NAFLD and Liver Fibrosis Are Not Associated With Reduced Femoral Bone Mineral Density in the General US Population

The association between vitamin E intake and hepatic steatosis in general and obese populations

PURPOSE

Using data from the National Health and Nutrition Examination Survey (NHANES) and employing Controlled Attenuation Parameter (CAP) measures, this study explores the correlation between vitamin E (VE) intake and hepatic steatosis and its impact on different subsets.

MATERIALS AND METHODS

We selected 5757 participants with CAP data from the 2017-2020 NHANES dataset. Daily VE intake was assessed by a 24-hour dietary recall. Hepatic fat content was quantified using transient elastography to measure CAP. Stratified multivariable regression analysis investigated relationships in different subsets, and a generalized additive model identified nonlinear relationships and thresholds.

RESULTS

After adjusting for confounders, higher VE intake correlated with lower CAP levels. Subgroup analyses and tests for interaction revealed a significantly stronger negative correlation between VE intake and CAP in obese individuals. Further analysis indicated a curvilinear relationship between VE intake and the severity of liver fat degeneration in both the general study population and the obese subgroup, demonstrating a threshold effect. In the general population, VE intake below the threshold (6.58 mg/day) is positively correlated with CAP levels, whereas intake above this threshold shows a negative correlation. For obese individuals, the threshold is set at 7.37 mg/day, above which the negative correlation with CAP is even more pronounced.

CONCLUSION

Our study revealed a negative correlation between VE intake and hepatic fat content, highlighting the potentially crucial role VE plays in obese fatty liver patients. Importantly, we identified threshold effects of VE intake in both general and obese populations. Our results support clinical nutritional interventions, personalized dietary guidance, and the development of drugs to combat fatty liver.

Effects of Metabolic Dysfunction-Associated Steatotic Liver Disease on Bone Density and Fragility Fractures: Associations and Mechanisms

Metabolic dysfunction-associated steatotic liver disease (MASLD) has profound adverse effects on bone health and homeostasis. MASLD appears to be associated with changes in bone mineral density (BMD) and fracture rate. However, the data are ambiguous and conflicting. Although several studies have shown that children and adolescents with MASLD have decreased BMD, the data on the prevalence of fragility fractures among children are scarce. In adults, increasing evidence suggests that MASLD decreases BMD and increases the risk of fragility fractures, which appears to be due to deterioration of bone architecture in addition to a decrease in BMD. Effects of MASLD on bone health may also be age- and race-specific. MASLD does not seem to increase fracture risk in children and adolescents but increases the risk of fractures in elderly men, especially those of Asian origin. From a mechanistic perspective, bone remodeling is a continuous process between osteoblasts (bone-forming) and osteoclasts (bone-resorbing), with any imbalance resulting in metabolic bone disease. In individuals with MASLD, loss of anabolic insulin receptor signaling (insulin resistance) in osteoblasts and increased receptor activator of nuclear factor κB (RANK)/RANK ligand signaling in osteoclasts (proinflammatory cytokines) swings the pendulum toward accelerated bone loss. These processes are further complicated by the concomitant presence of obesity, type 2 diabetes mellitus, or sarcopenia in individuals with MASLD. This study reviews the current literature associated with the effects of MASLD on BMD and fragility fractures in children/adolescents and adults. This review also discusses the pathomechanisms that link MASLD with changes in BMD and fragility fractures.

Association between fatty liver index and controlled attenuation parameters as markers of metabolic dysfunction-associated fatty liver disease and bone mineral density: observational and two-sample Mendelian randomization studies

Previously observational studies did not draw a clear conclusion on the association between fatty liver diseases and bone mineral density (BMD). Our large-scale studies revealed that MAFLD and hepatic steatosis had no causal effect on BMD, while some metabolic factors were correlated with BMD. The findings have important implications for the relationship between fatty liver diseases and BMD, and may help direct the clinical management of MAFLD patients who experience osteoporosis and osteopenia.

PURPOSE

Liver and bone are active endocrine organs with several metabolic functions. However, the link between metabolic dysfunction-associated fatty liver disease (MAFLD) and bone mineral density (BMD) is contradictory.

METHODS

Using the UK Biobank and National Health and Nutrition Examination Survey (NHANES) dataset, we investigated the association between MAFLD, steatosis, and BMD in the observational analysis. We performed genome-wide association analysis to identify single-nucleotide polymorphisms associated with MAFLD. Large-scale two-sample Mendelian randomization (TSMR) analyses examined the potential causal relationship between MAFLD, hepatic steatosis, or major comorbid metabolic factors, and BMD.

RESULTS

After adjusting for demographic factors and body mass index, logistic regression analysis demonstrated a significant association between MAFLD and reduced heel BMD. However, this association disappeared after adjusting for additional metabolic factors. MAFLD was not associated with total body, femur neck, and lumbar BMD in the NHANES dataset. Magnetic resonance imaging-measured steatosis did not show significant associations with reduced total body, femur neck, and lumbar BMD in multivariate analysis. TSMR analyses indicated that MAFLD and hepatic steatosis were not associated with BMD. Among all MAFLD-related comorbid factors, overweight and type 2 diabetes showed a causal relationship with increased BMD, while waist circumference and hyperlipidemia had the opposite effect.

CONCLUSION

No causal effect of MAFLD and hepatic steatosis on BMD was observed in this study, while some metabolic factors were correlated with BMD. This has important implications for understanding the relationship between fatty liver disease and BMD, which may help direct the clinical management of MAFLD patients with osteoporosis.

