Depression is associated with non-alcoholic fatty liver disease among adults in the United States

Depression and anxiety management in cirrhosis

Depressive and anxiety symptoms are more prevalent in patients with cirrhosis compared to the general population. Between 2009 and 2019, the prevalence of depression in cirrhosis increased by 80%, while the prevalence of generalized anxiety disorder increased by over 400%. When present, anxiety and depression are linked to lower health-related quality of life, more severe symptoms (eg, fatigue), and poorer response to medical treatment. Screening instruments for depression and anxiety have shown acceptable validity in patients with cirrhosis. However, the diagnosis of depression and anxiety disorder remains challenging in this population and should follow the established criteria for general populations. Treatment interventions are numerous and include patient education and support around liver disease, pharmacological agents, and psychotherapy. Antidepressants are the treatment of choice for patients with depressive or anxiety disorder and cirrhosis. However, consideration must be given to dose adjustment and choice of agent due to changes in their metabolism in patients with liver disease. Psychotherapy may be used as a stand-alone therapy or concomitantly with pharmacotherapy. The high prevalence and complexity of depressive and anxiety symptoms in patients with cirrhosis support the integrated care approach in which patients are cared for by multidisciplinary teams.

The liver-brain axis in metabolic dysfunction-associated steatotic liver disease

Metabolic dysfunction-associated steatotic liver disease (MASLD) affects around 30% of the global population. Studies suggest that MASLD is associated with compromised brain health and cognitive dysfunction, initiating a growing interest in exploring the liver-brain axis mechanistically within MASLD pathophysiology. With the prevalence of MASLD increasing at an alarming rate, leaving a large proportion of people potentially at risk, cognitive dysfunction in MASLD is a health challenge that requires careful consideration and awareness. This Review summarises the current literature on cognitive function in people with MASLD and discusses plausible causes for its impairment. It is likely that a multifaceted spectrum of factors works collectively to affect cognition in patients with MASLD. We describe the role of inflammation, vascular disease, and brain ageing and neurodegeneration as possible key players. This Review also highlights the need for future studies to identify the optimal test for diagnosing cognitive dysfunction in patients with MASLD, to examine the correlation between MASLD progression and the severity of cognitive dysfunction, and to evaluate whether new MASLD-targeted therapies also improve brain dysfunction.

Depression and the risk of non-alcohol fatty liver disease: Results from a cross-sectional study and a Mendelian randomization analysis

BACKGROUND

Previous studies have suggested that psychiatric factors may be pathogenic for NAFLD. However, the association between depression and NAFLD is not been consistent, and whether depression plays a causal role in the development of NAFLD remains unclear.

METHODS

We extracted data from the National Health and Nutrition Examination Survey (NHANES) 2017-2018 to assess the correlation between depression and NAFLD risk. Based on previous genome-wide association studies (GWAS) meta-analyses on NAFLD and depression, we performed a Mendelian randomization (MR) analysis to explore the causal effect of depression on NAFLD. The primary analysis method used in the MR analysis was inverse variance weighted.

RESULTS

We ultimately extracted the data from 3878 individuals in the NHANES database to perform the cross-sectional study. Multivariable-adjusted logistic regression showed that depressed individuals had a higher risk of NAFLD than controls (odds ratio [OR] 1.33, 95 % CI 1.03-1.72, p = 0.027) among women. Based on GWAS data, we included 36 genetic variants as instrumental variables to estimate the causal effect of depression on NAFLD risk. The MR analysis revealed a causal association between genetically predicted depression and an increased risk of NAFLD (OR = 1.504, 95 % CI 1.13-2.00, p = 0.005).

LIMITATIONS

The consistency of these findings in Eastern populations requires further longitudinal studies.

CONCLUSIONS

This cross-sectional study suggested that depression might increase the risk of NAFLD in women. The MR analysis demonstrated that there exists a causal association between genetically predicated depression and NAFLD risk.

Association of depression with severe non-alcoholic fatty liver disease: evidence from the UK Biobank study and Mendelian randomization analysis

The relationship between depression and severe non-alcoholic fatty liver disease (NAFLD) has not been clearly defined. We conducted a longitudinal cohort study and a two-sample Mendelian randomization (MR) analysis to assess the association of depression with severe NAFLD risk. We used individual data from the UK Biobank study with 481,181 participants, and summary data from published genome-wide association studies. The association between depression and severe NAFLD was assessed using Cox proportional hazards regression analysis. Two-sample MR for depression with NAFLD was conducted, the principal analysis employed the inverse variance weighted (IVW) approach. In the observational study, after a median follow-up of 13.46 years, 4,563 participants had severe NAFLD. In multivariable-adjusted model, participants with depression had an increased risk of severe NAFLD (hazards ratio:1.21, 95% confidence interval (CI):1.09-1.34), as compared to those without depression. In subgroup analyses, the association between depression and severe NAFLD risk was generally observed across different subgroups. For the MR, result also showed that genetically predicted depression was causally associated with a higher risk of NAFLD (odds ratio:1.55, 95%CI:1.10-2.19) in IVW. Our study revealed a prospective association of depression with severe NAFLD, thus potentially necessitating clinical monitoring of individuals with depression for severe NAFLD.

Persons with metabolic dysfunction-associated steatotic liver disease are at increased risk of severe depression

BACKGROUND AND AIM

Few population-based studies have investigated the association between metabolic dysfunction-associated steatotic liver disease (MASLD) and depression. Additionally, it remains unclear if depression affects progression to major adverse liver outcomes (MALO) in MASLD.

METHODS

All patients in Sweden with newly diagnosed MASLD between 2006 and 2020 were identified from the National Patient Register. Each patient was matched on age, sex, inclusion year, and municipality with up to 10 comparators from the general population. Cox regression was used to compare rates of severe depression in persons with MASLD to the comparators. In persons with MASLD, Cox regression was used to estimate rates of MALO using severe depression before baseline or diagnosed during follow-up as a time-varying exposure.

RESULTS

We included 11 301 persons with MASLD and 104 205 comparators who were followed for a median of 3.9 (IQR 1.5-7.6) and 4.9 years (IQR 2.3-8.7), respectively. The median age was 56 years and 5576 of 11 301 (49.3%) persons with MASLD were male. Incident severe depression developed in 228 of 11 301 (2.0%) persons with MASLD and 1160 of 104 205 (1.1%) comparators (fully adjusted hazard ratio [HR] = 1.8, 95% CI = 1.5-2.1). Of persons with MASLD, 25 of 1229 (2.0%) of those with severe depression before or after baseline progressed to MALO compared to 322 of 10 326 (3.1%) of those without severe depression (fully adjusted HR = 1.0, 95% CI = .6-1.5).

CONCLUSIONS

We confirm an association between MASLD and severe depression. However, no association between severe depression and incident MALO was found, but conclusions are limited by few observed outcomes.

Causal relationships between neuropsychiatric disorders and nonalcoholic fatty liver disease: A bidirectional Mendelian randomization study

BACKGROUND

Increasing evidences suggest that nonalcoholic fatty liver disease (NAFLD) is associated with neuropsychiatric disorders. Nevertheless, whether there were causal associations between them remained vague. A causal association between neuropsychiatric disorders and NAFLD was investigated in this study.

METHODS

We assessed the published genome-wide association study summary statistics for NAFLD, seven mental disorder-related diseases and six central nervous system dysfunction-related diseases. The causal relationships were first assessed using two-sample and multivariable Mendelian randomization (MR). Then, sensitivity analyses were performed, followed by a reverse MR analysis to determine whether reverse causality is possible. Finally, we performed replication analyses and combined the findings from the above studies.

RESULTS

Our meta-analysis results showed NAFLD significantly increased the risk of anxiety disorders (OR = 1.016, 95% CI = 1.010-1.021, P value < 0.0001). In addition, major depressive disorder was the potential risk factor for NAFLD (OR = 1.233, 95% CI = 1.063-1.430, P value = 0.006). Multivariable MR analysis showed that the causal effect of major depressive disorder on NAFLD remained significant after considering body mass index, but the association disappeared after adjusting for the effect of waist circumference. Furthermore, other neuropsychiatric disorders and NAFLD were not found to be causally related.

CONCLUSIONS

These results implied causal relationships of NAFLD with anxiety disorders and Major Depressive Disorder. This study highlighted the need to recognize and understand the connection between neuropsychiatric disorders and NAFLD to prevent the development of related diseases.

A narrative review of lifestyle management guidelines for metabolic dysfunction-associated steatotic liver disease

BACKGROUND AND AIMS

Metabolic dysfunction-associated steatotic liver disease management guidelines have been published worldwide; we aimed to summarize, categorize, and compare their lifestyle intervention recommendations.

APPROACH AND RESULTS

We searched metabolic dysfunction-associated steatotic liver disease/NAFLD management guidelines published between January 1, 2013, and June 31, 2024, through databases including PubMed/MEDLINE, Cochrane, and CINAHL. In total, 35 qualifying guidelines were included in the final analysis. Guideline recommendations were categorized into 5 domains (ie, weight reduction goals, physical activity, nutrition, alcohol, and tobacco smoking) and were ranked based on how frequently they appeared. A recommendation was defined as widely adopted if recommended in ≥24 (≥66.6%) of the guidelines. These included increasing physical activity; reducing body weight by 7%-10% to improve steatohepatitis and/or fibrosis; restricting caloric intake; undertaking 150-300 or 75-150 minutes/week of moderate or vigorous-intensity physical activity, respectively; and decreasing consumption of commercially produced fructose. The least mentioned topics, in ≤9 of the guidelines, evaluated environmental determinants of health, mental health, referring patients for psychological or cognitive behavioral therapy, using digital health interventions, and assessing patients' social determinants of health.

