Contribution of sarcopenia and physical inactivity to mortality in people with non-alcoholic fatty liver disease

Sarcopenia and metabolic dysfunction associated steatotic liver disease: Time to address both

Sarcopenia and metabolic dysfunction associated steatotic liver disease (MASLD) are closely intertwined. Sarcopenia, traditionally a disease of the older adult and chronic disease population, has been closely studied as one of the pathophysiologic conditions at play in the development of MASLD. They share similar risk factors of insulin resistance and physical inactivity. Given similar pathophysiology along the liver-muscle axis, sarcopenia has been studied as a risk factor for MASLD, and vice versa. Current research suggests a bidirectional relationship. Given the chronicity of MASLD as a chronic inflammatory liver disease, it can break down muscle mass and lead to sarcopenia, while sarcopenia promotes intramuscular lipid accumulation that releases cytokines that can aggravate inflammation in the liver. However, for the longest time, a lack of consensus definition for MASLD and sarcopenia made it difficult to study their relationship and outcomes. A recent nomenclature update to diagnosing MASLD has made it easier for researchers to identify cohorts for study. However, no gold standard technique to measure muscle mass or consensus sarcopenia definition has been identified yet. Future studies are needed to reach a consensus and reduce diagnostic variation. With similar pathophysiology and shared risk factors between the two diseases, future research may also identify potential therapeutic targets along the liver-muscle axis that would benefit both sarcopenia and MASLD in order to maximize their outcomes.

Large-scale greenway exposure reduces sedentary behavior: A natural experiment in China

As a global public health problem, sedentary behavior has attracted more and more attention. Although numerous studies have demonstrated many benefits of green spaces to health, causal evidence on how green spaces affect people's sedentary behavior is scarce. This study used a natural experiment to evaluate the impact of greenway intervention on sedentary behavior. Two waves of data were collected in 2016 and 2019 (before and after the intervention) at East Lake Greenway (102-km-long) in Wuhan, China, with 1020 participants in 52 neighborhoods. We adopted three major methods to evaluate the impact of greenway intervention on sedentary behavior, including Propensity Score Matching and difference-in-difference (PSM-DID) method (with both individual and neighborhood variables to match samples), continuous treatment DID method (with distance to the greenway as the continuous treatment), and mediation analysis (with moderate to vigorous physical activity or MVPA, and walking time as the mediator). The results revealed that the greenway intervention significantly reduced participants' sedentary time and the intervention has a distance decay effect. The closer to the greenway, the greater decrease in sedentary time after the greenway opening. Furthermore, we found that MVPA and walking time mediate the impact of the greenway intervention on the change in sedentary behavior. The effect of greenway intervention was more beneficial for those under the age of 60, those who were employed, or those who were married. Our findings provided robust evidence that exposure to urban greenways affects sedentary behavior and such green infrastructures help protect public health in high-density urban areas.

Quick and easy assessment of sarcopenia in cirrhosis: Can ultrasound be the solution?

Cirrhosis is frequently associated with sarcopenia, with reported rates of over 80% in patients with decompensated alcohol-related liver disease. Sarcopenia negatively impacts the prognosis of cirrhotic patients and affects the response to treatment of patients with hepatocellular carcinoma (HCC). For these reasons, identifying an easy-to-perform method to assess sarcopenia in is a key element in the optimization of care in this patient population. Assessment of muscle mass by computed tomography is considered the standard of care for the diagnosis of sarcopenia, but exposure to radiation and high costs limit its application in this setting, especially for repeated assessments. We believe that ultrasound, a cheap and harmless technique also used for HCC screening in cirrhotic patients, could have an expanding role in the diagnosis and follow-up of sarcopenia in these patients.

Association between non-alcoholic fatty liver disease and risk of sarcopenia: a systematic review and meta-analysis

OBJECTIVES

To determine the association of non-alcoholic fatty liver disease (NAFLD) with the incidence of sarcopenia.

DESIGN

Systematic review and meta-analysis of observational clinical studies.

SETTING AND PARTICIPANTS

Adults with NAFLD.

METHODS

Databases such as PubMed, Embase, Cochrane and Web of Science were searched for eligible studies published from the inception of each database up to 4 April 2023. All cross-sectional studies on the association between NAFLD and sarcopenia were included in this study. The quality of the included studies and risk of bias was assessed using the Agency for Healthcare Research and Quality checklist. STATA V.15.1 software was used for statistical analysis.

RESULTS

Of the 1524 retrieved articles, 24 were included in this review, involving 88 609 participants. Our findings showed that the prevalence of sarcopenia was higher in the NAFLD group than in the control group (pooled OR 1.74, 95% CI 1.39 to 2.17). In a subgroup analysis by region, patients with NAFLD showed an increased risk of sarcopenia (pooled OR 1.97, 95% CI 1.54 to 2.51) in the Asian group, whereas patients with NAFLD had no statistically significant association with the risk of sarcopenia in the American and European groups, with a pooled OR of 1.31 (95% CI 0.71 to 2.40) for the American group and a pooled OR of 0.99 (95% CI 0.21 to 4.69) for the European group. Similar results were observed in the sensitivity analysis, and no evidence of publication bias was observed.

CONCLUSIONS AND IMPLICATIONS

The current study indicated a significant positive correlation between NAFLD and sarcopenia, which may be affected by regional factors. This study provides the correlation basis for the relationship between NAFLD and sarcopenia and helps to find the quality strategy of sarcopenia targeting NAFLD.

Association between dietary inflammatory index and gallstones in US adults

Introduction

Previous studies have found that diet's inflammatory potential is related to various diseases. However, little is known about its relationship with gallstones. The present study aims to investigate the relationship between dietary inflammatory index (DII) and gallstones.

Methods

Data were obtained from the 2003-2020 National Health and Nutrition Examination Survey (NHANES). We used the nearest neighbor propensity score matching (PSM) with a ratio of 1:1 to reduce selection bias. Logistic regression models estimated the association between DII and gallstones. The non-linear relationship was explored with restricted cubic splines (RCS). BMI subgroup stratification was performed to explore further the connection between DII and gallstones in different populations.

Results

10,779 participants were included. Before and after PSM, gallstone group individuals had higher DII scores than non-gallstone group individuals (p < 0.05). Matched logistic regression analysis showed that DII scores were positively correlated with gallstone risk (adjusted OR = 1.14, 95% CI 1.01, 1.29). The stratified analysis showed that this association was stronger in overweight or obese people (adjusted OR = 1.18, 95% CI 1.03, 1.34). RCS analysis suggested that DII and gallstones showed a "J"-shaped non-linear dose-response relationship (p non-linear <0.001).

Conclusion

Higher DII score is positively associated with the risk of gallstones, particularly in overweight or obese population, and this relationship is a "J"-shaped non-linear relationship. These results further support that avoiding or reducing a pro-inflammatory diet can be an intervention strategy for gallstone management, particularly in the overweight or obese population.

Beneficial Effects of High-Intensity Interval Training and Dietary Changes Intervention on Hepatic Fat Accumulation in HFD-Induced Obese Rats

Lifestyle intervention encompassing nutrition and physical activity are effective strategies to prevent progressive lipid deposition in the liver. This study aimed to explore the effect of dietary change, and/or high-intensity interval training (HIIT) on hepatic lipid accumulation in high fat diet (HFD)-induced obese rats. We divided lean rats into lean control (LC) or HIIT groups (LH), and obese rats into obese normal chow diet (ND) control (ONC) or HIIT groups (ONH) and obese HFD control (OHC) or HIIT groups (OHH). We found that dietary or HIIT intervention significantly decreased body weight and the risk of dyslipidemia, prevented hepatic lipid accumulation. HIIT significantly improved mitochondrial fatty acid oxidation through upregulating mitochondrial enzyme activities, mitochondrial function and AMPK/PPARalpha/CPT1alpha pathway, as well as inhibiting hepatic de novo lipogenesis in obese HFD rats. These findings indicate that dietary alone or HIIT intervention powerfully improve intrahepatic storage of fat in diet induced obese rats. Keywords: Obesity, Exercise, Diet, Mitochondrial function, Lipid deposition.

Prevalence and outcome of sarcopenia in non-alcoholic fatty liver disease

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) includes a spectrum of conditions, progressing from mild steatosis to advanced fibrosis. Sarcopenia, characterized by decreased muscle strength and mass, shares common pathophysiological traits with NAFLD. An association exists between sarcopenia and increased NAFLD prevalence. However, data on the prevalence of sarcopenia in NAFLD and its impact on the outcomes of NAFLD remain inconsistent.

AIM

To analyze the prevalence and outcomes of sarcopenia in patients with NAFLD.

METHODS

We conducted a comprehensive search for relevant studies in MEDLINE, Embase, and Scopus from their inception to June 2023. We included studies that focused on patients with NAFLD, reported the prevalence of sarcopenia as the primary outcome, and examined secondary outcomes, such as liver fibrosis and other adverse events. We also used the Newcastle-Ottawa scale for quality assessment.

