Relationship Between Handgrip Strength and Nonalcoholic Fatty Liver Disease: Nationwide Surveys

Prevalence of Sarcopenia and Its Defining Components in Non-alcoholic Fatty Liver Disease Varies According to the Method of Assessment and Adjustment: Findings from the UK Biobank

Sarcopenia may increase non-alcoholic fatty liver disease (NAFLD) risk, but prevalence likely varies with different diagnostic criteria. This study examined the prevalence of sarcopenia and its defining components in adults with and without NAFLD and whether it varied by the method of muscle mass assessment [bioelectrical impedance (BIA) versus dual-energy X-ray absorptiometry (DXA)] and adjustment (height2 versus BMI). Adults (n = 7266) in the UK Biobank study (45-79 years) with and without NAFLD diagnosed by MRI, were included. Sarcopenia was defined by the 2018 European Working Group on Sarcopenia in Older People definition, with low appendicular skeletal muscle mass (ASM) assessed by BIA and DXA and adjusted for height2 or BMI. Overall, 21% of participants had NAFLD and the sex-specific prevalence of low muscle strength (3.6-7.2%) and sarcopenia (0.1-1.4%) did not differ by NAFLD status. However, NAFLD was associated with 74% (males) and 370% (females) higher prevalence of low ASM when adjusted for BMI but an 82% (males) to 89% (females) lower prevalence when adjusted for height2 (all P < 0.05). The prevalence of impaired physical function was 40% (males, P = 0.08) to 123% (females, P < 0.001) higher in NAFLD. In middle-aged and older adults, NAFLD was not associated with a higher prevalence of low muscle strength or sarcopenia but was associated with an increased risk of impaired physical function and low muscle mass when adjusted for BMI. These findings support the use of adiposity-based adjustments when assessing low muscle mass and the assessment of physical function in NAFLD.

Low Muscle Strength as Risk Factor for Non-Alcoholic Fatty Liver Disease in Different Metabolic Conditions

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) recently became a leading liver disease that threatens health worldwide. Low muscle strength, obesity, insulin resistance, and metabolic syndrome are recognized key factors for NAFLD. However, the impact of low muscle strength itself in different metabolic conditions has not been widely studied.

METHODS

A cross-sectional analysis was performed of a sample of 5,427 participants from the 2019 Korea National Health and Nutrition Examination Survey. Relative handgrip strength (rHGS, defined as handgrip strength/body mass index) was used to assess muscle strength. The cut-off values for a low rHGS were 1.405 for men and 0.850 for women. NAFLD was diagnosed if the Hepatic Steatosis Index was >36. Participants were stratified according to insulin resistance, metabolic syndrome, and central obesity for the subgroup analyses.

RESULTS

Complex sample multivariate logistic regression analysis revealed a significant association between low muscle strength and NAFLD after the adjustment for other confounders (odds ratio [OR], 1.92; P<0.001). In the insulin resistance, metabolic syndrome, and central obesity subgroups, a significant association between low muscle strength and NAFLD remained (OR, 1.66-4.19 depending on subgroup; all P<0.05), whereas it did not in the no central obesity group.

CONCLUSION

This study demonstrated that low muscle strength is correlated with a risk of NAFLD. This relationship was independent of insulin resistance and metabolic syndrome but was dependent on the presence of central obesity.

Muscle strength and non-alcoholic fatty liver disease/metabolic-associated fatty liver disease

This editorial comments on an article published in a recent issue of World Journal of Gastroenterology, entitled “Association of low muscle strength with metabolic dysfunction-associated fatty liver disease: A nationwide study”. We focused on the association between muscle strength and the incidence of non-alcoholic fatty liver disease (NAFLD) and metabolic-associated fatty liver disease (MAFLD), as well as the mechanisms underlying the correlation and related clinical applications. NAFLD, which is now redefined as MAFLD, is one of the most common chronic liver diseases globally with an increasing prevalence and is characterized by malnutrition, which may contribute to decreased muscle strength. Reduction of muscle strength reportedly has a pathogenesis similar to that of NAFLD/ MAFLD, including insulin resistance, inflammation, sedentary behavior, as well as insufficient vitamin D. Multiple studies have focused on the relationship between sarcopenia or muscle strength and NAFLD. However, studies investigating the relationship between muscle strength and MAFLD are limited. Owing to the shortage of specific medications for NAFLD/MAFLD treatment, early detection is essential. Furthermore, the relationship between muscle strength and NAFLD/MAFLD suggests that improvements in muscle strength may have an impact on disease prevention and may provide novel insights into treatments including dietary therapy, as well as tailored physical activity.

