Association between the Fatty Liver Index and Risk of Type 2 Diabetes in the EPIC-Potsdam Study

Common Denominator of MASLD and Some Non-Communicable Diseases

Currently, steatohepatitis has been designated as metabolic dysfunction-associated steatohepatitis (MASLD). MASLD risk factors mainly include metabolic disorders but can also include genetic, epigenetic, and environmental factors. Disease entities such as obesity, diabetes, cardiovascular disease, and MASLD share similar pathomechanisms and risk factors. Moreover, a bidirectional relationship is observed between the occurrence of certain chronic diseases and MASLD. These conditions represent a global public health problem that is responsible for poor quality of life and high mortality. It seems that paying holistic attention to these problems will not only help increase the chances of reducing the incidence of these diseases but also assist in the prevention, treatment, and support of patients.

Exploring the interconnected between type 2 diabetes mellitus and nonalcoholic fatty liver disease: Genetic correlation and Mendelian randomization analysis

Epidemiological and clinical studies have indicated a higher risk of nonalcoholic fatty liver disease (NAFLD) and type 2 diabetes mellitus (T2DM), implying a potentially shared genetic etiology, which is still less explored. Genetic links between T2DM and NAFLD were assessed using linkage disequilibrium score regression and pleiotropic analysis under composite null hypothesis. European GWAS data have identified shared genes, whereas SNP-level pleiotropic analysis under composite null hypothesis has explored pleiotropic loci. generalized gene-set analysis of GWAS data determines pleiotropic pathways and tissue enrichment using eQTL mapping to identify associated genes. Mendelian randomization analysis was used to investigate the causal relationship between NAFLD and T2DM. Linkage disequilibrium score regression analysis revealed a strong genetic correlation between T2DM and NAFLD, and identified 24 pleiotropic loci. These single-nucleotide polymorphisms are primarily involved in biosynthetic regulation, RNA biosynthesis, and pancreatic development. generalized gene-set analysis of GWAS data analysis revealed significant enrichment in multiple brain tissues. Gene mapping using these 3 methods led to the identification of numerous pleiotropic genes, with differences observed in liver and kidney tissues. These genes were mainly enriched in pancreas, brain, and liver tissues. The Mendelian randomization method indicated a significantly positive unidirectional causal relationship between T2DM and NAFLD. Our study identified a shared genetic structure between NAFLD and T2DM, providing new insights into the genetic pathogenesis and mechanisms of NAFLD and T2DM comorbidities.

Longitudinal Outcomes Associated With Metabolic Dysfunction-Associated Steatotic Liver Disease: A Meta-analysis of 129 Studies

BACKGROUND & AIMS

The progression of metabolic dysfunction-associated steatotic liver disease (MASLD) has been found to manifest in a series of hepatic and extrahepatic complications. A comprehensive meta-analysis of the longitudinal outcomes associated with MASLD has yet to be conducted.

METHODS

To investigate the longitudinal outcomes associated with MASLD, Medline and Embase databases were searched to identify original studies that evaluated the longitudinal risks of incident clinical outcomes among MASLD patients compared with non-MASLD individuals. DerSimonian Laird random-effects meta-analysis was performed. Pooled effect estimates were calculated, and heterogeneity among studies was evaluated.

RESULTS

One hundred twenty-nine studies were included in the meta-analysis. Meta-analysis revealed a significant increase in the risk of cardiovascular outcomes (hazard ratio [HR], 1.43; 95% confidence interval [CI], 1.27-1.60; P < .01), various metabolic outcomes such as incident hypertension (HR, 1.75; 95% CI, 1.46-2.08; P < .01), diabetes (HR, 2.56; 95% CI, 2.10-3.13; P < .01), pre-diabetes (HR, 1.69; 95% CI, 1.22-2.35; P < .01), metabolic syndrome (HR, 2.57; 95% CI, 1.13-5.85; P = .02), chronic kidney disease (HR, 1.38; 95% CI, 1.27-1.50; P < .01), as well as all cancers (HR, 1.54; 95% CI, 1.35-1.76; P < .01) among MASLD patients compared with non-MASLD individuals. By subgroup analysis, MASLD patients with advanced liver disease (HR, 3.60; 95% CI, 2.10-6.18; P < .01) were also found to be associated with a significantly greater risk (P = .02) of incident diabetes than those with less severe MASLD (HR, 1.63; 95% CI, 1.0-2.45; P = .02) when compared with non-MASLD.

CONCLUSIONS

The present study emphasizes the association between MASLD and its clinical outcomes including cardiovascular, metabolic, oncologic, and other outcomes. The multisystemic nature of MASLD found in this analysis requires treatment targets to reduce systemic events and end organ complications.

Carbon Dioxide (CO2) Dietary Emissions Are Related to Oxidative and Inflammatory Status in Adult Population

BACKGROUND

Carbon dioxide (CO2) is a primary greenhouse gas (GHG) causing global temperature to rise. Unsustainable diets induce an increment in the risk of obesity and noncommunicable diseases but also contribute to the global GSG burden.

OBJECTIVE

To assess whether CO2 dietary emissions influence the inflammatory and oxidative status of subjects with metabolic syndrome (MetS).

METHODS

As part of the PREDIMED-Plus study, 100 adults (55-75 years old) from the Balearic Islands, Spain, were recruited and classified according to their dietary CO2 emissions. Anthropometric parameters were determined, fasting blood samples were collected and plasma, neutrophils, and peripheral blood mononuclear cells (PBMCs) were obtained. Dietary inflammatory index (DII), adherence to a Mediterranean diet (ADM), fatty liver index (FLI), and estimated glomerular filtration (eGFR) were calculated. Clinical biochemical parameters, blood count, and oxidative stress and inflammatory biomarker levels were also determined.

RESULTS

DII was higher in participants with high dietary CO2 emissions. Adherence to the MedDiet was inversely associated with CO2 emissions. Malondialdehyde (MDA) levels were higher in urine and plasma samples from subjects with high dietary CO2 emissions. Reactive oxygen species (ROS) production by PBMCs was greater in participants with high CO2 emissions. Interleukin-15, resistin, and leptin plasma levels were increased in participants with high dietary CO2 emissions.

CONCLUSION

Dietary CO2 emissions influence oxidative status and inflammation in relation to the increased prooxidative and proinflammatory status in PBMCs and plasma. These biomarkers were useful for monitoring diet sustainability and health.

Fatty Liver Change in Older Adults as an Important Risk Factor for Type 2 Diabetes: A Nationwide Cohort Study

OBJECTIVE

To examine the association between changes in fatty liver disease (FLD) over time and the risk of type 2 diabetes in elderly individuals with prediabetes.

METHODS

A total of 156,984 elderly individuals with prediabetes who underwent national health screening in 2009 and 2011 were followed up through December 31, 2019. The FLD status was defined as a change in the fatty liver index. Prediabetes was defined as impaired fasting glucose levels at baseline. Multivariable Cox proportional hazards regression was used to calculate the hazard ratio and CIs for type 2 diabetes according to the changes in FLD.

RESULTS

During a median of 8.35 years of follow-up, type 2 diabetes developed in 29,422 (18.7%) elderly individuals with prediabetes. Multivariable adjusted hazard ratio of type 2 diabetes according to FLD change was 2.22 (95% CI, 2.11 to 2.34) in individuals with persistent FLD compared with those who have never had FLD. Although overall weight loss of 5% or more was associated with a 7% lower risk of type 2 diabetes in total participants, fatty liver status was important. Even with weight loss, those with a history of fatty liver-resolved FLD, new FLD, or persistent FLD-had an increased risk of type 2 diabetes. The risk of type 2 diabetes did not increase in individuals with sustained FLD-free status, regardless of weight change.

CONCLUSION

The presence and change of FLD are important factors for the development of type 2 diabetes in elderly individuals with prediabetes.

The association between fatty liver index and onset of diabetes: secondary analysis of a population-based cohort study

BACKGROUND

According to research, the fatty liver index (FLI) is associated with diabetes. However, few studies have been conducted to investigate the relationship between FLI and diabetes risk from various perspectives. This study comprehensively investigated the relationship between FLI and incident diabetes in a large Japanese population.

METHODS

This retrospective cohort study included 14,280 participants from Murakami Memorial Hospital in Japan from 2004 to 2015. The independent and dependent variables are FLI and risk of type 2 diabetes mellitus (T2DM), respectively. To examine the link between FLI and incident T2DM, Cox proportional-hazards regression was employed. In addition, we performed a number of sensitivity studies to guarantee the validity of the results. Moreover, we conducted subgroup analyses.

RESULTS

After adjusting covariates, the results showed that FLI was positively associated with the risk of T2DM (HR = 1.019, 95%CI: 1.012, 1.025). Additionally, the sensitivity analysis showed how reliable the outcomes were. And a stronger association between FLI and incident T2DM was observed in the regular exercisers (HR = 1.036, 95%CI: 1.019-1.053, P < 0.0001) and the population without ethanol consumption (HR = 1.028, 95%CI: 1.017-1.039, P < 0.0001). Besides, receiver operating characteristic (ROC) curve analysis showed that FLI was better than waist circumference, triglycerides, body mass index, and gamma-glutamyl transferase in predicting incident T2DM.

CONCLUSION

FLI is positively associated with incident T2DM.