CONCLUSIONS

Most guidelines recommend weight reduction through physical activity and improving nutrition, as these have proven positive effects on health outcomes when sustained. However, gaps regarding mental health and the social and environmental determinants of metabolic dysfunction-associated steatotic liver disease were found. To optimize behavioral modifications and treatment, we recommend carrying out studies that will provide further evidence on social support, environmental factors, and mental health, as well as further exploring digital health interventions.

Exploring the possible therapeutic mechanism of Danzhixiaoyao pills in depression and MAFLD based on "Homotherapy for heteropathy": A network pharmacology and molecular docking

Objective

Danzhixiaoyao pills (DXP) is a traditional Chinese medicine formula that has been effectively used in clinical practice to treat depression and metabolic associated fatty liver disease (MAFLD), but its therapeutic mechanism is not yet clear. The purpose of this study is to explore the possible mechanisms of DXP in treating depression and MAFLD using network pharmacology and molecular docking techniques based on existing literature reports.

Methods

By combining TCMSP, Swiss ADME, Swiss TargetPrediction, and UniProt databases, the active ingredients and potential targets of DXP were screened and obtained. By searching for relevant disease targets through Gene Cards, OMIM, and TTD databases, intersection targets between drugs and diseases were obtained. The network of "Disease - Potential targets - Active ingredients - Traditional Chinese medicine - Prescriptions" was constructed using Cytoscape 3.9.1 software, and the PPI network was constructed using STRING 12.0 database. The core targets were obtained through topology analysis. GO function enrichment and KEGG pathway enrichment analysis were conducted based on DAVID. The above results were validated by molecular docking using PyMol 2.5 and AutoDock Tool 1.5.7 software, and their possible therapeutic mechanisms were discussed.

Results

Network pharmacology analysis obtained 130 main active ingredients of drugs, 173 intersection targets between drugs and diseases, and 37 core targets. Enrichment analysis obtained 1390 GO functional enrichment results, of which 922 were related to biological process, 107 were related to cellular component, 174 were related to molecular function, and obtained 180 KEGG pathways. Molecular docking has confirmed the good binding ability between relevant components and targets, and the literature discussion has preliminarily verified the above results.

Conclusion

DXP can act on targets such as TNF, AKT1, ALB, IL1B, TP53 through active ingredients such as kaempferol, quercetin, naringenin, isorhamnetin, glyuranolide, etc, and by regulating signaling pathways such as pathways in cancer, MAPK signaling pathway, lipid and atherosclerosis, to exert its effect of "homotherapy for heteropathy" on depression and MAFLD. In addition, glyuranolide showed the strongest affinity with TNF (-7.88 kcal/mol), suggesting that it may play a key role in the treatment process. The research results provide a theoretical basis for elucidating the scientific connotation and mechanism of action of traditional Chinese medicine compound DXP, and provide new directions for its clinical application.

Development and validation of a predictive nomogram for the risk of MAFLD in postmenopausal women

Background and aim

Metabolic-associated fatty liver disease (MAFLD) has gradually become one of the main health concerns regarding liver diseases. Postmenopausal women represent a high-risk group for MAFLD; therefore, it is of great importance to identify and intervene with patients at risk at an early stage. This study established a predictive nomogram model of MAFLD in postmenopausal women and to enhance the clinical utility of the new model, the researchers limited variables to simple clinical and laboratory indicators that are readily obtainable.

Methods

Data of 942 postmenopausal women from January 2023 to October 2023 were retrospectively collected and divided into two groups according to the collection time: the training group (676 cases) and the validation group (226 cases). Significant indicators independently related to MAFLD were identified through univariate logistic regression and stepwise regression, and the MAFLD prediction nomogram was established. The C-index and calibration curve were used to quantify the nomogram performance, and the model was evaluated by measuring the area under the receiver operating characteristic curve (AUC), calibration curve, and decision curve analysis (DCA).

Results

Of 37 variables, 11 predictors were identified, including occupation (worker), body mass index, waist-to-hip ratio, number of abortions, anxiety, hypertension, hyperlipidemia, diabetes, hyperuricemia, and diet (meat and processed meat). The C-index of the training group predicting the related risk factors was 0.827 (95% confidence interval [CI] 0.794-0.860). The C-index of the validation group was 0.787 (95% CI 0.728-0.846). Calibration curves 1 and 2 (BS1000 times) were close to the diagonal, showing a good agreement between the predicted probability and the actual incidence in the two groups. The AUC of the training group was 0.827, the sensitivity was 0.784, and the specificity was 0.735. The AUC of the validation group was 0.787, the sensitivity was 0.674, and the specificity was 0.772. The DCA curve showed that the nomogram had a good net benefit in predicting MAFLD in postmenopausal women.

Conclusions

A predictive nomogram for MAFLD in postmenopausal women was established and verified, which can assist clinicians in evaluating the risk of MAFLD at an early stage.

Depressive symptom as a risk factor for cirrhosis in patients with primary biliary cholangitis: Analysis based on Lasso-logistic regression and decision tree models

BACKGROUND

Depressive symptoms are frequently observed in patients with primary biliary cholangitis (PBC). The role of depressive symptoms on cirrhosis has not been fully noticed in PBC. We aimed to establish a risk model for cirrhosis that took depressive symptoms into account.

METHODS

Depressive symptoms were assessed by the 17-item Hamilton Depression Rating Scale (HAMD-17). HAMD-17 score was analyzed in relation to clinical parameters. Least absolute shrinkage and selection operator (Lasso)-logistic regression and decision tree models were used to explore the effect of depressive symptoms on cirrhosis.

RESULTS

The rate of depressive symptom in patients with PBC (n = 162) was higher than in healthy controls (n = 180) (52.5% vs. 16.1%; p < .001). HAMD-17 score was negatively associated with C4 levels and positively associated with levels of alkaline phosphatase (ALP), γ-glutamyl transpeptidase (GGT), total bilirubin (TB), Immunoglobulin (Ig) G, and IgM (r = -0.162, 0.197, 0.355, 0.203, 0.182, 0.314, p < .05). In Lasso-logistic regression analysis, HAMD-17 score, human leukocyte antigen (HLA)-DRB1*03:01 allele, age, ALP levels, and IgM levels (odds ratio [OR] = 1.087, 7.353, 1.075, 1.009, 1.005; p < 0.05) were independent risk factors for cirrhosis. Elevated HAMD-17 score was also a discriminating factor for high risk of cirrhosis in patients with PBC in decision tree model.

CONCLUSIONS

Depressive symptoms were associated with disease severity. Elevated HAMD-17 score was a risk factor for cirrhosis in patients with PBC.

Identifying the most critical behavioral lifestyles associated with MAFLD: evidence from the NHANES 2017-2020

Background & aims

Accumulating studies have demonstrated associations between single lifestyle exposures and metabolic dysfunction-associated fatty liver disease (MAFLD). However, the joint effects of lifestyle exposures remain unclear, hindering the development of targeted prevention and control strategies. We aimed to investigate the joint associations between lifestyle exposomes and MAFLD.

Methods

This study included 5,002 participants from NHANES 2017-2020. Lifestyle exposomes, including sleep duration, metabolic equivalent of task (MET), Healthy Eating Index (HEI)-2015 score, alcohol consumption, and smoke exposure, were identified from questionnaire data. MAFLD was diagnosed by vibration-controlled transient elastography measurements and laboratory data. A logistic regression model and the weighted quantile sum method were used to evaluate the associations of single and joint lifestyle exposomes, respectively, with MAFLD. The population attributable fractions (PAFs) were calculated to assess the population benefits of different intervention strategies.

Results

Per-quartile range increases in sleep duration (OR=0.883, 95% CI: 0.826-0.944), MET (0.916, 0.871-0.963), and HEI-2015 score (0.827, 0.756-0.904) were significantly associated with MAFLD. The joint exposure of sleep duration, MET, and HEI-2015 score was associated with MAFLD (0.772, 0.688-0.865), with the highest weight (importance) for MET (0.526). PAFs revealed greater intervention benefits for sleep and the HEI-2015 when the majority of the population (>5%) had a low MAFLD risk (weak intervention targets), whereas MET was the most efficient intervention strategy when minority populations (≤5%) had a low MAFLD risk (strong intervention targets).

Conclusion

This study demonstrated significant associations between MAFLD and single and joint exposures to sleep duration, MET, and HEI-2015 and identified physical activity as the most important lifestyle factor. Further population benefit analyses may provide evidence and suggestions for population-level interventions.

ASSOCIATION BETWEEN ANXIETY AND DEPRESSION IN METABOLIC DYSFUNCTION-ASSOCIATED STEATOTIC LIVER DISEASE (MASLD)

BACKGROUND

This study aimed to assess the frequency and intensity of anxious and depressive symptoms in patients diagnosed with metabolic dysfunction-associated steatotic liver disease (MASLD).

