What Do We Know about Inequalities in NAFLD Distribution and Outcomes? A Scoping Review

Pharmacological treatment options for metabolic dysfunction-associated steatotic liver disease in patients with type 2 diabetes mellitus: A systematic review

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD) is closely related to type 2 diabetes mellitus (T2DM) through a common root in insulin resistance. The more severe stage, metabolic dysfunction-associated steatohepatitis (MASH), increases the risk for cardiovascular complications, liver cirrhosis and hepatocellular carcinoma. Several trials investigating established antidiabetic-drugs in patients with T2DM and MASLD have yielded promising results. Therefore, we aimed to systematically review the effect of T2DM-drug treatment on MALSD parameters.

METHODS

Medical databases were searched until January 2025 for controlled trials in patients with T2DM and MASLD/MASH. Studies that evaluated the effect of T2DM-medication on the severity of MASLD/MASH in T2DM patients were included. The quality of the studies was assessed by three independent reviewers using a set of Cochrane risk-of-bias tools.

RESULTS

Of 1748 references, 117 studies fulfilled the inclusion-criteria and were assessed for eligibility in full-text. Fifty-two articles were included. Data included a total of 64.708 patients and study populations ranged from 9 to 50.742. Heterogeneity in study-design and analysis hampered the comparability of the results. Most evidence was present for GLP-1 receptor agonists, SGLT2-inhibitors and PPAR-γ-agonists for regression of liver fibrosis and MASH.

CONCLUSION

Studies on the value of T2DM-drug treatment in the improvement of MASLD vary significantly in study design, size and quality. GLP-1 receptor agonists, PPAR-γ-agonists, SGLT2-inhibitors may all be preferred pharmacological interventions for patients with MASLD/MASH and T2DM. Newer agents like dual GLP-1/GIP or triple GLP-1/GIP/Glucagon agonists will likely play an important role in the treatment of MASLD/MASH in the near future.

Metabolic dysfunction-associated steatotic liver disease in adults

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the umbrella term that comprises metabolic dysfunction-associated steatotic liver, or isolated hepatic steatosis, through to metabolic dysfunction-associated steatohepatitis, the progressive necroinflammatory disease form that can progress to fibrosis, cirrhosis and hepatocellular carcinoma. MASLD is estimated to affect more than one-third of adults worldwide. MASLD is closely associated with insulin resistance, obesity, gut microbial dysbiosis and genetic risk factors. The obesity epidemic and the growing prevalence of type 2 diabetes mellitus greatly contribute to the increasing burden of MASLD. The treatment and prevention of major metabolic comorbidities such as type 2 diabetes mellitus and obesity will probably slow the growth of MASLD. In 2023, the field decided on a new nomenclature and agreed on a set of research and action priorities, and in 2024, the US FDA approved the first drug, resmetirom, for the treatment of non-cirrhotic metabolic dysfunction-associated steatohepatitis with moderate to advanced fibrosis. Reliable, validated biomarkers that can replace histology for patient selection and primary end points in MASH trials will greatly accelerate the drug development process. Additionally, noninvasive tests that can reliably determine treatment response or predict response to therapy are warranted. Sustained efforts are required to combat the burden of MASLD by tackling metabolic risk factors, improving risk stratification and linkage to care, and increasing access to therapeutic agents and non-pharmaceutical interventions.

The Management of Cardiometabolic Risk in MAFLD: Therapeutic Strategies to Modulate Deranged Metabolism and Cholesterol Levels

Background and Objectives: Fatty Liver Disease is a major health problem worldwide. We can distinguish liver steatosis as non-associated or associated with chronic/acute alcohol consumption. These two entities share similar stages ranging from hepatic fat storage (namely, steatosis) to inflammation, necrosis, and fibrosis until hepatocellular carcinoma (HCC). Over time, "Metabolic Associated Fatty Liver Disease" (MAFLD) has replaced nonalcoholic fatty liver disease (NAFLD) nomenclature and has included cardiometabolic criteria in these patients definition. Thus, obesity, type 2 diabetes mellitus (T2DM), hypertension, and dyslipidemia are MAFLD features and are of the metabolic syndrome. Importantly, there is not a specific treatment for MAFLD, but there are therapeutic strategies that act on metabolic dysfunction related to MAFLD. They can reduce the progression of liver fibrosis and its complications. Materials and Methods: For all these reasons, we conducted a narrative review of the literature, and we focused on metabolic dysfunction related to MAFLD, with a special regard for cholesterol metabolism. Results: MAFLD is a recently redefined condition that better describes the metabolism derangement responsible for fatty liver disease. This distinguishes MAFLD from NAFLD. In fact, the diagnostic criteria for MAFLD require the presence of liver steatosis together with at least one of the following: obesity, T2DM, or evidence of metabolic disorder such as hypertriglyceridemia, low high-density lipoprotein cholesterol, or hypertension. As a result, MAFLD is closely linked to an increased cardiometabolic risk. Current therapeutic approaches can be used to reduce this risk, focusing on lifestyle interventions and pharmacological strategies. Several treatments in patients diagnosed with MAFLD are mainly cholesterol-lowering remedies. Among these, Pro-protein Convertase Subtilisin/Kexin type 9 inhibitors (PCSK9i) show the most promising efficacy profile but data on liver fibrosis are lacking. Agonists of GLP-1 receptor, Sodium-glucose cotransporter-2 inhibitors (SGLT2i) and Dipeptidyl Peptidase-4 inhibitors (DPP-4i) have a " multi-hit " action allowing their use also in diabetic patients with MAFLD. Conclusions: Lifestyle modifications, some nutraceuticals, statins, incretins, and PCSK9i have changed the natural course and significantly improved the cardiometabolic outcomes of MAFLD. Emerging cholesterol-lowering drugs, such as Bempedoic acid, can overcome low compliance to statins' use and their controversial effect on liver fibrosis. Finally, medications targeting insulin resistance allow for strategic interventions of the convoluted pathophysiology of MAFLD in multiple steps, with the potential to reduce liver steatosis, inflammation, and necrosis and, sometimes even to reverse liver fibrosis.

Psychosocial risks in metabolic dysfunction-associated steatotic liver disease

INTRODUCTION

Metabolic dysfunction-associated steatotic liver disease (MASLD) is increasingly becoming more prevalent in the general population. MASLD is more common in persons with low socioeconomic status (SES), yet little is known about the psychosocial challenges associated with this disease, and clinical recommendations on how to approach psychosocial challenges are lacking.

AREAS COVERED

A PubMed search using the search terms MASLD, psychosocial risks, stigmatization, psychiatric comorbidities (i.e. depression, bipolar disorder, psychosis, attention deficit hyperactivity disorder, and substance abuse), SES, quality of life (QoL), over the past 20 years (2004-2024) was performed.