Fatty Liver Disease in Patients with Prediabetes and Overweight or Obesity

Non-alcoholic fatty liver disease (NAFLD) is a global health problem associated with liver morbimortality, obesity, and type 2 diabetes mellitus. This study aimed to analyze the prevalence of NAFLD (defined as a fatty liver index [FLI] ≥ 60) and its association with other cardiovascular risk (CVR) factors in patients with prediabetes and overweight/obesity. The present cross-sectional analysis uses baseline data from an ongoing randomized clinical trial. Sociodemographic and anthropometric characteristics, CVR (assessed by the REGICOR-Framingham risk equation), metabolic syndrome (MetS), and FLI-defined NAFLD (cut-off value of ≥60) were assessed. The prevalence of FLI-defined NAFLD was 78% overall. Men exhibited a worse cardiometabolic profile as compared to women, specifically, with higher values of systolic blood pressure (137.02 ± 13.48 vs. 131.22 ± 14.77 mmHg), diastolic blood pressure (85.33 ± 9.27 vs. 82.3 ± 9.12 mmHg), aspartate aminotransferase (AST) (27.23 ± 12.15 vs. 21.23 ± 10.05 IU/L), alanine aminotransferase (ALT) (34.03 ± 23.31 vs. 21.73 ± 10.80 IU/L), and higher CVR (5.58 ± 3.16 vs. 3.60 ± 1.68). FLI-defined NAFLD was associated with elevated AST, ALT, and the presence of MetS (73.7%) and CVR for the whole sample. People with prediabetes present a high burden of comorbidities related to CVR, despite clinical follow-up, and it is recommended to actively begin working with them to reduce their risks.

Identifying risk factors of developing type 2 diabetes from an adult population with initial prediabetes using a Bayesian network

Background

It is known that people with prediabetes increase their risk of developing type 2 diabetes (T2D), which constitutes a global public health concern, and it is associated with other diseases such as cardiovascular disease.

Methods

This study aimed to determine those factors with high influence in the development of T2D once prediabetes has been diagnosed, through a Bayesian network (BN), which can help to prevent T2D. Furthermore, the set of features with the strongest influences on T2D can be determined through the Markov blanket. A BN model for T2D was built from a dataset composed of 12 relevant features of the T2D domain, determining the dependencies and conditional independencies from empirical data in a multivariate context. The structure and parameters were learned with the bnlearn package in R language introducing prior knowledge. The Markov blanket was considered to find those features (variables) which increase the risk of T2D.

Results

The BN model established the different relationships among features (variables). Through inference, a high estimated probability value of T2D was obtained when the body mass index (BMI) was instantiated to obesity value, the glycosylated hemoglobin (HbA1c) to more than 6 value, the fatty liver index (FLI) to more than 60 value, physical activity (PA) to no state, and age to 48-62 state. The features increasing T2D in specific states (warning factors) were ranked.

Conclusion

The feasibility of BNs in epidemiological studies is shown, in particular, when data from T2D risk factors are considered. BNs allow us to order the features which influence the most the development of T2D. The proposed BN model might be used as a general tool for prevention, that is, to improve the prognosis.

Predicting Factors for Metabolic Non-Response to a Complex Lifestyle Intervention-A Replication Analysis to a Randomized-Controlled Trial

BACKGROUND

T2DM heterogeneity affects responsiveness to lifestyle treatment. Beta-cell failure and nonalcoholic fatty liver disease (NAFLD) independently predict T2DM, but NAFLD inconsistently predicts metabolic response to lifestyle intervention.

AIM

We attempt to replicate a prediction model deducted from the Tübinger Lifestyle Intervention Program by assessing similar metabolic factors to predict conversion to normal glucose regulation (NGR) in a comparable lifestyle intervention trial.

METHODS

In the Optimal Fiber Trial (OptiFiT), 131 Caucasian participants with prediabetes completed a one-year lifestyle intervention program and received a fiber or placebo supplement. We compared baseline parameters for responders and non-responders, assessed correlations of major metabolic changes and conducted a logistic regression analysis for predictors of remission to NGR.

RESULTS

NGR was achieved by 33 participants, respectively. At baseline, for the placebo group only, 1 h and 2 h glucose levels, glucose AUC and Cederholm index predicted conversion to NGR. HOMA-beta, HOMA-IR or liver fat indices did not differ between responders and non-responders of the placebo or the fiber group. Changes in waist circumference or fatty liver index correlated with changes in glycemia and insulin resistance, but not with changes in insulin secretion. Insulin-resistant NAFLD did not predict non-response. Differences in compliance did not explain the results.

CONCLUSIONS

Higher post-challenge glucose levels strongly predicted the metabolic non-response to complex lifestyle intervention in our cohort. Depending on the specific intervention and the investigated cohort, fasting glucose levels and insulin sensitivity might contribute to the risk pattern. Beta-cell function did not improve in accordance with other metabolic improvements, qualifying as a potential risk factor for non-response. We could not replicate previous data suggesting that an insulin-resistant fatty liver is a specific risk factor for treatment failure. Replication studies are required.

Sex and age differences in the association of fatty liver index-defined non-alcoholic fatty liver disease with cardiometabolic risk factors: a cross-sectional study

Background

Despite the extensive scientific evidence accumulating on the epidemiological risk factors for non-alcoholic fatty liver disease (NAFLD), evidence exploring sex- and age-related differences remains insufficient. The present cross-sectional study aims to investigate possible sex differences in the prevalence of FLI-defined NAFLD as well as in its association with common risk factors across different age groups, in a large sample of Spanish working adults.

Methods

This cross-sectional study included data from 33,216 Spanish adult workers (18–65 years) randomly selected during voluntary routine occupational medical examinations. Sociodemographic characteristics (age and social class), anthropometric (height, weight, and waist circumference) and clinical parameters (blood pressure and serum parameters) were collected. NAFLD was determined by the validated fatty liver index (FLI) with a cut-off value of ≥ 60. The presence of metabolic syndrome (MetS) was assessed according to the diagnostic criteria of the International Diabetes Federation. Cardiovascular risk was determined using the REGICOR-Framingham equation. The association between FLI-defined NAFLD and risk factors by sex and age was evaluated by multivariate logistic regression.

Results

The prevalence of FLI-defined NAFLD (FLI ≥ 60) was 19.1% overall, 27.9% (95% CI 23.3–28.5%) for men and 6.8% (95% CI 6.4–7.3%) for women and increasing across age intervals. As compared to women, men presented worse cardiometabolic and anthropometric profiles. The multivariate analysis model showed that hepatic steatosis assessed by FLI was strongly associated with age, HDL-cholesterol, social class, prediabetes, diabetes, prehypertension, hypertension, and smoking status for both men and women. The association between diabetes and hypertension with FLI-defined NAFLD was stronger in women than in men at both univariate and multivariate analyses.

Conclusions

Men presented a higher prevalence of NAFLD than women across all age intervals, as well as a worse cardiometabolic profile and a higher cardiovascular risk. Nevertheless, the association between FLI-defined NAFLD and diabetes or hypertension was significantly stronger in women than in men, possibly indicating that the presence of a dysmetabolic state might affect women more than men with regard to liver outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13293-022-00475-7.

There is a lack of evidence exploring sex- and age-related differences on the epidemiological risk factors for non-alcoholic fatty liver disease.

In our sample, hepatic steatosis assessed by FLI is more prevalent in men than women and is associated with age, lower social class and a dysmetabolic state characterized by prediabetes or diabetes, prehypertension or hypertension and low HDL-cholesterol.

Importantly, we observed that although FLI-defined NAFLD is strongly associated with cardiometabolic imbalances in both sexes, its association with diabetes and hypertension is stronger in women than in men, regardless of age.

We also observed that such association in women is evident even at stages preceding diabetes and hypertension and at younger ages.

Retinol and Retinol Binding Protein 4 Levels and Cardiometabolic Disease Risk

BACKGROUND

Despite mechanistic studies linking retinol and RBP4 (retinol binding protein 4) to the pathogenesis of cardiovascular diseases (CVD) and type 2 diabetes (T2D), epidemiological evidence is still conflicting. We investigated whether conflicting results of previous studies may be explained by differences in the association of retinol and RBP4 with cardiometabolic risk across subgroups with distinct sex, hypertension state, liver, or kidney function.

METHODS

We used case-cohorts nested in the EPIC (European Prospective Investigation Into Cancer and Nutrition)-Potsdam cohort (N=27 548) comprising a random sample of participants (n=2500) and all physician-verified cases of incident CVD (n=508, median follow-up time 8.2 years) and T2D (n=820, median follow-up time 6.3 years). We estimated nonlinear and linear multivariable-adjusted associations between the biomarkers and cardiometabolic diseases by restricted cubic splines and Cox regression, respectively, testing potential interactions with hypertension, liver, and kidney function. Additionally, we performed 2-sample Mendelian Randomization analyses in publicly available data.

RESULTS

The association of retinol with cardiometabolic risk was modified by hypertension state (P interaction CVD<0.001; P interaction T2D<0.001). Retinol was associated with lower cardiometabolic risk in participants with treated hypertension (hazard ratio_{per SD} [95% CI]: CVD, 0.71 [0.56-0.90]; T2D, 0.81 [0.70-0.94]) but with higher cardiometabolic risk in normotensive participants (CVD, 1.32 [1.06-1.64]; T2D, 1.15 [0.98-1.36]). Our analyses also indicated a significant interaction between RBP4 and hypertension on CVD risk (P interaction=0.04). Regarding T2D risk, we observed a u-shaped association with RBP4 in women (P nonlinearity=0.01, P effect=0.02) and no statistically significant association in men. The biomarkers' interactions with liver or kidney function were not statistically significant. Hypertension state-specific associations for retinol concentrations with cardiovascular mortality risk were replicated in National Health and Nutrition Examination Survey III.