RESULTS

Of the 29 studies included, the prevalence of sarcopenia in NAFLD varied widely (1.6% to 63.0%), with 20 studies reporting a prevalence of more than 10.0%. Substantial heterogeneity was noted in the measurement modalities for sarcopenia. Sarcopenia was associated with a higher risk of advanced fibrosis (odd ratio: 1.97, 95% confidence interval: 1.44-2.70). Increased odds were consistently observed in fibrosis assessment through biopsy, NAFLD fibrosis score/body mass index, aspartate aminotransferase to alanine aminotransferase ratio, diabetes (BARD) score, and transient elastography, whereas the fibrosis-4 score showed no such association. Sarcopenia in NAFLD was associated with a higher risk of steatohepatitis, insulin resistance, cardiovascular risks, and mortality.

CONCLUSION

This systematic review highlights the critical need for standardized diagnostic criteria and measurement methods for sarcopenia in NAFLD patients. The variability in study designs and assessment methods for sarcopenia and liver fibrosis may account for the inconsistent findings. This review demonstrates the multidimensional impact of sarcopenia on NAFLD, indicating its importance beyond liver-related events to include cardiovascular risks, mortality, and metabolic complications.

Systemic immune-inflammation index and all-cause and cause-specific mortality in sarcopenia: a study from National Health and Nutrition Examination Survey 1999-2018

Background

Sarcopenia, common in the elderly, often linked to chronic diseases, correlates with inflammation.The association between SII and mortality in sarcopenia patients is underexplored, this study investigates this relationship in a U.S. adult cohort.

Methods

We analyzed 1999-2018 NHANES data, focusing on 2,974 adults with sarcopenia. Mortality outcomes were determined by linking to National Death Index (NDI) records up to December 31, 2019. Using a weighted sampling design, participants were grouped into three groups by the Systemic Immune-Inflammation Index (SII). We used Cox regression models, adjusting for demographic and clinical variables, to explore SII's association with all-cause and cause-specific mortality in sarcopenia, performing sensitivity analyses for robustness.

Results

Over a median follow-up of 9.2 years, 829 deaths occurred. Kaplan-Meier analysis showed significant survival differences across SII groups. The highest SII group showed higher hazard ratios (HRs) for all-cause and cause-specific mortality in both crude and adjusted models. The highest SII group had a higher HR for all-cause(1.57, 1.25-1.98), cardiovascular(1.61, 1.00-2.58), cancer(2.13, 1.32-3.44), and respiratory disease mortality(3.21, 1.66-6.19) in fully adjusted models. Subgroup analyses revealed SII's association with all-cause mortality across various demographics, including age, gender, and presence of diabetes or cardiovascular disease. Sensitivity analyses, excluding participants with cardiovascular diseases, those who died within two years of follow-up, or those under 45 years of age, largely reflected these results, with the highest SII group consistently demonstrating higher HRs for all types of mortality in both unadjusted and adjusted models.

Conclusion

Our study is the first to demonstrate a significant relationship between SII and increased mortality risks in a sarcopenia population.

Approaching the Sarcopenic Patient with Nonalcoholic Steatohepatitis-related Cirrhosis

Sarcopenia is a well-known complication of chronic liver disease (CLD), and it is almost always observed in patients with cirrhosis, at least in those with decompensated disease. Since nonalcoholic fatty liver disease (NAFLD), recently renamed metabolic dysfunction-associated steatotic liver disease (MASLD), is becoming the leading cause of end-stage liver disease, a new scenario characterized by the frequent coexistence of NAFLD, obesity, and sarcopenia is emerging. Although it is not yet resolved whether the bidirectional relationship between sarcopenia and NAFLD subtends causal determinants, it is clear that the interaction of these two conditions is associated with an increased risk of poor outcomes. Notably, during the course of CLD, deregulation of the liver-muscle-adipose tissue axis has been described. Unfortunately, owing to the lack of properly designed studies, specific therapeutic guidelines for patients with sarcopenia in the context of NAFLD-related CLD have not yet been defined. Strategies aimed to induce the loss of fat mass together with the maintenance of lean body mass seem most appropriate. This can be achieved by properly designed diets integrated with specific nutritional supplementations and accompanied by adequate physical exercise. Future studies aiming to add to the knowledge of the correct assessment and approach to sarcopenia in the context of NAFLD-related CLD are eagerly awaited.

Understanding the Burden of Nonalcoholic Fatty Liver Disease: Time for Action

The prevalence of nonalcoholic fatty liver disease (NAFLD) in the United States is 38%, having increased by 50% within the past 3 decades. The estimated NAFLD prevalence among people with type 2 diabetes is 55-70%. The presence of type 2 diabetes is associated with a higher likelihood of progression of NAFLD to fibrosis development, liver transplant, and death. Cardiovascular disease is the main cause of mortality among people with NAFLD, and the risk of death is significantly higher in people with both NAFLD and type 2 diabetes. NAFLD carries high patient and economic burdens but low awareness among both the general public and health care providers. This article reviews the epidemiology of NAFLD and discusses the need for appropriate risk stratification, referral for specialty care, management of cardiometabolic risk factors, and treatment of the disease. The authors present a call to action to raise awareness of NAFLD and address its increasing burden in a systematic and efficient manner.

The association of testosterone with sarcopenia and frailty in chronic liver disease

BACKGROUND

Testosterone is an important anabolic hormone responsible for maintaining body composition and muscle mass and circulates mostly albumin-bound, or sex hormone binding globulin (SHBG)-bound or free in the plasma. Of these fractions, the latter is bioactive and exerts the androgenic effects on male population. Liver cirrhosis, the advanced stage of any chronic liver disease characterized by permanent distortions to the hepatic architecture, disrupts the hypothalamic-pituitary-gonadal axis, leading to diminished levels of free testosterone and hypogonadism.

METHODS

We retrieved the PubMed database to provide a synopsis of testosterone's physiology and action and summarize the effect of sarcopenia in pre-cirrhotic and cirrhotic patients. Moreover, we scoped to provide insight into the relationship of testosterone levels with sarcopenia, frailty and survival in cirrhotic and non-cirrhotic population as well as to discuss the efficacy of exogenous testosterone supplementation on the anthropometric parameters and survival of those patients.

RESULTS

Low testosterone levels have been associated with sarcopenia, reduced body lean mass, decreased bone mineral density and frailty, thus leading to increased morbidity and mortality especially among cirrhotic patients. Furthermore, exogenous testosterone administration significantly ameliorated body composition on patients with chronic hepatic disease, without significant adverse effects. However, the current literature does not suggest any significant effect on survival of those patients. Moreover, the long-term safety of testosterone use remains an open question.

CONCLUSION

Low serum testosterone is strongly correlated with sarcopenia, frailty, higher rate of hepatic decompensation and mortality. Nonetheless, exogenous supplementation of testosterone did not ameliorate the liver-related outcomes and complications.

The changing epidemiology of adult liver transplantation in the United States in 2013-2022: The dominance of metabolic dysfunction-associated steatotic liver disease and alcohol-associated liver disease

BACKGROUND

The high prevalence of obesity in the United States drives the burden of NASH, recently renamed as metabolic dysfunction-associated steatohepatitis (MASH). We assessed the most recent trends in liver transplantation in the United States.

METHODS

The Scientific Registry of Transplant Recipients (SRTR 2013-2022) was used to select adult (18 years or above) candidates who underwent liver transplant.

RESULTS

There were 116,292 candidates who underwent liver transplant with known etiology of chronic liver disease. In candidates without HCC, the most common etiology was alcohol-associated liver disease (ALD), increasing from 23% (2013) to 48% (2022), followed by NASH/MASH, which increased from 19% to 27%; the rates of viral hepatitis decreased (chronic hepatitis C: 28%-4%; chronic hepatitis B: 1.8%-1.1%) (all trend p<0.01). The proportion of HCC decreased from 25% (2013-2016) to 17% (2021-2022). Among HCC cohort, the proportion of chronic hepatitis C decreased from 60% (2013) to 27% (2022), NASH/MASH increased from 10% to 31%, alcohol-associated liver disease increased from 9% to 24% (trend p<0.0001), and chronic hepatitis B remained stable between 5% and 7% (trend p=0.62). The rapid increase in the proportion of NASH/MASH in HCC continued during the most recent study years [20% (2018), 28% (2020), 31% (2022)]; the trend remained significant after adjustment for age, sex, ethnicity, obesity, and type 2 diabetes.

CONCLUSIONS

Liver transplant etiologies in the United States have changed over the last decade. Alcohol-associated liver disease and NASH/MASH remain the 2 most common indications for transplantation among those without HCC, and NASH/MASH is the most common in patients with HCC.

Differential Mortality Outcomes in Real-world Patients with Lean, Nonobese, and Obese Nonalcoholic Fatty Liver Disease

Background and Aims

Nonalcoholic fatty liver disease (NAFLD) is commonly associated with obesity but can develop in normal-weight people (lean NAFLD). We compared outcomes in lean, overweight, and obese NAFLD.

Methods

This retrospective chart review included patients at Stanford University Medical Center with NAFLD confirmed by imaging between March 1995 and December 2021. Lean, overweight, and obese patients had body mass index of <25.0, >25.0 and <29.9, and ≥30.0 kg/m2 for non-Asian and >23.0 and ≥27.5 for overweight and obese Asian patients.