Association between handgrip strength, nonalcoholic fatty liver disease, advanced hepatic fibrosis and its modifiers: Evidence from the NHANES database of the USA

BACKGROUND AND AIM

Nonalcoholic fatty liver disease (NAFLD) and advanced hepatic fibrosis (AHF) have been associated with sarcopenia. However, modifiers of this association have been less studied.

METHODS

This study used data from the NHANES database 2011-2014 of the USA. Adults aged 18 years or older, had complete information of handgrip strength test and NAFLD and AHF status were eligible for inclusion. NAFLD was defined using the Fatty Liver Index (FLI). AHF was defined using the NAFLD fibrosis score (NFS). Univariate and multivariate logistic regression were performed to determine the associations between the study variables and prevalent NAFLD and AHF.

RESULTS

A total of 19 931 participants were selected from the 2011-2014 NHANES database. The multivariate analysis showed that stronger grip strength was significantly and independently associated with decreased odds for NAFLD (tertile 2: adjusted odd ratio [aOR]: 0.41, 95% confidence interval [CI]: 0.29-0.59; tertile 3: aOR: 0.11, 95% CI: 0.05-0.24) and AHF (tertile 2: aOR: 0.66, 95% CI: 0.46-0.94; tertile 3: aOR: 0.28, 95% CI: 0.12-0.63). In stratified analyses, strongest grip strength was significantly associated with reduced odds for NAFLD regardless of age, body mass index, and having diabetes or not. Strongest grip strength was associated with reduced odds for NAFLD in individuals who had moderate to ideal physical activity (aOR: 0.31).

CONCLUSIONS

Grip strength has an inverse association with prevalent NAFLD and AHF in the US population, which appears to be modified by physical activity level. Future prospective cohort studies are needed to clarify the role of physical activity in modifying the risks.

Associations between muscle mass, strength, and performance and non-alcoholic fatty liver disease

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is a rising global health issue. The influence of muscle in its pathophysiology has recently gained attention. Our aim was to investigate the association of low muscle mass, strength, and performance with the presence and severity of NAFLD.

METHODS

Patients with metabolic syndrome followed in an outpatient clinic, were consecutively included, between April 1st and December 31st, 2019. Abdominal ultrasound for the diagnosis of NAFLD, NAFLD fibrosis score (NFS) and Fibrosis-4 Index (FIB-4) for determination of significant fibrosis, dual-energy X-ray absorptiometry for calculation of skeletal muscle index (SMI = appendicular skeletal mass / weight x100) and sarcopenic index (SI = appendicular skeletal mass / Body Mass Index), and the Short Physical Performance Battery for muscle strength and performance assessment were performed. Sarcopenia was defined as low muscle strength and low SMI or SI.

RESULTS

A total of 157 patients were included, of which 68.8% had NAFLD, 66.2% low SMI, 50.3% low SI, 16.6% low performance and 11.5% low strength. In patients with NAFLD, prevalence of significant fibrosis by NFS was 15.7%. Low SMI was associated with presence of NAFLD when adjusted for age, sex, type 2 diabetes mellitus, hypertension, and dyslipidemia, but not for body mass index and waist circumference. Low SMI, low SI, and sarcopenia were associated with significant fibrosis in univariate analysis; the small number of events precluded a multivariable analysis.

CONCLUSIONS

Low SMI was associated with NAFLD independently of demographics and comorbidities but not of other parameters of body composition. This contrasts with most studies published on this matter.

2019 Global NAFLD Prevalence: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

The increasing rates of obesity and type 2 diabetes mellitus may lead to increased prevalence of nonalcoholic fatty liver disease (NAFLD). We aimed to determine the current and recent trends on the global and regional prevalence of NAFLD.

METHODS

Systematic search from inception to March 26, 2020 was performed without language restrictions. Two authors independently performed screening and data extraction. We performed meta-regression to determine trends in NAFLD prevalence.