CONCLUSIONS

Our findings suggest a hypertension-dependent relationship between plasma retinol and cardiometabolic risk and complex interactions of RBP4 with sex and hypertension on cardiometabolic risk.

Dihydroceramide- and ceramide-profiling provides insights into human cardiometabolic disease etiology

Metabolic alterations precede cardiometabolic disease onset. Here we present ceramide- and dihydroceramide-profiling data from a nested case-cohort (type 2 diabetes [T2D, n = 775]; cardiovascular disease [CVD, n = 551]; random subcohort [n = 1137]) in the prospective EPIC-Potsdam study. We apply the novel NetCoupler-algorithm to link a data-driven (dihydro)ceramide network to T2D and CVD risk. Controlling for confounding by other (dihydro)ceramides, ceramides C18:0 and C22:0 and dihydroceramides C20:0 and C22:2 are associated with higher and ceramide C20:0 and dihydroceramide C26:1 with lower T2D risk. Ceramide C16:0 and dihydroceramide C22:2 are associated with higher CVD risk. Genome-wide association studies and Mendelian randomization analyses support a role of ceramide C22:0 in T2D etiology. Our results also suggest that (dh)ceramides partly mediate the putative adverse effect of high red meat consumption and benefits of coffee consumption on T2D risk. Thus, (dihydro)ceramides may play a critical role in linking genetic predisposition and dietary habits to cardiometabolic disease risk.

Long-term effects of the changes in hepatic steatosis status on the risk of incident type 2 diabetes mellitus: A 15-year community-based prospective cohort study

AIMS

We investigated the long-term effect of changes in hepatic steatosis on the risk of developing T2DM.

METHODS

We evaluated 3510 participants from the 2001-2016 Korean Genome and Epidemiology Study. Those with significant alcohol consumption or T2DM during 2001-2004 were excluded. Steatosis was defined as non-alcoholic fatty liver disease-liver fat score (NAFLD-LFS) of over -0.64, and baseline values were assessed between 2001 and 2002. Differences in NAFLD-LFS (ΔLFS) and changes in steatosis status (no, intermittent [resolved or incident], and persistent steatosis) were assessed between 2003 and 2004. Changes in the risk of diabetes status were observed until 2016.

RESULTS

Over 52,650 person-years of follow-up, T2DM developed in 296 participants (8.4%). The incidence of diabetes in those with no steatosis, intermittent steatosis, and persistent steatosis during follow-up increased by 5.1%, 14.1%, and 27.1% respectively. Multivariate-adjusted analysis revealed that the risk was higher in those with persistent steatosis than those with no steatosis and intermittent steatosis. Baseline NAFLD-LFS and ΔLFS was associated with increased risk of incident T2DM.

CONCLUSIONS

Initial severity as well as aggravation of steatosis is an independent predictor of incident T2DM. Strategies aimed at reducing liver fat may prevent future development of diabetes among patients with NAFLD.

Non-alcoholic Fatty Liver Disease and the Risk of Incident Atrial Fibrillation in Young Adults: A Nationwide Population-Based Cohort Study

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is a multisystem disease including cardiovascular. However, the association between NAFLD and the risk of incident atrial fibrillation (AF), especially in young adults, remains unclear. We aimed to evaluate the association between NAFLD as assessed by the fatty liver index (FLI) and the risk of AF in young adults.

METHODS

We identified individuals aged 20-39 years who underwent health examinations conducted by the Korean National Health Insurance Corporation between January 2009 and December 2012. Individuals with significant liver disease, heavy alcohol consumption, or prevalent AF were excluded. We categorized based on FLI: <30, 30 to <60, and ≥60. Incident AF was evaluated as the primary outcome.

RESULTS

We included 5,333,907 subjects (mean age, 31 ± 5 years; men, 57%). During a mean follow-up of 7.4 ± 1.1 years, 12,096 patients had newly diagnosed AF (incidence rate 0.31 per 1,000 person-years). After adjustment, subjects with FLI 30 to <60 and FLI ≥60 showed a higher risk of AF compared to those with FLI <30 (hazard ratio [HR] 1.21, 95% confidence interval [CI, 1.15-1.27] and HR 1.47, 95% CI [1.39-1.55], p < 0.001, respectively). In women, the increased AF risk was accentuated in the higher FLI group than in the individuals with FLI <30, compared with men (p-for-interaction = 0.023). A higher incident AF risk in the higher FLI groups was consistently observed in various subgroups.

CONCLUSION

Among young adults, NAFLD assessed using FLI was positively correlated with the AF risk. These findings support the evidence of AF screening in young adults with high FLI scores.

Circulating PCSK7 Level is Independently Associated with Obesity, Triglycerides Level and Fatty Liver Index in a General Population without Medication

AIM

Dyslipidemia and altered iron metabolism are typical features of non-alcoholic fatty liver disease (NAFLD). Proprotein convertase subtilisin/kexin type 7 (PCSK7), a transmembrane-anchored endonuclease, is associated with triglycerides level and processing of transferrin receptor 1. However, the significance of circulating PCSK7 has not been fully addressed, though prosegment PCSK7 is secreted from cells. We investigated the associations of plasma PCSK7 level with several parameters.

METHODS

Plasma PCSK7 concentration was measured in 282 subjects (male/female: 126/156) without medication of the Tanno-Sobetsu Study, a population-based cohort study.

RESULTS

There was no significant sex difference in PCSK7 level. Current smoking habit, but not alcohol drinking habit, was associated with increased PCSK7 level. PCSK7 concentration was negatively correlated with age and blood urea nitrogen and was positively correlated with body mass index (BMI) and levels of γ-glutamyl transpeptidase (γGTP), triglycerides and fatty liver index (FLI), which is calculated by BMI, waist circumference and levels of γGTP and triglycerides, as a noninvasive and simple predictor of NAFLD. There were no significant correlations of PCSK7 level with levels of iron and plasma PCSK9, a secreted PCSK family member and a regulator of low-density lipoprotein cholesterol level. Multivariable regression analyses after adjustment of age, sex and current smoking habit showed that PCSK7 concentration was independently associated with BMI (β=0.130, P=0.035), triglycerides (β=0.141, P=0.027) or FLI (β=0.139, P=0.030).

CONCLUSIONS

Plasma PCSK7 concentration is independently associated with chronic liver disease including obesity and elevated triglycerides level in a general population of individuals who had not regularly taken any medications.

Fatty liver index as a predictive marker for the development of diabetes: A retrospective cohort study using Japanese health check-up data

Background & aims

Fatty liver is associated with incident diabetes, and the fatty liver index (FLI) is a surrogate marker for non-alcoholic fatty liver disease (NAFLD). We aimed to determine whether or not FLI was associated with incident diabetes in relation to obesity and prediabetic levels in the general Japanese population.

Methods

This was a retrospective study using the Japanese health check-up database of one health insurance from FY2015 to FY2018. This study included 28,991 individuals with prediabetes. First, we stratified all participants into two groups: “high-risk,” comprising patients with HbA1c >6.0%, and “standard,” comprising the rest. Subsequently, we divided them into four groups according to FLI (<30 or not) and obesity (BMI <25 kg/m² or not). Subsequently, the incidence rate of diabetes was compared among the groups after 3 years of follow-up using multiple logistic regression models after adjusting for potential confounders.

Results

After 3 years of follow-up, 1,547 new cases of diabetes were found, and the cumulative incidence was 2.96% for the standard group and 26.1% for the high-risk group. In non-obese individuals, odds ratios (95% confidence interval) for FLI ≥30 versus FLI <30 were: 1.44 (1.09–1.92) for the standard group and 1.42 (0.99–2.03) for the high-risk group. In the high-risk group, obesity (BMI ≥25 kg/m²) but FLI <30 was not a risk factor for developing diabetes.

Conclusion

Although high FLI is generally considered to be a risk factor for developing diabetes, obesity might have been a confounding factor. However, the present study showed that high FLI is a risk factor for the development of diabetes, even in non-obese individuals. Our results include suggestion to develop a screening tool to effectively identify people at high risk of developing diabetes from the population (especially non-obese prediabetes) who are apparently at low health risk and are unlikely to be targeted for health guidance.

Fatty liver index and progression to type 2 diabetes: a 5-year longitudinal study in Spanish workers with pre-diabetes

OBJECTIVE

The main aim of the study was to evaluate the association between non-alcoholic fatty liver disease (NAFLD), estimated by fatty liver index (FLI), and the development of type 2 diabetes (T2D) in a large cohort of adult workers with pre-diabetes.

DESIGN

Prospective cohort study.

SETTING

Occupational health services from Spain.

PARTICIPANTS

16 648 adult workers (aged 20-65 years) with pre-diabetes (fasting plasma glucose (FPG) of 100-125 mg/dL).

OUTCOME AND MEASURES

FLI was calculated based on measurements of triglycerides, body mass index, waist circumference and γ-glutamyltransferase. The population was classified into three categories: FLI<30 (no hepatic steatosis), FLI 30-60 (intermediate status) and FLI>60 (hepatic steatosis). Sociodemographic, anthropometric, dietary habits, physical activity and clinical data were collected from all subjects. The incidence rate of T2D was determined after 5 years of follow-up.

RESULTS

After 5 years of follow-up, 3706 of the 16 648 participants (22.2%) were diagnosed with T2D, corresponding to an annual rate of progression of 4.5%. FLI was strongly associated with T2D conversion. The incidence rates of T2D in the FLI<30, FLI 30-60 and FLI>60 groups were significantly different after 5 years of follow-up were 19/6,421 (0.3%), 338/4,318 (7.8%) and 3,349/5,909 (56.7%), respectively. This association remained significant for FLI>60 after adjustment for, age, diet, physical activity, FPG, blood pressure, social class and smoking habits (adjusted HR=6.879; 95% CI 5.873 to 8.057 for men, and HR=5.806; 95% CI 4.863 to 6.932 for women).