Results

A total of 9061 lean (10.2%), overweight (31.7%), and obese (58.1%) patients were included. Lean patients were 5 years older than obese patients (53±17.4 vs. 48.7±15.1 years), more were female (59.6% vs. 55.2%), white (49.1% vs. 46.5%), had NASH (29.2% vs. 22.5%), cirrhosis (25.3% vs.19.2%), or nonliver cancer (25.3% vs. 18.3%). Fewer had diabetes (21.7% vs. 35.8%) or metabolic comorbidities (all p<0.0001). Lean NAFLD patients had liver-related mortality similar to other groups but higher overall (p=0.01) and nonliver-related (p=0.02) mortality. After multivariable model adjustment for covariates, differences between lean and obese NAFLD in liver-related, nonliver-related, and overall mortality (adjusted hazard ratios of 1.34, 1.00, and 1.32; p=0.66, 0.99, and 0.20, respectively) were not significant.

Conclusions

Lean NAFLD had fewer metabolic comorbidities but similar adverse or worse outcomes, suggesting that it is not benign. Healthcare providers should provide the same level of care and intervention as for overweight and obese NAFLD.

Metabolic associated fatty liver disease and sarcopenia additively increase mortality: a real-world study

BACKGROUND AND AIMS

Sarcopenia is associated with worse prognosis for non-alcoholic fatty liver disease (NAFLD). However, disease progression in the MAFLD-related sarcopenia is largely unknown. We aimed to clarify the relationship between MAFLD and/or sarcopenia with mortality and liver fibrosis in the real world.

METHODS

A total of 13,692 individuals were selected from the third National Health and Nutrition Examination Surveys and linked mortality until December 2019. MAFLD is diagnosed based on a radiologically diagnosed hepatic steatosis and the presence of any one of the following three conditions: overweight/obesity, diabetes mellitus (DM), or metabolic dysregulation. Sarcopenia is defined by weight-adjusted skeletal muscle mass.

RESULTS

The mean age was 43.7 ± 15.97 years, and 47.3% of the individuals were male. MAFLD was diagnosed in 4207/13,692 (30.73%) participants, and the proportion of sarcopenic was 19.42% amongst subjects with MAFLD. The mean follow-up duration was of 23.7 ± 7.62 years. MAFLD (aHR 1.152, 95% CI 1.070-1.241) and sarcopenia (aHR 1.123, 95% CI 1.042-1.210) were related to increased all-cause mortality in MAFLD after adjustment for age, sex, race, marital status, education, and smoking. Stratified analysis revealed that MAFLD and sarcopenia additively increased the risk of mortality (aHR 1.247, 95% CI 1.132-1.373) and liver fibrosis (aOR 2.296, 95% CI 1.718-3.069 assessed by NFS score >0.676; aOR 2.218, 95% CI 1.788-2.752 assessed by FIB-4 score >1.3) in fully adjusted models (P < 0.001 for all).

CONCLUSION

Sarcopenia in individuals with MAFLD portends increased mortality and significant liver fibrosis. Novel therapeutic strategies targeting at increasing skeletal muscle mass should be explored for patients with MAFLD.

Lifestyle interventions in nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is a dynamic chronic liver disease that develops in close association with metabolic irregularities. Between 2016 and 2019, the global prevalence among adults was reported as 38% and among children and adolescents it was about 10%. NAFLD can be progressive and is associated with increased mortality from cardiovascular disease, extrahepatic cancers and liver complications. Despite these numerous adverse outcomes, no pharmacological treatments currently exist to treat nonalcoholic steatohepatitis, the progressive form of NAFLD. Therefore, the main treatment is the pursuit of a healthy lifestyle for both children and adults, which includes a diet rich in fruits, nuts, seeds, whole grains, fish and chicken and avoiding overconsumption of ultra-processed food, red meat, sugar-sweetened beverages and foods cooked at high heat. Physical activity at a level where one can talk but not sing is also recommended, including leisure-time activities and structured exercise. Avoidance of smoking and alcohol is also recommended. Policy-makers, community and school leaders need to work together to make their environments healthy by developing walkable and safe spaces with food stores stocked with culturally appropriate and healthy food items at affordable prices as well as providing age-appropriate and safe play areas in both schools and neighbourhoods.

U-Shaped Association of Standardized Serum 25-Hydroxyvitamin D with Risk of Low Muscle Mass: A Population-Based Cross-Sectional Study

Background

In the United States (U.S.) general population, the association between standardized serum 25-hydroxyvitamin D (25(OH)D) concentration and risk of low muscle mass (LMM) remains unclear. Our research aimed to determine whether or not there was a relationship between serum 25(OH)D concentration and risk of LMM.

Methods

We analyzed the cross-sectional data of the US population that participated in the National Health and Nutrition Examination Survey between 2011 and 2014. The relationship between serum 25(OH)D concentration and LMM risk was evaluated using restricted cubic spline (RCS) with multivariate logistic regression model and subgroup analysis.

Results

In all, we included 10,256 people in our analysis. The RCS plot demonstrated a U-shaped relationship between serum 25(OH)D concentration and risk of LMM (P for nonlinearity <0.05). At a Vitamin D concentration of 38.5 nmol/L, LMM risk was at its lowest. Based on analyses stratified by age, sex, hypertension, and diabetes mellitus (DM), serum 25(OH)D concentration and risk of LMM were U-curve correlated for those age 40 or older, male, with hypertension, or without DM. However, LMM risk was positively related to serum 25(OH)D concentration in those younger than age 40 or in women.

Conclusion

There is a U-shaped relationship between serum 25(OH)D concentration and the risk of LMM in the general U.S. population. Careful monitoring and appropriate Vitamin D supplementation might lessen the risk of LMM.

Lean nonalcoholic fatty liver disease and sarcopenia

Nonalcoholic fatty liver disease (NAFLD) has become one of the most common chronic liver diseases in the world. The risk factor for NAFLD is often considered to be obesity, but it can also occur in people with lean type, which is defined as lean NAFLD. Lean NAFLD is commonly associated with sarcopenia, a progressive loss of muscle quantity and quality. The pathological features of lean NAFLD such as visceral obesity, insulin resistance, and metabolic inflammation are inducers of sarcopenia, whereas loss of muscle mass and function further exacerbates ectopic fat accumulation and lean NAFLD. Therefore, we discussed the association of sarcopenia and lean NAFLD, summarized the underlying pathological mechanisms, and proposed potential strategies to reduce the risks of lean NAFLD and sarcopenia in this review.

Establishment and evaluation of a novel practical tool for the diagnosis of pre-sarcopenia in young people with diabetes mellitus

OBJECTIVE

Sarcopenia has been recognized as a third category of complications in people with diabetes. However, few studies focus on the reduction of skeletal muscle mass in young people with diabetes. The aim of this study was to investigate risk factors of pre-sarcopenia in young patients with diabetes and establish a practical tool to diagnose pre-sarcopenia in those people.

METHODS

Patients (n = 1246) enrolled from the National Health and Nutrition Examination Survey (NHANES) cycle year of 2011 to 2018 were randomly divided into the training set and validation set. The all-subsets regression analysis was used to select the risk factors of pre-sarcopenia. A nomogram model for the prediction of pre-sarcopenia in the diabetic population was established based on the risk factors. The model was evaluated by the area under the receiver operating characteristic curve for discrimination, calibration curves for calibration, and decision curve analysis curves for clinical utility.

RESULTS

In this study, gender, height, and waist circumference were elected as predictive factors for pre-sarcopenia. The nomogram model presented excellent discrimination in training and validation sets with areas under the curve of 0.907 and 0.912, respectively. The calibration curve illustrated excellent calibration, and the decision curve analysis showed a wide range of good clinical utility.

CONCLUSIONS

This study develops a novel nomogram that integrates gender, height, and waist circumference and can be used to easily predict pre-sarcopenia in diabetics. The novel screen tool is accurate, specific, and low-cost, highlighting its potential value in clinical application.

Higher mortality among lean patients with non-alcoholic fatty liver disease despite fewer metabolic comorbidities

BACKGROUND & AIMS

Non-alcoholic fatty liver disease (NAFLD) can develop in individuals who are not overweight. Whether lean persons with NAFLD have lower mortality and lower incidence of cirrhosis, cardiovascular diseases (CVD), diabetes mellitus (DM) and cancer than overweight/obese persons with NAFLD remains inconclusive. We compared mortality and incidence of cirrhosis, CVD, DM and cancer between lean versus non-lean persons with NAFLD.

METHODS

This is a retrospective study of adults with NAFLD in a single centre from 2012 to 2021. Primary outcomes were mortality and new diagnosis of cirrhosis, CVD, DM and cancer. Outcomes were modelled using competing risk analysis and Cox proportional hazards regression analysis.

RESULTS

A total of 18,594 and 13,420 patients were identified for cross-sectional and longitudinal analysis respectively: approximately 11% lean, 25% overweight, 28% class 1 obesity and 35% class 2-3 obesity. The median age was 51.0 years, 54.6% were women. The median follow-up was 49.3 months. Lean patients had lower prevalence of metabolic diseases at baseline and lower incidence of cirrhosis and DM than non-lean patients and no difference in CVD, any cancer or obesity-related cancer during follow-up. However, lean patients had significantly higher mortality with incidence per 1000 person-years of 16.67, 10.11, 7.37 and 8.99, respectively, in lean, overweight, obesity class 1 and obesity class 2-3 groups respectively.

CONCLUSIONS

Lean patients with NAFLD had higher mortality despite lower incidence of cirrhosis and DM, and similar incidence of CVD and cancer and merit similar if not more attention as non-lean patients with NAFLD.