RESULTS

We identified 17,244 articles from literature search and included 245 eligible studies involving 5,399,254 individuals. The pooled global prevalence of NAFLD was 29.8% (95% confidence interval [CI], 28.6%-31.1%); of these, 82.5% of included articles used ultrasound to diagnose NAFLD, with prevalence of 30.6% (95% CI, 29.2%-32.0%). South America (3 studies, 5716 individuals) and North America (4 studies, 18,236 individuals) had the highest NAFLD prevalence at 35.7% (95% CI, 34.0%-37.5%) and 35.3% (95% CI, 25.4%-45.9%), respectively. From 1991 to 2019, trend analysis showed NAFLD increased from 21.9% to 37.3% (yearly increase of 0.7%, P < .0001), with South America showing the most rapid change of 2.7% per year, followed by Europe at 1.1%.

CONCLUSIONS

Despite regional variation, the global prevalence of NAFLD is increasing overall. Policy makers must work toward reversing the current trends by increasing awareness of NAFLD and promoting healthy lifestyle environments.

Association between grip strength and non-alcoholic fatty liver disease: A systematic review and meta-analysis

Background

The association between grip strength (GS) and non-alcoholic fatty liver disease (NAFLD) has been reported by recent epidemiological studies, however, the results of these studies are inconsistent. This meta-analysis was conducted to collect all available data and estimate the risk of NAFLD among people with low GS, as well as the risk of low GS among patients with NAFLD.

Methods

We systematically searched several literature databases including PubMed, Web of Science, Cochrane Library, and Embase from inception to March 2022. These observational studies reported the risk of NAFLD among people with low GS and/or the risk of low GS among patients with NAFLD. Qualitative and quantitative information was extracted, statistical heterogeneity was assessed using the I² test, and potential for publication bias was assessed qualitatively by a visual estimate of a funnel plot and quantitatively by calculation of the Begg’s test and the Egger’s test.

Results

Of the citations, 10 eligible studies involving 76,676 participants met inclusion criteria. The meta-analysis of seven cross-section studies (69,757 participants) showed that people with low GS had increased risk of NAFLD than those with normal GS (summary OR = 3.32, 95% CI: 1.91–5.75). In addition, the meta-analysis of four studies (14,920 participants) reported that the risk of low GS patients with NAFLD was higher than those in normal people (summary OR = 3.31, 95% CI: 2.45–4.47).

Conclusion

In this meta-analysis, we demonstrated a strong relationship between low GS and NAFLD. We found an increased risk of NAFLD among people with low GS, and an increased risk of lower GS among NAFLD patients.

Systematic review registration

[www.crd.york.ac.uk/prospero], identifier [CRD42022334687].

Association between Physical Activity and Non-Alcoholic Fatty Liver Disease in Adults with Metabolic Syndrome: The FLIPAN Study

Background: A lifestyle with regular PA (physical activity) and Mediterranean diet has benefits on NAFLD (non-alcoholic fatty liver disease) and MetS (metabolic syndrome). Objectives: To assess the association between physical activity and NAFLD in adults with MetS. Design: Cross-sectional study in 155 participants (40−60 years old) from Balearic Islands and Navarra (Spain) with diagnosis of NAFLD and MetS, and BMI (body mass index) between 27 and 40 Kg/m2. Methods: PA level was categorized into two groups according to weekly METs (metabolic equivalents of tasks). PA was assessed using a validated Minnesota questionnaire and accelerometers. MetS parameters were assessed by blood collection analysis and NAFLD by abdominal MRI (magnetic resonance imaging). Results: Participants with high PA showed more energy expenditure and expended more calories than ingested (−143.9 Kcal/day; p < 0.001). PA was a risk factor for AST (aspartate aminotransferase) (adjusted OR: 7.26; 95% CI: 1.79−29.40) and a protective factor for ALT (alanine aminotransferase) (adjusted OR: 0.24; 95% CI: 0.12−0.48), GGT (gamma-glutamyl transferase) (adjusted OR: 0.52; 95% CI: 0.29−0.94) and IFC-NMR (intrahepatic fat content by nuclear magnetic resonance) (adjusted OR: 0.26; 95% CI: 0.12−0.56) when sociodemographic confounders were considered. Conclusions: NAFLD patients with high PA showed more positive relationship on MetS parameters and liver profile (ALT, GGT, IFC-NMR) than subjects with low PA, but not for AST. Difference between calories ingested and expended influenced this relationship.