EXPERT OPINION

Persons with MASLD often experience psychosocial adversities that may be expressed as lower SES, high prevalence of depression, and reduced QoL. Knowledge gaps remain regarding the association between severe mental disorders (e.g. psychosis and bipolar disorders). Timely detection and treatment of MASLD in persons with psychosocial risks may require attention and cross-field collaboration. Studies on QoL in persons with MASLD differ in methodology which makes formal comparisons difficult. Psychosocial adversity may be a barrier to lifestyle modifications, which remain the cornerstone of MASLD management. Guidelines on how to address psychosocial adversities in a clinical setting are warranted to improve outcomes and decrease further multimorbidity.

Disparities in Metabolic Dysfunction-Associated Steatotic Liver Disease Prevalence, Diagnosis, Treatment, and Outcomes: A Narrative Review

BACKGROUND

Metabolic dysfunction-associated steatotic liver disease (MASLD), formerly known as non-alcoholic fatty liver disease (NAFLD), is a leading cause of morbidity and mortality, and health disparities have been shown to influence disease burden.

AIM

In this review, we aim to characterize disparities in prevalence, diagnosis, treatment, and outcomes of MASLD, and to make recommendations for next steps to minimize these disparities.

METHODS

Literature search on PubMed and Scopus databases was conducted to identify relevant articles published before September 2, 2024.

RESULTS

Relative to women and White populations, MASLD is more common in men and Hispanic populations and less common in Black populations. It is also more prevalent among those with lower SES. Noninvasive clinical scores may perform differently across groups, and screening practices vary both for initial disease and for progression to metabolic dysfunctionassociated steatohepatitis (MASH), formerly called non-alcoholic steatohepatitis (NASH). Women and Black and Hispanic patients suffer worse outcomes including rates of progression to MASH and mortality.

CONCLUSIONS

Health disparities related to race, ethnicity, gender, and socioeconomic factors impact multiple stages of care for patients with MASLD.

Discovering novel Cathepsin L inhibitors from natural products using artificial intelligence

Cathepsin L (CTSL) is a promising therapeutic target for metabolic disorders. Current pharmacological interventions targeting CTSL have demonstrated potential in reducing body weight gain, serum insulin levels, and improving glucose tolerance. However, the clinical application of CTSL inhibitors remains limited. In this study, we used a combination of artificial intelligence and experimental methods to identify new CTSL inhibitors from natural products. Through a robust deep learning model and molecular docking, we screened 150 molecules from natural products for experimental validation. At a concentration of 100 µM, we found that 36 of them exhibited more than 50 % inhibition of CTSL. Notably, 13 molecules displayed over 90 % inhibition and exhibiting concentration-dependent effects. The molecular dynamics simulation on the two most potent inhibitors, Plumbagin and Beta-Lapachone, demonstrated stable interaction at the CTSL active site. Enzyme kinetics studies have shown that these inhibitors exert an uncompetitive inhibitory effect on CTSL. In conclusion, our research identifies Plumbagin and Beta-Lapachone as potential CTSL inhibitors, offering promising candidates for the treatment of metabolic disorders and illustrating the effectiveness of artificial intelligence in drug discovery.

Socioeconomic factors associated with the presence of and outcomes in metabolic dysfunction-associated steatotic liver disease

BACKGROUND AND AIMS

The association between socioeconomic factors and disease severity is not well studied in people living with metabolic dysfunction-associated steatotic liver disease (MASLD). We thus examined if socioeconomic factors influence the presence of, or risk for future, major adverse liver outcomes (MALOs) in people living with MASLD.

METHODS

We conducted a register-based cohort study that included all individuals with a MASLD diagnosis between 1987 and 2020 in Sweden. Logistic and Cox regression were used to examine the association between socioeconomic factors (country of birth, educational level, and marital status) and the presence of MALOs before or upon MASLD diagnosis or during follow-up, respectively.

RESULTS

In total, 14 026 people living with MASLD were identified, among whom the median age was 55 years, 50% were male and 775 (5.5%) had MALOs before or upon diagnosis. The adjusted odds ratio (aOR) for pre-existing MALOs was higher in divorced (aOR = 1.29, 95% confidence interval [CI] = 1.06-1.57) compared to married individuals. The aOR for pre-existing MALOs was lower among those with >12 years of education (aOR = .76, 95% CI = .62-.93) compared to individuals with an education level of 10-12 years. During a 5.2-year median follow-up, several socioeconomic factors were associated with increased rates of developing MALOs in a crude model; however, none were independently associated with incident MALOs after adjustment for confounders.

CONCLUSIONS

Socioeconomic factors were associated with somewhat higher odds for prevalent, but not incident, MALOs in people living with MASLD, after adjustments. This suggests primarily that risk factors for fibrosis progression are differently distributed across socioeconomic subgroups.

The burden of cirrhosis and other chronic liver disease in the middle east and North Africa (MENA) region over three decades

BACKGROUND

Cirrhosis comprises a significant health challenge in the Middle East and North African (MENA) region impacting healthcare systems and communities. This study sought to investigate trends in the burden of cirrhosis and other chronic liver disease, different etiologies, deaths, and the disability burden utilizing data from the Global Burden of Disease (GBD) database.

METHODS

Analyzing epidemiological trends from 1990 to 2021 across 21 MENA countries, this research utilized data on age-standardized incidence rates (ASIR), age-standardized death rates, and age-standardized disability-adjusted life years (DALYs) to evaluate the burden of cirrhosis and other chronic liver disease. The study also examined national variations and sociodemographic relationships.

RESULTS

The study identified a 114.9% increase in cirrhosis and other chronic liver disease incidence within the MENA region between 1990 and 2021, with 7,344,030 incident cases reported in 2021. The ASIR showed a steeper rise in females (9.6%) compared to males (7.0%). Etiology-specific analysis revealed an increase in the ASIR for MASLD related cirrhosis and other chronic liver disease by 22.2%, while those due to alcohol as well as hepatitis B and C decreased by 28.1%, 59.3%, and 30%, respectively. Despite the rising incidence, overall age-standardized death rates across all etiologies decreased by 54.3%, with DALYs showing a 51.4% decrease during the same period. Country-specific trends varied significantly, with Oman recording the highest annual ASIR increase (0.64%), and Qatar observing the most substantial annual reduction in age-standardized death rates (-2.88%).