Clinics in Liver Disease: Update on Nonalcoholic Steatohepatitis: Sarcopenia and Nonalcoholic Fatty Liver Disease

Dual diagnoses of sarcopenia and nonalcoholic fatty liver disease (NAFLD) increase the risk of all cause mortality and severe liver disease, regardless of nationality. General agreement about diagnostic criteria for sarcopenia includes loss of skeletal muscle mass, weakness, and reduced physical performance. Histopathology demonstrates loss of type 2 muscle fibers, more than type 1 fibers and myosteatosis, a risk factor for severe liver disease. Low skeletal mass and NAFLD are inversely related; the mechanism is through decreased insulin signaling and insulin resistance, critical for metabolic homeostasis. Weight loss, exercise, and increased protein intake have been effective in reducing NAFLD and sarcopenia.

Osteosarcopenia in NAFLD/MAFLD: An Underappreciated Clinical Problem in Chronic Liver Disease

Chronic liver disease (CLD), including non-alcoholic fatty liver disease (NAFLD) and its advanced form, non-alcoholic steatohepatitis (NASH), affects a significant portion of the population worldwide. NAFLD is characterised by fat accumulation in the liver, while NASH is associated with inflammation and liver damage. Osteosarcopenia, which combines muscle and bone mass loss, is an emerging clinical problem in chronic liver disease that is often underappreciated. The reductions in muscle and bone mass share several common pathophysiological pathways; insulin resistance and chronic systemic inflammation are the most crucial predisposing factors and are related to the presence and gravity of NAFLD and to the worsening of the outcome of liver disease. This article explores the relationship between osteosarcopenia and NAFLD/MAFLD, focusing on the diagnosis, prevention and treatment of this condition in patients with CLD.

Vigorous physical activity provides protection against all-cause deaths among adults patients with nonalcoholic fatty liver disease (NAFLD)

BACKGROUND

Mortality benefits of vigorous leisure time physical activity (LTPA) among adults with NAFLD is not known.

AIM

To investigate association between LTPA and reduction in all-cause mortality among adults with NAFLD.

METHODS

We used NHANES (1999-2006) self-reported PA data for adults (≥40 years) with mortality follow-up through December 31, 2015. US-Fatty Liver Index in absence of secondary causes identified NAFLD. Moderate and vigorous LTPA were calculated by the 2018 PA Guidelines for Americans.

RESULTS

NAFLD prevalence among 5211 adults (46.2% male; 75.8% white; mean age 53.2 years) was 32.7%. Adults with NAFLD were less likely to report the recommended minimal PA (≥ 150 min/week, 55.5% vs 64.8%) or highly active PA (≥300 min/week, 39.2% vs 48.5%) compared to adults without NAFLD. Over a median follow-up of 12.3 years, 355 deaths among adults with NAFLD and 510 deaths among adults without NAFLD were registered. In the metabolic comorbidities-adjusted model, adults with NAFLD who reported ≥50% of their total PA as vigorous activity had a 56% reduction in all-cause mortality risk (HR:0.44, 95%CI: 0.25-0.76) and cancer-specific mortality risk (HR: 0.21, 0.06-0.66) but not cardiac-specific mortality (p > 0.05) compared to adults with NAFLD who did not report any LTPA. This association remained significant even among adults with NAFLD who met the recommended minimal PA, among adults with NAFLD who reported any LTPA, and among adults with NAFLD who had metabolic abnormalities and in sensitivity analysis.

CONCLUSIONS

Engaging in vigorous activity is beneficial for adults with NAFLD - especially those with metabolic abnormalities.

Impact of Sarcopenia on Non-Alcoholic Fatty Liver Disease

With the increasing incidence of non-alcoholic fatty liver disease (NAFLD) and the aging of the population, sarcopenia is attracting attention as one of the pathological conditions involved in the development and progression of NAFLD. In NAFLD, sarcopenia is closely associated with insulin resistance and results from the atrophy of skeletal muscle, an insulin target organ. In addition, inflammatory cytokines that promote skeletal muscle protein breakdown, low adiponectin levels leading to decreased insulin sensitivity, and hyperleptinemia are also involved in NAFLD pathogenesis. The presence of sarcopenia is a prognostic factor and increases the risk of mortality in patients with cirrhosis and post-treatment liver cancer. Sarcopenia, the presence of which mainly occurs due to decreased muscle mass, combined with increased visceral fat, can lead to sarcopenia-associated obesity, which increases the risk of NASH, liver fibrosis, and cardiovascular disease. In order to treat sarcopenia, it is necessary to properly evaluate sarcopenia status. Patients with high BMI, as in sarcopenic obesity, may improve with caloric restriction. However, inadequate oral intake may lead to further loss of muscle mass. Aerobic and resistance exercise should also be used appropriately.

Causes and risk profiles of mortality among individuals with nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in the United States and worldwide. Though nonalcoholic fatty liver per se may not be independently associated with an increased risk for all-cause mortality, it is associated with a number of harmful metabolic risk factors, such as type 2 diabetes mellitus, hyperlipidemia, obesity, a sedentary lifestyle, and an unhealthy diet. The fibrosis stage is a predictor of all-cause mortality in NAFLD. Mortality in individuals with NAFLD has been steadily increasing, and the most common cause-specific mortality for NAFLD is cardiovascular disease, followed by extra-hepatic cancer, liver-related mortality, and diabetes. High-risk profiles for mortality in NAFLD include PNPLA3 I148M polymorphism, low thyroid function and hypothyroidism, and sarcopenia. Achieving weight loss through adherence to a high-quality diet and sufficient physical activity is the most important predictor of improvement in NAFLD severity and the benefit of survival. Given the increasing health burden of NAFLD, future studies with more long-term mortality data may demonstrate an independent association between NAFLD and mortality.

Interaction between sarcopenia and nonalcoholic fatty liver disease

Sarcopenia and nonalcoholic fatty liver disease (NAFLD) are common health problems related to aging. Despite the differences in their diagnostic methods, several cross-sectional and longitudinal studies have revealed the close link between sarcopenia and NAFLD. Sarcopenia and NAFLD are linked by several shared pathogenetic mechanisms, including insulin resistance, hormonal imbalance, systemic inflammation, myostatin and adiponectin dysregulation, nutritional deficiencies, and physical inactivity, thus implicating a bidirectional relationship between sarcopenia and NAFLD. However, there is not sufficient data to support a direct causal relationship between sarcopenia and NAFLD. Moreover, it is currently difficult to conclude whether sarcopenia is a risk factor for nonalcoholic steatohepatitis (NASH) or is a consequence of NASH. Therefore, this review intends to touch on the shared common mechanisms and the bidirectional relationship between sarcopenia and NAFLD.

Association between perfluoroalkyl substances exposure and the prevalence of nonalcoholic fatty liver disease in the different sexes: a study from the National Health and Nutrition Examination Survey 2005-2018

There is evidence that perfluoroalkyl substances (PFASs) have effects on liver toxicity, and the effects may exhibit sex differences. Our study aims to explore the association between exposure to four PFASs (perfluorooctanoic acid, PFOA; perfluorooctane sulfonate, PFOS; perfluorohexane sulfonate, PFHxS; and perfluorononanoate, PFNA) and the risk of nonalcoholic fatty liver disease (NAFLD) in adults ≥ 20 years old in the US population. The data were based on the National Health and Nutrition Examination Survey (NHANES) 2005-2018. We used Poisson regression to explore the association between the four PFASs and NAFLD. We included 3464 participants; of these, 1200 (34.64%) individuals were defined as having NAFLD, and the prevalence of NAFLD was 39.52% in men and 30.40% in women. After Poisson regression, among the premenopausal and postmenopausal and total women, PFOA had a significantly positive association with NAFLD (p < 0.05). After principal component analysis, the "composite PFAS" was associated with NAFLD in postmenopausal and total women, and the RRs (95% CIs) were 1.306 (1.075, 1.586) and 1.161 (1.007, 1.339), respectively. In adults, we found that PFASs were associated with NAFLD, and the associations varied by sex, particularly for PFOA and PFNA, which had a positive association with NAFLD in women.

Diet was less significant than physical activity in the prognosis of people with sarcopenia and metabolic dysfunction-associated fatty liver diseases: Analysis of the National Health and Nutrition Examination Survey III

BACKGROUND

Sarcopenia is prevalent in metabolic dysfunction-associated fatty liver diseases (MAFLD), and the primary treatment for both diseases is lifestyle modification. We studied how dietary components and physical activity affect individuals with sarcopenia and MAFLD.

MATERIALS AND METHODS

We conducted a study utilizing National Health and Nutrition Examination Survey (NHANES) III (1988-1994) data with Linked Mortality file (through 2019). The diagnosis of fatty liver disease (FLD) was based on ultrasound images revealing moderate and severe steatosis. Using bioelectrical measures, sarcopenia was assessed. Using self-report data, dietary intake and physical activity levels were evaluated.

RESULTS

Among 12,259 participants, 2,473 presented with MAFLD, and 290 of whom had sarcopenia. Higher levels of physical activity (odds ratio [OR] = 0.51 [0.36-0.95]) and calorie (OR = 0.58 [0.41-0.83]) intake reduced the likelihood of sarcopenia in MAFLD patients. During a median follow-up period of 15.3 years, 1,164 MAFLD and 181 MAFLD patients with sarcopenia perished. Increased activity levels improved the prognosis of patients with sarcopenia (Insufficiently active, HR = 0.75 [0.58-0.97]; Active, HR = 0.64 [0.48-0.86]), which was particularly pronounced in older patients.