Associations Between Relative Grip Strength and the Risk of 15 Cancer Sites

INTRODUCTION

Grip strength is the most commonly used muscle strength proxy in clinical research. However, evidence regarding the associations of grip strength with cancer has been mainly restricted to overall cancer risk. Therefore, this study aims to evaluate the associations between grip strength relative to BMI and 15 cancer sites as well as with all-cause cancer mortality.

METHODS

A total of 445,555 participants (53.8% women, mean age=56.3 years) were recruited across the United Kingdom. The association of grip strength relative to BMI (expressed as 1 SD) with incidence and mortality from 15 cancer sites was investigated using Cox proportional hazard models. All analyses were conducted in April 2021.

RESULTS

Over an 8.8-year follow-up period, 37,291 patients were diagnosed with cancer, and 11,363 died of it. After covariate adjustment, higher relative grip strength per 1 SD was associated with a lower risk of incident endometrial (hazard ratio=0.76, 95% CI=0.71, 0.81), liver (hazard ratio=0.81, 95% CI=0.74, 0.88), gallbladder (hazard ratio=0.83, 95% CI=0.73, 0.94), kidney (hazard ratio=0.89, 95% CI=0.84, 0.95), and colorectal (hazard ratio=0.94, 95% CI=0.91, 0.98) cancer as well as with lower risk of gallbladder, colorectal, endometrial, liver, and all-cause cancer mortality.

CONCLUSIONS

Grip strength relative to BMI was associated with incidence and mortality from endometrial, gallbladder, colorectal, liver, all-cause cancer, and breast and kidney cancer incidence, independent of major confounding factors, including comorbidity, diet, and physical activity.

Age- and Sex-Specific Differences in Distribution of Cardiometabolic Diseases and Associations of Hand-Grip Strength Indices with Type 2 Diabetes in Korean Adults

Background: To evaluate age- and sex-specific differences in the distribution of cardiometabolic diseases and associations of hand-grip strength (HGS) indices with type 2 diabetes (T2D). Methods: This cross-sectional observational study enrolled participants from the Korea National Health and Nutrition Examination Survey (n = 16,126, age ≥19 years). Information on cardiometabolic diseases was obtained through surveys or proper criteria applied for undiagnosed participants. Absolute and body size-adjusted HGS indices were evaluated. Clinical manifestations were compared, and associations of HGS indices with T2D were estimated by using odd ratio (OR). Results: Prevalence of T2D in all, younger, and older groups were 13.1%, 4.2%, and 21.4%, respectively. Proportions of cardiometabolic diseases were all higher in those with than without T2D in sex-stratified age groups, whereas obesity (OB) and nonalcoholic fatty liver disease (NAFLD) were higher in younger T2D, and hypertension (HTN) was higher in older T2D in both sexes. Adjusted HGS significantly correlated with cardiometabolic parameters, and thus, high ORs for T2D in low tertiles of adjusted HGS were shown in all groups, whereas high ORs for T2D in low tertiles of absolute HGS were observed only in older men. Conclusions: Among highly prevalent cardiometabolic diseases associated with T2D, OB and NAFLD were more prevalent in younger T2D, but HTN was more prevalent in older T2D in both sexes. Low adjusted HGS was associated with higher T2D risk in all groups, whereas low absolute HGS was associated with higher T2D risk in older men. Thus, adjusted HGS might be useful in screening especially younger or obese T2D.

Longitudinal Associations Between Hand Grip Strength and Non-Alcoholic Fatty Liver Disease in Adults: A Prospective Cohort Study

Purpose: This study aimed to determine the longitudinal association between hand grip strength (HGS) and the development of non-alcoholic fatty liver disease (NAFLD) in adults. Design: A cohort study. Methods: This study was conducted in a general Chinese population (n = 14,154) from 2013-2018. NAFLD was diagnosed by liver ultrasonography during evaluating alcohol consumption. The associations between the HGS and NAFLD were assessed using a multivariable Cox proportional hazards regression model. Results: During the study period with a mean follow-up duration of 3.20 years, 2,452 participants developed NAFLD. The risk of NAFLD decreased progressively with increasing HGS in both men and women (P for trend <0.0001). The multivariate-adjusted hazard ratios (95% CI) for NAFLD incidence across the quartiles of HGS were 1 (reference), 0.90 (0.79, 1.02), 0.69 (0.60, 0.79), and 0.44 (0.37, 0.52) for men and 1 (reference), 0.82 (0.69, 0.96), 0.54 (0.45, 0.66), and 0.41 (0.33, 0.52) for women, respectively. The interaction terms for body mass index (BMI)-HGS and waist-HGS were significant in men and women (all P < 0.0001). The participants with normal BMIs and waist circumferences had the lowest hazard ratios on the subgroup analyses. The sensitivity analysis that defined NAFLD using the hepatic steatosis and fatty liver indices revealed results that were similar to the main analyses. Conclusion: The present study indicates that the HGS is inversely associated with the incidence of NAFLD.