Liver fibrosis, NT-ProBNP and mortality in patients with MASLD: A population-based cohort study

BACKGROUND & AIM

Liver fibrosis is the strongest predictor of liver-related mortality in many chronic liver diseases. NT-ProBNP is independently associated with cardiovascular mortality in general population settings. Here, we evaluate the relative contribution of non-invasively identified liver fibrosis and NT-ProBNP on all-cause and cardiovascular mortality in patients with metabolic (dysfunction)-associated steatotic liver disease (MASLD).

METHODS AND RESULTS

Serum NT-ProBNP levels were measured in 4229 patients with MASLD from the general population without a known history of heart failure that participated in the 1999-2004 cycles of the National Health and Nutrition Examination Survey. Presence of liver fibrosis was estimated using the Fibrosis-4 index (FIB-4). We applied Cox proportional hazard models adjusted for cardiovascular risk factors to evaluate the association between NT-ProBNP and FIB-4 levels and all-cause and cardiovascular mortality through December 2019. Mortality was lower for participants with normal levels of both biomarkers, intermediate if a single biomarker was elevated and highest when both were above the chosen threshold. In the multivariable-adjusted models, both elevated FIB-4 (≥2.67) and elevated NT-ProBNP levels (≥125 pg/ml) were independently associated with higher risks of all-cause mortality (HR 2.2, 95 % CI 1.5-3.2 and HR 1.6, 95 % CI 1.4-2.0, respectively) and cardiovascular mortality (HR 2.1, 95 % CI 1.2-3.7 and HR 2.1, 95 % CI 1.5-2.9, respectively). The associations remained consistent in subgroup analyses based on sex, obesity and age.

CONCLUSIONS

Both FIB-4 and NT-ProBNP are independently associated with higher mortality in patients with MASLD. Their combined use might prove useful to risk-stratify patients in clinical practice.

Anti-osteoporotic treatments in the era of non-alcoholic fatty liver disease: friend or foe

Over the last years non-alcoholic fatty liver disease (NAFLD) has grown into the most common chronic liver disease globally, affecting 17-38% of the general population and 50-75% of patients with obesity and/or type 2 diabetes mellitus (T2DM). NAFLD encompasses a spectrum of chronic liver diseases, ranging from simple steatosis (non-alcoholic fatty liver, NAFL) and non-alcoholic steatohepatitis (NASH; or metabolic dysfunction-associated steatohepatitis, MASH) to fibrosis and cirrhosis with liver failure or/and hepatocellular carcinoma. Due to its increasing prevalence and associated morbidity and mortality, the disease-related and broader socioeconomic burden of NAFLD is substantial. Of note, currently there is no globally approved pharmacotherapy for NAFLD. Similar to NAFLD, osteoporosis constitutes also a silent disease, until an osteoporotic fracture occurs, which poses a markedly significant disease and socioeconomic burden. Increasing emerging data have recently highlighted links between NAFLD and osteoporosis, linking the pathogenesis of NAFLD with the process of bone remodeling. However, clinical studies are still limited demonstrating this associative relationship, while more evidence is needed towards discovering potential causative links. Since these two chronic diseases frequently co-exist, there are data suggesting that anti-osteoporosis treatments may affect NAFLD progression by impacting on its pathogenetic mechanisms. In the present review, we present on overview of the current understanding of the liver-bone cross talk and summarize the experimental and clinical evidence correlating NAFLD and osteoporosis, focusing on the possible effects of anti-osteoporotic drugs on NAFLD.

Association of chronic liver disease with bone diseases and muscle weakness

The liver is a vital organ involved in nutrient metabolism, hormone regulation, immunity, cytokine production, and gut homeostasis. Impairment in liver function can result in malnutrition, chronic inflammation, decreased anabolic hormone levels, and dysbiosis. These conditions eventually cause an imbalance in osteoblast and osteoclast activities, resulting in bone loss. Osteoporosis is a frequent complication of chronic liver disease (CLD) that adversely affects quality of life and increases early mortality. Sarcopenia is another common complication of CLD characterized by progressive loss of skeletal muscle mass and function. Assessment criteria for sarcopenia specific to liver disease have been established, and sarcopenia has been reported to be associated with an increase in the risk of liver disease-related events and mortality in patients with CLD. Owing to their similar risk factors and underlying pathophysiological mechanisms, osteoporosis and sarcopenia often coexist (termed osteosarcopenia), progress in parallel, and further exacerbate the conditions mentioned above. Therefore, comprehensive management of these musculoskeletal disorders is imperative. This review summarizes the clinical implications and characteristics of osteoporosis, extending to sarcopenia and osteosarcopenia, in patients with CLD caused by different etiologies.

Associations of Serum Iron Status with MAFLD and Liver Fibrosis in the USA: a Nationwide Cross-Section Study

Metabolic dysfunction-associated fatty liver disease (MAFLD) is a new terminology characterized by liver steatosis. Iron status is related to many metabolic diseases. However, the researches on the associations of serum iron status with MAFLD are limited. The objective of this study was to investigate the associations of serum iron status biomarkers with MAFLD and liver fibrosis. A total of 5892 adults were enrolled in the current cross-sectional study using the 2017-March 2020 National Health and Nutrition Examination Survey. Liver steatosis and liver fibrosis were defined by the median values of controlled attenuation parameter ≥ 274 dB/m and liver stiffness measurement ≥ 8 kPa, respectively. The multivariable logistic/linear regression and restricted cubic spline analysis were conducted. After adjusting for potential confounders, higher ferritin levels were associated with higher odds of MAFLD (OR 4.655; 95% CI 2.301, 9.418) and liver fibrosis (OR 7.013; 95% CI 3.910, 12.577). Lower iron levels were associated with a higher prevalence of MAFLD (OR 0.622; 95% CI 0.458, 0.844) and liver fibrosis (OR 0.722; 95% CI 0.536, 0.974). Lower transferrin saturation (TSAT) was associated with a higher prevalence of MAFLD (OR 0.981; 95% CI 0.970, 0.991) and liver fibrosis (OR 0.988; 95% CI 0.979, 0.998). Higher ferritin levels, lower iron levels, and TSAT were associated with a higher prevalence of MAFLD and liver fibrosis. This study extended the knowledge of modifying iron status to prevent MAFLD and liver fibrosis. More prospective and mechanism studies were warranted to confirm the conclusions.