CONCLUSION

In the general population, hyperglycemia was highly related to MAFLD prognosis. Physical inactivity and a protein-restricted diet corresponded to sarcopenia, with physical inactivity being connected to poor outcomes. Adding protein supplements would be beneficial for older people with sarcopenia who are unable to exercise due to frailty, while the survival benefits were negligible.

The Evidence Surrounding Non-Alcoholic Fatty Liver Disease in Individuals with Cancer: A Systematic Literature Review

Emerging evidence indicates an association between non-alcoholic fatty liver disease (NAFLD), cancer development and mortality. Cancer treatment-induced metabolic and hepatic dysfunction may be associated with increased rates of NAFLD. The review aims to investigate current evidence surrounding NAFLD in adults (≥18 years) with cancer including prevalence, effect of cancer treatments, metabolic co-morbidities, and mortality. Embase, Scopus, PubMed, and CINAHL were searched from inception to December 2021 including randomized controlled trials and observational studies. Twenty-three articles were included, comprising 142,218 participants. The overall risk of bias for observational studies was determined as low for 10 studies and neutral for 12 studies, and the RCT was determined as some concerns. The prevalence of NAFLD, based on imaging or histology, in adults with cancer ranged from 0.5 to 81.3%, with higher prevalence in breast, colorectal and gynecological cancers. Higher rates of NAFLD were also seen in patients who (i) underwent treatments-including chemotherapy and hormone therapy and/or who (ii) had higher BMI or other metabolic co-morbidities. NAFLD was associated with an increase in all-cause and cancer-related mortality. Based on review results, it is recommended that further assessment is carried out to determine whether liver screening in high-risk patients is cost effective and if interventions can be implemented to improve hepatic and health outcomes in adults with cancer.

Nonalcoholic fatty liver disease and accelerated loss of skeletal muscle mass: A longitudinal cohort study

BACKGROUND AND AIMS

Whether subjects with NAFLD are at increased risk of sarcopenia is not well established.

APPROACH AND RESULTS

This is a cohort study of 52,815 men and women of 20 years of age or older who underwent at least two health check-up exams with bioelectrical impedance analysis and abdominal ultrasound imaging. Bioelectrical impedance analysis was used to calculate appendicular skeletal muscle mass (ASM). NAFLD was assessed by ultrasonography, and its severity was assessed by the NAFLD fibrosis score (NFS). We estimated the 5-year change in ASM comparing participants with and without NAFLD at baseline using mixed linear models. The 5-year change in ASM in participants without and with NAFLD was -225.2 g (95% CI -232.3, -218.0) and -281.3 g (95% CI -292.0, -270.6), respectively (p < 0.001). In multivariable adjusted analysis, the difference in 5-year change in ASM comparing participants with and without NAFLD was -39.9 g (95% CI -53.1, -26.8). When participants with NAFLD were further divided by NAFLD severity, ASM loss was much faster in participants with NAFLD with intermediate to high NFS than in those with low NFS.

CONCLUSIONS

Participants with NAFLD were at increased risk of sarcopenia, indicated by faster loss of skeletal muscle mass. Patients with NAFLD may need screening and early intervention to mitigate skeletal muscle mass loss.

Differential influences of serum vitamin C on blood pressure based on age and sex in normotensive individuals

Aim

Hypertension is among the most prevalent chronic diseases with diverse etiology, affecting over 1 billion people globally. In numerous studies, vitamin C inversely correlated with blood pressure and was suspected to have antihypertensive properties. Currently, there is conflicting evidence regarding the relationship between vitamin C and blood pressure, with most studies being conducted on hypertensive subjects. The principal objective of this project was to investigate the relationship between vitamin C and blood pressure in normotensive adult subjects.

Methods

A total of 2,533 individuals aged 20 years and above were enrolled in the present study from the National Health and Nutrition Examination Survey (NHANES) 2017-2018. Outcome variables were systolic blood pressure (SBP) and diastolic blood pressure (DBP). Serum vitamin C was regarded as an independent variable. EmpowerStats software and R (version 3.4.3) were used to examine the association between vitamin C and SBP or DBP.

Results

Vitamin C was reversely correlated with both SBP (β = −0.02, 95% CI: −0.03 to −0.00, p = 0.0306) and DBP (β = −0.02, 95% CI: −0.04 to −0.01, p = &lt;0.0011) after adjusting all covariates. This reverse relationship may be affected by a number of factors, including a person’s gender, age, race, and ethnicity. A U-shaped association between vitamin C and SBP in females and an inverted one between vitamin C and DBP in males were detected, respectively. We further calculated the inflection points at 90.3 μmol/L for females and 40 μmol/L for males. It is somewhat surprising that a reverse U-shaped distribution between vitamin C and SBP and DBP in people over 50 was detected, and the point of inflection of vitamin C were all located at 40 μmol/L.

Conclusion

Vitamin C was negatively correlated with both SBP and DBP in this cross-sectional analysis. However, a U-shaped relationship and an inverted one were also observed in certain people, which implied that, though vitamin C is considered a vital antioxidant, maintaining vitamin C at appropriate levels may be beneficial according to different populations.

Ammonium quantification in human plasma by proton nuclear magnetic resonance for staging of liver fibrosis in alcohol-related liver disease and nonalcoholic fatty liver disease

Liver fibrosis staging is a key element driving the prognosis of patients with chronic liver disease. Currently, biopsy is the only technique capable of diagnosing liver fibrosis in patients with alcohol-related liver disease (ArLD) and nonalcoholic fatty liver disease (NAFLD) unequivocally. Noninvasive (e.g. plasma-based) biomarker assays are attractive tools to diagnose and stage disease, yet must prove that they are reliable and sensitive to be used clinically. Here, we demonstrate proton nuclear magnetic resonance as a method to rapidly quantify the endogenous concentration of ammonium ions from human plasma extracts and show their ability to report upon early and advanced stages of ArLD and NAFLD. We show that, irrespective of the disease etiology, ammonium concentration is a more robust and informative marker of fibrosis stage than current clinically assessed blood hepatic biomarkers. Subject to validation in larger cohorts, the study indicates that the method can provide accurate and rapid staging of ArLD and NAFLD without the need for an invasive biopsy.

Sarcopenia, healthy living, and mortality in patients with chronic liver diseases

Chronic liver diseases (CLDs) are associated with increased morbidity and mortality. Sarcopenia is an important complication of CLD that can be impacted by several modifiable risk factors. Our aim was to assess the associations between healthy living, sarcopenia, and long-term outcomes among patients with CLD. We used the Third National Health and Nutrition Examination Survey data with National Death Index-linked mortality files. We used the American Heart Association's Life's Simple 7 (LS7) metrics as surrogates of healthy living. The study included 12,032 subjects (34.9% CLDs [0.5% hepatitis B virus (HBV), 1.8% hepatitis C virus (HCV), 5.7% alcohol-associated liver disease (ALD), 26.9% nonalcoholic fatty liver disease (NAFLD)] and 65.1% controls). Prevalence of sarcopenia was higher among NAFLD than other CLDs and the controls (40.7% in NAFLD, 27.2% in ALD, 22.4% in HCV, 16.8% in HBV, and 18.5% in controls; p < 0.001). Among NAFLD and ALD, patients with sarcopenia were less likely to meet ideal LS7 metrics than those without sarcopenia. During 27 years of follow-up, among 4 patients with CLDs and the controls, all-cause cumulative mortality was highest among patients with HCV (35.2%), followed by ALD (34.7%) and NAFLD (29.6%). The presence of sarcopenia was associated with higher risk of all-cause mortality only among subjects with NAFLD (hazard ratio [HR] 1.24; 95% confidence interval [CI] 1.01-1.54; p = 0.04). Among subjects with NAFLD, presence of sarcopenia was associated with higher risk of cardiovascular-specific (HR 2.28 [1.71-3.05; p < 0.01]), cancer-specific (HR 1.90 [1.37-2.65]; p < 0.01), diabetes-specific (HR 6.42 [2.87-14.36]; p < 0.01), and liver-specific mortality (HR 2.49 [1.08-5.76]; p = 0.04). The multivariable model showed that component of LS7 metrics that provided the strongest protection against sarcopenia were ideal body mass index, ideal blood pressure, ideal physical activity, and ideal glycemic control among subjects with NAFLD subjects. Conclusions: Among subjects with NAFLD, sarcopenia is associated with a higher risk of all-cause mortality and liver mortality. Attainment of ideal LS7 metrics provides protection against sarcopenia in NAFLD.

Effect of Exercise Training on Serum Transaminases in Patients With Nonalcoholic Fatty Liver Disease: A Systematic Review and Meta-Analysis

Background/Purpose: Nonalcoholic fatty liver disease (NAFLD) constitutes a spectrum of liver diseases associated with various metabolic disorders. Exercise interventions reportedly manage the clinical outcomes of NAFLD, but their efficacy depends on exercise as well as characteristics of patient. We hypothesized that exercise could alleviate the elevated transaminases level, which may be associated with the characteristics of patients (age/bodyweight/sex) or exercise variables (frequency/intensity/duration). Therefore, we examined the effect of exercise on serum transaminases, and identified the variables influencing transaminases in NAFLD patients.