CONCLUSION

NAFLD assessed by FLI independently predicted the risk of conversion to T2D among people with pre-diabetes. FLI may be an easily determined and valuable early predictor for T2D in people with pre-diabetes. FLI-based assessment of NAFLD in subjects with pre-diabetes in routine clinical practice could allow the adoption of effective measures to prevent and reduce their progression to T2D.

Fatty liver index as a predictor for type 2 diabetes in subjects with normoglycemia in a nationwide cohort study

Our aim was to evaluate whether fatty liver index (FLI) is associated with the risk of type 2 diabetes (T2DM) development within the Spanish adult population and according to their prediabetes status; additionally, to examine its incremental predictive value regarding traditional risk factors. A total of 2260 subjects (Prediabetes: 641 subjects, normoglycemia: 1619 subjects) from the Di@bet.es cohort study were studied. Socio-demographic, anthropometric, clinical data and survey on habits were recorded. An oral glucose tolerance test was performed and fasting determinations of glucose, lipids and insulin were made. FLI was calculated and classified into three categories: Low (< 30), intermediate (30–60) and high (> 60). In total, 143 people developed diabetes at follow-up. The presence of a high FLI category was in all cases a significant independent risk factor for the development of diabetes. The inclusion of FLI categories in prediction models based on different conventional T2DM risk factors significantly increase the prediction power of the models when all the population was considered. According to our results, FLI might be considered an early indicator of T2DM development even under normoglycemic condition. The data also suggest that FLI could provide additional information for the prediction of T2DM in models based on conventional risk factors.

High level of fatty liver index predicts new onset of diabetes mellitus during a 10-year period in healthy subjects

Fatty liver index (FLI), a predictor of nonalcoholic fatty liver disease, has been reported to be associated with several metabolic disorders. This study aimed to evaluate the relationship between FLI and new onset of diabetes mellitus (DM). We investigated the association of FLI with new onset of DM during a 10-year period in subjects who received annual health examinations (n = 28,990). After exclusion of subjects with DM at baseline and those with missing data, a total of 12,290 subjects (male/female: 7925/4365) who received health examinations were recruited. FLI was significantly higher in males than in females. During the 10-year period, DM was developed in 533 males (6.7%) and 128 females (2.9%). Multivariable Cox proportional hazard models with a restricted cubic spline showed that the risk of new onset of DM increased with a higher FLI at baseline in both sexes after adjustment of age, fasting plasma glucose, habits of alcohol drinking and current smoking, family history of DM and diagnosis of hypertension and dyslipidemia at baseline. When the subjects were divided into subgroups according to tertiles of FLI level at baseline (T1–T3) in the absence and presence of impaired fasting glucose (IFG), hazard ratios after adjustment of the confounders gradually increased from T1 to T3 and from the absence to presence of IFG in both male and female subjects. In conclusion, a high level of FLI predicts new onset of DM in a general population of both male and female individuals.

Utility of Fatty Liver Index to predict reversion to normoglycemia in people with prediabetes

Background

Fatty Liver Index (FLI) is strongly associated with changes in glycemic status and incident Type 2 Diabetes (T2D). The probability of reverting to normoglycemia from a state prediabetes could be determined by FLI, however such relationship remains poorly understood.

Aim

To determine the clinical interest of using FLI to estimate prediabetes reversion at 5 years in patients with impaired fasting plasma glucose at baseline, and identify those factors associated with changes in FLI, that could contribute to the reversion of prediabetes.

Methods

This 5-year cohort study included 16,648 Spanish working adults with prediabetes. Prediabetes was defined as fasting plasma glucose (FPG) between 100 and 125 mg/dl according to the ADA criteria, while prediabetes reversion was defined as a FPG <100 mg/dL. The population was classified as: FLI <30 (no hepatic steatosis), FLI 30–59 (intermediate status), and FLI ≥60 (hepatic steatosis).

Results

At 5 years follow-up, 33.7% of subjects reverted to normoglycemia (annual rate of 6.7%). The adjusted binomial logistic regression model showed that scoring FLI <30 (OR 1.544; 95% CI 1.355–1.759), performing at least 150 min/week of physical activity (OR 4.600; 95% CI 4.088–5.177) and consuming fruits and vegetables daily (OR 1.682; 95% CI 1.526–1.855) were associated with the probability of reverting form prediabetes to normoglycemia. The ROC curve for prediction of reversion showed that FLI (AUC 0.774;95% CI 0.767–0.781) was a better predictor than FPG (AUC 0.656; 95% CI 0.648–0.664).

Conclusions

Regular physical activity, healthy dietary habits and absence of hepatic steatosis are independently associated with the probability of reversion to normoglycemia in adult workers with prediabetes at baseline. Low FLI values (especially FLI< 30) may be useful to predict the probability of prediabetes reversion, especially in active subjects with healthy eating habits, and thus identify those who might benefit from early lifestyle intervention.

NAFLD, Insulin Resistance, and Diabetes Mellitus Type 2

Nonalcoholic fatty liver disease is a condition defined by fat accumulation in hepatocytes not promoted by excessive alcohol consumption. It is highly prevalent and is strongly associated with insulin resistance, metabolic syndrome, and diabetes type II. Insulin resistance plays a crucial role in the multifactorial etiopathogenesis of this condition leading to accumulation of free fatty acids in the liver cells, thus causing lipotoxicity, inflammation, and fibrosis. In this review, we will focus on currently known pathogenesis of nonalcoholic fatty liver disease. Numerous investigation strategies are available to establish the diagnosis, from biochemical markers and ultrasound to various molecular and advanced imaging techniques and liver biopsy. Prevention is crucial. However, effective and promising therapies are strongly demanded.

Nonalcoholic fatty liver disease and the risk of atrial fibrillation stratified by body mass index: a nationwide population-based study

We evaluated the association between nonalcoholic fatty liver disease (NAFLD) and incident atrial fibrillation (AF) and analyzed the impact of NAFLD on AF risk in relation to body mass index (BMI). A total of 8,048,055 subjects without significant liver disease who were available fatty liver index (FLI) values were included. Subjects were categorized into 3 groups based on FLI: < 30, 30 to < 60, and ≥ 60. During a median 8-year of follow-up, 534,442 subjects were newly diagnosed as AF (8.27 per 1000 person-years). Higher FLI was associated with an increased risk of AF (hazard ratio [HR] 1.053, 95% confidence interval [CI] 1.046–1.060 in 30 ≤ FLI < 60, and HR 1.115, 95% CI 1.106–1.125 in FLI ≥ 60). In underweight subjects (BMI < 18.5 kg/m²), higher FLI raised the risk of AF (by 1.6-fold in 30 ≤ FLI < 60 and by twofold in FLI ≥ 60). In normal- and overweight subjects, higher FLI was associated with an increased risk of AF, but the HRs were attenuated. In obese subjects, higher FLI was not associated with higher risk of AF. NAFLD as assessed by FLI was independently associated with an increased risk of AF in nonobese subjects with BMI < 25 kg/m². The impact of NAFLD on AF risk was accentuated in lean subjects with underweight.

Fatty liver index and risk of diabetes incidence: A systematic review and dose-response meta-analysis of cohort studies

AIMS

Fatty Liver Index (FLI) is a surrogate index for diagnosis of Fatty Liver Disease (FLD). We performed a dose-response meta-analysis to investigate the relationship between FLI and diabetes incidence in prospective cohort studies.

METHODS

We conducted a systematic search of articles up to November 2019 in PubMed, SCOPUS, Cochrane library, and Embase. Hazard Ratios (HRs) with corresponding 95% confidence intervals (CIs) of studies were pooled using meta-analysis with DerSimonian and Laird random-effects models to find combined HRs. Dose-response effect of this relationship was also assessed.

RESULTS

Twenty-seven studies providing 70,918 participants were included in the meta-analysis. Pooled results showed that the highest category of FLI was associated with an increased incidence of diabetes [HR: 2.88, 95% CI: 2.18-3.81; P for heterogeneity: 0.001]. Subgroup analysis based on sex, continent, and the quality of study could not explain the source of heterogeneity. The pooled HR from the random-effects dose-response model indicated a significant association between FLI level and risk of diabetes incidence (Coef=0.0239, p=0.001).

CONCLUSION

Our dose-response meta-analysis revealed a direct relationship between FLI and HR of diabetes incidence.

Correlation of gut Firmicutes/Bacteroidetes ratio with fibrosis and steatosis stratified by body mass index in patients with non-alcoholic fatty liver disease

We investigated the gut microbiota in patients with non-alcoholic fatty liver disease (NAFLD) and its correlation with fibrosis and steatosis stratified by body mass index, as reflected in the controlled attenuation parameter and transient elastography values. A cross-sectional study was performed on 37 patients with NAFLD at Cipto Mangunkusumo National General Hospital from December 2018 to March 2019. The gut microbiota was investigated in fecal samples with 16S RNA sequencing using the MiSeq next-generation sequencing platform (Illumina). NAFLD was more common in patients with metabolic syndrome. Firmicutes, Bacteroidetes, and Proteobacteria were the predominant phyla. Bacteroides was more dominant than Prevotella, contrary to the results of previous studies on healthy populations in Indonesia. Microbiota dysbiosis was observed in most samples. The gastrointestinal microbiota diversity was significantly decreased in patients with NAFLD, high triglyceride levels, and central obesity. The Firmicutes/Bacteroidetes ratio correlated with steatosis and obesity, whereas some of the other species in lower taxonomy levels were mostly associated with steatosis and obesity without fibrosis. Proteobacteria was the only phylum strongly correlated with fibrosis in patients with an average body mass index. The gut microbiota diversity was decreased in patients with NAFLD, high triglyceride levels, and central obesity, and certain gut microbes were correlated with fibrosis and steatosis.