METHODS

This is a descriptive and cross-sectional study, resulting from 106 patients from the Hepatology outpatient clinic at the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo, Brazil without a history of alcohol abuse, verified by the alcohol use disorders identification test (AUDIT). These were assessed using the sociodemographic data sheet, Hospital Anxiety and Depression Scale (HADS), Hamilton Anxiety Rating Scale (HAM-A), and Hamilton Depression Scale (HAM-D).

RESULTS

A total of 69.8% were women and 30.2% were men, with a mean age of 61 years. The majority (71.7%) discovered MASLD through routine exams, presenting as comorbidities: Type 2 diabetes mellitus (59.4%), Dyslipidemia (49.1%), Arterial hypertension (68.9%), Obesity (61.3%) and Metabolic syndrome [MetS (63.2%)]. The HADS scale indicates 34% probability of anxiety and 33% depressive symptoms. The Hamilton's scales of intensity indicates 63.9% severe anxiety and 54.3% severe depression. There is also a relationship between anxiety, depression and the female gender, as well as between depression and MetS.

CONCLUSION

The findings point to the presence of anxiety and depression in more than one third of MASLD patients, most with severe symptoms. The group is concentrated in the elderly, with many comorbidities, including MetS. There was a positive correlation between anxiety, depression and being female; also, being significant between MetS and depression.

Association between nonalcoholic fatty liver disease and erectile dysfunction among American Adults from the National Health and Nutrition Examination Survey: a cross-sectional study

Nonalcoholic fatty liver disease (NAFLD) is a pressing public health concern. NAFLD is recognized as a disease with systemic involvement. Erectile dysfunction is a prevalent condition among men. The study examined the relationship between NAFLD, assessed via U.S. Fatty Liver Index (USFLI), and erectile dysfunction. The study used cross-sectional data from the National Health and Nutrition Examination Survey conducted between 2001 and 2004 to examine the health of those over 20 years of age, collecting details on their erectile dysfunction, USFLI, and several other essential variables. A USFLI score equal to or exceeding 30 was chosen to diagnose NAFLD, while a USFLI score below 10 was utilized to exclude the presence of fatty liver. There were 3763 participants, with 29.1% (1095/3763) who experienced erectile dysfunction. After accounting for all potential covariates, USFLI was positively associated with erectile dysfunction (OR, 1.02; 95% CI, 1.02 ~ 1.03; P < 0.001). Compared with individuals with Q1 (USFLI < 10), the adjusted odds ratio values for USFLI and erectile dysfunction in Q2 (10 ≤ USFLI < 30) and Q3 (USFLI ≥ 30, NAFLD) were 1.84 (95% CI: 1.46 ~ 2.32, p < 0.001) and 2.18 (95% CI: 1.66 ~ 2.87, p < 0.001), respectively. The association USFLI and erectile dysfunction exhibited an L-shaped curve (nonlinear, P = 0.014). The odds ratio value of developing erectile dysfunction was 1.03 (95% CI: 1.021 ~ 1.04, P < 0.001) in participants with USFLI < 50.18. This study identified a positive correlation between USFLI and erectile dysfunction within the adult American population. Our findings imply that NAFLD might constitute an independent risk factor for erectile dysfunction.

Depression and NAFLD risk: A meta-analysis and Mendelian randomization study

BACKGROUND

Both depression and nonalcoholic fatty liver disease (NAFLD) have a high global prevalence. Growing evidence suggests an association between depression and NAFLD, while the association remains unclear. Thus, in this study, we aimed to explore the effect of depression on the risk of developing NAFLD.

METHODS

The meta-analysis examined the association between depression and the risk of NAFLD by including observational studies. Relevant studies were searched in PubMed, Embase, the Cochrane Library, and Web of Science. Then a two-sample Mendelian randomization (MR) analysis was performed to explore causal association using genetic instruments identified from a genome-wide association study.

RESULTS

Six eligible studies were included in the meta-analysis, involving 289,22 depression cases among 167,554 participants. Meta-analysis showed a significant association between depression and a higher risk of developing NAFLD (OR = 1.14, 95 % CI: [1.05, 1.24], P = 0.002). However, we found no convincing evidence supporting a causal role of genetically predicted depression with NAFLD risk (OR = 0.861, 95 % CI: [0.598, 1.238], P = 0.420).

LIMITATIONS

The insufficient number of included studies, the use of summary-level data, and restrictions on population sources are the major limiting factors.

CONCLUSIONS

Meta-analysis and MR analysis demonstrated inconsistent results on the relationship between depression and a high risk of developing NAFLD. Specifically, meta-analysis confirmed that depression increases the risk of developing NAFLD, while MR analysis did not support a causal association between genetically determined depression and the risk of NAFLD.

Endogenous sex hormones and nonalcoholic fatty liver disease in US adults

BACKGROUND AND AIMS

Sex steroid hormones and sex hormone-binding globulin (SHBG) have a role in predisposing individuals to nonalcoholic fatty liver disease (NAFLD), but their effects are known to differ between men and women. The testosterone-to-estradiol ratio (T/E2 ratio) and free androgen index (FAI) were known biomarkers for the hormonal milieu. We investigated whether sex steroid hormones, T/E2 ratio, FAI, and SHBG were associated with NAFLD in US adults.

METHODS

A cross-sectional analysis using the 2013-2016 National Health and Nutrition Examination Survey (NHANES) was performed. NAFLD was defined by utilizing the Hepatic Steatosis Index (HSI) and the US fatty liver index (USFLI) without other causes of chronic liver disease.

RESULTS

Out of 8687 subjects (49.5% male), low total testosterone levels were associated with progressively higher odds of NAFLD in men. Increasing T/E2 ratio was inversely associated with higher odds of NAFLD in men. Low serum SHBG levels were independently associated with an increased risk of NAFLD regardless of sex and menopausal status. Increasing FAI was independently associated with NAFLD. When we additionally adjusted for SHBG, T/E2 ratio, not total testosterone, was inversely associated with NAFLD in a dose-dependent manner. Increasing FAI was associated with higher odds of NAFLD in premenopausal women and marginally associated with NAFLD in postmenopausal women.

CONCLUSION

The T/E2 ratio and SHBG were inversely associated with an increased risk of NAFLD in men. In women, increasing FAI was associated with NAFLD, whereas SHBG was inversely associated with NAFLD.

Association between dietary vitamin A intake from different sources and non-alcoholic fatty liver disease among adults

Non-alcoholic fatty liver disease (NAFLD) has become an urgent public health issue with high global prevalence, but data on NAFLD are inconsistent. The association of total dietary vitamin A intake with the NAFLD risk was not well documented in previous studies. To explore the relationship between dietary vitamin A intake from different sources and NAFLD risk among American adults. Data were collected from the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2014. Logistic regression and restricted cubic spline models were used to estimate the relationship between total dietary vitamin A intake and NAFLD risk. 6,613 adult participants were included. After adjusting potential confounders, the odds ratios (ORs) with 95% confidence intervals (CIs) of NAFLD for the highest quartile intake of total vitamin A, preformed vitamin A, provitamin A carotenoids were respectively 0.86 (0.69-1.06), 0.97 (0.74-1.28), and 0.78 (0.61-0.99), compared to the lowest quartile. Stratifying gender and age, provitamin A carotenoids intake was inversely associated with NAFLD risk in females and participants aged < 45 years. Dose-response analysis indicated a linear negative relationship between provitamin A carotenoids intake and NAFLD risk. Provitamin A carotenoids intake was inversely associated with NAFLD, especially in women and those aged < 45 years among adult American.

Depression in nonalcoholic fatty liver disease and all-cause/cause-specific mortality

BACKGROUND

Depression has been associated with nonalcoholic fatty liver disease (NAFLD). Data addressing the impact of depression on NAFLD-related mortality are evolving. We aim to study the association of depression in NAFLD and all-cause/cause-specific mortality in the United States.

METHODS

A total of 11,877 individuals with NAFLD in the 2007-2016 National Health and Nutrition Examination Survey with the availability of linked mortality through 2019 were analysed. NAFLD was defined by utilizing the hepatic steatosis index in the absence of known causes of chronic liver disease. Depression and functional impairment due to depression were assessed using the Patient Health Questionnaire.

RESULTS

During the median follow-up of 7.6 years, individuals with depression among individuals with NAFLD had a 35% higher all-cause mortality than those without depression (hazard ratio [HR]: 1.35, 95% confidence interval [CI]: 1.03-1.75) after adjusting for demographic, lifestyle and clinical risk factors. NAFLD with functional impairment due to depression had a 62% higher all-cause mortality than NAFLD without functional impairment (HR: 1.62, 95% CI: 1.10-2.39). Depression in NAFLD was associated with an approximately 50% increase in the risk for cardiovascular mortality, with a 2-fold higher cardiovascular mortality in those with functional impairment compared to those without (HR: 2.07, 95% CI: 1.30-3.30). However, there was no significant difference in cancer- and accident-related mortalities in NAFLD with or without depression.

CONCLUSIONS

Depression among individuals with NAFLD was associated with a higher risk for all-cause and cardiovascular mortality in the United States.