Methods: Article search was conducted using electronic databases (PubMed, Web of Science, EMBASE, ScienceDirect, Google Scholar) until December 2021. Studies that involved examination and comparison of the effect of an exercise intervention on alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels in NAFLD/nonalcoholic steatohepatitis patients were included. We calculated pooled effect upon a meta-analysis, determined correlations (between transaminases and characteristics of patients/exercise) by meta-regression, and assessed the influencing variable through subgroup analysis.

Results: A total of 18 studies (22 trials) with 1098 NAFLD patients (exercise = 568; control = 530) were included. The pooled outcomes revealed that exercise intervention significantly decreased both ALT (p = 0.004) and AST (p = 0.001) levels in NAFLD patients. Meta-regression analysis showed decreased ALT (coef. = 1.138, p &lt; 0.01) and AST (coef. = 0.459, p = 0.041) after intervention was correlated with the age of patients. Particularly, patients aged 30–39 years (MD: −25.89 U/L, 95% CI: −36.40 to −15.37, p &lt; 0.00001) and 40–49 years (MD: −12.17 U/L, 95% CI: −20.38 to −3.96, p = 0.004) represented a substantial decrease in ALT levels. Additionally, the 50–59 years age group tended to have decreased ALT levels (MD: −3.94 U/L, 95% CI: −8.19 to 0.31, p = 0.07); however, patients above 60 years did not respond (p = 0.92) to exercise intervention. In contrast, exercise-induced AST reduction was found in only the 30–39 years age group (MD: −11.92 U/L, 95% CI: −16.78 to −7.06, p &lt; 0.00001) and not in patients under the 40–49 (p = 0.19), and 50–59 groups (p = 0.12) and above 60 years (p = 0.15).

Conclusion: Our findings suggest that the age of NAFLD patients may be an important variable in improving the levels of serum transaminases, and clinically young patients may have greater benefits from exercise than older patients.

Prevalence of frailty in patients with non-cirrhotic non-alcoholic fatty liver disease

OBJECTIVE

End-stage chronic liver disease is associated with accelerated ageing and increased frailty. Frailty measures have provided clinical utility in identifying patients at increased risk of poor health outcomes, including those awaiting liver transplantation. However, there is limited data on the prevalence and severity of frailty in patients with non-cirrhotic non-alcoholic fatty liver disease (NAFLD). The aim of this study was to evaluate the prevalence of frailty and prefrailty in patients with non-cirrhotic NAFLD and correlate with severity of liver disease.

DESIGN

A cross-sectional analysis of functional and laboratory frailty assessments, including the Fried frailty index (FFI), a self-reported frailty index (SRFI) and a lab-based frailty index (FI-LAB), was performed in a cohort of 109 patients with NAFLD, and results compared with fibrosis staging based on transient elastography.

RESULTS

Patients with NAFLD had a high prevalence of prefrailty and frailty, with a median SRFI score of 0.18 (IQR: 0.18), FFI of 1 (IQR: 1) and FI-LAB of 0.18 (IQR: 0.12). Using the SRFI, 45% of F0/F1 patients were classified as prefrail and 20% were classified as frail, while in F2/F3 patients this increased to 36% and 41%, respectively. SRFI, 30 s sit-to-stand and FI-LAB scores increased with increasing liver fibrosis stages (p=0.001, 0.006 and <0.001, respectively). On multivariate linear regression, female gender was identified as a significant predictor of elevated frailty scores.

CONCLUSION

This study identifies a high prevalence of frailty in individuals with non-cirrhotic NAFLD. Addressing frailty through early rehabilitation interventions may reduce overall morbidity and mortality in this population.

American Association of Clinical Endocrinology Clinical Practice Guideline for the Diagnosis and Management of Nonalcoholic Fatty Liver Disease in Primary Care and Endocrinology Clinical Settings: Co-Sponsored by the American Association for the Study of Liver Diseases (AASLD)

OBJECTIVE

To provide evidence-based recommendations regarding the diagnosis and management of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) to endocrinologists, primary care clinicians, health care professionals, and other stakeholders.

METHODS

The American Association of Clinical Endocrinology conducted literature searches for relevant articles published from January 1, 2010, to November 15, 2021. A task force of medical experts developed evidence-based guideline recommendations based on a review of clinical evidence, expertise, and informal consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.

RECOMMENDATION SUMMARY

This guideline includes 34 evidence-based clinical practice recommendations for the diagnosis and management of persons with NAFLD and/or NASH and contains 385 citations that inform the evidence base.

CONCLUSION

NAFLD is a major public health problem that will only worsen in the future, as it is closely linked to the epidemics of obesity and type 2 diabetes mellitus. Given this link, endocrinologists and primary care physicians are in an ideal position to identify persons at risk on to prevent the development of cirrhosis and comorbidities. While no U.S. Food and Drug Administration-approved medications to treat NAFLD are currently available, management can include lifestyle changes that promote an energy deficit leading to weight loss; consideration of weight loss medications, particularly glucagon-like peptide-1 receptor agonists; and bariatric surgery, for persons who have obesity, as well as some diabetes medications, such as pioglitazone and glucagon-like peptide-1 receptor agonists, for those with type 2 diabetes mellitus and NASH. Management should also promote cardiometabolic health and reduce the increased cardiovascular risk associated with this complex disease.

Fatty Hepatocytes Induce Skeletal Muscle Atrophy In Vitro: A New 3D Platform to Study the Protective Effect of Albumin in Non-Alcoholic Fatty Liver

The liver neutralizes endogenous and exogenous toxins and metabolites, being metabolically interconnected with many organs. Numerous clinical and experimental studies show a strong association between Non-alcoholic fatty liver disease (NAFLD) and loss of skeletal muscle mass known as sarcopenia. Liver transplantation solves the hepatic-related insufficiencies, but it is unable to revert sarcopenia. Knowing the mechanism(s) by which different organs communicate with each other is crucial to improve the drug development that still relies on the two-dimensional models. However, those models fail to mimic the pathological features of the disease. Here, both liver and skeletal muscle cells were encapsulated in gelatin methacryloyl and carboxymethylcellulose to recreate the disease’s phenotype in vitro. The 3D hepatocytes were challenged with non-esterified fatty acids (NEFAs) inducing features of Non-alcoholic fatty liver (NAFL) such as lipid accumulation, metabolic activity impairment and apoptosis. The 3D skeletal muscle tissues incubated with supernatant from fatty hepatocytes displayed loss of maturation and atrophy. This study demonstrates the connection between the liver and the skeletal muscle in NAFL, narrowing down the players for potential treatments. The tool herein presented was employed as a customizable 3D in vitro platform to assess the protective effect of albumin on both hepatocytes and myotubes.

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

Background: There is evidence that vitamin B12 and associated metabolite levels are changed in non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH); however, their association has been in dispute. Methods: We included 8397 individuals without previous liver condition or excess alcohol intake from the National Health and Nutrition Examination Survey (NHANES) 1999–2004. NAFLD was diagnosed with Fatty Liver Index (FLI) ≥ 60 or USFLI ≥ 30, and participants with advanced fibrosis risks were identified with elevated non-alcoholic fatty liver disease fibrosis score (NFS), fibrosis 4 index (FIB-4), or aspartate aminotransferase (AST)/platelet ratio index (APRI). Step-wide logistic regression adjusting for confounders was used to detect the association between NAFLD or advanced fibrosis with serum vitamin B12, folate, red blood cell folate (RBC folate), homocysteine (HCY), and methylmalonic acid (MMA). Results: The weighted prevalence of NAFLD was 44.2%. Compared with non-NAFLD participants, patients with NAFLD showed significantly increased RBC folate level and RBC counts, decreased serum vitamin B12 and folate, and similar HCY and MMA levels. NAFLD with advanced fibrosis risk had higher MMA and HCY, reduced serum vitamin B12, and similar serum folate and RBC folate levels than NAFLD with low fibrosis risk. Only RBC folate was independently associated with an increased risk of NAFLD (OR (95% CI): 2.24 (1.58, 3.18)). In all participants, MMA (OR: 1.41 (1.10, 1.80)) and HCY (OR: 2.76 (1.49, 5.11)) were independently associated with increased risk for advanced fibrosis. In participants with NAFLD, this independent association still existed (OR: 1.39 (1.04, 1.85) for MMA and 1.95 (1.09, 3.46) for HCY). In all participants, the area under the receiver operating characteristic curve (ROC AUC) on fibrosis was 0.6829 (0.6828, 0.6831) for MMA and 0.7319 (0.7318, 0.7320) for HCY; in participants with NAFLD, the corresponding ROC AUC was 0.6819 (0.6817, 0.6821) for MMA and 0.6926 (0.6925, 0.6928) for HCY. Conclusion: Among vitamin B12-associated biomarkers, RBC folate was independently associated with elevated NAFLD risk, whereas MMA and HCY were associated with increased risk for advanced fibrosis in the total population and NAFLD participants. Our study highlighted the clinical diagnostic value of vitamin B12 metabolites and the possibility that vitamin B12 metabolism could be a therapeutic target for NASH. Further studies using recent perspective data with biopsy proven NASH could be conducted to validate our results.

