in Hispanic males. The gender differences can be explained by body fat distribution, lifestyle, or sex hormone metabolism. We evaluated anthropometric and metabolic differences by gender in children with and without NAFLD.

METHODS

We included 194 participants (eutrophic, overweight, and individuals with obesity). The presence of NAFLD was determined using ultrasonography, and we evaluated the association between this disease with metabolic and anthropometric variables by gender.

RESULTS

The mean age was 10.64±2.54 years. The frequency of NAFLD in boys was 24.51% and in girls was 11.96% (OR=2.39; 95%CI=1.10-5.19; p=0.025). For girls, NAFLD was significantly associated with triglycerides (p=0.012), homeostatic model assessment of insulin resistance (HOMA-IR) (p=0.048), and the visceral adiposity index (VAI) (p=0.024). The variables related to NAFLD in a gender-specific manner were body mass index (BMI) (p=0.001), waist circumference (WC) (p<0.001), HDL cholesterol (p=0.021), alanine aminotransferase (ALT) (p<0.001), and aspartate aminotransferase (AST) (p=0.002).

CONCLUSIONS

In our study NAFLD is more frequent in boys, only ALT, and no other clinical or metabolic variables, were associated with NAFLD in these patients. HOMA-IR, VAI, triglyceride levels, and ALT were associated with NAFLD only in girls. The ALT cut-off points for the development of NAFLD in our study were 28.5U/L in females and 27.5U/L in males. Our findings showed that NAFLD should be intentionally screened in patients with obesity, particularly in boys.

Prevalence and Risk Factors of Elevated Liver Enzymes in Japanese Women With Polycystic Ovary Syndrome

Background

Polycystic ovary syndrome (PCOS) is a common endocrine disorder among reproductive-aged women. While PCOS is associated with an increased risk of obesity and insulin resistance, little is known regarding the prevalence of and risk factors for nonalcoholic fatty liver disease (NAFLD) among Japanese women with PCOS. We estimated the prevalence of and risk factors for elevated liver enzymes, as the index of NAFLD, in Japanese women with PCOS.

Methods

We retrospectively reviewed 102 reproductive-aged women who visited the Department of Gynecology, Kyoto Medical Center in Japan from January 2000 to September 2016. Inclusion criterion was confirmed diagnosis of PCOS using International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10) codes. Exclusion criteria were women with a history of liver diseases, missing body mass index (BMI) and serum alanine aminotransferase (ALT) data, and pregnancy. Data regarding age; BMI; and levels of blood glucose, serum lipid, liver enzymes, and sex hormones were obtained from medical records. Elevated liver enzymes was defined as ALT > 19 IU/L. Optimal cutoffs for risk factors for elevated liver enzymes were calculated to determine predictors of elevated liver enzymes using area under the curve (AUC) by receiver-operating characteristics (ROC).

Results

The prevalence of elevated liver enzymes was 33.3%. BMI was significantly higher in PCOS patients than in those without elevated liver enzymes (25.3 vs. 20.7 kg/m², P < 0.05). ROC analyses were performed using BMI and blood glucose and testosterone levels because BMI and blood glucose showed differences between the groups and testosterone is related to fatty liver. AUC of the model including BMI and blood glucose and testosterone levels was 0.861 (sensitivity, 66.7%; specificity, 100%).

Conclusions

These findings suggest that elevated liver enzymes are common in women with PCOS. An algorism using BMI and blood glucose and testosterone levels might be useful to determine elevated liver enzymes in women with PCOS. Our finding may be useful for the study of NAFLD among Japanese women with PCOS since several previous studies have indicated elevated liver enzymes to be related to the potential presence of NAFLD. Further examination, including abdominal ultrasonography and/or liver biopsy data, is required to confirm these results.

The role of anthropometric indices in the prediction of non-alcoholic fatty liver disease in the PERSIAN Guilan Cohort study (PGCS)

Introduction: Non-alcoholic fatty liver disease (NAFLD) is an obesity-associated health problem that causes other liver diseases for the patient. Four anthropometric indices: body mass index (BMI), waist circumference (WC), waist-to-hip ratio (WHR) and waist-to-height ratio (WHtR) were analyzed as NAFLD predictors in the present study. Methods: From the total number of individuals who referred to the PERSIAN Guilan Cohort study (PGCS) located in the north of Iran during the period of study, a total of 960 people were enrolled in the present study. NAFLD was diagnosed using through an abdominal ultrasound exam. Height, weight, WC, BMI, WHR and WHtR were later calculated. Chi-square, ANOVA and logistic regression analyses were used to analyze the risk factors. Results: Out of the 960 individuals who were enrolled in the study, 597 (62.2%) were male and 363 (37.8%) were female (with an average age of 47.21 ± 7.29 years). There was a significant relationship between weight and NAFLD (P<0.001). There was also a significant relationship between BMI (OR= 8.41; 95% CI = 5.59-12.75), WC (OR= 2.67; 95% CI = 2.05-3.48), WHR (OR= 3.84; 95% CI = 2.26-6.52), WHtR (OR= 28.53; 95% CI = 6.94-117.31) and NAFLD (P<0.001). The results of the logistic regression analysis showed that WHtR, BMI and WC were effective predictors for the risk of NAFLD while WHtR played a more important role in the prediction of NAFLD. Conclusion: Anthropometric indices, especially WHtR, as a simple screening tool, seem to be an important criterion for the detection of NAFLD.