Combined effects of lifestyle risk factors on fatty liver index

Background

Factors of lifestyle may have a major impact on liver-related morbidity and mortality.

We examined independent and joint effects of lifestyle risk factors on fatty liver index (FLI), a biomarker of hepatic steatosis, in a population-based cross-sectional national health survey.

Methods

The study included 12,368 participants (5784 men, 6584 women) aged 25–74 years. Quantitative estimates of alcohol use, smoking, adiposity and physical activity were used to establish a total score of risk factors, with higher scores indicating an unhealthier lifestyle. FLI was calculated based on an algorithm including body mass index, waist circumference, serum gamma-glutamyltransferase and triglycerides.

Results

The occurrence of FLI ≥ 60% indicating fatty liver increased from 2.4% in men with zero risk factors to 81.9% in those with a total risk score of 7–8 (p <  0.0005 for linear trend) and in women from 0 to 73.5% (p <  0.0005). The most striking individual impacts on the likelihood for FLI above 60% were observed for physical inactivity (p <  0.0005 for both genders) and alcohol consumption (p <  0.0005 for men). Interestingly, coffee consumption was also found to increase with increasing risk factor scores (p <  0.0005 for linear trend in both genders).

Conclusions

The data indicates that unfavorable combinations of lifestyle risk factors lead to a high likelihood of hepatic steatosis. Use of FLI as a diagnostic tool may benefit the assessment of interventions aimed at maintaining a healthy lifestyle and prevention of liver-related morbidity.

Associations of short stature and components of height with incidence of type 2 diabetes: mediating effects of cardiometabolic risk factors

AIMS/HYPOTHESIS

This study aimed to evaluate associations of height as well as components of height (sitting height and leg length) with risk of type 2 diabetes and to explore to what extent associations are explainable by liver fat and cardiometabolic risk markers.

METHODS

A case-cohort study within the European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam study comprising 26,437 participants who provided blood samples was designed. We randomly selected a subcohort of 2500 individuals (2029 diabetes-free at baseline and with anamnestic, anthropometrical and metabolic data for analysis). Of the 820 incident diabetes cases identified in the full cohort during 7 years of follow-up, 698 remained for analyses after similar exclusions.

RESULTS

After adjustment for age, potential lifestyle confounders, education and waist circumference, greater height was related to lower diabetes risk (HR per 10 cm, men 0.59 [95% CI 0.47, 0.75] and women 0.67 [0.51, 0.88], respectively). Leg length was related to lower risk among men and women, but only among men if adjusted for total height. Adjustment for liver fat and triacylglycerols, adiponectin and C-reactive protein substantially attenuated associations between height and diabetes risk, particularly among women.

CONCLUSIONS/INTERPRETATION

We observed inverse associations between height and risk of type 2 diabetes, which was largely related to leg length among men. The inverse associations may be partly driven by lower liver fat content and a more favourable cardiometabolic profile.

[Predictive value of body mass index combined with waist circumference for new-onset nonalcoholic fatty liver disease in patients with type 2 diabetes mellitus]

OBJECTIVE

To investigate the predictive value of body mass index (BMI) combined with waist circumference (WC) for new-onset nonalcoholic fatty liver disease (NAFLD) in patients with type 2 diabetes mellitus (T2DM).

METHODS

This community-based prospective cohort study was conducted among 3501 T2DM patients without NAFLD recruited from the staff of Kailuan Company, who underwent routine physical examination in the year 2006 and 2007, and a total of 2920 subjects were included in the final analysis. According to the baseline BMI and WC, the subjects were divided into group A (with normal BMI and WC), group B (with normal BMI but elevated WC), group C (with elevated BMI but a normal WC) and group D (with elevated BMI and WC). The subjects in the 4 groups were followed for the occurrence of NAFLD by reviewing their reports of physical examinations during the periods of 2008-2009, 2010-2011, 2012-2013, 2014-2015 and 2016-2017. The cumulative incidence of NAFLD was compared across the 4 groups and Cox regression analysis was used to test the correlation of BMI and WC with new onset of NAFLD.

RESULTS

The cumulative incidence of NAFLD increased progressively in the 4 groups (50%, 66%, 68% and 77%, respectively). Cox regression analysis showed that compared with group A, groups B, C and D had increased risks of NAFLD after adjusting for age, gender and other risk factors, with HR values of 1.62, 1.98 and 2.47, respectively.

CONCLUSIONS

Elevated BMI and WC are both independent risk factors for NAFLD in type 2 diabetic patients, and the combination of BMI and WC has a greater predictive value for NAFLD than either of them alone.

Circulating total bilirubin and risk of non-alcoholic fatty liver disease in the PREVEND study: observational findings and a Mendelian randomization study

The relationship between circulating total bilirubin and incident non-alcoholic fatty liver disease (NAFLD) is uncertain. We aimed to assess the association of total bilirubin with the risk of new-onset NAFLD and investigate any causal relevance to the association using a Mendelian randomization (MR) study. Plasma total bilirubin levels were measured at baseline in the PREVEND prospective study of 3824 participants (aged 28–75 years) without pre-existing cardiovascular disease or NAFLD. Incident NAFLD was estimated using the biomarker-based algorithms, fatty liver index (FLI) and hepatic steatosis index (HSI). Odds ratios (ORs) (95% confidence intervals) for NAFLD were assessed. The genetic variant rs6742078 located in the UDP-glucuronosyltransferase (UGT1A1) locus was used as an instrumental variable. Participants were followed up for a mean duration of 4.2 years. The multivariable adjusted OR (95% CIs) for NAFLD as estimated by FLI (434 cases) was 0.82 (0.73–0.92; p = 0.001) per 1 standard deviation (SD) change in log_e total bilirubin. The corresponding adjusted OR (95% CIs) for NAFLD as estimated by HSI (452 cases) was 0.87 (0.78–0.97; p = 0.012). The rs6742078 variant explained 20% of bilirubin variation. The ORs (95% CIs) for a 1 SD genetically elevated total bilirubin level was 0.98 (0.69–1.38; p = 0.900) for FLI and 1.14 (0.81–1.59; p = 0.451) for HSI. Elevated levels of total bilirubin were not causally associated with decreased risk of NAFLD based on MR analysis. The observational association may be driven by biases such as unmeasured confounding and/or reverse causation. However, due to low statistical power, larger-scale investigations are necessary to draw definitive conclusions.

Fatty liver index as a predictor of increased risk of cardiometabolic disease: finding from the Kuopio Ischaemic Heart Disease Risk Factor Study Cohort

OBJECTIVE

Fatty liver disease (FLD), a global epidemic, is also a predictor of cardiometabolic disease (CMD) (type 2 diabetes or cardiovascular disease). Our objective was to examine whether progressive FLD, as assessed by fatty liver index (FLI), predicts increasing future CMD risk compared with relatively stable FLD, among middle-aged men.

DESIGN

Prospective epidemiological study.

SETTING

University affiliated research centre in Kuopio, Eastern Finland.

PARTICIPANTS

Our subjects were 501 men without CMD during the initial 4-year follow-up in the Kuopio Ischaemic Heart Disease Risk Factor Study cohort.

OUTCOME MEASURE

Over the initial 4-year follow-up, 135 men (26.9%) had a significant (≥10) FLI increase. The association of 4-year FLI increase with incident CMD was analysed in multivariable-adjusted Cox regression models, adjusting for baseline constitutional and lifestyle factors (model 1) and, in addition, metabolic and inflammation biomarker factors (model 2).

RESULTS

During a mean follow-up of 15 years, 301 new CMD cases occurred. We used subjects with low baseline FLI and no significant 4-year FLI increase as the reference. For subjects with intermediate baseline FLI and significant 4-year FLI increase, the HRs and 95% CIs for incident CMD in model 1 (2.13 (1.45 to 3.13)) and model 2 (1.73 (1.13 to 2.66)) exceeded values for subjects with similar baseline FLI without a significant 4-year change (HRs (95% CIs) were 1.36 (0.94 to 1.97) for model 1 and 1.18 (0.81 to 1.70) for model 2). They approached HRs (95% CI) for subjects who maintained high FLI over the 4 years (HRs (95% CIs) were 2.18 (1.54 to 3.10) in model 1 and 1.85 (1.21 to 2.82) in model 2).

CONCLUSION

Persons with significant FLI increase are likely with increasing CMD risk. Such persons should be evaluated for progressive FLD and CMD and managed to reduce CMD risk.

Fatty liver index is a strong predictor of changes in glycemic status in people with prediabetes: The IT-DIAB study

Background & aims

In patients at metabolic risk, nonalcoholic fatty liver disease is a strong and highly prevalent predictor for type 2 diabetes. Its assessment in clinical practice is not easy but the fatty liver index (FLI) could be used as a surrogate. Here, we studied the association between the FLI and the conversion to new-onset diabetes (NOD) or prediabetes reversion in patients with prediabetes.

Methods

The IT-DIAB observational study included 389 individuals with prediabetes, defined as fasting plasma glucose (FPG) between 110 and 125 mg/dL. NOD conversion was defined as a first FPG value ≥ 126 mg/dL and prediabetes reversion as a first FPG value < 110 mg/dL. The associations of both events with baseline FLI were studied separately using multivariate Cox models.