CONCLUSION

The study highlights evolving trends in cirrhosis and other chronic liver disease within the MENA region, emphasizing the necessity for comprehensive, etiology, and gender-specific interventions. Despite an increasing incidence, the observed improvements in mortality rates and age-standardized disability burden indicate progress in public health efforts to mitigate cirrhosis's impact. These findings point to the complex nature of cirrhosis outcomes and the urgent need for tailored strategies to manage its increasing burden effectively.

Envisioning how to advance the MASH field

Since 1980, the cumulative effort of scientists and health-care stakeholders has advanced the prerequisites to address metabolic dysfunction-associated steatotic liver disease (MASLD), a prevalent chronic non-communicable liver disease. This effort has led to, among others, the approval of the first drug specific for metabolic dysfunction-associated steatohepatitis (MASH; formerly known as nonalcoholic steatohepatitis). Despite substantial progress, MASLD is still a leading cause of advanced chronic liver disease, including primary liver cancer. This Perspective contextualizes the nomenclature change from nonalcoholic fatty liver disease to MASLD and proposes important considerations to accelerate further progress in the field, optimize patient-centric multidisciplinary care pathways, advance pharmacological, behavioural and diagnostic research, and address health disparities. Key regulatory and other steps necessary to optimize the approval and access to upcoming additional pharmacological therapeutic agents for MASH are also outlined. We conclude by calling for increased education and awareness, enhanced health system preparedness, and concerted action by policy-makers to further the public health and policy agenda to achieve at least parity with other non-communicable diseases and to aid in growing the community of practice to reduce the human and economic burden and end the public health threat of MASLD and MASH by 2030.

Food inequity and insecurity and MASLD: burden, challenges, and interventions

Liver disease prevalence, severity, outcomes and hepatic risk factors (for example, unhealthy diet) are heavily affected by socioeconomic status and food insecurity. Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most prevalent liver disease globally and is likely to co-occur with other liver diseases associated with food insecurity. Though weight reduction and adopting a healthy diet can reverse the course of MASLD, gaps between recommendations and practice transcend individual responsibility and preference. Broader sociocultural determinants of food choices (social nutrition) include food insecurity, community and social norms and the local environment, including commercial pressures that target people experiencing poverty, ethnic minorities and children. Food insecurity is a barrier to a healthy diet, as a low-quality diet is often less expensive than a healthy one. Consequently, food insecurity is an 'upstream' risk factor for MASLD, advanced fibrosis and greater all-cause mortality among patients with liver disease. Intervening on food insecurity at four major levels (environment, policy, community and health care) can reduce the burden of liver disease, thereby reducing social and health inequities. In this Review, we report on the current research in the field, the need for implementing proven interventions, and the role liver specialists can have.

Nonalcoholic steatohepatitis/metabolic dysfunction-associated steatohepatitis emerging market: Preparing managed care for early intervention, equitable access, and integrating the patient perspective

Nonalcoholic steatohepatitis (NASH)/metabolic dysfunction-associated steatohepatitis (MASH) is an advanced form of liver disease that can lead to significant morbidity and mortality primarily due to hepatic complications including fibrosis, cirrhosis, hepatocellular carcinoma, and liver failure, as well as cardiovascular disease. As the development of NASH/MASH is closely linked to cardiometabolic risk factors such as obesity and type 2 diabetes mellitus, its prevalence is increasing along with the prevalence of those conditions. Identifying at-risk patients or those early in the disease process is essential to optimizing care and may prevent future complications. Current treatment options include disease-modifying interventions, off-label use of US Food and Drug Administration (FDA)-approved medications for comorbid conditions, and resmetirom, the recently first-ever FDA-approved medication specifically for use in NASH/MASH. There is also considerable continued activity in related drug development research with several other potential emerging treatments. With the increasing prevalence of NASH/MASH and emerging treatments, it is important for managed care organizations (MCOs) to be prepared to assist in patient care and implement equitable treatment management. Understanding patient perspectives and their experience with NASH/MASH provides insights for MCOs such as the need for education of both health care providers and patients to encourage early diagnosis and for enhancing access to individualized care including resources and support. Additionally, MCOs can consider potential management strategies for new and emerging treatments.

Health condition and socioeconomic status mediate the causal effect of reproductive traits on nonalcoholic fatty liver disease: evidence from Mendelian randomization study

Background

Observational data posits a correlation between reproductive traits and nonalcoholic fatty liver disease (NAFLD), but their causal inference is still unclear. This investigation seeks to elucidate the causal influence of reproductive traits on NAFLD and determine the intervening role of health condition and socioeconomic status in these connections.

Methods

Utilizing a Mendelian Randomization (MR) approach, this research leveraged a comprehensive dataset from the Genome-wide Association Study (GWAS) database. The study incorporated body mass index, major depression, educational level, household income and Townsend deprivation index as intermediary variables. Initially, a bidirectional two-sample MR study was conducted to explore the genetic associations between reproductive traits and NAFLD. Then, two-step MR analyses were implemented to quantify the extent of mediation by these indicators. The weighted inverse variance method was the primary analytical approach, complemented by several sensitivity analyses to affirm the robustness of the MR assumptions. Finally, these findings were validated in the FinnGen research.

Results

The bidirectional MR analysis indicated that earlier reproductive traits (age at menarche, age at first sexual intercourse, and age at first birth) were associated with an elevated risk of NAFLD, absent any evidence of the reverse relationship. Body mass index accounted for 35.64% of the association between premature menarche and NAFLD. Additionally, body mass index, major depression, educational level and household income mediated 41.65%, 14.35%, 37.88%, and 18.59% of the connection between early sexual intercourse and NAFLD, respectively. Similarly, these same variables elucidated 36.36%, 15.58%, 41.56%, and 22.73% of the correlation between younger age at first birth and NAFLD.

Conclusion

Our study elucidated the causal relationships between reproductive traits and NAFLD. Potential underlying mechanisms may involve factors such as body mass index, major depression, educational attainment and household income.

When in the lifecourse? Socioeconomic position across the lifecourse and biological health score

PURPOSE

Educational attainment is associated with multiphysiological wear and tear. However, associations with measures of socioeconomic position (SEP) across different life-stages are not established.

METHODS

Using regression models and data from 8105 participants from the UK Household Longitudinal Study (Understanding Society), we examined associations of lifecourse SEP with an overall biological health score (BHS). BHS is broader than usual measures of biological 'wear and tear' and is based on six physiological subsystems (endocrine, metabolic, cardiovascular, inflammatory/immune, liver, and kidney), with higher scores indicating worse health. Lifecourse SEP was based on respondents' parental, first, and most recent occupations.