Causal effects of non-alcoholic fatty liver disease on osteoporosis: a Mendelian randomization study

Background

Osteoporosis (OP) is a systemic skeletal disease characterized by compromised bone strength leading to an increased risk of fracture. There is an ongoing debate on whether non-alcoholic fatty liver disease (NAFLD) is an active contributor or an innocent bystander in the pathogenesis of OP. The aim of this study was to assess the causal association between NAFLD and OP.

Methods

We performed two-sample Mendelian randomization (MR) analyses to investigate the causal association between genetically predicted NAFLD [i.e., imaging-based liver fat content (LFC), chronically elevated serum alanine aminotransferase (cALT) and biopsy-confirmed NAFLD] and risk of OP. The inverse variant weighted method was performed as main analysis to obtain the causal estimates.

Results

Imaging-based LFC and biopsy-confirmed NAFLD demonstrated a suggestive causal association with OP ([odds ratio (OR): 1.003, 95% CI: 1.001-1.004, P < 0.001; OR: 1.001, 95% CI: 1.000-1.002, P = 0.031]). The association between cALT and OP showed a similar direction, but was not statistically significant (OR: 1.001, 95% CI: 1.000-1.002, P = 0.079). Repeated analyses after exclusion of genes associated with confounding factors showed consistent results. Sensitivity analysis indicated low heterogeneity, high reliability and low pleiotropy of the causal estimates.

Conclusion

The two-sample MR analyses suggest a causal association between genetically predicted NAFLD and OP.

Associations of metabolic dysfunction-associated fatty liver disease and hepatic fibrosis with bone mineral density and risk of osteopenia/osteoporosis in T2DM patients

Background

Existing evidence on the associations of liver steatosis and fibrosis with bone mineral density (BMD) and risk of osteopenia/osteoporosis was limited with conflicting results. We aimed to evaluate the associations of metabolic dysfunction-associated fatty liver disease (MAFLD) and hepatic fibrosis with BMD and risk of osteopenia/osteoporosis in type 2 diabetes mellitus (T2DM) patients.

Methods

Baseline information of an ongoing cohort of 249 T2DM patients in Xiamen, China was analyzed. MAFLD was defined as the presence of hepatic steatosis [diagnosed by either hepatic ultrasonography scanning or fatty liver index (FLI) score >60] for T2DM patients. BMD was measured using dual-energy x-ray absorptiometry at total lumbar (L2-4), femur neck (FN), and total hip (TH) and was categorized as normal (T ≥ -1.0), osteopenia (-2.5 < T < -1.0), or osteoporosis (T ≤ -2.5) according to its minimum T-score.

Results

Among the 249 T2DM patients, prevalence rates of MAFLD, osteopenia, and osteoporosis were 57.8%, 50.6%, and 17.7%, respectively. Patients with MAFLD had significantly higher BMD T-scores of L2-4, FN, and TH and the minimum as well as lower prevalence of osteoporosis than patients without MAFLD. Hepatic steatosis indices, including FLI score, fatty liver (FLI ≥ 60 or hepatic ultrasonography scanning), and MAFLD, were significantly and positively associated with all T-scores, while hepatic fibrosis index and FIB-4 score, but not NAFLD fibrosis score (NFS), were negatively associated with all T-scores. MAFLD was significantly associated with the decreased risk of osteopenia/osteoporosis and osteoporosis with unadjusted odds ratios (ORs) (95% CI) of 0.565 (0.324-0.987) and 0.434 (0.224-0.843) (both p-values < 0.05), respectively. As for liver fibrosis, FIB-4 score, but not NFS, was significantly associated with elevated risk of osteoporosis with an unadjusted OR (95% CI) per SD increase of FIB-4 score of 1.446 (1.080-1.936, p-value = 0.013). Adjusting for potential confounding variables, especially body mass index, in the multivariable regression analyses, all associations of hepatic steatosis and fibrosis indices with BMD and risk of osteopenia/osteoporosis were not statistically significant.

Conclusion

MAFLD and hepatic fibrosis were not significantly associated with BMD and risk of osteopenia/osteoporosis independent of obesity. Nevertheless, screening and management of MAFLD and osteopenia/osteoporosis were still important for the prevention of fracture in T2DM patients.

Liver stiffness is associated with all-cause mortality in patients with NAFLD: A systematic review and meta-analysis

BACKGROUND AND AIMS

Several studies reported an association between liver stiffness measurement (LSM) obtained through vibration-controlled transient elastography (VCTE) and all-cause mortality in patients with nonalcoholic fatty liver disease (NAFLD). The objective of this systematic review and meta-analysis was to summarize available evidence on the nature and magnitude of this association.

METHODS

We systematically searched PubMed-MEDLINE and Scopus up to April 2023 for observational cohort studies in which LSM was measured with VCTE in patients with NAFLD or in general population settings, with a follow-up ≥1 year and with available data on all-cause mortality. Measures of association from individual studies were meta-analysed using random effects models. Of the 517 titles initially scrutinized, we included seven studies with data on 18 771 participants (47.1% male) and a mean follow-up of 3.6 years. We included effect estimates obtained in the models with the highest degree of adjustment for potential confounders available in each study.