Nonalcoholic Fatty Liver Disease as a Systemic Disease and the Need for Multidisciplinary Care

Nonalcoholic fatty liver disease (NAFLD) is currently the most common chronic liver disease, and there has been a rapid increase in cases worldwide. NAFLD is rapidly becoming the leading cause of hepatocellular carcinoma and is also associated with an increased risk of cardiovascular disease or exacerbation of other organ diseases, thus posing a significant health problem from both a medical and a socioeconomic perspective. NAFLD is a systemic disease and requires the involvement of numerous medical professionals. Multidisciplinary collaboration, in which different professionals within different specialties come together and work together toward a common goal, supports better patient care by integrating perspectives of multiple experts and facilitating the exchange of opinions. Due to the large number of potential patients, gastroenterologists and hepatologists cannot manage the patients alone, and collaboration between specialists in various fields, including family doctors, dentists, nutritionists, and pharmacists is required for treatment of NAFLD. This review will discuss NAFLD from the perspective of various specialties and introduce multidisciplinary collaboration.

Depression and risk of gastrointestinal disorders: a comprehensive two-sample Mendelian randomization study of European ancestry

BACKGROUND

Major depressive disorder (MDD) is clinically documented to co-occur with multiple gastrointestinal disorders (GID), but the potential causal relationship between them remains unclear. We aimed to evaluate the potential causal relationship of MDD with 4 GID [gastroesophageal reflux disease (GERD), irritable bowel syndrome (IBS), peptic ulcer disease (PUD), and non-alcoholic fatty liver disease (NAFLD)] using a two-sample Mendelian randomization (MR) design.

METHODS

We obtained genome-wide association data for MDD from a meta-analysis (N = 480 359), and for GID from the UK Biobank (N ranges: 332 601-486 601) and FinnGen (N ranges: 187 028-218 792) among individuals of European ancestry. Our primary method was inverse-variance weighted (IVW) MR, with a series of sensitivity analyses to test the hypothesis of MR. Individual study estimates were pooled using fixed-effect meta-analysis.

RESULTS

Meta-analyses IVW MR found evidence that genetically predicted MDD may increase the risk of GERD, IBS, PUD and NAFLD. Additionally, reverse MR found evidence of genetically predicted GERD or IBS may increase the risk of MDD.

CONCLUSIONS

Genetically predicted MDD may increase the risk of GERD, IBS, PUD and NAFLD. Genetically predicted GERD or IBS may increase the risk of MDD. The findings may help elucidate the mechanisms underlying the co-morbidity of MDD and GID. Focusing on GID symptoms in patients with MDD and emotional problems in patients with GID is important for the clinical management.

Association between depression and metabolic dysfunction-associated fatty liver disease/significant fibrosis

BACKGROUND

An association between depression and metabolic dysfunction-associated fatty liver disease (MAFLD) appears logical on the basis of previous observations linking depression to nonalcoholic fatty liver disease. We aim to investigate the association between depression and MAFLD and significant fibrosis.

METHODS

This cross-sectional study was conducted on data from National Health and Nutrition Examination Survey, 2017 to March 2020 Pre-pandemic dataset. Depression and depression-related functional impairment were assessed using the Patient Health Questionnaire (PHQ-9). MAFLD, based on the criteria proposed by an international expert panel, and significant fibrosis were defined by transient elastography.

RESULTS

Of the 3327 individuals (mean age: 46.9 years, 50.2 % men), the prevalence of depression and functional impairment due to depression was higher among individuals with MAFLD or significant fibrosis than among those without. Individuals with depression were approximately 70 % more likely to have MAFLD than those without. In multivariable analyses, depression was associated with an increased risk of MAFLD (odds ratio [OR]: 1.77, 95 % confidence interval [CI]:1.33-2.36 for ≥263 dB/m and OR: 1.70, 95 % CI: 1.20-2.41 for ≥285 dB/m). These associations were more pronounced in postmenopausal women than premenopausal women. In terms of significant fibrosis, depression remained an independent predictor of significant fibrosis; however, it attenuated after adjustment for body mass index.

LIMITATIONS

Temporal causality and residual confounders could not be entirely investigated due to the study design.

CONCLUSIONS

Depression was independently associated with MAFLD and significant fibrosis in a nationally representative sample of adults in the US.

Associations of depression score with metabolic dysfunction-associated fatty liver disease and liver fibrosis

BACKGROUND

Growing evidence suggests a link between depression and nonalcoholic fatty liver disease (NAFLD). Recently, a change from NAFLD to metabolic dysfunction-associated fatty liver disease (MAFLD) has been proposed. The aim of this study was to determine whether depression scores are associated with newly defined MAFLD as well as liver fibrosis in the US general population.

METHODS

This cross-sectional study utilized data from the 2017-March 2020 cycle of the National Health and Nutrition Examination Survey in the US. The depression score was assessed with the Patient Health Questionnaire-9 (PHQ-9). Transient elastography was utilized to evaluate hepatic steatosis and fibrosis with controlled attenuation parameters and liver stiffness measurements, respectively. All the analyses accounted for the complex design parameters and sampling weights of the survey.

RESULTS

A total of 3263 eligible subjects aged 20 years and older were included. The estimated prevalence of mild and major depression was 17.0 % (95 % confidence interval [CI]: 14.8-19.3 %) and 7.1 % (6.1-8.1 %), respectively. For every one-unit increase in depression score, a subject was 1.05 (1.02-1.08) times more likely to have MAFLD. Compared to the minimal depression group, those with mild depression had an odds ratio (OR) of 1.54 (1.06-2.25) for MAFLD. The depression score was not associated with clinically significant liver fibrosis.

CONCLUSION

The depression score measured by PHQ-9 was independently associated with MAFLD among US adults.

LIMITATIONS

Causal relationship is not available due to the cross-sectional nature of the survey design.

Geographical similarity and differences in the burden and genetic predisposition of NAFLD

NAFLD has become a major public health problem for more than 2 decades with a growing prevalence in parallel with the epidemic of obesity and type 2 diabetes (T2D). The disease burden of NAFLD differs across geographical regions and ethnicities. Variations in prevalence of metabolic diseases, extent of urban-rural divide, dietary habits, lifestyles, and the prevalence of NAFLD risk and protective alleles can contribute to such differences. The rise in NAFLD has led to a remarkable increase in the number of cases of cirrhosis, hepatocellular carcinoma, hepatic decompensation, and liver-related mortality related to NAFLD. Moreover, NAFLD is associated with multiple extrahepatic manifestations. Most of them are risk factors for the progression of liver fibrosis and thus worsen the prognosis of NAFLD. All these comorbidities and complications affect the quality of life in subjects with NAFLD. Given the huge and growing size of the population with NAFLD, it is expected that patients, healthcare systems, and the economy will suffer from the ongoing burden related to NAFLD. In this review, we examine the disease burden of NAFLD across geographical areas and ethnicities, together with the distribution of some well-known genetic variants for NAFLD. We also describe some special populations including patients with T2D, lean patients, the pediatric population, and patients with concomitant liver diseases. We discuss extrahepatic outcomes, patient-reported outcomes, and economic burden related to NAFLD.

Association between antidepressant use and liver fibrosis in patients with type 2 diabetes: a population based study

BACKGROUND

The prevalence of liver fibrosis among diabetic patients is increasing rapidly. Our study aims at exploring the relationship between antidepressant use and liver fibrosis in diabetic patients.

METHODS

We conducted this cross-sectional study through the cycle of National Health and Nutrition Examination Survey (NHANES) 2017-2018. The study population were consisted of patients with type 2 diabetes and reliable vibration-controlled transient elastography (VCTE) results. The presence of liver fibrosis and steatosis were assessed by the median values of liver stiffness measurement (LSM) and controlled attenuation parameter (CAP), respectively. Antidepressants included selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), serotonin and norepinephrine reuptake inhibitors (SNRIs) and serotonin antagonists and reuptake inhibitors (SARIs). Patients with evidence of viral hepatitis and significant alcohol consumption were excluded. Logistic regression analysis was performed to evaluate the association between antidepressant use and both steatosis and significant (≥ F3) liver fibrosis after adjustment for potential confounders.

RESULTS

Our study population consisted of 340 women and 414 men, of whom 87 women(61.3%) and 55(38.7%) men received antidepressants. The most commonly used antidepressants were SSNIs(48.6%), SNRIs(22.5%) and TCAs(12.7%), followed by SARIs(10.6%) and other antidepressants(5.6%). 165 participants had significant liver fibrosis by VCTE, with a weighted overall prevalence of 24%(95% CI 19.2-29.5). In addition, 510 patients had evidence of hepatic steatosis by VCTE with a weighted overall prevalence of 75.4%(95% CI 69.2-80.7). After adjusting confounders, no significant association was observed between antidepressant use and significant liver fibrosis or cirrhosis.

CONCLUSIONS

In conclusion, in this cross-sectional study, we found that antidepressant drugs was not associated with liver fibrosis and cirrhosis in patients with type 2 diabetes in a nationwide population.

Sex differences in the relationship between hepatic steatosis, mood and anxiety disorders

OBJECTIVE

To investigate the association between non-alcoholic fatty liver disease (NAFLD), alcoholic liver disease (ALD), mental symptoms (mood, anxiety disorders and distress) by sex.

METHODS

This a cross-sectional study performed in working-age adults from a Health Promotion Center (primary care) in São Paulo, Brazil. Self-reported mental symptoms from rating scales (21-item Beck Anxiety Inventory, Patient Health Questionnaire-9, and K6 distress scale) were evaluated by hepatic steatosis (NAFLD and ALD). Logistic regression models estimated the association between hepatic steatosis subtypes and mental symptoms by Odds ratios (OR) adjusted by confounders in the total sample and sex stratified.