RESULTS

Associations with SEP at all life-stages demonstrated higher BHS with increasing disadvantage (e.g. slope index of inequality (SII) (95 % CI) for most recent SEP: 0.04 (0.02, 0.06)). There was little difference in the magnitude of associations for SEP measured at each life-stage. Cumulative disadvantage across the lifecourse showed a stepped association with increasing BHS (SII (95 % CI): 0.05 (0.04, 0.07)). Associations were largely driven by metabolic, cardiovascular, and inflammatory systems.

CONCLUSION

Our results suggest that disadvantaged SEP across the lifecourse contributes cumulatively to poorer biological health, highlighting that every life-stage should be a target for public health policies and intervention.

The Association between Educational Attainment and the Risk of Nonalcoholic Fatty Liver Disease among Chinese Adults: Findings from the REACTION Study

Background/Aims

: Low educational attainment is a well-established risk factor for nonalcoholic fatty liver disease (NAFLD) in developed areas. However, the association between educational attainment and the risk of NAFLD is less clear in China.

Methods

: A cross-sectional study including over 200,000 Chinese adults across mainland China was conducted. Information on education level and lifestyle factors were obtained through standard questionnaires, while NAFLD and advanced fibrosis were diagnosed using validated formulas. Outcomes included the risk of NAFLD in the general population and high probability of fibrosis among patients with NAFLD. Logistic regression analysis was employed to estimate the risk of NAFLD and fibrosis across education levels. A causal mediation model was used to explore the potential mediators.

Results

: Comparing with those receiving primary school education, the multi-adjusted odds ratios (95% confidence intervals) for NAFLD were 1.28 (1.16 to 1.41) for men and 0.94 (0.89 to 0.99) for women with college education after accounting for body mass index. When considering waist circumference, the odds ratios (95% CIs) were 0.94 (0.86 to 1.04) for men and 0.88 (0.80 to 0.97) for women, respectively. The proportions mediated by general and central obesity were 51.00% and 68.04% for men, while for women the proportions were 48.58% and 32.58%, respectively. Furthermore, NAFLD patients with lower educational attainment showed an incremental increased risk of advanced fibrosis in both genders.

Conclusions

: In China, a low education level was associated with a higher risk of prevalent NAFLD in women, as well as high probability of fibrosis in both genders.

Leisure-Time Physical Activity in Subjects with Metabolic-Dysfunction-Associated Steatotic Liver Disease: An All-Cause Mortality Study

Background: Metabolic-dysfunction-associated steatotic liver disease (MASLD) affects 30% of adults worldwide and is associated with obesity and cardiovascular risk factors. If left untreated, it can progress to severe liver disease. Lifestyle changes such as physical activity and weight loss help to reduce the severity and risk of mortality. This study estimated the impact of MASLD and leisure-time physical activity (LTPA) on mortality and examined how gender mediates this effect in a Southern Italian population. Methods: This work is a population-based prospective cohort study of inhabitants of Castellana Grotte (>30 years old) in Southern Italy, which began in 1985. Participants provided general health information, underwent anthropometric measurements and ultrasonography, and completed a validated questionnaire on their food intake and LTPA. The vital status was tracked through local municipalities Results: In total, 1826 participants (39% with MASLD) were enrolled in this study, drawn from 2970 eligible subjects; the mean age was 51.91 (±14.76) years and 56.2% were men. Subjects with MASLD who practiced low LTPA had a significantly higher risk of death than those who did not have MASLD and practiced high LTPA. In addition, subjects with MASLD who practiced low LTPA were about 19% less likely to survive to the age of 82 years. As regards gender, both men and women with MASLD and low LTPA showed a significant risk of death, but this was higher in women. Conclusions: The presence of MASLD, especially in women, increases the risk of death from all causes. LTPA plays a key role in the disease and reduces mortality in these individuals.

Socioeconomic status and health disparities drive differences in accelerometer-derived physical activity in fatty liver disease and significant fibrosis

BACKGROUND AND AIMS

The cornerstone of clinical management of patients with nonalcoholic fatty liver disease (NAFLD) are lifestyle changes such as increasing physical activity (PA) aimed at improving cardiometabolic risk. To inform NAFLD prevention and treatment guidelines we aimed to: (i) quantify the role of PA on lowering the risk for NAFLD and fibrosis; (ii) characterize NAFLD and fibrosis association with PA in the context of socioeconomic environment.

METHODS

A sample of 2648 participants from the NHANES 2003-2006 was selected to develop survey weighted multivariable logistic regression models for predicting NAFLD and significant fibrosis, diagnosed non-invasively via fatty liver index (FLI) and fibrosis-4 (FIB-4) index. The PA measures were obtained from a hip-worn accelerometer.

RESULTS

The predictive model for NAFLD showed AUC of 0.687 and a decrease of 43% in NAFLD risk with moderate vigorous PA (MVPA) (OR = 0.569, p < 0.001). The predictive model for fibrosis had AUC of 0.755 and there was a 48% and a 70% decrease in significant fibrosis risk with MVPA (OR = 0.518, p = 0.022) and total log activity count (TLAC) (OR = 0.296, p = 0.017), respectively. Participants with NAFLD and NAFLD with fibrosis engage in declining PA. Despite having jobs with higher level of PA and participating in more moderate-to-vigorous PA, a larger proportion of Hispanics participants had NAFLD and significant fibrosis.

CONCLUSIONS

These findings demonstrate the role of PA as a protective factor against the presence of NAFLD and significant fibrosis. Protective levels of PA in NAFLD differ by races.

Inequities in primary liver cancer in Europe: The state of play

Given the increasing burden of liver cancer in Europe, it is crucial to investigate how social determinants of health (SDoH) affect liver cancer risk factors and access to care in order to improve health outcomes equitably. This paper summarises the available evidence on the differential distribution of liver cancer risk factors, incidence, and health outcomes in the European Economic Area and the United Kingdom from an SDoH perspective. Vulnerable and marginalised populations have low socio-economic and educational levels and are the most affected by liver cancer risk factors. Reasons for this include varied access to hepatitis B virus vaccination and limited access to viral hepatitis B and C screening, harm reduction, and treatment. Additionally, alcohol-related liver disease remains highly prevalent among individuals with low education, insecure employment, economic instability, migrants, and deprived populations. Moreover, significant variation exists across Europe in the proportion of adults with steatotic liver disease, overweight/obesity, and diabetes, based on geographical area, gender, socio-economic and educational background, and density of ultra-processed food outlets. Inequities in cirrhosis mortality rates have been reported, with the highest death rates among individuals living in socio-economically disadvantaged areas and those with lower educational levels. Furthermore, insufficient healthcare access for key populations with primary liver cancer is influenced by complex healthcare systems, stigmatisation, discrimination, low education, language barriers, and fear of disclosure. These challenges contribute to inequities in liver cancer care pathways. Future studies are needed to explore the different SDoH-interlinked effects on liver cancer incidence and outcomes in European countries. The ultimate goal is to develop evidence-based multilevel public health interventions that reduce the SDoH impact in precipitating and perpetuating the disproportionate burden of liver cancer in specific populations.