RESULTS

When analysed as a categorical variable based on specific LSM cut-offs, liver fibrosis was associated with an increased risk of all-cause death (HR 2.10, 95% CI 1.56-2.83; test for overall effect z = 4.919, p < 0.001). Results were consistent when LSM was considered as a continuous variable (HR for 1 kPa increase: 1.03, 95% CI 1.01-1.05; test for overall effect z = 3.341, p = 0.001). There was borderline significant heterogeneity among the studies (I2  = 50.2% and I2  = 66.7% in the two analyses, respectively). No significant publication bias was detected by funnel plot analysis and Egger's and Begg's tests.

CONCLUSION

The present meta-analysis indicates that LSM, as a proxy of liver fibrosis, is independently and directly associated with a higher mortality risk in patients with NAFLD.

Association between resolved hepatitis B virus infection and femoral and spinal bone mineral density in American adults: a cross-sectional study

Background

Hepatitis B virus (HBV) infection is a global health concern that can potentially affect bone health. However, the specific association between resolved HBV infection and bone mineral density (BMD) remains unclear. This cross-sectional study aimed to investigate the potential association between resolved HBV infection and femoral and spinal BMD in adults in the United States.

Methods

This cross-sectional study included participants aged 20-79 years with negative HBV surface antigen (HBsAg) from the 2005-2010, 2013-2014, and 2017-2018 cycles of the National Health and Nutrition Examination Survey. Resolved HBV infection was defined as negative HBsAg with positive HBV core antibody. BMD was measured using dual-energy X-ray absorptiometry. Propensity score matching (PSM) was performed to balance baseline characteristics.

Results

A total of 10,333 eligible participants were identified and matched, of whom 737 (7.1%) had resolved HBV infection. Men with resolved HBV infection had significantly lower femoral and spinal BMD compared to those with no HBV infection, both before and after PSM. In the matched population, resolved HBV infection in men was negatively associated with femoral BMD (β= -0.024, 95% CI: -0.047 to -0.002, p = 0.0332) and spinal BMD (β= -0.025, 95% CI: -0.048 to -0.002, p = 0.0339). Postmenopausal women exhibited similar trends to men, while premenopausal women showed a tendency towards higher BMD, although statistical significance was not consistently achieved. Subgroup and sensitivity analyses supported the robustness of the findings.

Conclusion

The study suggests a negative association between resolved HBV infection and femoral and spinal BMD in adult men in the United States. It highlights the importance of routine bone density assessments and the consideration of anti-osteoporotic therapy, if necessary, in individuals with resolved HBV infection.

Relationship between nonalcoholic fatty liver disease and bone mineral density in elderly Chinese

OBJECTIVE

As our society grows older, both bone loss and fatty liver have become important issues. However, the relationship between reduced bone mineral density and fatty liver remains controversial. The purpose of this study was to investigate the relationship between nonalcoholic fatty liver disease and less bone mineral density in the ankles of Chinese people over 65.

METHODS

The research included 716 older adults over the age of 65 who underwent a comprehensive health screening. A logistic regression model was used to investigate the relationship between nonalcoholic fatty liver disease (NAFLD) and ankle bone mineral density.

RESULTS

A logistic regression model was used to analyze the odds ratios of reduced bone mineral density between patients with fatty liver and controls. In the adjusted model, adjustments were made for age, sex, systolic blood pressure, diastolic blood pressure, overweight rate, history of hypertension, history of diabetes, history of smoking, history of alcohol consumption, fasting glucose, hemoglobin, urea, creatinine, triglycerides, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, waist circumference, total protein, albumin, and globulin. The adjusted OR (aOR) for reduced bone mineral density was 0.66 [95% confidence interval (CI) = 0.45-0.97, P = 0.034 < 0.05]. In subgroup analysis by age, sex, and BMI, women, age > 75 years, and BIM < 25 were statistically significant.

CONCLUSION

This study suggested that NAFLD is associated with a reduced risk of reduced heel bone mass. More research needs to be done to back up the results of this study and look into possible problems.

Nonalcoholic Fatty Liver Disease in Patients with Type 2 Diabetes: Screening, Diagnosis, and Treatment

Nonalcoholic fatty liver disease (NAFLD), recently renamed metabolic dysfunction-associated steatotic liver disease (MASLD) affects ~70% of patients with type 2 diabetes (T2D), with ~20% showing signs of advanced liver fibrosis. Patients with T2D are at an increased risk of developing cirrhosis, liver failure, and hepatocellular carcinoma and their liver-related mortality is doubled compared with non-diabetic individuals. Nonetheless, the condition is frequently overlooked and disease awareness is limited both among patients and among physicians. Given recent epidemiological evidence, clinical practice guidelines recommend screening for NAFLD/MASLD and advanced liver fibrosis in patients with T2D. While many drugs are currently being tested for the treatment of NAFLD/MASLD, none of them have yet received formal approval from regulatory agencies. However, several classes of antidiabetic drugs (namely pioglitazone, sodium-glucose transporter 2 inhibitors, glucagon-like peptide 1 receptor agonists, and multi-agonists) have shown favorable effects in terms of liver enzymes, liver fat content and, in some occasions, on histologic features such as inflammation and fibrosis. Therefore, diabetologists have the opportunity to actively treat NAFLD/MASLD, with a concrete possibility of changing the natural history of the disease. In the present narrative review, we summarize evidence and clinical recommendations for NAFLD/MAFLD screening in the setting of T2D, as well as on the effect of currently available glucose-lowering drugs on hepatic endpoints.

Causal association of NAFLD with osteoporosis, fracture and falling risk: a bidirectional Mendelian randomization study

Introduction

The causal association between non-alcoholic fatty liver disease (NAFLD) and osteoporosis remains controversial in previous epidemiological studies. We employed a bidirectional two-sample Mendelian analysis to explore the causal relationship between NAFLD and osteoporosis.