Green Tea Consumption May Be Associated with Cardiovascular Disease Risk and Nonalcoholic Fatty Liver Disease in Type 2 Diabetics: A Cross-Sectional Study in Southeast China

Dietary factors play a crucial role in the management of type 2 diabetes mellitus (T2DM) by reducing cardiovascular disease (CVD) risk. Therefore, we aimed to examine the associations between habitual green tea consumption and risk factors of CVD among T2DM patients. A total of 1013 patients with T2DM were included in a community-based cross-sectional study. Data on dietary habits, including tea consumption, were collected using a food frequency questionnaire. A multivariable logistic regression model was used to analyze the associations. In men, as compared with nongreen tea drinkers, odds ratios (ORs) (95% confidence interval [CI]) of nonalcoholic fatty liver disease (NAFLD) were 2.06 (95% CI, 1.20-3.55) for those with green tea consumption of once per day and 2.45 (95% CI, 1.31-4.58) for more than or equal to twice per day (P-trend = .004); ORs (95% CI) of general obesity were 2.19 (95% CI, 1.02-4.68) and 2.70 (95% CI, 1.18-6.21), respectively (P-trend = .021); whereas no such association was found in women. Sensitivity analysis according to self-awareness of their T2DM status revealed that the positive association between green tea consumption and general obesity was not reliable. Higher intake of green tea was still positively associated with NAFLD, but it only persisted in participants aged ≥52 years or the lower dietary quality subgroup in further analyses. Our findings suggest that tea consumption was associated with an increased risk of NAFLD among male T2DM patients aged 52 years or older, and those with lower dietary quality, which needs to be confirmed in future prospective studies.

Lower hand grip strength in older adults with non-alcoholic fatty liver disease: a nationwide population-based study

Although both liver and muscle are metabolically active endocrine organs, and non-alcoholic fatty liver disease (NAFLD) and sarcopenia may share common pathogenic determinants, there have been few clinical studies of the relationship between NAFLD and muscle strength, especially in the elderly. We conducted a nationally representative population-based, cross-sectional study using data from the Korea National Health and Nutrition Examination Survey, which involved 1,897 men aged ≥50 years and 2,206 postmenopausal women. NAFLD was defined using the hepatic steatosis index (HSI) and low muscle strength was defined using the Korea-specific cut-off point of hand grip strength (HGS). Men and women with NAFLD had 7.3% and 7.9% lower HGS than controls, respectively. The odds ratios for low muscle strength in the presence of NAFLD were 2.51 in men and 2.34 in women. HSI inversely correlated with HGS in both men and women. Consistently, compared with men and women in the lowest HSI quartile, those in the highest quartile had 7.6% and 12.4% lower HGS, respectively, and were 5.63- and 3.58-times more likely to have low muscle strength, respectively. These results provide the first clinical evidence that NAFLD can be associated with muscular impairment in older adults, as demonstrated by lower muscle strength.

Moderation Effect of Handgrip Strength on the Associations of Obesity and Metabolic Syndrome With Fatty Liver in Adolescents

INTRODUCTION/BACKGROUND

This study aimed to evaluate the effect of handgrip strength on the associations of body mass index and metabolic syndrome with an indicator of nonalcoholic fatty liver disease in adolescents.

METHODOLOGY

In data of 1690 adolescents aged 10-18 yr from the Korea National Health and Nutrition Examination Survey 2014-2016, alanine amino-transferase levels, age, sex, bodyweight-, sex-, and age-standardized handgrip strength, age- and sex-specific body mass index Z-scores, and metabolic syndrome severity scores were assessed. Nonalcoholic fatty liver disease was defined based on alanine amino-transferase levels (boys ≥52U/L, girls ≥44U/L) in adolescents who were overweight. Moderation analysis via the PROCESS procedure was performed.