Changes in the Prevalence, Incidence, and Disability-Adjusted Life Years of Non-alcoholic Fatty Liver Disease in the United States Between 1990 and 2019

INTRODUCTION

This study aimed to determine trends in the prevalence, incidence, and disability-adjusted life years (DALYs) of Non-alcoholic Fatty Liver Disease (NAFLD) in the US across different states and age groups between 1990 and 2019.

METHODS

Using the Global Burden of Disease database, this study analyzed the prevalence, incidence, and DALYs of NAFLD in the US between 1990 and 2019. We computed relative percentage changes, performed Joinpoint regression analyses of trends, and compared these between states and age groups (5-19, 20-55, and more than 55 years old).

RESULTS

In the United States, the prevalence of NAFLD increased more than the global average over the study period (+ 30.7% vs. + 24.5%), especially in the 5-19-year-old age group. Among all states, Kansas, Washington, and California had the highest increase in prevalence and the District of Columbia followed by Massachusetts and North Carolina had the lowest increase in prevalence. The increase in incidence was greater in the US than the global average (+ 37.18% vs. + 7.28%). West Virginia, Ohio, and Kentucky had the highest increase in incidence. The increase in DALYs was greater in the US compared to the global average (+ 57.15% vs. + 12.65%). Alaska, West Virginia, and Kentucky had the highest increase in DALYs. The increased incidence and DALYs were found in all states except in the District of Columbia.

CONCLUSION

The prevalence of NAFLD in the US has increased more rapidly than the global average, especially in the pediatric population. South and Midwest states have the highest increase in prevalence, incidence, and DALYs of NAFLD. The District of Columbia was the only state that has decreased incidence and DALYs.

Safety-Net Primary Care and Endocrinology Clinicians' Knowledge and Perspectives on Screening for Nonalcoholic Fatty Liver Disease: A Mixed-Methods Evaluation

OBJECTIVE

Clinical guidelines have expanded the indications for nonalcoholic fatty liver disease (NAFLD) screening to type 2 diabetes mellitus and obesity, which are conditions common in populations who receive care in urban safety-net settings. This study aimed to evaluate safety-net primary care and endocrinology clinicians' knowledge of NAFLD, determine barriers and facilitators to screening, and examine perspectives on the use of electronic health record tools for risk assessment.

METHODS

Sequential explanatory mixed methods using survey and qualitative interviews with primary care, primary care subspecialty, and endocrinology clinicians in an urban safety-net health care system.

RESULTS

A total of 109 participants completed the survey (36.5% response rate), and 13 participated in interviews. Most respondents underestimated or did not know the prevalence of NAFLD (68%), did not use the recommended noninvasive tests for risk stratification (65%), and few were comfortable with screening for (27%) or managing (17%) NAFLD. Endocrinologists had greater knowledge of risk factors but lower rates of comfort and more often felt that screening was not their responsibility. The qualitative themes included the following: (1) lack of knowledge about screening, (2) concern for underdiagnosing NAFLD, (3) perception of severity impacts beliefs about screening, (4) screening should occur in primary care but is not normative practice, (5) concerns exist about benefit, (6) competing demands with a complex population hinder screening, and (7) a need for easier ways to integrate screening into practice.

CONCLUSION

Knowledge gaps may hamper uptake of new guidelines for NAFLD screening in primary care and endocrinology clinics in an urban safety-net health care system. Implementation strategies focused on training and educating clinicians and informed by behavioral economics may increase screening.

Non-Pharmacological Approach to Diet and Exercise in Metabolic-Associated Fatty Liver Disease: Bridging the Gap between Research and Clinical Practice

This review provides a practical and comprehensive overview of non-pharmacological interventions for metabolic-associated fatty liver disease (MASLD), focusing on dietary and exercise strategies. It highlights the effectiveness of coffee consumption, intermittent fasting, and Mediterranean and ketogenic diets in improving metabolic and liver health. The review emphasizes the importance of combining aerobic and resistance training as a critical approach to reducing liver fat and increasing insulin sensitivity. Additionally, it discusses the synergy between diet and exercise in enhancing liver parameters and the role of gut microbiota in MASLD. The paper underscores the need for a holistic, individualized approach, integrating diet, exercise, gut health, and patient motivation. It also highlights the long-term benefits and minimal risks of lifestyle interventions compared to the side effects of pharmacological and surgical options. The review calls for personalized treatment strategies, continuous patient education, and further research to optimize therapeutic outcomes in MASLD management.

Global burden of cirrhosis and other chronic liver diseases due to nonalcoholic fatty liver disease, 1990-2019

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) has become the leading cause of cirrhosis and other chronic liver diseases (COCLDs).

AIM

To conduct a comprehensive and comparable updated analysis of the global, regional, and national burden of COCLDs due to NAFLD in 204 countries and territories from 1990 and 2019 by age, sex, and sociodemographic index.

METHODS

Data on COCLDs due to NAFLD were collected from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019. Numbers and age-standardized prevalence, death, and disability-adjusted life years (DALYs) were estimated through a systematic analysis of modelled data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2019. The estimated annual percentage change was used to determine the burden trend.

RESULTS

In 2019, the global age-standardized prevalence rate of COCLDs due to NAFLD was 15022.90 per 100000 population [95% uncertainty interval (UI): 13493.19-16764.24], which increased by 24.51% (22.63% to 26.08%) from 1990, with an estimated annual percentage change of 0.78 (95% confidence interval: 0.74-0.82). In the same year, however, the age-standardized death rate and age-standardized DALYs per 100000 population were 1.66 (95%UI: 1.20-2.17) and 43.69 (95%UI: 31.28-58.38), respectively. North Africa and the Middle East had the highest prevalence rates of COCLDs due to NAFLD. The death rate increased with age up to the 95+ age group for both sexes. Males had higher numbers of prevalence, death rate, and DALYs than females across all age groups before the 65-69 age group. The sociodemographic index was negatively correlated with the age-standardized DALYs.

CONCLUSION

Globally, the age-standardized prevalence rate has increased during the past three decades. However, the age-standardized death rate and age-standardized DALYs decreased. There is geographical variation in the burden of COCLDs due to NAFLD. It is strongly recommended to improve the data quality of COCLDs due to NAFLD across all countries and regions to facilitate better monitoring of the burden of COCLDs due to NAFLD.