Method

The NAFLD instrumental variables (IVs) were obtained from a large Genome-wide association study (GWAS) meta-analysis dataset of European descent. Two-sample Mendelian randomization (MR) analyses were used to estimate the causal effect of NAFLD on osteoporosis, fracture, and fall. Reverse Mendelian randomization analysis was conducted to estimate the causal effect of osteoporosis on NAFLD. The inverse-variance weighted (IVW) method was the primary analysis in this analysis. We used the MR-Egger method to determine horizontal pleiotropic. The heterogeneity effect of IVs was detected by MR-Egger and IVW analyses.

Results

Five SNPs (rs2980854, rs429358, rs1040196, rs738409, and rs5764430) were chosen as IVs for NAFLD. In forward MR analysis, the IVW-random effect indicated the causal effect of NAFLD on osteoporosis (OR= 1.0021, 95% CI: 1.0006-1.0037, P= 0.007) but not on fracture (OR= 1.0016, 95% CI: 0.998-1.0053, P= 0.389) and fall (OR= 0.9912, 95% CI: 0.9412-1.0440, P= 0.740). Furthermore, the reverse Mendelian randomization did not support a causal effect of osteoporosis on NAFLD (OR= 1.0002, 95% CI: 0.9997-1.0007, P= 0.231). No horizontal pleiotropic was detected in all MR analyses.

Conclusions

The results of this study indicate a causal association between NAFLD and osteoporosis. NAFLD patients have a higher risk of osteoporosis but not fracture and falling risk. In addition, our results do not support a causal effect of osteoporosis on NAFLD.

Nonalcoholic Fatty Liver Disease Is Associated With Decreased Bone Mineral Density in Adults: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis aimed to investigate the effect of nonalcoholic fatty liver disease (NAFLD) on bone mineral density (BMD) and the risk of osteoporosis and osteoporotic fracture in adults. We searched PubMed, MEDLINE, Embase, CINAHL, Web of Science, Cochrane Library, and Scopus for observational studies published from inception to January 2023 that reported adjusted effect sizes of NAFLD on BMD, osteopenia/osteoporosis, and osteoporotic fracture. The data were synthesized using multilevel and random-effects models. A total of 19 studies were included; of these, nine (21,294 participants) evaluated the effect of NAFLD on BMD, six (133,319 participants) investigated the risk of osteoporosis, and five (227,901 participants) assessed the risk of osteoporotic fracture. This meta-analysis showed that NAFLD was associated with decreased BMD (mean difference -0.019 g/cm2 , 95% confidence interval [CI] -0.036 to -0.002, I2 = 93%) and increased risks of osteoporosis (adjusted risk ratio [RR] = 1.28, 95% CI 1.08 to 1.52, I2 = 84%) and osteoporotic fractures (adjusted RR = 1.17, 95% CI 1.00 to 1.37, I2 = 67%). Subgroup analyses revealed that NAFLD had a significantly detrimental effect on BMD in men and on the BMD of the femoral neck and total hip. Stratified analyses by ethnicity demonstrated that NAFLD was not associated with BMD, osteoporosis, or osteoporotic fracture in non-Asian populations. The publication bias of all included studies was low; however, there was considerable heterogeneity among the studies, warranting a careful interpretation of the findings. Overall, our results suggest that NAFLD is associated with decreased BMD and an increased risk of osteoporosis or osteoporotic fractures. Male sex and the BMD of the femoral neck and total hip may be potential risk factors for decreased BMD in adults with NAFLD. Additionally, ethnic disparities were observed between Asian and non-Asian populations regarding BMD and osteoporotic fractures. © 2023 American Society for Bone and Mineral Research (ASBMR).

Differential Association of Sex Hormones with Metabolic Parameters and Body Composition in Men and Women from the United States

Sex hormones impact body composition. Data on the specific impact of each hormone on different body depots in men and women are scarce. The aim of this study is to evaluate the association between testosterone, estradiol and body fat distribution in the general population. This is a population-based cross-sectional study based on data from the 2013-2016 cycles of the National Health and Nutrition Examination Survey. Dual energy X-ray absorptiometry (DXA) and liquid chromatography tandem mass spectrometry were performed on participants aged 18-59 years to evaluate body composition and sex hormone levels, respectively. Weighted multivariable linear regression analyses were performed to evaluate the association between these parameters after adjustment for potential confounders. A total of 6655 participants (3309 males and 3346 females) was included in the analysis. Men with lower testosterone levels were older, had a higher body mass index (BMI) and had a generally unfavorable metabolic profile, while no specific trends were found in women. Among men, testosterone was positively associated with lean body mass and was negatively associated with fat mass and the android/gynoid (A/G) ratio, while an opposite trend was found for estradiol. Among women, testosterone did not impact body composition, while estradiol levels were positively associated with lean mass and were negatively associated with fat mass. Our results support the notion that the impact of different sex hormones on specific fat depots varies substantially between men and women.

High prevalence of metabolic diseases, liver steatosis and fibrosis among Chinese psychiatric patients

BACKGROUND

We aimed to investigate the differences of metabolic disorders between the general population and psychiatric patients, with an emphasis on the prevalence and influencing factors of liver fibrosis in psychiatric patients.

METHODS

A total of 734 psychiatric patients and 734 general population matched for age, sex, and BMI were enrolled from Shanghai, China. All participants underwent blood pressure, glucose, lipid profile measurements, and anthropometric parameters including body weight, height and waist circumference. FibroScan examinations were also performed on psychiatric patients. Liver steatosis and fibrosis were diagnosed by controlled attenuation parameter (CAP) and liver stiffness measurement (LSM) by professional staff.