Results

After a median follow-up of 3.9 years (range 0.1–6.1), 138 individuals (35.5%) converted to NOD. FLI was associated with a higher risk of NOD conversion (unadjusted HR per SD = 1.54, _95%CI 1.27–1.86, p<0.0001), even after multiple adjustment on FPG, HbA_1c and diabetes risk score (adjusted HR per SD 1.31, _95%CI 1.07–1.61, p = 0.008). FLI was also associated with prediabetes reversion: adjusted HR per SD = 0.85, _95%CI 0.75–0.96, p = 0.0077. Changes in FLI were significantly associated with changes in FPG during follow-up (p<0.0001). When compared to a full model including the diabetes risk score, FPG, HbA_1C and FLI, only HbA_1C added a significant prediction information (AUROC: 72.8% for full model vs 69.4% for the model without HbA_1C; p = 0.028), while the removal of FLI to the full model did not alter its predictive value (AUROC 72.2%). The predictive value for NOD conversion was not significantly better for HOMA-IR compared to FLI (AUROC: 69.3 vs 63.7%, p = 0.067).

Conclusions

FLI is a simple, practical score to further stratify the risk of conversion to NOD or the possibility of prediabetes reversion in clinical practice, independently of classical glucose parameters.

Trial registration

ClincialTrials.gov number NCT01218061 and NCT01432509.

Association of fatty liver index with risk of incident type 2 diabetes by metabolic syndrome status in an Eastern Finland male cohort: a prospective study

OBJECTIVE

Fatty liver disease (FLD) is increasingly recognised as a predictor of cardiometabolic risk. Our objective was to examine if metabolic syndrome (MS) status affects the association of FLD with incident type 2 diabetes (T2D) in middle-aged men.

DESIGN

Prospective epidemiological study.

SETTING

University affiliated research centre in Kuopio, Eastern Finland.

PARTICIPANTS

Our subjects were 1792 Finnish men without diabetes at baseline in the KuopioIschaemicHeart Disease Risk Factor Study cohort.

OUTCOME MEASURE

Using fatty liver index (FLI), the association of baseline FLD with incident T2D was analysed in multivariable-adjusted Cox regression models, considering their MS statuses. The main models were adjusted for constitutional factors, lifestyle factors, biomarkers of inflammation and for high (FLI ≥60) versus low (FLI <30) FLI categories.

RESULTS

During a mean follow-up of 19 years, 375 incident cases of T2D were recorded. In the full model, the HR (HR (95% CI)) for T2D was 3.68 (2.80 to 4.82). The association was attenuated, but maintained, with further adjustment for metabolic factors. When MS status was adjusted for in place of metabolic factors, the HRs (95% CIs) were 2.63 (1.92 to 3.59) for FLI ≥60 and 1.77 (1.35 to 2.31) for MS.In MS-stratified analysis, FLI predicted T2D only among persons without MS. In unstratified analysis with subjects categorised by FLI-MS, persons with FLI ≥60 without MS had increased risk for T2D (HR=3.19 (2.26 to 4.52)) compared with persons with FLI <30 without MS. Persons with FLI <30 and MS had greater risk (HR=4.31 (2.15 to 8.61)) and persons with both FLI ≥60 and MS had the greatest risk (HR=4.66 (3.42 to 6.35)).

CONCLUSION

Generally, FLD (FLI ≥60) predicts T2D. It specifically predicted T2D among men without MS but not among men with MS, for whom MS alone already increases the risk. Both FLI and MS can complement each other in screening and surveillance for persons with increased T2D risk.

Association of fatty liver disease with mortality outcomes in an Eastern Finland male cohort

Objective

Fatty liver disease (FLD) has been associated with extrahepatic morbidity outcomes. However, reports on the association of FLD, assessed using fatty liver index (FLI), with mortality outcomes have been inconsistent. Our objective was to examine the effect of metabolic factors (blood pressure, insulin, fasting glucose, lipoproteins) on the associations of FLI with mortality outcomes among middle-aged men.

Study design

Prospective cohort study.

Methods

Our subjects were 1893 men at baseline from 1984 to 1989 in the Kuopio Ischaemic Heart Disease Risk Factor Study cohort. Multivariable Cox regression models were used to analyse the association of baseline FLI, with the HRs for all-cause, disease, cardiovascular, non-cardiovascular and cancer mortality outcomes.

Results

The mean FLI in the FLI categories were 16.2 in the low and reference category (FLI<30), 43.4 in the intermediate FLI category (FLI=30–<60) and 77.5 in the high FLI (FLD) category (FLI≥60). Over an average follow-up of 20 years, 848 disease deaths were recorded through Finnish national cause of death register. In models adjusted for constitutional, lifestyle and inflammatory factors, for the high (FLI≥60) vs low (FLI<30) FLI category, the HRs (95% CI) for mortality outcomes were 1.50 (1.26–1.78) for all-cause mortality; 1.56 (1.31–2.86) for disease mortality; 1.51 (1.18–1.94) for cardiovascular disease (CVD) mortality; 1.42 (1.12–1.80) for non-CVD mortality and 1.45 (1.02–2.07) for cancer mortality. With further adjustment for metabolic factors, the HRs were 1.25 (1.01–1.53) for all-cause mortality; 1.26 (1.02–1.56) for disease mortality; 1.06 (0.78–1.43) for CVD mortality; 1.46 (1.09–1.94) for non-CVD mortality and 1.49 (0.97–2.29) for cancer mortality.

Conclusion

High FLI (FLD) is associated with increased risks of mortality outcomes. The FLI-CVD mortality association can be largely explained by metabolic factors. Persons with FLD should be monitored for metabolic deterioration and extrahepatic morbidity to improve their prognoses.

Non-Alcoholic Fatty Liver Disease and Risk of Incident Type 2 Diabetes: Role of Circulating Branched-Chain Amino Acids

Non-alcoholic fatty liver disease (NAFLD) is likely to be associated with elevated plasma branched-chain amino acids (BCAAs) and may precede the development of type 2 diabetes (T2D). We hypothesized that BCAAs may be involved in the pathogenesis of T2D attributable to NAFLD and determined the extent to which plasma BCAAs influence T2D development in NAFLD. We evaluated cross-sectional associations of NAFLD with fasting plasma BCAAs (nuclear magnetic resonance spectroscopy), and prospectively determined the extent to which the influence of NAFLD on incident T2D is attributable to BCAA elevations. In the current study, 5791 Prevention of REnal and Vascular ENd-stage Disease (PREVEND) cohort participants without T2D at baseline were included. Elevated fatty liver index (FLI) ≥60, an algorithm based on triglycerides, gamma-glutamyltransferase, body mass index (BMI) and waist circumference, was used as proxy of NAFLD. Elevated FLI ≥ 60 was present in 1671 (28.9%) participants. Cross-sectionally, BCAAs were positively associated with FLI ≥ 60 (β = 0.208, p < 0.001). During a median follow-up of 7.3 years, 276 participants developed T2D, of which 194 (70.2%) had an FLI ≥ 60 (log-rank test, p < 0.001). Cox regression analyses revealed that both FLI ≥60 (hazard ratio (HR) 3.46, 95% CI 2.45⁻4.87, p < 0.001) and higher BCAA levels (HR 1.19, 95% CI 1.03⁻1.37, p = 0.01) were positively associated with incident T2D. Mediation analysis showed that the association of FLI with incident T2D was in part attributable to elevated BCAAs (proportion mediated 19.6%). In conclusion, both elevated FLI and elevated plasma BCAA levels are associated with risk of incident T2D. The association of NAFLD with T2D development seems partly mediated by elevated BCAAs.

The fatty liver index, a simple and useful predictor of metabolic syndrome: analysis of the Korea National Health and Nutrition Examination Survey 2010-2011

PURPOSE

Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease worldwide, and it is the hepatic manifestation of metabolic syndrome (MetS). We aimed to estimate the prevalence of NAFLD defined by the fatty liver index (FLI), in order to investigate the association between FLI and metabolic disorders and to determine the cutoff value of FLI to screen for MetS.

SUBJECTS AND METHODS

This study utilized a national representative sample of Korean adults (the Korean National Health and Nutrition Examination Surveys) which was conducted in 2010-2011. A total of 10,107 adults aged 19 years or older were selected. NAFLD was diagnosed on the basis of an increased FLI (≥60) after the exclusion of alcohol or viral liver disease.

RESULTS

NAFLD was identified in 1,134 subjects (age-standardized prevalence, 10.0%). When subjects were categorized into three groups by FLI (<20, 20-59, and ≥60), the higher FLI group showed a higher prevalence of hypertension (49.7% vs 14.4%), diabetes mellitus (DM; 20.4% vs 3.8%), and MetS (74.9% vs 7.4%). FLI was positively associated with age, body mass index, blood pressure, hemoglobin A1c, and homeostasis model assessment of insulin resistance (P for trend <0.001). In the multivariate analysis, the higher FLI group had a significantly higher risk for hypertension (OR =2.92, 95% CI =2.18-3.90, P<0.001), DM (OR =4.38, 95% CI =2.96-6.49, P<0.001), and MetS (OR =24.85, 95% CI =17.33-35.64, P<0.001). However, no increase was observed for cardiovascular disease after adjustment of other risk factors. The cutoff value of the FLI estimated to predict the presence of MetS was 20 (area under the curve 0.849, sensitivity 0.828, and negative predictive value 91.9%).