Prevalence and Risk Factors of MASLD and Liver Fibrosis amongst the Penitentiary Population in Catalonia: The PRISONAFLD Study

BACKGROUND AND AIMS

The prevalence of chronic non-communicable diseases, particularly metabolic syndrome (MetS), has increased among the prison population. Nevertheless, we have limited data on metabolic dysfunction-associated steatotic liver disease (MASLD), the hepatic manifestation of this syndrome. We aimed to investigate the prevalence and risk factors of MASLD and MASLD-associated liver fibrosis in the penitentiary population in Catalonia, Spain.

METHOD

A cross-sectional observational study involving eight penitentiary centers. Participants had at least one metabolic disorder and were at a closed-regimen penitentiary. Individuals with concomitant liver diseases and/or alcohol risk consumption were excluded. Significant fibrosis and MASLD were defined as liver stiffness ≥8 kPa and a controlled attenuation parameter ≥275 dB/m by vibration-controlled transient elastography (VCTE), respectively. After exclusions, metabolic inmates with VCTE were analyzed. Logistic regression analysis was performed to identify predictors of MASLD and MASLD-associated significant fibrosis.

RESULTS

Out of the 4338 inmates studied, 1290 (29.7%) had metabolic disorders, and 646 (14.9%) underwent VCTE. The mean age was 48.0 years (SD 12.1), and 89.5% were male. MASLD prevalence was 33.9%. Significant fibrosis and MASLD-associated significant fibrosis were found in 16.4% and 9.4% of inmates, respectively. In the multivariate analysis, T2D, waist circumference, MetS, and higher ALT values were identified as independent risk factors for MASLD and MASLD-associated significant fibrosis amongst the prison population.

CONCLUSIONS

Metabolic disorders including MASLD are highly prevalent among inmates. The prevalence of significant fibrosis seems notably higher than that of the general population, underscoring the need for targeted screening programs and therapeutic interventions in the incarcerated population.

The silent burden of non-alcoholic fatty liver disease in the elderly: A global burden of disease analysis

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) represents a significant health threat worldwide. The growing trend towards an aging population, along with an alarming rise in obesity and diabetes, may have significant implications for the burden of NAFLD.

AIM

To assess the impact of NAFLD on the elderly.

METHODS

We utilised data from the Global Burden of Disease study between 2010 and 2019 to conduct a comprehensive analysis of the prevalence, mortality, and disability-adjusted life years (DALYs) associated with NAFLD in the elderly (65-89 years), stratified by region, nation, sociodemographic Index and sex.

RESULTS

Globally, there were an estimated 228 million cases, 87,230 deaths and 1.46 million DALYs attributed to NAFLD in the elderly. Geographically, the Western Pacific region had the highest burden of NAFLD in the elderly. From 2010 to 2019, there was an increasing prevalence rate in all areas, with the most pronounced change observed in the Western Pacific region (annual percentage change (APC) +0.95%, p < 0.001). Over the study period, there was a more rapid increase in NAFLD prevalence in men (APC +0.74%, p < 0.001) than in women (APC +0.63%, p < 0.001). In most regions, death and DALYs rates have declined, with the exception of the Americas, where there was a slight increase (APC +0.25%, p = 0.002 and 0.38%, p < 0.001, respectively).

CONCLUSION

Over the past decade, the burden of NAFLD in the elderly has been increasing, necessitating immediate and inclusive measures to tackle the rising burden.

Lifestyle interventions in nonalcoholic fatty liver disease

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

Comments on: Nonalcoholic Fatty Liver Disease Predicts Acute Kidney Injury Readmission in Heart Failure Hospitalizations: A Nationwide Analysis

The article titled "Nonalcoholic Fatty Liver Disease Predicts Acute Kidney Injury Readmission in Heart Failure Hospitalizations: A Nationwide Analysis" has been read with great interest. I highly appreciate the authors' efforts to expand the knowledge on non-alcoholic fatty liver disease (NAFLD) and its association with acute kidney injury. I concur with the authors' conclusion that heart failure patients with NAFLD have an increased incidence of hospital readmissions due to acute kidney injury. Nonetheless, I would like to add a few points that would significantly enhance the value of this study and highlight areas of improvement for future research. First, the authors used a nationally representative database, which, while providing comprehensive information about patients in the United States, does not include data from other countries, thus questioning the applicability of these findings to other nations. Second, the authors should have considered ethnicity in their study design, as previous research has shown that NAFLD is more prevalent among Hispanics. Third, the authors should have commented on the important confounders: family history and socioeconomic status of patients. Patients with a family history of NAFLD have a greater propensity to develop grave manifestations of the disease early in life. Similarly, individuals with low socioeconomic status are at an increased risk of NAFLD. The study could have provided more reliable findings by matching the groups for these confounders, mitigating the risk of error and bias.

Prediction of clinical events by liver stiffness and chronic kidney disease by NAFLD in patients with type-2 diabetes

BACKGROUND & AIMS

Non-alcoholic fatty liver disease (NAFLD) is associated with poorer glycemic control and a higher risk of type-2 diabetes (T2D) complications, extrahepatic and cardiovascular disease (CVD). Our study aim was to evaluate the association between NAFLD, T2D complications, and the development of overall clinical events (OCE) (CV, liver-related, and mortality) in patients with T2D.

METHODS

Prospective single-center study comprising T2D subjects with no history of CVD and non-T2D matched controls. Patients were selected from the Outpatient Diabetes Clinic of Vall d'Hebron Hospital and related primary care centers.

RESULTS

186 diabetics and 57 controls were included. Amongst T2D, 124/186 subjects had NAFLD (66.6%). T2D-NAFLD subjects showed a heavier metabolic burden and higher median liver stiffness (5.6kPa [4.5-7.3] vs 4.8 [4.2-5.8]; p=0.004) compared to non-NAFLD diabetics. During a median follow-up of 5.6 years, 33 (17.7%) T2D patients developed OCE vs 4 (7.0%) controls (p=0.049). No differences were found for OCE between NAFLD and non-NAFLD diabetics (16.9% vs 19.4%; p=0.68). CV was the most reported outcome and only one liver event occurred. NAFLD diabetics showed more often chronic kidney disease (CKD), whereas T2D complications and subclinical CVD rates were similar. A higher liver stiffness, older age, and male gender were independently associated with OCE amongst the entire T2D population and NAFLD diabetics.

CONCLUSIONS

NAFLD and liver stiffness were associated with CKD and clinical outcomes in diabetics, respectively. A hepatic evaluation is recommended to identify high-risk T2D patients that would benefit from early referral to specialized care.