RESULTS

Among 7241 participants (70.5% men, median age: 45 years), the frequency of steatosis was of 30.7% (25.1% NAFLD), being higher in men than women (70.5% vs. 29.5%, p < 0.0001), regardless of the steatosis subtype. Metabolic risk factors were similar in both subtypes of steatosis, but not mental symptoms. Overall, NAFLD was inversely associated with anxiety (OR = 0.75, 95%CI 0.63-0.90) and positively associated with depression (OR = 1.17, 95%CI 1.00-1.38). On the other hand, ALD was positively associated with anxiety (OR = 1.51; 95%CI 1.15-2.00). In sex-stratified analyses, only men presented an association of anxiety symptoms with NAFLD (OR = 0.73; 95%CI 0.60-0.89) and ALD (OR = 1.60; 95%CI 1.18-2.16).

CONCLUSIONS

The complex association between different types of steatosis (NAFLD and ALD), mood and anxiety disorders indicates the need for a deeper understanding of their common causal pathways.

Nonalcoholic fatty liver disease from a primary care perspective

Nonalcoholic fatty liver disease (NAFLD) affects up to one-third of the US population. Approximately one-fifth of patients with NAFLD have nonalcoholic steatohepatitis (NASH), characterized by hepatocyte damage and inflammation with or without fibrosis. NASH leads to greater risk of liver-related complications and liver-related mortality, with the poorest outcomes seen in patients with advanced fibrosis. NASH is also associated with other metabolic comorbidities and conveys an increased risk of adverse cardiovascular outcomes and extrahepatic cancers. Despite its high prevalence, NAFLD is frequently underdiagnosed. This is a significant concern, given that early diagnosis of NAFLD is a key step in preventing progression to NASH. In this review, we describe the clinical impact of NASH from the perspective of both the clinician and the patient. In addition, we provide practical guidance on the diagnosis and management of NASH for primary care providers, who play a pivotal role in the frontline care of patients with NASH, and we use case studies to illustrate real-world scenarios encountered in the primary care setting.

The Role of the Stress Response in Metabolic Dysfunction-Associated Fatty Liver Disease: A Psychoneuroendocrineimmunology-Based Perspective

The novel term metabolic dysfunction-associated fatty liver disease (MAFLD), which has been proposed to describe the major cause of hepatic disease, pinpoints the coexistence of multiple metabolic disturbances and liver steatosis, giving rise to different phenotypic manifestations. Within the psychoneuroendocrineimmunological (PNEI) network that regulates body-mind interactions, the stress response plays a pervasive role by affecting metabolic, hormonal, immune, and behavioral balance. In this perspective, we focus on chronic psychosocial stress and high levels of cortisol to highlight their role in MAFLD pathogenesis and worsening. From a PNEI perspective, considering the stress response as a therapeutic target in MAFLD allows for simultaneously influencing multiple pathways in the development of MAFLD, including dysmetabolism, inflammation, feeding behaviors, gut-liver axis, and dysbiosis, with the hope of better outcomes.

Prevalence of non-alcoholic fatty liver disease in pediatric mental disorder inpatients: a tertiary mental health referral hospital study

BACKGROUND AND AIM

Studies have revealed a high prevalence of non-alcoholic fatty liver disease (NAFLD) among adult patients with mental disorders, as well as its associate risk factors, however little is known about these in pediatric population. The aim of the present study is to investigate the prevalence of NAFLD in pediatric inpatients with mental disorder, as well as to explore the risk factors.

METHODS

In this retrospective study, we included 1156 pediatric inpatients with mental disorder admitted to our hospital between January 2020 and December 2021, including inpatients with schizophrenia, bipolar disorder, depressive disorder and other mental disorders. Relevant clinical data were obtained from the electronic medical records. We calculated the prevalence rate of NAFLD, and compared NAFLD prevalence between gender, mental disorders types, antipsychotics use, and comorbidities. Multivariable logistic regression was used to examine risk factors associated with NAFLD.

RESULTS

The prevalence of NAFLD in pediatric inpatients with mental disorders was 7.35% (85/1156). Patients with NAFLD had senior age than those without NAFLD (15.33±1.75 vs 14.21±1.95 year-old, P<0.001). The NAFLD prevalence in participants with schizophrenia (12.11%) was higher than in participants with bipolar disorder (8.45%), depressive disorder (7.06%) and other mental disorders (2.97%)(p=0.002). The NAFLD prevalence was higher in participants who used antipsychotics (8.70%) than those who didn't (5.45%) (p=0.038). Multivariate analysis revealed that senior age, body weight (overweight/obese) and dyslipidemia were independent risk factors for NAFLD in pediatric inpatients with mental disorders.

CONCLUSIONS

The NAFLD prevalence was is higher in those patients with schizophrenia and receiving antipsychotic medication. Metabolic factors and longer evolution may explain these differences.

Impact of nonalcoholic fatty liver disease-related metabolic state on depression

Nonalcoholic fatty liver disease (NAFLD), also recently referred as metabolic (dysfunction)-associated fatty liver disease (MAFLD), is characterized by hepatocyte steatosis in the setting of metabolic risk conditions and in the absence of an underlying precursor, for instance alcohol consumption, hepatotropic viruses and hepatotoxic drugs. A possible association between NAFLD and depression has been proposed, owing to intersecting pathophysiological pathways. This narrative review aimed to summarize the current evidence that illustrate the potential pathophysiological and clinical linkage between NAFLD-related metabolic state and depression. Prefrontal cortex lesions are suggested to be a consequence of liver steatosis-associated systematic hyperinflammatory state, a phenomenon also occurring in depression. In addition, depressive symptoms are present in neurotransmitter imbalances. These abnormalities seem to be correlated with NAFLD/MAFLD, in terms of insulin resistance (IR), ammonia and gut dysbiosis' impact on serotonin, dopamine, noradrenaline levels and gamma aminobutyric acid receptors. Furthermore, reduced levels of nesfatin-1 and copine-6-associated BDNF (brain-derived neurotrophic factor) levels have been considered as a probable link between NAFLD and depression. Regarding NAFLD-related gut dysbiosis, it stimulates mediators including lipopolysaccharides, short-chain fatty acids and bile acids, which play significant role in depression. Finally, western diet and IR, which are mainstay components of NAFLD/MAFLD, are, also, substantiated to affect neurotransmitters in hippocampus and produce neurotoxic lipids that contribute to neurologic dysfunction, and thus trigger emotional disturbances, mainly depressive symptoms.

Metabolic Associated Fatty Liver Disease as a Risk Factor for the Development of Central Nervous System Disorders

MAFLD/NAFLD is the most ordinary liver disease categorized by hepatic steatosis with the increase of surplus fat in the liver and metabolic liver dysfunction, which is associated with bigger mortality and a high medical burden. An association between MAFLD/NAFLD and central nervous system disorders including psychological disorders has been demonstrated. Additionally, MAFLD/NAFLD has been correlated with various types of neurodegenerative disorders such as amyotrophic lateral sclerosis or Parkinson’s disease. Contrasted to healthy controls, patients with MAFLD/NAFLD have a greater prevalence risk of extrahepatic complications within multiple organs. Dietary interventions have emerged as effective strategies for MAFLD/NAFLD. The PI3K/AKT/mTOR signaling pathway involved in the regulation of Th17/Treg balance might promote the pathogenesis of several diseases including MAFLD/NAFLD. As extrahepatic complications may happen across various organs including CNS, cooperative care with individual experts is also necessary for managing patients with MAFLD/NAFLD.

Self-Management and Associated Factors among Patients with Non-Alcoholic Fatty Liver Disease: A Cross-Sectional Study

Self-management is critical and essential for controlling non-alcoholic fatty liver disease, delaying progression, and preventing complications. However, information about the self-management characteristics of this population is scarce. This study explores the characteristics and self-management levels and the factors associated with self-management in patients with non-alcoholic fatty liver disease in Korea. A convenience sample of 150 patients diagnosed with non-alcoholic fatty liver disease was recruited from April to November 2019. Demographics and clinical findings were collected, and self-management, self-efficacy, fatigue, and depressive symptoms were assessed using questionnaires. Multiple linear regression analysis was performed to examine the factors associated with self-management. Self-management levels were moderate (Mean = 3.4, SD = 0.61). Self-management differed significantly by age, sex, marital status, occupation, and health education experience. Self-efficacy (β = 0.074, p = 0.020) showed a significant association with self-management, which explained 25.0% of the variance after controlling for age, sex, marital status, health education experience, occupation, controlled attenuation parameter score, and body mass index. Self-efficacy is a critical determinant of self-management among patients with non-alcoholic fatty liver disease. The study findings could assist healthcare professionals in facilitating self-management compliance and developing multidisciplinary team-based interventions for sustainable self-management.