Effect of Exercise on Sarcopenia among Cancer Survivors: A Systematic Review

Simple Summary

Sarcopenia is a condition characterized by loss of skeletal muscle mass and low muscle strength or physical performance. Cancer survivors are likely to be impacted by sarcopenia and suffer from a worse prognosis. Exercise has been suggested to be a promising tool to attenuate sarcopenia, but its effect among cancer survivors has not been systematically tested yet. We conducted a systematic review of seven interventional studies examining the effects of exercise on sarcopenia among cancer survivors. Results suggested that exercise improved muscle quantity and potentially reversed sarcopenia among breast, gastric, prostate and liver cancer survivors. If the relationship is further supported by larger trials, we could potentially identify cancer survivors at higher risk of adverse health outcomes by screening for sarcopenia and improve their prognosis and quality of life through exercise interventions.

Abstract

Sarcopenia is related to adverse health outcomes in cancer survivors. Previous reviews reported exercise improved muscle mass or function in cancer survivors, but thus far a systematic review examining the effect of exercise on sarcopenia in this population has not been conducted. Therefore, we systematically searched PubMed, CENTRAL (Cochrane Central Register of Controlled Trials) and ClinicalTrials.gov for publications and ongoing trials (through November 2021) that reported exercise interventions and diagnosed sarcopenia among cancer survivors. Seven exercise trials were eligible for this review. Six of seven studies showed exercise increased skeletal muscle post intervention (1.6% to 5.4% increase within intervention groups compared to baseline, p ≤ 0.07; 2.1% to 12.8% greater increase for intervention than control groups, p ≤ 0.02) and in the three studies that reported sarcopenia reversal, an improvement (18.2% to 42.9% decrease in sarcopenia in exercise groups, 5.2% increase to 16.7% decrease in sarcopenia in control groups, p = 0.04) was observed. Existing research indicates the potential for exercise to improve health outcomes for cancer survivors through building muscle and attenuating sarcopenia. More high-quality, long-term, large randomized controlled trials examining effects of different exercise types and doses to improve sarcopenia should be conducted to further explore this important topic.

Impact of Sarcopenia on the Severity of the Liver Damage in Patients With Non-alcoholic Fatty Liver Disease

An extensive body of the literature shows a strong interrelationship between the pathogenic pathways of non-alcoholic fatty liver disease (NAFLD) and sarcopenia through the muscle-liver-adipose tissue axis. NAFLD is one of the leading causes of chronic liver diseases (CLD) affecting more than one-quarter of the general population worldwide. The disease severity spectrum ranges from simple steatosis to non-alcoholic steatohepatitis (NASH), cirrhosis, and its complications: end-stage chronic liver disease and hepatocellular carcinoma. Sarcopenia, defined as a progressive loss of the skeletal muscle mass, reduces physical performances, is associated with metabolic dysfunction and, possibly, has a causative role in NAFLD pathogenesis. Muscle mass is a key determinant of the whole-body insulin-mediated glucose metabolism and impacts fatty liver oxidation and energy homeostasis. These mechanisms drive the accumulation of ectopic fat both in the liver (steatosis, fatty liver) and in the muscle (myosteatosis). Myosteatosis rather than the muscle mass per se, seems to be closely associated with the severity of the liver injury. Sarcopenic obesity is a recently described entity which associates both sarcopenia and obesity and may trigger worse clinical outcomes including hepatic fibrosis progression and musculoskeletal disabilities. Furthermore, the muscle-liver-adipose tissue axis has a pivotal role in changes of the body composition, resulting in a distinct clinical phenotype that enables the identification of the "sarcopenic NAFLD phenotype." This review aims to bring some light into the complex relationship between sarcopenia and NAFLD and critically discuss the key mechanisms linking NAFLD to sarcopenia, as well as some of the clinical consequences associated with the coexistence of these two entities: the impact of body composition phenotypes on muscle morphology, the concept of sarcopenic obesity, the relationship between sarcopenia and the severity of the liver damage and finally, the future directions and the existing gaps in the knowledge.

Impact of Sarcopenia and Myosteatosis in Non-Cirrhotic Stages of Liver Diseases: Similarities and Differences across Aetiologies and Possible Therapeutic Strategies

Sarcopenia is defined as a loss of muscle strength, mass and function and it is a predictor of mortality. Sarcopenia is not only a geriatric disease, but it is related to several chronic conditions, including liver diseases in both its early and advanced stages. Despite the increasing number of studies exploring the role of sarcopenia in the early stages of chronic liver disease (CLD), its prevalence and the relationship between these two clinical entities are still controversial. Myosteatosis is characterized by fat accumulation in the muscles and it is related to advanced liver disease, although its role in the early stages is still under researched. Therefore, in this narrative review, we firstly aimed to evaluate the prevalence and the pathogenetic mechanisms underlying sarcopenia and myosteatosis in the early stage of CLD across different aetiologies (mainly non-alcoholic fatty liver disease, alcohol-related liver disease and viral hepatitis). Secondly, due to the increasing prevalence of sarcopenia worldwide, we aimed to revise the current and the future therapeutic approaches for the management of sarcopenia in CLD.

FAT AND MUSCLE COMPONENTS OF BODY WEIGHT AND THEIR RELATIONSHIP WITH THE CONCENTRATION OF SERUM ADIPOKINES IN PATIENTS WITH NONALCOHOLIC FATTY LIVER DISEASE

OBJECTIVE

The aim: Identify differences in indexes of body fat and muscle masses, as well as blood adipokines in patients with nonalcoholic fatty liver disease, from gender-appropriate healthy men and women.

PATIENTS AND METHODS

Materials and methods: 135 patients with non-alcoholic fatty liver disease with normal, overweight and obesity and 20 almost healthy individuals for the control group were examined. Verification of the diagnosis was performed in accordance with the recommendations of the unified clinical protocol. An anthropometric examination of patients was performed according to the method, which included the determination of 48 anthropometric parameters. The formulas determined the absolute amount of adipose and muscle tissue. Levels of adipokines (leptin and adiponectin) were determined by enzyme-linked immunosorbent assay.

RESULTS

Results: According to Matiegka, body fat was 30.2-35.2% higher, and muscle body weight was 17.4-29.1% lower in patients with non-alcoholic fatty liver disease compared to healthy people. The concentration of leptin in the serum of patients with nonalcoholic fatty liver disease was statistically significantly higher (2.05-3.78 times) compared with almost healthy individuals. At the same time, the indicators of adiponectin concentration (1.54-1.92 times) and log A / L index (1.16-1.32 times) were lower. Correlations between changes in muscle mass and adipokines concentration have been established.

CONCLUSION

Conclusions: In addition to the known increase in body fat in non-alcoholic fatty liver disease, there has been established a significant decrease in muscle mass. A direct correlation between adiponectin concentration and an inverse correlation between leptin levels and muscle mass in patients with nonalcoholic fatty liver disease was found.

The Role of Physical Activity in Nonalcoholic and Metabolic Dysfunction Associated Fatty Liver Disease

Sedentary behavior constitutes a pandemic health threat contributing to the pathophysiology of obesity and type 2 diabetes (T2D). Sedentarism is further associated with liver disease and particularly with nonalcoholic/metabolic dysfunction associated fatty liver disease (NAFLD/MAFLD). Insulin resistance (IR) represents an early pathophysiologic key element of NAFLD/MAFLD, prediabetes and T2D. Current treatment guidelines recommend regular physical activity. There is evidence, that physical exercise has impact on a variety of molecular pathways, such as AMP-activated protein kinase and insulin signaling as well as glucose transporter 4 translocation, modulating insulin action, cellular substrate flow and in particular ectopic lipid and glycogen storage in a positive manner. Therefore, physical exercise can lead to substantial clinical benefit in persons with diabetes and/or NAFLD/MAFLD. However, experience from long term observational studies shows that the patients’ motivation to exercise regularly appears to be a major limitation. Strategies to integrate everyday physical activity (i.e., nonexercise activity thermogenesis) in lifestyle treatment schedules might be a promising approach. This review aggregates evidence on the impact of regular physical activity on selected molecular mechanisms as well as clinical outcomes of patients suffering from IR and NAFLD/MAFLD.

The relationship between high-density lipoprotein cholesterol (HDL-C) and glycosylated hemoglobin in diabetic patients aged 20 or above: a cross-sectional study

AIM

The incidence rate of diabetes is increasing year by year, seriously threatening human health. As a predictor of glycemic control, glycated hemoglobin is reported to be related to various complications and prognoses of diabetes. Besides, HDL-C dyslipidemia is a component of metabolic syndrome and may be related to various cardiovascular and cerebrovascular diseases. The principal objective of this project was to investigate the relationship between HDL-C and glycosylated hemoglobin in adult diabetic patients.

METHODS

A total of 3171 adult diabetic patients aged 20 years and above were included in the present study from the National Health and Nutrition Examination Survey (NHANES). HDL-C and glycosylated hemoglobin were regarded as independent and dependent variables, respectively. EmpowerStats software and R (version 3.4.3) were used to examine the association between HDL-C and glycosylated hemoglobin.

RESULTS

HDL-C was inversely associated with glycohemoglobin after adjusting for other covariates (β = - 0.004, 95% CI:- 0.008 to - 0.000, p = 0.044). Race/ethnicity and age were considered the most prominent interactive factors that affect the relationship between HDL and glycosylated hemoglobin by the interaction analysis. A U-shaped association was detected between HDL-C and glycosylated hemoglobin for people of other race/ethnicity or aged 60 and above, which had an inflection point of HDL-C at 60 mg/dL. In contrast, we observed an inverted U-shaped distribution between HDL-C and glycosylated hemoglobin in people under 40 with point of inflection located at 60 mg/dL as well.