Young Adult Physical Activity Trajectories and Midlife Nonalcoholic Fatty Liver Disease

Importance

Physical activity (PA) is recommended for preventing and treating nonalcoholic fatty liver disease (NAFLD). Yet, how long-term patterns of intensity-based physical activity, including moderate-intensity PA (MPA) and vigorous-intensity PA (VPA), might affect the prevalence of NAFLD in middle age remains unclear.

Objective

To identify distinct intensity-based PA trajectories from young to middle adulthood and examine the associations between PA trajectories and NAFLD prevalence in midlife.

Design, Setting, and Participants

This population-based cohort of 2833 participants used the Coronary Artery Risk Development in Young Adults study data. The setting included field clinics in Birmingham, Alabama; Chicago, Illinois; Minneapolis, Minnesota; and Oakland, California. Data analysis was completed in March 2023.

Exposures

PA was self-reported at 8 examinations over 25 years (1985-1986 to 2010-2011) and separately scored for MPA and VPA.

Main Outcomes and Measures

NAFLD was defined as liver attenuation values less than 51 Hounsfield units after exclusion of other causes of liver fat, measured using computed tomography in year 25 (2010-2011).

Results

Among a total of 2833 participants included in the sample, 1379 (48.7%) self-identified as Black, 1454 (51.3%) as White, 1206 (42.6%) as male, and 1627 (57.4%) as female from baseline (1985-1986) (mean [SD] age, 25.0 [3.6] years) to year 25 (2010-2011) (mean [SD] age, 50.1 [3.6] years). Three MPA trajectories were identified: very low stable (1514 participants [53.4%]), low increasing (1096 [38.7%]), and moderate increasing (223 [7.9%]); and 3 VPA trajectories: low stable (1649 [58.2%]), moderate decreasing (1015 [35.8%]), and high decreasing (169 [6.0%]). After adjustment for covariates (sex, age, race, study center, education, smoking status, and alcohol consumption), participants in the moderate decreasing (risk ratio [RR], 0.74; 95% CI, 0.54-0.85) and the high decreasing (RR, 0.59; 95% CI, 0.44-0.80) VPA trajectories had a lower risk of NAFLD in middle age, relative to participants in the low stable VPA trajectory. Adjustments for baseline body mass index and waist circumference attenuated these estimates, but the results remained statistically significant. The adjusted RRs across the MPA trajectories were close to null and not statistically significant.

Conclusions and Relevance

This cohort study of Black and White participants found a reduced risk of NAFLD in middle age for individuals with higher levels of VPA throughout young to middle adulthood compared with those with lower VPA levels. These results suggest the need for promoting sustainable and equitable prevention programs focused on VPA over the life course to aid in lowering NAFLD risk.

Prevalence of non-alcoholic fatty liver disease and its association with lifestyle habits in adults in Chile: a cross-sectional study from the National Health Survey 2016-2017

Non-alcoholic fatty liver disease (NAFLD) represents an excessive fat accumulation within the liver, usually associated with excess body weight. A liver biopsy is the gold standard for diagnosis, but it is inapplicable in population-based studies. In large populations, non-invasive methods could be used, which may also serve to identify potential protective factors. We aimed to (a) estimate NAFLD prevalence in the adult population in Chile by using non-invasive methods and (b) determine the association between the presence of NAFLD and lifestyle habits. The National Health Survey of Chile 2016–2017 was analysed. We included individuals aged 21–75 years, without infectious diseases nor risky alcohol consumption. NAFLD was detected by either fatty liver index (FLI; considers circulating TAG, circulating γ-glutamyl-transferase, BMI and waist circumference), lipid accumulation product (LAP; considers sex, circulating TAG and waist circumference) or their combination. Lifestyle habits were determined by questionnaires. We included 2774 participants, representative of 10 599 094 (9 831 644, 11 366 544) adults in Chile. NAFLD prevalence (95 % CI) was 39·4 % (36·2, 42·8) by FLI, 27·2 % (24·2, 30·4) by LAP and 23·5 % (20·7, 26·5) by their combination. The prevalence progressively increased with increasing BMI. Of note, less smoking and more moderate-vigorous physical activity and whole-grain consumption were associated with lower odds of having NAFLD, independently of BMI. At least one out of four adults in Chile is afflicted with NAFLD. Health promotion strategies focused on controlling excess body weight and promoting specific lifestyle habits are urgently required.

A global research priority agenda to advance public health responses to fatty liver disease

BACKGROUND & AIMS

An estimated 38% of adults worldwide have non-alcoholic fatty liver disease (NAFLD). From individual impacts to widespread public health and economic consequences, the implications of this disease are profound. This study aimed to develop an aligned, prioritised fatty liver disease research agenda for the global health community.

METHODS

Nine co-chairs drafted initial research priorities, subsequently reviewed by 40 core authors and debated during a three-day in-person meeting. Following a Delphi methodology, over two rounds, a large panel (R1 n = 344, R2 n = 288) reviewed the priorities, via Qualtrics XM, indicating agreement using a four-point Likert-scale and providing written feedback. The core group revised the draft priorities between rounds. In R2, panellists also ranked the priorities within six domains: epidemiology, models of care, treatment and care, education and awareness, patient and community perspectives, and leadership and public health policy.

RESULTS

The consensus-built fatty liver disease research agenda encompasses 28 priorities. The mean percentage of 'agree' responses increased from 78.3 in R1 to 81.1 in R2. Five priorities received unanimous combined agreement ('agree' + 'somewhat agree'); the remaining 23 priorities had >90% combined agreement. While all but one of the priorities exhibited at least a super-majority of agreement (>66.7% 'agree'), 13 priorities had <80% 'agree', with greater reliance on 'somewhat agree' to achieve >90% combined agreement.

CONCLUSIONS

Adopting this multidisciplinary consensus-built research priorities agenda can deliver a step-change in addressing fatty liver disease, mitigating against its individual and societal harms and proactively altering its natural history through prevention, identification, treatment, and care. This agenda should catalyse the global health community's efforts to advance and accelerate responses to this widespread and fast-growing public health threat.

IMPACT AND IMPLICATIONS

An estimated 38% of adults and 13% of children and adolescents worldwide have fatty liver disease, making it the most prevalent liver disease in history. Despite substantial scientific progress in the past three decades, the burden continues to grow, with an urgent need to advance understanding of how to prevent, manage, and treat the disease. Through a global consensus process, a multidisciplinary group agreed on 28 research priorities covering a broad range of themes, from disease burden, treatment, and health system responses to awareness and policy. The findings have relevance for clinical and non-clinical researchers as well as funders working on fatty liver disease and non-communicable diseases more broadly, setting out a prioritised, ranked research agenda for turning the tide on this fast-growing public health threat.