RESULTS

Compared with the general population, psychiatric patients revealed significantly higher burden of metabolic disorders. The overall prevalence of liver steatosis (CAP ≥ 233 dB/m) and fibrosis (LSM ≥ 7.0 kPa) was 48.7% and 15.5% in psychiatric patients. Psychiatric patients with liver steatosis or fibrosis showed worse metabolic profile. Meanwhile, the prevalence of liver fibrosis was also significantly higher in patients with overweight, central obesity, diabetes, hypertension, metabolic syndrome, and liver steatosis. In logistic regression analyses, age, BMI and visceral adiposity index were independent risk factors for liver fibrosis in psychiatric patients. Additionally, antipsychotic medication was suggested to be associated with an increased risk of liver fibrosis in psychiatric patients with liver steatosis.

CONCLUSIONS

Prevalence of liver steatosis and fibrosis is high in Chinese psychiatric patients. Those with antipsychotic polypharmacy and obesity are at high risk, and may benefit from early liver assessment in preventing fibrosis progression.

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.

Metabolic associated fatty liver disease and bone mineral density: a cross-sectional study of the National Health and Nutrition Examination Survey 2017-2018

This research is a cross-sectional study based on the participants aged 50 years and older from National Health and Nutrition Examination Survey (NHANES) database. The metabolic associated fatty liver disease (MAFLD) population has higher BMD and a lower risk of osteoporosis than those without MAFLD.

INTRODUCTION

MAFLD is a new definition presented by panel of experts based on non-alcoholic fatty liver disease in 2020. However, the link between MAFLD and bone mineral density (BMD) is uncertain. Thus, the present study aimed to investigate the relationship between MAFLD and BMD.

METHODS

This cross-sectional study included subjects aged ≥ 50 years from the National Health and Nutrition Examination Survey 2017-2018. Multivariate linear regression models were performed to investigate the association between MAFLD and BMD. Moreover, the relationship between MAFLD and osteoporosis was assessed using multiple logistic regression models.

RESULTS

Finally, 817 participants (non-MAFLD, n = 436; MAFLD, n = 381) were included in the final analysis. The results demonstrated that participants with MAFLD showed higher femoral BMDs than those without MAFLD, especially among males aged ≥ 50 years and females aged ≥ 65 years. Moreover, the results showed that obese men (BMI ≥ 30 kg/m²) with MAFLD had higher femoral BMDs than the control group according to subgroup analyses stratified by BMI, but this trend was not present in women. In addition, multiple logistic regression models showed that participants with MAFLD had no increased risks of osteoporosis.

CONCLUSION

The present study found that the MAFLD population has higher BMD and a lower risk of osteoporosis than those without MAFLD. Because the present study was a cross-sectional study, we could not identify the cause-effect relation between MAFLD and BMD. Therefore, additional research needs to be performed to explore the influences of MAFLD on bone metabolism in the future.

Liver fibrosis is associated with impaired bone mineralization and microstructure in obese individuals with non-alcoholic fatty liver disease

BACKGROUND AND PURPOSE

Chronic liver diseases are associated with increased bone fracture risk, mostly in end-stage disease and cirrhosis; besides, data in non-alcoholic fatty liver disease (NAFLD) are limited. Aim of this study was to investigate bone mineralization and microstructure in obese individuals with NAFLD in relation to the estimated liver fibrosis.

METHODS

For this cross-sectional investigation, we analyzed data from 1872 obese individuals (44.6 ± 14.1 years, M/F: 389/1483; BMI: 38.3 ± 5.3 kg/m²) referring to the Endocrinology outpatient clinics of Sapienza University, Rome, Italy. Participants underwent clinical work-up, Dual-Energy X-ray Absorptiometry for assessing bone mineral density (BMD) and microarchitecture (trabecular bone score, TBS). Liver fibrosis was estimated by Fibrosis Score 4 (FIB-4). Serum parathyroid hormone (PTH), 25(OH) vitamin D, osteocalcin and IGF-1 levels were measured.

RESULTS

Obese individuals with osteopenia/osteoporosis had greater FIB-4 than those with normal BMD (p < 0.001). FIB-4 progressively increased in presence of degraded bone microarchitecture (p < 0.001) and negatively correlated with the serum osteocalcin (p < 0.001) and IGF-1 (p < 0.001), which were both reduced in presence of osteopenia/osteoporosis. FIB-4 predicted IGF-1 reduction in multivariable regression models adjusted for confounders (β: - 0.18, p < 0.001). Higher FIB-4 predicted bone fragility with OR 3.8 (95%C.I:1.5-9.3); this association persisted significant after adjustment for sex, age, BMI, diabetes, smoking status and PTH at the multivariable logistic regression analysis (OR 1.91 (95%C.I:1.15-3.17), p < 0.01), with AUROC = 0.842 (95%C.I:0.795-0.890; p < 0.001).

CONCLUSION

Our data indicate the presence of a tight relation between NAFLD-related liver fibrosis, lower bone mineral density and degraded microarchitecture in obese individuals, suggesting potential common pathways underlying liver and bone involvement in obesity and insulin resistance-associated disorders.

Associations of phthalates with NAFLD and liver fibrosis: A nationally representative cross-sectional study from NHANES 2017 to 2018

OBJECTIVE

Although phthalates are common environmental pollutants, few studies have focused on the relationship of phthalates exposure with non-alcoholic fatty liver disease (NAFLD) or liver fibrosis, and especially, the alternative phthalates have been questioned in recent years about whether they are better choices. Thus, this study aimed to explore the associations of exposure to major phthalates or alternative phthalates with NAFLD and liver fibrosis.