CONCLUSION

NAFLD prevalence using FLI is significantly higher in subjects with metabolic disorder including MetS. FLI might be a useful screening tool to detect subjects who may require early management of MetS and who have a high cardiovascular risk.

Ideal cardiovascular health associated with fatty liver: Results from a multi-ethnic survey

BACKGROUND AND AIMS

Little is known about the role of liver enzymes as predictors of non-liver-related morbidity and mortality. The ideal cardiovascular health (CVH) score proposed by the American Heart Association (AHA) can be used to predict mortality and morbidity. We investigated the association of the CVH score with liver enzymes and the risk of non-alcoholic fatty liver disease (NAFLD) among US adults.

METHODS

By using the National Health and Nutrition Examination Survey database (cross-sectional), the CVH score was calculated as meeting ideal levels of the following components: 4 behaviors (smoking, body mass index, physical activity and diet adherence) and 3 factors (total cholesterol, blood pressure and fasting glucose).

RESULTS

Individuals with a higher CVH score ("better CVH") had a more favorable profile of liver biomarkers. Adjusted (for age, gender, race, poverty to income ratio, education, marital status and alcohol intake) linear regression indicated significant and negative associations between liver biomarkers and CVH score: (β = -0.069, p < 0.001) for alanine aminotransferase, (β = -0.095, p < 0.001), aspartate aminotransferase, (β = -0.067, p < 0.001), alkaline phosphatase and (β = -0.125, p < 0.001) and fatty liver index. In the logistic regression, with the same confounders, individuals with a higher CVH score had 12% less likelihood of NAFLD compared with those with a lower score. Furthermore, each CVH metric separately was inversely linked to the risk of NAFLD.

CONCLUSIONS

For the first time among US adults, our findings shed light on the role CVH on liver biomarkers.

Lifestyle intervention for morbid obesity: effects on liver steatosis, inflammation, and fibrosis

The prevalence of obesity-related nonalcoholic fatty liver disease (NAFLD) is rising. NAFLD may result in nonalcoholic steatohepatitis (NASH), progressing to liver cirrhosis. Weight loss is recommended to treat obesity-related NASH. Lifestyle intervention may improve NASH; however, pertinent trials have so far focused on overweight patients, whereas patients with obesity are at highest risk of developing NAFLD. Furthermore, reports of effects on liver fibrosis are scarce. We evaluated the effect of lifestyle intervention on NAFLD in a real-life cohort of morbidly obese patients. In our observational study, 152 patients underwent lifestyle intervention, with a follow-up of 52 weeks. Noninvasive measures of obesity, metabolic syndrome, liver steatosis, liver damage, and liver fibrosis were analyzed. Treatment response in terms of weight loss was achieved in 85.1% of patients. Dysglycemia and dyslipidemia improved. The proportion of patients with fatty liver dropped from 98.1 to 54.3% ( P < 0.001). Weight loss >10% was associated with better treatment response ( P = 0.0009). Prevalence of abnormal serum transaminases fell from 81.0 to 50.5% ( P < 0.001). The proportion fibrotic patients, as determined by the NAFLD fibrosis score, dropped from 11.8 to 0% ( P < 0.05). Low serum levels of adiponectin correlated with degree of liver damage, i.e., serum liver transaminases ( r = -0,32, P < 0.05). Serum levels of adiponectin improved with intervention. In conclusion, lifestyle intervention effectively targeted obesity and the metabolic syndrome. Liver steatosis, damage and fibrosis were ameliorated in this real-life cohort of morbidly obese patients, mediated in part by changes in the adipokine profile. Patients with weight loss of >10% seemed to benefit most. NEW & NOTEWORTHY We demonstrate new evidence that lifestyle intervention is effective in treating NAFLD in the important group of patients with (morbid) obesity. Although current guidelines on the therapy of NASH recommend weight loss of 5-7%, weight reduction >10% may be favorable in morbid obesity. Serum levels of adipokines correlate with liver damage, which is indicative of their pathogenetic importance in human NASH. Our study adds to the limited body of evidence that NAFLD-associated liver fibrosis may resolve with lifestyle intervention.

Fatty liver index is a predictor of incident diabetes in patients with prediabetes: The PREDAPS study

OBJECTIVES

We evaluated the ability of the Fatty Liver Index (FLI), a surrogate marker of hepatic steatosis, to predict the development of type 2 diabetes (T2D) at 3 years follow-up in a Spanish cohort with prediabetes from a prospective observational study in primary care (PREDAPS).

METHODS

FLI was calculated at baseline for 1,142 adult subjects with prediabetes attending primary care centers, and classified into three categories: FLI <30 (no steatosis), FLI 30-60 (intermediate) and FLI ≥60 (hepatic steatosis). We estimated the incidence rate of T2D in each FLI category at 3 years of follow-up. The association between FLI and incident T2D was calculated using Cox regression models adjusted for age, sex, educational level, family history of diabetes, lifestyles, hypertension, lipid profile and transaminases.

RESULTS

The proportion of subjects with prediabetes and hepatic steatosis (FLI ≥60) at baseline was 55.7%. The incidence rate of T2D at 3 years follow-up was 1.3, 2.9 and 6.0 per 100 person-years for FLI<30, FLI 30->60 and FLI ≥60, respectively. The most significant variables increasing the risk of developing T2D were metabolic syndrome (hazard ratio [HR] = 3.02; 95% confidence interval [CI] = 2.14-4.26) and FLI ≥60 (HR = 4.52; 95%CI = 2.10-9.72). Moreover, FLI ≥60 was independently associated with T2D incidence: the HR was 4.97 (95% CI: 2.28-10.80) in the base regression model adjusted by sex, age and educational level, and 3.21 (95%CI: 1.45-7.09) in the fully adjusted model.

CONCLUSIONS

FLI may be considered an easy and valuable early indicator of high risk of incident T2D in patients with prediabetes attended in primary care, which could allow the adoption of effective measures needed to prevent and reduce the progression of the disease.

Nonalcoholic Fatty Liver Disease and Type 2 Diabetes Mellitus

Type 2 diabetes mellitus (T2DM) and nonalcoholic fatty liver disease (NAFLD) commonly exist together. It has been regarded as a manifestation of the metabolic syndrome. The presentations of NAFLD range from simple steatosis (NAFL), nonalcoholic steatohepatitis (NASH), and cirrhosis. NAFLD has a prevalence of 70% among T2DM patients. Overweight/obesity and insulin resistance (IR) have been strongly linked with NAFLD. Noninvasive assessment and staging of disease are based on clinical parameters such as age, sex, liver function test, platelet count, lipid profile, BMI, and imaging modalities such as USG, transient elastography (TE), and magnetic resonance imaging mass spectroscopy. Such clinical scoring systems and TE are useful in the early detection of NAFLD and predicting fibrosis. The principle behind the management of NAFLD with T2DM involves an indirect effect through improvement in IR and glycemia and thus is used for the treatment of T2DM as well.

Ideal cardiovascular health predicts lower risk of abnormal liver enzymes levels in the Chilean National Health Survey (2009-2010)

High levels of gamma glutamyltransferase (gamma-GT) and alanine aminotransferase (ALT), as well as fatty liver index (FLI) has been associated with higher cardiovascular disease risk factors in adults. The aim of this study was to examine the relationship between gamma-GT, ALT, and fatty liver index FLI levels across a gradient number of ideal cardiovascular health metrics in a representative sample of adults from the Chilean National Health Survey 2009-2010. Data from 1,023 men and 1,449 women (≥ 15 years) from the Chilean Health Survey 2009-2010 were analyzed. Ideal cardiovascular health was defined as meeting ideal levels of the following components: four behaviours (smoking, body mass index, physical activity and diet adherence) and three factors (total cholesterol, blood pressure and fasting glucose). Adults were grouped into three categories according to their number of ideal cardiovascular health metrics: ideal (5-7 metrics), intermediate (3-4 metrics), and poor (0-2 metrics). Blood levels of gamma-GT and ALT were measured and the FLI was calculated. A higher number of ideal cardiovascular health index metric was associated with lower gamma-GT, ALT and FLI (p from trend analysis <0.001). Also, adults meeting at least 3-4 metrics were predicted less likely to have prevalence of abnormal levels of gamma-GT and FLI (p<0.001) compared to adults who met only 0-2 metrics. These findings reinforce the usefulness of the ideal cardiovascular health metrics proposed by the American Heart Association as a tool to identify target subjects and promote cardiovascular health in South-American adults.

Is there a J-shaped relationship between the fatty liver index and risk of microalbuminuria in the general population?

BACKGROUND

We investigated whether the fatty liver index (FLI), as a clinical indicator of hepatic fat accumulation based on body mass index, gamma-glutamyl-transferase, triglycerides, and waist circumference, has an association with microalbuminuria.

METHODS

We analyzed anthropometric and biochemical data from a nation-wide, population-based, cross-sectional study. A total of 1605 participants included were healthy native Korean 40years or older and divided into quintiles according to their log-FLI and sex. Microalbuminuria was defined as urine albumin/creatinine ratio (UACR) between 30 and 300mg/g.

RESULTS

Participants in higher quintiles of log-FLI were more obese and hypertensive and had greater glycemic exposure, poorer lipid profiles, and greater increases in log-UACR compared with lower quintiles. Linear regression analysis demonstrated that log-FLI was associated with systolic and diastolic blood pressure, body mass index, waist circumference, fasting plasma glucose, glycated hemoglobin, and log-UACR. In logistic regression adjusted for age, sex, body mass index, waist circumference, and fasting plasma glucose, the OR of microalbuminuria was elevated in quintile 1 (adjusted OR=2.161, 95% CI=0.453-10.31) and quintile 5 (adjusted OR=6.387, 95% CI=1.317-51.58), when compared to quintile 2.