Support Needs and Coping Strategies in Non-Alcoholic Fatty Liver Disease (NAFLD): A Multidisciplinary Approach to Potential Unmet Challenges beyond Pharmacological Treatment

Non-alcoholic fatty liver disease (NAFLD) is the most frequently occurring chronic liver disease, affecting approximately 25–30% of the adult general population worldwide. NAFLD reflects excess hepatic accumulation of fat in the absence of increased alcohol intake, and, due to its close association with obesity, is frequently referred to as the ‘hepatic manifestation’ of metabolic syndrome. Indeed, a high percentage of individuals with NAFLD present with a combination of the cardio-metabolic comorbidities that are associated with the metabolic syndrome. In addition to its well-established link with the metabolic syndrome and increased risk for cardiovascular disease, NAFLD has also been associated with certain mental health issues (e.g., depression and stress). Although this link is now being increasingly recognized, there are still unmet needs regarding the holistic management of patients with NAFLD, which could further contribute to feelings of social isolation and loneliness. The latter conditions are also increasingly reported to pose a substantial risk to overall health and quality of life. To date, there is limited research that has explored these issues among patients with NAFLD, despite existing data which indicate that perceived loneliness and isolation may pose an additional health risk. Notably, many features associated with NAFLD have been related to these concepts, such as perceived stigma, fatigue, stress, and confusion regarding this diagnosis. As such, this review aimed to assess such potential problems faced by patients with NAFLD, and to explore the possibility of unmet support needs which could lead to perceived social isolation. Moreover, the importance of a compassionate approach towards such patients is discussed, together with potential coping strategies. Future research directions and the need for a multidisciplinary approach are also highlighted.

Vitality, mental health and role-physical mediate the influence of coping on depressive symptoms and self-efficacy in patients with non-alcoholic fatty liver disease: A cross-sectional study

OBJECTIVE

Our aim was to determine whether the association between active coping and depressive symptoms in patients with non-alcoholic fatty liver disease (NAFLD) was mediated by vitality, and whether diabetes and obesity could impact on this relationship. We also wanted to find out whether mental health and role-physical modulated the relationship between passive/avoidance coping and self-efficacy, and the role of liver fibrosis.

METHODS

Depressive symptoms (BDI-II), self-efficacy (GSE), coping (COPE-28) and quality of life (SF-12) were evaluated in 509 biopsy-proven NAFLD patients in this cross-sectional study. Mediation and moderated mediation models were conducted using the SPSS PROCESS v3.5 macro.

RESULTS

Vitality mediated the relationship between active coping and depressive symptoms (-2.254, CI = -2.792 to -1.765), with diabetes (-0.043, p = 0.017) and body mass index (BMI) (-0.005, p = 0.009) moderating the association. In addition, mental health (-6.435, CI = -8.399 to -4.542) and role-physical (-1.137, CI = -2.141 to -0.315) mediated the relationship between passive/avoidance coping and self-efficacy, with fibrosis stage (0.367, p < 0.001) moderating this association. Specifically, the presence of diabetes and significant fibrosis, and a higher BMI, were associated with greater negative impact on participant depressive symptoms or self-efficacy.

CONCLUSION

A maladaptive coping style was associated with poorer vitality, mental health and role-physical in NAFLD patients, which along with the presence of metabolic comorbidity (diabetes and obesity) and significant fibrosis predicted more depressive symptoms or poorer self-efficacy in these patients. These results suggested incorporating emotional and cognitive evaluation and treatment in patients with NAFLD.

Linking Nonalcoholic Fatty Liver Disease and Brain Disease: Focusing on Bile Acid Signaling

A metabolic illness known as non-alcoholic fatty liver disease (NAFLD), affects more than one-quarter of the world's population. Bile acids (BAs), as detergents involved in lipid digestion, show an abnormal metabolism in patients with NAFLD. However, BAs can affect other organs as well, such as the brain, where it has a neuroprotective effect. According to a series of studies, brain disorders may be extrahepatic manifestations of NAFLD, such as depression, changes to the cerebrovascular system, and worsening cognitive ability. Consequently, we propose that NAFLD affects the development of brain disease, through the bile acid signaling pathway. Through direct or indirect channels, BAs can send messages to the brain. Some BAs may operate directly on the central Farnesoid X receptor (FXR) and the G protein bile acid-activated receptor 1 (GPBAR1) by overcoming the blood-brain barrier (BBB). Furthermore, glucagon-like peptide-1 (GLP-1) and the fibroblast growth factor (FGF) 19 are released from the intestine FXR and GPBAR1 receptors, upon activation, both of which send signals to the brain. Inflammatory, systemic metabolic disorders in the liver and brain are regulated by the bile acid-activated receptors FXR and GPBAR1, which are potential therapeutic targets. From a bile acid viewpoint, we examine the bile acid signaling changes in NAFLD and brain disease. We also recommend the development of dual GPBAR1/FXR ligands to reduce side effects and manage NAFLD and brain disease efficiently.

Dietary linoleic acid and the ratio of unsaturated to saturated fatty acids are inversely associated with significant liver fibrosis risk: A nationwide survey

Since no pharmaceuticals have been proven to effectively reduce liver fibrosis, dietary fatty acids may be beneficial as one of the non-pharmaceutical interventions due to their important roles in liver metabolism. In this cross-sectional study, we analyzed the data from the 2017–2018 cycle of National Health and Nutrition Examination Survey to examine the associations between the proportion and composition of dietary fatty acid intakes with significant liver fibrosis among US population. The dietary fatty acid consumptions were calculated based on two 24-h dietary recalls. Significant liver fibrosis was diagnosed based on liver stiffness measurement value derived from the vibration controlled transient elastography. Multivariate logistic regression analysis and sensitivity analysis were performed to assess the association between dietary fatty acid consumption and significant liver fibrosis risk. Finally, restricted cubic spline analysis was carried out to explore the dose–response between polyunsaturated fatty acids (PUFA) or linoleic acid intakes and the risk of significant liver fibrosis. The results showed that the multivariate adjusted odds ratios (95% confidence intervals) of significant liver fibrosis were 0.34 (0.14–0.84), 0.68 (0.50–0.91), and 0.64 (0.47–0.87) for the highest level of unsaturated to saturated fatty acid ratio, dietary PUFA, and linoleic acid intakes compared to the lowest reference, respectively. The sensitivity analysis and restricted cubic spline analysis produced similar results, reinforcing the inverse association of unsaturated to saturated fatty acid ratio, PUFA, and linoleic acid consumptions with significant liver fibrosis risk. However, other dietary fatty acids did not show the statistically significant association with significant liver fibrosis. In conclusion, dietary linoleic acid may play a key role in the inverse association between the unsaturated to saturated fatty acid ratio and the risk of significant liver fibrosis. Further studies are needed to confirm these findings.

Depression and non-alcoholic fatty liver disease: Association and potential mechanisms

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in the world, and is closely related to the high incidence of obesity, metabolic syndrome, type 2 diabetes, arteriosclerotic cardiovascular disease, and colorectal tumor. Depression is a common mental disorder that is characterized by high incidence, high recurrence rate, high disability rate, and high suicide rate, which has serious harm to patients' physical and mental health, reduce the quality of life of patients. In recent years, as more and more attention has been paid to mental health of NAFLD patients, the relationship between NAFLD and depression has become one of the hot research topics. Studies have shown that the incidence of depression in NAFLD patients is higher than that in non-NAFLD patients, and the incidence of NAFLD in depressed patients is also higher. Some research results have been published on the mechanism of comorbidity between the two. This paper reviews the research progress on the correlation and common mechanism between NAFLD and depression, aiming to lay a foundation for further research on the comorbidities of NAFLD and depression, and provide a basis and research direction for the diagnosis and treatment of patients with both comorbidities.

Interrelationship between physical activity and depression in nonalcoholic fatty liver disease

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is associated with a sedentary lifestyle and depressive symptoms. It is also well established that physical inactivity and depressive symptoms are related. However, an investigation of the interaction between all of these factors in NAFLD has not been previously conducted.

AIM

To investigate the interrelationship between physical inactivity and depressive symptoms in individuals with NAFLD.

METHODS

Data from the Rancho Bernardo Study of Healthy Aging were utilized. 589 individuals were included in the analyses (43.1% male; 95.8% non-Hispanic white; aged 60.0 ± 7.0 years). NAFLD was defined by using the hepatic steatosis index, depression using the Beck Depression Inventory, and physical activity by self-report of number of times per week of strenuous activity. Multivariable generalized linear regression models with Gamma distribution were performed to investigate the proposed relationship.

RESULTS

About 40% of the sample had evidence of NAFLD, 9.3% had evidence of depression, and 29% were physically inactive. Individuals with NAFLD and depression were more likely to be physically inactive (60.7%) compared to individuals with neither NAFLD nor depression (22.9%), individuals with depression without NAFLD (37.0%), and individuals with NAFLD without depression (33.3%). After accounting for various comorbidities (i.e., age, sex, diabetes, hypertension, obesity), individuals with NAFLD and higher levels of physical activity were at a decreased odds of having depressive symptoms [16.1% reduction (95% confidence interval: -25.6 to -5.4%), P = 0.004], which was not observed in those without NAFLD.

CONCLUSION

Individuals with NAFLD have high levels of physical inactivity, particularly those with depressive symptoms. Because this group is at high risk for poor outcomes, practitioners should screen for the coexistence of depressive symptoms and NAFLD. This group should receive appropriate interventions aimed at increasing both participation and levels of intensity of physical activity.

Association between nonalcoholic fatty liver disease and depression: A systematic review and meta-analysis of observational studies

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is associated with an increased prevalence of psychological conditions such as depression and anxiety. However, the correlation between NAFLD and depression has not been well illustrated.