RESULTS

The prevalence of nonalcoholic fatty liver disease was 1.5% among all adolescents and 6.7% among those who were overweight. In all adolescents and adolescents who were overweight, age- and sex-specific body mass index Z-scores and metabolic syndrome scores had positive associations with nonalcoholic fatty liver disease after adjusting for bodyweight-, sex-, and age-standardized handgrip strength. Bodyweight-, sex-, and age-standardized handgrip strength had an inverse association with nonalcoholic fatty liver disease after adjusting for metabolic syndrome scores, and this association became nonsignificant after adjusting for age- and sex-specific body mass index Z-scores. There were positive associations between age- and sex-specific body mass index Z-scores and alanine amino-transferase levels when bodyweight-, sex-, and age-standardized handgrip strength values were ≤-0.13 in overweight adolescents and ≤0.74 in all adolescents, whereas these associations were nonsignificant or negative above those cut-off values. These cut-off values of bodyweight-, sex-, and age-standardized handgrip strength for the relationship between metabolic syndrome scores and alanine amino-transferase levels were -0.15 in overweight adolescents and 0.55 in all adolescents.

CONCLUSIONS

A higher bodyweight-, sex-, and age-standardized handgrip strength may attenuate the risk of obesity and metabolic syndrome for an indicator of nonalcoholic fatty liver disease in adolescents.

Association of grip strength with non-alcoholic fatty liver disease: investigation of the roles of insulin resistance and inflammation as mediators

BACKGROUND/OBJECTIVES

The purpose of this study was to examine the association between muscle weakness and non-alcoholic fatty liver disease (NAFLD), and whether the association is partly explained by insulin resistance or inflammation.

SUBJECTS/METHODS

Subjects were 3922 adults who participated in the 2015 Korea National Health and Nutrition Examination Survey. Relative grip strength (rGS; calculated as maximal grip strength divided by BMI) was used to predict NAFLD defined by NAFLD liver fat score. Participants were classified into four groups according to the quartiles of rGS distribution (Q1-Q4). Insulin resistance was assessed by triglycerides and glucose (TyG) index. Inflammation was measured with C-reactive protein (CRP). Fibrosis was assessed by the Fibrosis-4 index (FIB-4) and the NAFLD fibrosis score.

RESULTS

rGS had significant negative associations with TyG index and CRP (all p < 0.001). rGS was a significant predictor of NAFLD (OR, 0.54-0.19 in Q2-Q4 men; OR, 0.54-0.08 in Q2-Q4 women, all p < 0.001). Adjustment for other participant factors did not substantially affect the results. Addition of TyG index changed the estimates for NAFLD slightly and addition of CRP increased the ORs by 10-20% in Q3-Q4 women. In the subpopulation with NAFLD (n = 946), rGS showed strong inverse relationships with FIB-4 and NAFLD fibrosis score (all p < 0.001).

CONCLUSIONS

Grip strength was inversely associated not only with the risk of NAFLD but also with its severity. Insulin resistance and inflammation explained only a small portion of the association between grip strength and NAFLD risk.

Sarcopenia in nonalcoholic fatty liver disease: new challenges for clinical practice

Introduction: Sarcopenia is increasingly recognized in patients with nonalcoholic liver disease (NAFLD). Initially recognized as a consequence of advanced liver disease, there is now emerging evidence that sarcopenia may be a novel risk factor for the development of NAFLD, with a role in fibrosis and disease progression.Areas covered: This review examines the epidemiology, pathogenesis, and complex interplay between NAFLD and sarcopenia. Furthermore, the authors discuss the challenges with diagnosis of sarcopenia in the clinic and the evidence-based management of sarcopenia in patients with NAFLD. A MEDLINE and PubMed search was undertaken using the terms; 'sarcopenia,' 'frailty,' 'muscle,' 'obesity,' 'non-alcoholic fatty liver disease,' 'non-alcoholic steatohepatitis', and 'cirrhosis' up to 31 September 2019.Expert opinion: Sarcopenia may be masked by the co-existence of morbid obesity, which is most notable in patients with NAFLD. Sarcopenia is a key indicator of adverse outcomes in patients with cirrhosis, such as hepatic decompensation, poor quality of life and premature mortality. Patients with NAFLD and advanced fibrosis/cirrhosis should undergo anthropometric measures (handgrip strength), dry body mass index, and measures of physical frailty (including muscle function, not just mass) to enable targeted early interventions of nutrition (low fat, 1.5 g/kg/day protein intake, 2-3 hourly food intake) and exercise (combined resistance and aerobic).