METHODS

Data of 1450 adults from the National Health and Nutrition Examination Survey (NHANES) 2017-2018 were collected. The urinary metabolite concentrations of di-2-ethylhexyl phthalate (DEHP), diisononyl phthalate (DINP) and diisodecyl phthalate (DIDP) were detected. Controlled attenuation parameter (CAP) and median liver stiffness measurement (LSM) were acquired for quantitative diagnosis of NAFLD and liver fibrosis by vibration-controlled transient elastography. Multivariate logistic regression analysis and linear regression analysis were performed to examine the associations between phthalates and NAFLD and liver fibrosis.

RESULTS

After adjustment of the potential factors, the prevalence of NAFLD was significantly elevated among those in the fourth quartile of mono-(2-ethyl-5-carboxypentyl) phthalate (OR, 95%CI = 2.719, 1.296, 5.700, P = 0.016), mono (2-ethyl-5-hydroxyhexyl) phthalate (OR, 95%CI = 2.073, 1.111, 3.867, P = 0.037). No significant association was found between the alternative phthalates and NAFLD. The similar result was gained by linear regression analysis that MECPP was still significantly associated with Ln CAP (Q4 vs. Q1: β, 95%CI = 0.067, 0.017, 0.118, P = 0.027). After adjustment for the same covariates, no significant association between phthalates and liver fibrosis was found in logistics regression analysis.

CONCLUSIONS

All in all, higher prevalence of NAFLD is correlated with DEHP but not DINP or DIDP in American adults. There is no significant relationship between phthalates and liver fibrosis defined as LSM ≥ 8 Kpa. Nevertheless, further research is needed to provide evidence of causality.

Nonalcoholic fatty liver disease and osteoporosis: A potential association with therapeutic implications

Nonalcoholic fatty liver disease (NAFLD) and osteoporosis are two highly prevalent metabolic diseases. Increasing experimental evidence supports a pathophysiological link between NAFLD and osteoporosis. A key feature could be chronic, low-grade inflammation, which characterizes NAFLD and possibly affects bone metabolism. In this context, several factors, including but not limited to receptor activator of nuclear factor kappa-B ligand, osteoprotegerin, osteopontin and osteocalcin, may serve as mediators. In the clinical setting, most but not all epidemiological evidence indicates that NAFLD is associated with lower bone mineral density or osteoporosis in adults. Although an association between NAFLD and osteoporosis has not yet been established, and thus remains speculative, pharmacological considerations already exist. Some of the current and emerging pharmacological options for NAFLD have shown possible anti-osteoporotic properties (eg, vitamin E, obeticholic acid, semaglutide), while others (eg, pioglitazone, canagliflozin) have been associated with increased risk of fractures and may be avoided in patients with NAFLD and concomitant osteoporosis, especially those at high fracture risk. Conversely, some anti-osteoporotic medications (denosumab) might benefit NAFLD, while others (raloxifene) might adversely affect it and, consequently, may be avoided in patients with osteoporosis and NAFLD. If an association between NAFLD and osteoporosis is established, a medication that could target both diseases would be a great advancement. This review summarizes the main experimental and clinical evidence on the potential association between NAFLD and osteoporosis and focuses on treatment considerations derived from this potential association.

The Imbalance of Mitochondrial Homeostasis of Peripheral Blood-Derived Macrophages Mediated by MAFLD May Impair the Walking Ability of Elderly Patients with Osteopenia

Introduction. Many Asian cohort studies have shown that nonalcoholic fatty liver disease (NAFLD), now renamed as metabolic dysfunction-associated fatty liver disease (MAFLD), increases the risk of osteoporosis, yet the effect of MAFLD on elderly patients with osteopenia (OPe) has not been reported. Objective. This study aimed to explore the influence of MAFLD on the function of macrophages in patients with OPe. Methods. A total of 107 elderly OPe patients with or without MAFLD who visited the Huadong Hospital Affiliated to Fudan University (Shanghai, China) between January 1st, 2021, and September 30th, 2021, were evaluated for an interviewer-assisted questionnaire, as well as clinical and biological assessments. Results. Comparing two groups of elderly patients with the same bone mass level, we found that the six-minute walking distance ( $P=0.012$ ) and short physical performance battery (SPPB) score ( $P=0.0029$ ) of the elderly OPe patients with MAFLD are worse than those in OPe patients without MAFLD. Our results confirmed that the mitochondrial reactive oxygen species (mtROS) in peripheral blood of OPe patients with MAFLD was significantly higher than those without. We also observed the mitochondrial metabolism level of peripheral blood-derived macrophages in the included patients and peripheral blood macrophages in patients with MAFLD with more unbalanced mitochondrial dynamics of macrophages, more weakened mitochondrial respiratory capacity, and greater mitochondrial microstructure damage, when compared with the elderly patients without MAFLD. Conclusions. To conclude, our data revealed that MAFLD itself may aggravate the inflammatory state in elderly OPe people due to mitochondrial homeostasis imbalance of peripheral blood macrophages. Damaged monocyte-macrophages might trigger attenuation of the walking ability of OPe patients.

Chronic lead exposure induces fatty liver disease associated with the variations of gut microbiota

BACKGROUND

Lead (Pb) has been suggested as an endocrine-disrupting chemical. However, few studies have investigated the association between chronic Pb exposure and fatty liver disease.

OBJECTIVES

We aimed to investigate the association of chronic Pb exposure with fatty liver disease and whether the variations of the gut microbiota involve in the mechanism of the fatty liver disease induced by chronic Pb exposure.

METHODS

We conducted a cross-sectional study of 3066 rural participants in East China. Blood lead level (BLL) was detected, and abdominal ultrasonography was used to diagnose hepatic steatosis. Both the definition of non-alcoholic fatty liver disease (NAFLD) and metabolic dysfunction-associated fatty liver disease (MAFLD) were used. Wistar rats were randomly divided into two groups and each group was exposed to 0 or 0.05% w/v Pb through drinking water for 28 weeks. The relevant parameters of hepatic lipid metabolism and gut microbiota were analyzed.