CONCLUSIONS

HDL-C in diabetic patients is inversely associated with glycosylated hemoglobin and may be relevant to glycemic control. However, a U-shaped relationship was also observed in a certain kind of people, which implied that, though HDL-C is considered as metabolism and anti-atherogenic property, for diabetics, it is not the higher, the better.

Management of non-alcoholic fatty liver disease in patients with sarcopenia

INTRODUCTION

Sarcopenia usually occurs with aging, sedentary lifestyle, unhealthy dietary habits, and chronic disorders pathophysiologically and bi-directionally linked to obesity and nonalcoholic fatty liver disease (NAFLD). Because of the global increase in aging and obesity populations, patients with concomitant sarcopenia and NAFLD are common, accompanied by various disorders relevant to obesity and sarcopenia, with across-the-board impact on socio-economic and public health life worldwide. Therefore, developing effective and practical management of these patients has become a pressing clinical issue.

AREAS COVERED

The authors searched literature from PubMed and Ovid MEDLINE up until Feb 2020. Emerging data on the management of sarcopenia and nonalcoholic fatty liver disease were examined and discussed.

EXPERT OPINION

Although NAFLD in patients with sarcopenia has become a critical problem worldwide, we still don't know much about the management of such patients. Based on theoretical speculations, we can recommend lifestyle intervention, including diet control with adequate protein intake, exercise intervention, and weight reduction as the mainstay of management at the first stage. More studies are needed in the future to identify the most suitable treatment and solve this important problem.

Rapid Onset of Weight Gain and Liver Dysfunction Successfully Treated With Nutrition and Exercise

Physical inactivity is one of the causes of most metabolic syndromes. The incidence of metabolic syndrome is expected to increase in the near future because of the reduced opportunities for exercise caused by COVID-19. Non-alcoholic fatty liver disease (NAFLD) is currently the most common cause of chronic liver disease. Changes in diet and lifestyle have led to a dramatic increase in the prevalence of NAFLD in the world. NAFLD is characterized by excessive triglyceride (TG) accumulation in the hepatocytes due to both increased inflow of free fatty acids and de novo hepatic lipogenesis. Thus far, no study quantitatively assessed the liver fat deposition after a rapid decline in physical activity. Herein, we describe a case of a 17-year-old Japanese boy with severe fat infiltration of the liver, due to a rapid decline in physical activity, treated at our facility. Our rehabilitation and nutritional support teams administered appropriate exercise and nutrition support to reduce weight and improve liver dysfunction. Our findings support dietary changes and exercise therapy to manage such cases.

Association between Activity and Brain-Derived Neurotrophic Factor in Patients with Non-Alcoholic Fatty Liver Disease: A Data-Mining Analysis

Reduction in activity links to the development and progression of non-alcoholic fatty liver disease (NAFLD). Brain-derived neurotrophic factor (BDNF) is known to regulate an activity. We aimed to investigate the association between reduction in activity and BDNF in patients with NAFLD using data-mining analysis. We enrolled 48 NAFLD patients. Patients were classified into reduced (n = 21) or normal activity groups (n = 27) based on the activity score of the Chronic Liver Disease Questionnaire-NAFLD/non-alcoholic steatohepatitis. Circulating BDNF levels were measured using an enzyme-linked immunoassay. Factors associated with reduced activity were analyzed using decision-tree and random forest analyses. A reduction in activity was seen in 43.8% of patients. Hemoglobin A1c and BDNF were identified as negative independent factors for reduced activity (hemoglobin A1c, OR 0.012, p = 0.012; BDNF, OR 0.041, p = 0.039). Decision-tree analysis showed that “BDNF levels ≥ 19.1 ng/mL” was the most important classifier for reduced activity. In random forest analysis, serum BDNF level was the highest-ranked variable for distinguishing between the reduced and normal activity groups (158 valuable importance). Reduced activity was commonly seen in patients with NAFLD. Data-mining analyses revealed that BNDF was the most important independent factor corresponding with the reduction in activity. BDNF may be an important target for the prevention and treatment of NAFLD.

Association of Body Composition and Sarcopenia with NASH in Obese Patients

Obese patients often suffer from sarcopenia or sarcopenic obesity (SO) that can trigger inflammatory diseases including non-alcoholic steatohepatitis (NASH). Sarcopenia and SO can be diagnosed through measuring parameters of body composition such as skeletal muscle mass (SMM), skeletal muscle index (SMI) and fat mass (FM) obtained by bioelectrical impedance analysis (BIA). The aim of this study was to assess the relationship of body composition and NASH in patients with obesity. A total of 138 patients with obesity that underwent bariatric surgery were included in this study. BIA was used to estimate body composition. A liver biopsy was taken intraoperatively and histological assessment of NASH was performed. A total of 23 patients (17%) were classified as NASH and 65 patients (47%) met the criteria for borderline NASH. Body mass index (BMI) was significantly higher in patients with NASH compared to borderline NASH and no NASH (56.3 kg/m² vs. 51.6 kg/m² vs. 48.6 kg/m², p = 0.004). Concerning body composition, FM, but also SMM and SMI were significantly higher in patients with NASH (p-values 0.011, 0.005 and 0.006, resp.). Fat mass index (FMI) and weight-adjusted skeletal muscle index (SMI_weight) failed to reach statistical significance (p-values 0.067 and 0.661). In patients with obesity, higher FM were associated with NASH. Contrary to expectations, SMM and SMI were also higher in patients with NASH. Therefore, higher body fat, rather than sarcopenia and SO, might be decisive for development of NASH in patients with obesity.

Non-alcoholic fatty liver disease and sarcopenia additively increase mortality: a Korean nationwide survey

BACKGROUND

Sarcopenia is an independent risk factor not only for advanced-stage non-alcoholic fatty liver disease (NAFLD) but also for mortality. We investigated the association of sarcopenia and/or NAFLD with mortality among the Korean general population.

METHODS

Individuals aged 35-75 years without any history of cancer, ischaemic heart disease, ischaemic stroke, or secondary causes of chronic liver disease were selected from the Korean National Health and Nutrition Examination Surveys from 2008 to 2015. Their mortality data until December 2018 were retrieved from the National Death Registry. NAFLD and sarcopenia were defined by hepatic steatosis index and appendicular skeletal muscle mass divided by body mass index (BMI), respectively.

RESULTS

A total of 28 060 subjects were analysed [mean age, 50.6 (standard error, 0.1) years, 48.2 (0.3) % men]; the median follow-up duration was of 6.8 (interquartile range, 4.8, 8.4) years. NAFLD predicted mortality after adjustment for age, sex, BMI, hypertension, dyslipidaemia, and smoking (HR 1.32, 95% CI 1.03-1.70), but this prediction lost its statistical significance after additional adjustment for diabetes mellitus. In contrast, NAFLD with advanced fibrosis independently increased the risk of mortality after adjustment for all covariates (HR 1.68, 95% CI 1.02-2.79). Stratified analysis revealed that NAFLD and sarcopenia additively increased the risk of mortality as an ordinal scale (HR 1.46, 95% CI 1.18-1.81, P for trend = 0.001). The coexistence of NAFLD and sarcopenia increased the risk of mortality by almost twice as much, even after adjustment for advanced fibrosis (HR 2.18, 95% CI 1.38-3.44).

CONCLUSIONS

Concurrent NAFLD and sarcopenia conferred a two-fold higher risk of mortality. The observation that NAFLD and sarcopenia additively increase mortality suggests that risk stratification would be helpful in predicting mortality among those with metabolic derangement.

Sarcopenia in nonalcoholic fatty liver disease and all-cause and cause-specific mortality in the United States

BACKGROUND & AIMS

Nonalcoholic fatty liver disease (NAFLD) has been associated with sarcopenia. However, mortality in the setting of NAFLD-related sarcopenia remains undefined. We aim to determine the all-cause and cause-specific mortality from sarcopenia among adults with NAFLD in the USA.

METHODS

11 065 individuals in the Third National Health and Nutrition Examination Survey were studied and linked mortality through 2015 was analysed. NAFLD was diagnosed based on presence of ultrasonographic hepatic steatosis without other known liver diseases. Sarcopenia was defined as skeletal muscle index determined by bioelectrical impedance analysis. The Cox proportional hazard model was used to assess all-cause mortality and cause-specific mortality, and hazard ratio (HR) adjusted for known risk factors.

RESULTS

During a median follow-up of 23 years or more, sarcopenia was associated with increased all-cause mortality (HR 1.27, 95% confidence interval [CI] 1.11-1.44). Only in individuals with NAFLD, sarcopenia was associated with a higher risk for all-cause mortality, while this association was absent in those without NAFLD. Individuals with both sarcopenia and NAFLD had a higher risk for all-cause mortality (HR 1.28 95% CI 1.06-1.55) compared with those without sarcopenia and NAFLD. Furthermore, sarcopenia was associated with a higher risk for cancer- and diabetes-related mortality among those with NAFLD. This association was not noted in those without NAFLD.

CONCLUSION

In this nationally representative sample of US adults, sarcopenia was associated with a higher risk for all-cause, cancer- and diabetes-related mortality in individuals with NAFLD.