METHODS

Studies that investigate the association between nonalcoholic fatty liver disease and depression were searched in multiple electronic databases. Pooled odds ratios (ORs) and confidence intervals (CIs) of the included articles were calculated using a fixed- or random effects model.

RESULTS

A total of seven articles were included in this study. The results of the meta-analysis showed that compared with those without nonalcoholic fatty liver disease, individuals with it had a significantly increased risk of depression (pooled OR = 1.13, 95% CI: 1.03, 1.24, p = 0.007), and there was evidence that heterogeneity was not significant (I² = 13.6%, p for heterogeneity = 0.324). Moreover, depressed patients had a significantly increased risk of developing nonalcoholic fatty liver disease compared with non-depressed patients (pooled OR = 1.46, 95% CI: 1.15, 1.85, p = 0.002), and evidence of non-significant heterogeneity was observed (I² = 0%, p = 0.837 for heterogeneity).

LIMITATIONS

The majority of the included articles in this study are cross-sectional studies and could not elucidate the causal relationship, so further longitudinal studies are needed to clarify the causal relationship.

CONCLUSION

Nonalcoholic fatty liver and depression are highly correlated, the two interact with each other and have a high risk of comorbidities. In the future more high quality prospective studies will be needed to validate our results.

Gut-derived systemic inflammation as a driver of depression in chronic liver disease

Depression and chronic liver disease (CLD) are important causes of disability, morbidity and mortality worldwide and their prevalence continues to rise. The rate of depression in CLD is high compared to that of the general population and is comparable to the increased rates observed in other medical comorbidities and chronic inflammatory conditions. Notably, a comorbid diagnosis of depression has a detrimental effect on outcomes in cirrhosis. Systemic inflammation is pivotal in cirrhosis-associated immune dysfunction - a phenomenon present in advanced CLD (cirrhosis) and implicated in the development of complications, organ failure, disease progression, increased infection rates and poor outcome. The presence of systemic inflammation is also well-documented in a cohort of patients with depression; peripheral cytokine signals can result in neuroinflammation, behavioural change and depressive symptoms via neural mechanisms, cerebral endothelial cell and circumventricular organ signalling, and peripheral immune cell-to-brain signalling. Gut dysbiosis has been observed in both patients with cirrhosis and depression. It leads to intestinal barrier dysfunction resulting in increased bacterial translocation, in turn activating circulating immune cells, leading to cytokine production and systemic inflammation. A perturbed gut-liver-brain axis may therefore explain the high rates of depression in patients with cirrhosis. The underlying mechanisms explaining the critical relationship between depression and cirrhosis remain to be fully elucidated. Several other psychosocial and biological factors are likely to be involved, and therefore the cause is probably multifactorial. However, the role of the dysfunctional gut-liver-brain axis as a driver of gut-derived systemic inflammation requires further exploration and consideration as a target for the treatment of depression in patients with cirrhosis.

Depressive symptoms in non-alcoholic fatty liver disease are identified by perturbed lipid and lipoprotein metabolism

Non-alcoholic fatty liver disease (NAFLD) and depression are common disorders and have bidirectional contributing relationships to metabolic syndrome. We aimed to determine whether a fasting serum signature of recent, self-reported depressive symptoms could be identified in a heterogeneous NAFLD cohort using nuclear magnetic resonance (NMR)-based metabolomics integrated with clinical chemistry. Serum nuclear magnetic resonance (NMR) metabolite profiles and corresponding clinical chemistry were compared between patients with depressive symptoms in the last 12-months (n = 81) and patients without recent depressive symptoms (n = 137 controls) using multivariate statistics. Orthogonal partial least squares discriminant analysis (OPLS-DA) of the biochemical and metabolomic data identified NAFLD patients with recent depression with a cross-validated accuracy of 61.5%, independent of age, sex, medication, and other comorbidities. This led to the development of a diagnostic algorithm with AUC 0.83 for future testing in larger clinical cohorts. Serum triglycerides, VLDL cholesterol, and the inflammatory biomarker GlycA were key metabolites increased in patients with recent depressive symptoms, while serum glutamine level was reduced. Here, serum NMR metabolite analysis provides a link between disturbed lipid metabolism, inflammation, and active mental health issues in NAFLD, irrespective of disease severity.

Prevalence of Pruritus and Association with Anxiety and Depression in Patients with Nonalcoholic Fatty Liver Disease

Patient-reported outcomes are important in nonalcoholic fatty liver disease (NAFLD). Pruritus is of special interest for evolving therapies with farnesoid X receptor (FXR) agonists. The aim of this study was to investigate the prevalence of pruritus in a real-life NAFLD cohort and analyze associations with anxiety and depression. Pruritus was assessed using a visual analogue- (VAS) and 5-D itch-scale (5-D). Anxiety and depression were evaluated by Beck’s-Depression-Inventory (BDI) and the Hospital Anxiety and Depression Scale (HADS-A, HADS-D). An optimal logistic regression model was found with a stepwise procedure to investigate variables associated with pruritus. In total, 123 NAFLD patients were recruited. VAS and 5-D were highly correlated (Spearman’s correlation coefficient 0.89). Moderate/severe pruritus was reported in 19% (VAS) and 21% (5-D) of patients. Anxiety and depression were present in 12% and 4% (HADS-A and HADS-D, respectively) and 12% (BDI) of cases. There was a significant association between VAS and BDI (p = 0.019). The final multivariate model for 5-D included diabetes mellitus (OR 4.51; p = 0.01), BDI (OR 5.98; p = 0.024), and HADS-A (OR 7.75; p = 0.011). One-fifth of NAFLD patients reported moderate or severe pruritus. 5-D was significantly associated with diabetes mellitus, depression, and anxiety. These findings should be tested in larger populations and considered in candidates for treatment with FXR agonists.

Metabolic dysfunction-associated fatty liver disease and liver fibrosis: Prevalence and associated factors in the middle-aged and older US population

AIM

The global burden of chronic liver disease is substantial. Limited studies have reported the prevalence of metabolic dysfunction-associated fatty liver disease (MAFLD) and liver fibrosis among middle-aged and older people. Therefore, we aimed to determine the nationwide prevalence of and associated factors for MAFLD and fibrosis in adults aged 45-79 years from the United States.

METHODS

This cross-sectional study utilized data from the 2017-2018 cycle of the National Health and Nutrition Examination Survey conducted with a nationally representative sample of the civilian, noninstitutionalized US population. Hepatic steatosis and fibrosis were assessed by transient elastography with controlled attenuation parameter and liver stiffness measurement, respectively.

RESULTS

A total of 1186 eligible participants aged 45-79 years were finally included in the analyses. The estimated prevalence of MAFLD, significant fibrosis (F ≥ F2), and advanced fibrosis (F ≥ F3) was 48.6% (95% confidence interval [CI], 43.1%-54.0%), 9.5% (95% CI, 6.8%-12.7%), and 6.7% (95% CI, 4.1%-10.1%), respectively. Multivariable logistic regression revealed an increased MAFLD predisposition in subjects with metabolic disorders including overweight/obesity, abdominal obesity, hypertension, and diabetes mellitus. Moreover, the presence of depression was an independent and strong predictor of MAFLD risk (odds ratio = 3.23; 95% CI, 1.37-7.11). Elevated liver enzymes, hypertension, diabetes mellitus, hepatitis virus infection, and steatosis were associated with a high risk of significant fibrosis.

CONCLUSIONS

Newly defined MAFLD is highly prevalent in the US middle-aged and older population. Approximately 1 in 10 people has significant liver fibrosis. In addition to metabolic disorders, the presence of depression potentially increases the risk of MAFLD.

Non-alcoholic fatty liver disease in irritable bowel syndrome: More than a coincidence?

Irritable bowel syndrome (IBS) and non-alcoholic fatty liver disease (NAFLD) are amongst the most common gastrointestinal and liver conditions encountered in primary and secondary care. Recently, there has been interest in the apparent co-incidence of NAFLD in patients with IBS mainly driven by improved understanding of their shared risk factors and pathophysiology. In this paper we summarize the shared risk factors which include; overlapping nutritional and dietary factors as well as shared putative mechanisms of pathophysiology. These include changes in the gut microbiome, gut permeability, immunity, small bowel bacterial overgrowth and bile acid metabolism. This paper describes how these shared risk factors and etiological factors may have practical clinical implications for these highly prevalent conditions. It also highlights some of the limitations of current epidemiological data relating to estimates of the overlapping prevalence of the two conditions which have resulted in inconsistent results and, therefore the need for further research. Early recognition and management of the overlap could potentially have impacts on treatment outcomes, compliance and morbidity of both conditions. Patients with known IBS who have abnormal liver function tests or significant risk factors for NAFLD should be investigated appropriately for this possibility. Similarly, IBS should be considered in patients with NAFLD and symptoms of abdominal pain associated with defecation, an altered bowel habit and bloating.

Protective effect of quercetin against the metabolic dysfunction of glucose and lipids and its associated learning and memory impairments in NAFLD rats

BACKGROUND

Quercetin (QUE) is a flavonol reported with anti-inflammatory and antioxidant activities, and previous results from the group of this study have demonstrated its neuroprotective effect against lipopolysaccharide-induced neuropsychiatric injuries. However, little is known about its potential effect on neuropsychiatric injuries induced or accompanied by metabolic dysfunction of glucose and lipids.