RESULTS

In humans, after adjusting for potential confounders, the odds of having NAFLD and MAFLD were significantly increased by 54% and 52% in the participants in the fourth BLL quartile (OR 1.54, 95% CI 1.24, 1.91 and OR 1.52, 95% CI 1.22, 1.89). In the rats, chronic Pb exposure induced the increased visceral fat, hepatic steatosis, and dysbiosis of the gut microbiota, including the decrease of richness, diversity, evenness and phylogenetic diversity of the gut microbiota and the significant alternations of the gut microbiota composition, particularly, the decrease of the relative abundance of Coprococcus and Oscillospira at the genus level.

CONCLUSIONS

Chronic Pb exposure could induce fatty liver disease, which may be associated with the variations of the gut microbiota.

Physical activity and diet quality in relation to non-alcoholic fatty liver disease: A cross-sectional study in a representative sample of U.S. adults using NHANES 2017-2018

The association of physical activity (PA) and diet quality with non-alcoholic fatty liver disease (NAFLD) and NAFLD-related fibrosis have never been examined in a representative sample of U.S. adults using a more precise form of measuring NAFLD. The purpose of this study was to assess the associations of PA and diet quality (Healthy Eating Index [HEI]-2015) with NAFLD and a subset with advanced fibrosis (F3-4) as assessed by vibration-controlled transient elastography with controlled attenuation parameter in a representative sample of U.S. adults. This cross-sectional analysis uses data from 2017-2018 National Health and Nutrition Examination Survey. NAFLD was defined as controlled attenuation parameter ≥285 dB/m, and high likelihood of advanced fibrosis as liver stiffness measurements ≥8.6 kPa. Associations of HEI-2015 from 24-h dietary recalls and self-reported PA and sedentary behavior were estimated in multivariable-adjusted logistic regression models of NAFLD and advanced fibrosis. In 2892 adults, the prevalence of NAFLD and advanced fibrosis was 35.6% and 5.6%, respectively. We found that high adherence to U.S. dietary recommendations (highest vs. lowest HEI-2015 tertile) and more PA (middle tertile vs. lowest) were associated with reduced odds of NAFLD (Adjusted OR and 95% CI; 0.60 (0.44, 0.84) and 0.65 (0.42, 0.99), respectively). More PA was inversely associated with advanced fibrosis (Adjusted OR = 0.35, 95%CI 0.16, 0.75). Diet quality and PA are associated with reduced odds of NAFLD, and PA may be critical even for those with advanced liver disease. These behaviors should be the focus of targeted public health interventions.

Associations of Uric Acid With Liver Steatosis and Fibrosis Applying Vibration Controlled Transient Elastography in the United States: A Nationwide Cross-Section Study

BACKGROUND AND OBJECTIVE

Serum uric acid (UA) is related to many metabolic diseases. However, the association of UA with liver diseases was not very clear. The objective of this study is to clarify the relationship of UA with liver steatosis and fibrosis.

METHODS

This is a cross-sectional study of 4364 people of National Health and Nutrition Examination Survey (NHANES) 2017-2018. Liver steatosis and fibrosis were assessed by controlled attenuation parameter (CAP) and liver stiffness measurements (LSM) using Vibration-controlled transient elastography (VCTE). Linear and logistic regressions were performed.

RESULTS

After adjusting for potential confounders, UA levels were associated with the prevalence of liver steatosis [OR=2.097 (95%CI: 1.245, 3.534)] and liver fibrosis [OR=2.983 (95%CI: 1.797, 4.952)]. Furthermore, the results were consistent in the subgroup analyses of males and females.

CONCLUSIONS

UA levels were positively associated with the prevalence of liver steatosis and fibrosis.

Association of Metabolic Dysfunction-Associated Fatty Liver Disease and Liver Stiffness With Bone Mineral Density in American Adults

CONTEST

The relationship between metabolic dysfunction-associated fatty liver disease (MAFLD) and liver stiffness and bone mineral density (BMD) remains unclear.

OBJECTIVES

We aimed to investigate the association between MAFLD and liver stiffness and BMD in the United States population.

METHODS

A cross-sectional study among 2031 participants over 50 years old in the National Health and Nutrition Examination Survey (NHANES) 2017-2018 was performed. All patients underwent vibration controlled transient elastography (VCTE) and dual-energy x-ray absorptiometry (DXA). The linear and logistic regression model were used to analyze the association between the MAFLD and liver stiffness and osteoporosis, with adjustments for known covariates. Furthermore, the sensitive analyses were conducted to explore the relationship between MAFLD and liver stiffness and whole osteoporosis (include femoral and lumbar osteoporosis).

RESULTS

MAFLD was prevalent in the study population, with a prevalence of 50.9% for men and 40.7% for women. The multiple linear models demonstrated positive associations between MAFLD and liver stiffness and total femur BMD, femur neck BMD, trochanter BMD, intertrochanter BMD. In multiple logistic regression models, both MAFLD and significant liver fibrosis were negatively associated with femoral osteoporosis (OR=0.41, 95% CI: 0.27 to 0.63; OR=0.67, 95% CI: 0.33-1.37, respectively). Nonetheless, when BMI was adjusted, the association between MAFLD and liver stiffness and osteoporosis became insignificant. Besides, as showed in the sensitive analyses, the relationship between MAFLD and liver stiffness and whole osteoporosis were stable.

CONCLUSIONS

These results suggest that MAFLD and liver stiffness were associated with higher femoral and lumbar bone mineral density in individuals aged over 50 years. But the results may be confounded by BMI.