CONCLUSIONS

There appears to be a J-shaped association between FLI and UACR in healthy general population.

Bioavailable testosterone is independently associated with Fatty Liver Index in postmenopausal women

INTRODUCTION

Previous studies have examined the correlation between hyperandrogenemia and non-alcoholic fatty liver disease (NAFLD) in women and showed contradictory results. Therefore, we aimed to evaluate the relationship between testosterone level and Fatty Liver Index (FLI), as a surrogate marker for NAFLD, in a cohort of postmenopausal women.

MATERIAL AND METHODS

A total of 150 postmenopausal women were included in this cross-sectional study. Anthropometric and biochemical parameters, as well as blood pressure, were obtained. Non-alcoholic fatty liver disease is assessed by FLI, an algorithm based on body mass index, waist circumference, triglycerides and γ-glutamyl transferase, as a simple and accurate predictor of hepatic steatosis. Women were divided into three groups (FLI < 30, n = 80; 30 ≤ FLI < 60, n = 44; FLI ≥ 60, n = 26). Homeostasis model assessment of insulin resistance (HOMA-IR) as a surrogate marker of insulin resistance was calculated.

RESULTS

Multiple linear regression analysis revealed that the best model consisted of 4 parameters (e.g., bioavailable testosterone (β = 0.288, p = 0.001), log HOMA-IR (β = 0.227, p = 0.005), log high-sensitivity C-reactive protein (β = 0.322, p < 0.001), and retinol-binding protein 4 (β = 0.226, p < 0.001)). Adjusted R² for the best model was 0.550, which means that as much as 55.0% of variation in FLI could be explained with this model.

CONCLUSIONS

Bioavailable testosterone is independently associated with FLI in postmenopausal women.

Fatty Liver Index and Lipid Accumulation Product Can Predict Metabolic Syndrome in Subjects without Fatty Liver Disease

Background. Fatty liver index (FLI) and lipid accumulation product (LAP) are indexes originally designed to assess the risk of fatty liver and cardiovascular disease, respectively. Both indexes have been proven to be reliable markers of subsequent metabolic syndrome; however, their ability to predict metabolic syndrome in subjects without fatty liver disease has not been clarified. Methods. We enrolled consecutive subjects who received health check-up services at Taipei Veterans General Hospital from 2002 to 2009. Fatty liver disease was diagnosed by abdominal ultrasonography. The ability of the FLI and LAP to predict metabolic syndrome was assessed by analyzing the area under the receiver operating characteristic (AUROC) curve. Results. Male sex was strongly associated with metabolic syndrome, and the LAP and FLI were better than other variables to predict metabolic syndrome among the 29,797 subjects. Both indexes were also better than other variables to detect metabolic syndrome in subjects without fatty liver disease (AUROC: 0.871 and 0.879, resp.), and the predictive power was greater among women. Conclusion. Metabolic syndrome increases the cardiovascular disease risk. The FLI and LAP could be used to recognize the syndrome in both subjects with and without fatty liver disease who require lifestyle modifications and counseling.

Associations of the fatty liver and hepatic steatosis indices with risk of cardiovascular disease: Interrelationship with age

BACKGROUND

The fatty liver index (FLI) and the hepatic steatosis index (HSI), are biomarker-based algorithms developed as proxies for non-alcoholic fatty liver disease (NAFLD). We assessed associations of FLI and HSI with cardiovascular disease (CVD) risk.

MATERIALS AND METHODS

The FLI and HSI were estimated at baseline in the PREVEND cohort involving 6340 participants aged 28-75years without pre-existing CVD.

RESULTS

During a median follow-up of 10.5years, 631 CVD events occurred. In age-and sex-adjusted analysis, the hazard ratio (HR) (95% CI) for CVD comparing FLI≥60 versus FLI<30 was 1.53 (1.25-1.88); which was attenuated to 0.89 (0.70-1.13) on adjustment for conventional cardiovascular risk factors. The association remained absent after additional adjustment for potential confounders 0.85 (0.65-1.11). Comparing HSI>36 versus HSI<30, the corresponding adjusted HRs were 1.29 (1.02-1.65), 0.84 (0.65-1.09) and 0.79 (0.55-1.13) respectively. Subgroup analyses suggested a positive association in younger participants (<50years) for FLI and inverse associations in older participants (≥50years) for both indices (P for interaction for all=0.001).

CONCLUSION

Current data suggest age interactions in the association of NAFLD (as assessed by FLI or HSI) with CVD risk in a general Caucasian population.

Type 2 diabetes mellitus and non-alcoholic fatty liver disease: a systematic review and meta-analysis

AIM

The aim of this study was the evaluation of the prevalence of NAFLD in patients with type 2 diabetes mellitus.

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is an emerging disease with high prevalence in patients with type 2 diabetes mellitus (T2DM). Many studies have reported the prevalence of NAFLD in type 2 diabetes mellitus patients. However, these results are inconsistent.

METHODS

A Literature search was conducted in PubMed, Scopus, web of science and Science Direct from 2005 to August 2017. The necessary information was extracted. Heterogeneity was evaluated using I² statistic. Meta-regression analyses were performed to the estimation of the relationship between the year of study and sample size with the prevalence of NAFLD. Publication bias was assessed by both Begg rank correlation and Egger tests. Subgroup analysis was performed for identification of sources heterogeneity.

RESULTS

Seventeen studies involving 10897 type 2 diabetes mellitus patients with NAFLD were included in this meta-analysis. The overall prevalence of NAFLD in type 2 diabetes mellitus patients by random effects models was 54% (95% CI, 45%- 64%). There is a significant heterogeneity across studies with (I²= 99%, p> 0.01). The funnel plot as graphically and Begg and Egger as statistically showed no publication bias among studies. Subgroup analysis indicated that the prevalence of NAFLD in type 2 diabetes mellitus patients differed in predictive factors such as lipid profile, BMI, HbA1c, AST, and ALT. This finding in spite of heterogeneity of documents is corresponding to the positive correlation between NAFLD and type 2 diabetes mellitus.

CONCLUSION

The findings indicated that the overall prevalence of NAFLD among type 2 diabetes mellitus patients is significantly higher. It can be concluded that type 2 diabetes mellitus patients should be managed to prevent NAFLD.

Fatty liver index as a simple predictor of incident diabetes from the KoGES-ARIRANG study

The fatty liver index (FLI), calculated from serum triglyceride, body mass index, waist circumference, and gamma-glutamyltransferase, is considered a surrogate marker of nonalcoholic fatty liver disease (NAFLD). We investigated whether FLI predicts the development of diabetes mellitus (DM) and assessed the predictive ability of FLI for new onset of DM in a prospective population-based cohort study.We analyzed a total of 2784 adults (944 men and 1840 women) aged 40 to 70 years without DM at baseline. Participants were classified according to FLI values into 3 groups: FLI < 30, no NAFLD; 30 ≤ FLI ≤ 59, intermediate NAFLD; and FLI ≥ 60, participants with NAFLD. The area under the receiver-operating characteristic curve (AUC), net reclassification improvement (NRI), and integrated discrimination improvement (IDI) were calculated to determine whether FLI improved DM risk prediction.During a mean of 2.6 years follow-up, 88 (3.16%) participants developed DM. The odds ratio analyzed from multivariable-adjusted models (95% confidence interval [CI]) for new onset of DM increased in a continuous manner with increased FLI (<30 vs 30-59 vs ≥60 = 1 vs 1.87 [95% CI 1.05-3.33] vs 2.84 [95% CI 1.4-5.75], respectively). The AUC significantly increased when FLI was added to the conventional DM prediction model (0.835, 95% CI: 0.789-0.881, P = 0.0289 vs traditional DM prediction model). The category-free NRI was 0.417 (95% CI: 0.199-0.635) and the IDI was 0.015 (95% CI: 0.003-0.026) for overall study participants.We found that FLI, a surrogate marker of hepatic steatosis, resulted in significant improvement in DM risk prediction. Our finding suggests that FLI may have clinical and prognostic information for incident DM among the Korean adult population.

Non-alcoholic fatty liver disease and diabetes

Non-alcoholic fatty liver disease (NAFLD) and type 2 diabetes (T2DM) are common conditions that regularly co-exist and can act synergistically to drive adverse outcomes. The presence of both NAFLD and T2DM increases the likelihood of the development of complications of diabetes (including both macro- and micro- vascular complications) as well as augmenting the risk of more severe NAFLD, including cirrhosis, hepatocellular carcinoma and death. The mainstay of NAFLD management is currently to reduce modifiable metabolic risk. Achieving good glycaemic control and optimising weight loss are pivotal to restricting disease progression. Once cirrhosis has developed, it is necessary to screen for complications and minimise the risk of hepatic decompensation. Therapeutic disease modifying options for patients with NAFLD are currently limited. When diabetes and NAFLD co-exist, there are published data that can help inform the clinician as to the most appropriate oral hypoglycaemic agent or injectable therapy that may improve NAFLD, however most of these data are drawn from observations in retrospective series and there is a paucity of well-designed randomised double blind placebo controlled studies with gold-standard end-points. Furthermore, given the heterogeneity of inclusion criteria and primary outcomes, as well as duration of follow-up, it is difficult to draw robust conclusions that are applicable across the entire spectrum of NAFLD and diabetes. In this review, we have summarised and critically evaluated the available data, with the aim of helping to inform the reader as to the most pertinent issues when managing patients with co-existent NAFLD and T2DM.