METHODS

A nonalcoholic fatty liver disease (NAFLD) rat model was induced via a high-fat diet (HFD), and glucolipid parameters and liver function were measured. Behavioral performance was observed via the open field test (OFT) and the Morris water maze (MWM). The plasma levels of triggering receptor expressed on myeloid cells-1 (TREM1) and TREM2 were measured via enzyme-linked immunosorbent assay (ELISA). The protein expression levels of Synapsin-1 (Syn-1), Synaptatogmin-1 (Syt-1), TREM1 and TREM2 in the hippocampus were detected using western blotting. Morphological changes in the liver and hippocampus were detected by HE and Oil red or silver staining.

RESULTS

Compared with the control rats, HFD-induced NAFLD model rats presented significant metabolic dysfunction, hepatocyte steatosis, and impaired learning and memory ability, as indicated by the increased plasma concentrations of total cholesterol (TC) and triglyceride (TG), the impaired glucose tolerance, the accumulated fat droplets and balloon-like changes in the liver, and the increased escaping latency but decreased duration in the target quadrant in the Morris water maze. All these changes were reversed in QUE-treated rats. Moreover, apart from improving the morphological injuries in the hippocampus, treatment with QUE could increase the decreased plasma concentration and hippocampal protein expression of TREM1 in NAFLD rats and increase the decreased expression of Syn-1 and Syt-1 in the hippocampus.

CONCLUSIONS

These results suggested the therapeutic potential of QUE against NAFLD-associated impairment of learning and memory, and the mechanism might involve regulating the metabolic dysfunction of glucose and lipids and balancing the protein expression of synaptic plasticity markers and TREM1/2 in the hippocampus.

Non-Alcoholic Fatty Liver Disease (NAFLD) and Potential Links to Depression, Anxiety, and Chronic Stress

Non-alcoholic fatty liver disease (NAFLD) constitutes the most common liver disease worldwide, and is frequently linked to the metabolic syndrome. The latter represents a clustering of related cardio-metabolic components, which are often observed in patients with NAFLD and increase the risk of cardiovascular disease. Furthermore, growing evidence suggests a positive association between metabolic syndrome and certain mental health problems (e.g., depression, anxiety, and chronic stress). Given the strong overlap between metabolic syndrome and NAFLD, and the common underlying mechanisms that link the two conditions, it is probable that potentially bidirectional associations are also present between NAFLD and mental health comorbidity. The identification of such links is worthy of further investigation, as this can inform more targeted interventions for patients with NAFLD. Therefore, the present review discusses published evidence in relation to associations of depression, anxiety, stress, and impaired health-related quality of life with NAFLD and metabolic syndrome. Attention is also drawn to the complex nature of affective disorders and potential overlapping symptoms between such conditions and NAFLD, while a focus is also placed on the postulated mechanisms mediating associations between mental health and both NAFLD and metabolic syndrome. Relevant gaps/weaknesses of the available literature are also highlighted, together with future research directions that need to be further explored.

Impact of major depression and antidepressant use on alcoholic and non-alcoholic fatty liver disease: A population-based study

BACKGROUND AND AIMS

The effect of major depression and antidepressant use on patient survival in chronic liver disease is unknown. We evaluated the impact of major depressive disorder (MDD) and antidepressants on survival among patients with alcoholic liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD).

METHODS

The Health Improvement Network database, the largest medical database in the United Kingdom, was used to identify incident ALD (n = 4148) and NAFLD (n = 19 053) in patients between 1986 and 2017. Our primary outcome was development of decompensated cirrhosis or death. MDD and each class of antidepressants were assessed in multivariate Cox proportional hazards models as time-varying covariates. Models were adjusted for age, sex, socio-economic status and comorbidities.

RESULTS

MDD rate was higher among patients with ALD (22.8%) compared to those with NAFLD (16.1%), P < .01. Antidepressant usage was common in patients with ALD (47.4%) and NAFLD (40.8%). After adjusting for covariates, MDD (adjusted hazard ratio [AHR]: 0.80, 95% CI: 0.63-1.02 for NAFLD; and AHR 1.01, 0.88-1.15 for ALD) was not associated with improved decompensated cirrhosis-free survival. The antidepressant mirtazapine was associated with worse decompensated cirrhosis-free survival among NAFLD (AHR 2.16, 95% CI: 1.32-3.52) and ALD (AHR 1.53, 1.09-2.15) cohorts. Similarly, mirtazapine was associated with mortality in both cohorts.

CONCLUSIONS

MDD was not associated with worse outcomes for ALD or NAFLD. Mirtazapine was associated with an increased risk of decompensated cirrhosis or death, which was not observed with other antidepressants. Prospective studies are warranted to confirm these findings.

Classifying depression using blood biomarkers: A large population study

BACKGROUND

Depression is a common mood disorder characterized by persistent low mood or lack of interest in activities. People with other chronic medical conditions such as obesity and diabetes are at greater risk of depression. Diagnosing depression can be a challenge for primary care providers and others who lack specialized training for these disorders and have insufficient time for in-depth clinical evaluation. We aimed to create a more objective low-cost diagnostic tool based on patients' characteristics and blood biomarkers.

METHODS

Blood biomarker results were obtained from the National Health and Nutrition Examination Survey (NHANES, 2007-2016). A prediction model utilizing random forest (RF) in NHANES (2007-2014) to identify depression was derived and validated internally using out-of-bag technique. Afterwards, the model was validated externally using a validation dataset (NHANES, 2015-2016). We performed four subgroup comparisons (full dataset, overweight and obesity dataset (BMI≥25), diabetes dataset, and metabolic syndrome dataset) then selected features using backward feature selection from RF.

RESULTS

Family income, Gamma-glutamyl transferase (GGT), glucose, Triglyceride, red cell distribution width (RDW), creatinine, Basophils count or percent, Eosinophils count or percent, and Bilirubin were the most important features from four models. In the training set, AUC from full, overweight and obesity, diabetes, and metabolic syndrome datasets were 0.83, 0.80, 0.82, and 0.82, respectively. In the validation set, AUC were 0.69, 0.63, 0.66, and 0.64, respectively.

CONCLUSION

Results of routine blood laboratory tests had good predictive value for distinguishing depression cases from control groups not only in the general population, but also individuals with metabolism-related chronic diseases.

Risk of severe illness of COVID-19 patients with NAFLD and increased NAFLD fibrosis scores

Background

There is still little knowledge about the association of liver fibrosis with the clinical outcomes of COVID‐19 patients with non‐alcoholic fatty liver disease (NAFLD). The aim of the study was to determine the association of NAFLD fibrosis score (NFS)–determined liver fibrosis with clinical outcomes of COVID‐19 patients with NAFLD.

Methods

The NAFLD was diagnosed by the Hepatic Steatosis Index (HSI) in the absence of other causes of chronic liver diseases. NFS was used to evaluate the severity of liver fibrosis.

Results

A total of 86 COVID‐19 patients with NAFLD were included. The median age was 43.5 years, and 58.1% of patients were male. Thirty‐eight (44.2%) patients had advanced liver fibrosis according to the NFS. Multivariate analysis indicated that concurrent diabetes (odds ratio [OR] 8.264, 95% confidence interval [CI] 1.202–56.830, p = 0.032) and advanced liver fibrosis (OR 11.057, 95% CI 1.193–102.439, p = 0.034) were independent risk factors of severe illness in COVID‐19 patients with NAFLD.

Conclusion

NAFLD patients with NFS‐determined advanced liver fibrosis are at higher risk of severe COVID‐19.

Risk factors of liver injury in patients with coronavirus disease 2019 in Jiangsu, China: A retrospective, multi-center study

We aimed to describe liver injury and identify the risk factors of liver injury in coronavirus disease (COVID-19) patients without chronic liver diseases (CLD). The clinical data of 228 confirmed COVID-19 patients without CLD were retrospectively collected from ten hospitals in Jiangsu, China. Sixty-seven (29.4%) of 228 patients without CLD showed abnormal liver function on admission, including increased alanine aminotransferase (ALT) (25 [11.0%]) U/L, aspartate aminotransferase (AST) 30 [13.2%]) U/L, gamma-glutamyl transferase (GGT) 28 [12.4%]) U/L, total bilirubin (Tbil) 16 [7.0%] μmol/L, and alkaline phosphatase (ALP) 10 [4.5%]) U/L. During hospitalization, 129 (56.3%) of 228 patients showed abnormal liver function, including elevated ALT (84 [36.8%]), AST (58 [25.4%]), GGT (67 [29.5%]), and Tbil (59 [25.9%]). Age over 50 years (odds ratio [OR], 2.086; 95% confidence interval [CI], 1.030-4.225; p = .041), male sex (OR, 2.737; 95% CI, 1.418-5.284; p = .003), and lopinavir-ritonavir (OR, 2.504; 95% CI, 1.187-5.283; p = .016) were associated with higher risk of liver function abnormality, while the atomized inhalation of interferon α-2b (OR, 0.256; 95% CI 0.126-0.520; p < .001) was associated with reduced risk of liver function abnormality during hospitalization. Mild to moderate liver injury was common in COVID-19 patients in Jiangsu, China. Age over 50 years, male sex, and lopinavir-ritonavir were the independent risk factors of liver impairment in COVID-19 patients during hospitalization.