Association of nonalcoholic fatty liver disease and carotid media-intima thickness: A systematic review and a meta-analysis

Introduction

The relationship between cardiovascular disorders and nonalcoholic fatty liver disease (NAFLD) has been extensively studied. To better pool this data and make a more definite conclusion, we performed a meta-analysis to evaluate the association between NAFLD and the thickness of media and intima of carotid artery (CIMT) and cardiovascular disorders.

Methods

We searched PubMed, Ovid, Scopus, ProQuest, Web of Science, and the Cochrane Library, and analyzed the pooled data using R studio and the "metafor" package.

Results

The final analysis included a total of 59 studies with 16,179 cases and 26,120 control individuals. NAFLD was shown to be associated with an increase of 0.1231 mm (20.6%) in carotid artery intima-media thickness (CIMT) (p = 0.002, 95% confidence interval [CI]: 0.0462-0.2000) in individuals with NAFLD. The prevalence of atherosclerotic plaques in the carotid arteries and the occurrence of NAFLD are significantly correlated, according to a meta-analysis based on 17 distinct studies (p = 0.001, 1.28-1.43, 95% CI, odds ratio = 1.356).

Conclusion

Patients with increased CIMT are considerably more likely to have NAFLD. Large prospective investigations are required to corroborate these findings and their prognostic significance, along with the effectiveness of the available interventions.

Computerized Tomography-Based Screening for Moderate to Severe Hepatic Steatosis in a Multiethnic Population

Background and Aim Data on prevalence of nonalcoholic fatty liver disease in Hawaii is limited. This study determined the prevalence of moderate to severe hepatic steatosis within a multicultural, multiethnic, and multiracial cohort in Hawaii undergoing computerized tomography (CT) for reasons unrelated to fatty liver disease. Methods The authors performed a retrospective analysis of all patients who were members of an integrated health care system with CT scans including the liver between January 1, 2020, and December 31, 2020. Moderate to severe hepatic steatosis was determined by an average attenuation value < 40 Hounsfield units for non-contrast-enhanced CT and a mean attenuation value < 90 Hounsfield units for contrast-enhanced CT. Patients' electronic medical records were reviewed for existing diagnoses of hepatic steatosis, obesity, and diabetes mellitus type 2 and data to calculate a Fibrosis-4 (FIB-4) index. Results Approximately 26.6% had moderate to severe hepatic steatosis, while only 11.3% of those patients had an active diagnosis of fatty liver disease. Native Hawaiians and Pacific Islanders (33.1%) had the greatest prevalence of hepatic steatosis, followed by White people (28.4%), Asian people (27.7%), and other ethnicities (10.8%). About 61.4% patients with fatty liver had a diagnosis of obesity, while 33.4% had a body mass index < 30.0 kg/m². Finally, 86.2% patients had enough information in their electronic medical records from which to calculate a FIB-4 score and the mean FIB-4 index was 1.66 ± 3.50. Conclusions Moderate to severe hepatic steatosis is common among patients undergoing CT studies for reasons not related to hepatic steatosis in this multiethnic population most of whom did not have a diagnosis of fatty liver disease.

Non-alcoholic fatty liver disease (NAFLD) and mental illness: Mechanisms linking mood, metabolism and medicines

Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in the world and one of the leading indications for liver transplantation. It is one of the many manifestations of insulin resistance and metabolic syndrome as well as an independent risk factor for cardiovascular disease. There is growing evidence linking the incidence of NAFLD with psychiatric illnesses such as schizophrenia, bipolar disorder and depression mechanistically via genetic, metabolic, inflammatory and environmental factors including smoking and psychiatric medications. Indeed, patients prescribed antipsychotic medications, regardless of diagnosis, have higher incidence of NAFLD than population norms. The mechanistic pharmacology of antipsychotic-associated NAFLD is beginning to emerge. In this review, we aim to discuss the pathophysiology of NAFLD including its risk factors, insulin resistance and systemic inflammation as well as its intersection with psychiatric illnesses.

Worldwide long-term trends in the incidence of nonalcoholic fatty liver disease during 1990–2019: A joinpoint and age-period-cohort analysis

Background

Non-alcoholic fatty liver disease (NAFLD) was previously a neglected disease that is now becoming a worldwide pandemic. A better understanding of its incidence and long-term trends will help to increase public awareness of the disease and the development of future prevention strategies.

Methods

The incidence rates of NAFLD during 1990–2019 were collected from the Global Burden of Disease Study 2019 database according to the following parameters: sex, age, socio-demographic index, and geographical region. Estimated annual percentage changes and joinpoint models were used to assess the long-term trend of NAFLD, and an age-period-cohort model was used to assess the extents of the age, period, and cohort effects.

Results

Adult males, postmenopausal females, Latin American populations, and people in developing countries had a high risk of developing NAFLD. The joinpoint model indicated a new trend of increasing NAFLD incidence in 2005. Age was a risk factor affecting NAFLD incidence, with this effect increasing in more-recent periods. Younger birth cohorts had lower risks of NAFLD.

Conclusions

Recent prevention measures for NAFLD have achieved good initial results. However, it remains a high priority to increase the public awareness of this condition, develop its diagnostic criteria, identify cost-effective screening methods, and seek policy support to act against NAFLD, which will be a major public health problem in the future.

How Mexicans' Emotional Responses to Non-Alcoholic Fatty Liver Disease Can Help Inform Culturally Congruent Health Care

INTRODUCTION

This article aims to increase understanding of how Mexican immigrants respond to learning about non-alcoholic fatty liver disease (NAFLD), a spectrum disease with a heavy burden among Mexican-origin people.

METHODOLOGY

This article presents findings from qualitative interviews (n = 26) that formed part of a mixed-methods study of foreign-born Mexican immigrants carried out in 2019 to 2020 in southern Arizona to assess NAFLD awareness.

RESULTS

We documented common experiences of surprise, fear, and hope during study participation, all of which motivated research participants to reduce their NAFLD risk by seeking additional information, sharing it with others, and making lifestyle changes.

DISCUSSION

Understanding how these emotional experiences are tied to cultural and historical factors-including Mexico's high rates of liver disease, participant's limited access to health care, and the ability to address the NAFLD risk with lifestyle changes-may promote the development of more effective and culturally congruent care in this population.

Periodontal and Hepatic Parameters in Obese Patients Undergoing Bariatric Surgery

PURPOSE

Current discoveries imply a connection between periodontitis and metabolic associated fatty liver disease (MAFLD). This study aimed to determine the prevalence of periodontitis and MAFLD in obese patients with BMI >40, employing the most reliable diagnostic methods, namely liver biopsy, and detailed periodontal examination.

MATERIALS AND METHODS

Liver biopsy and periodontal examination were performed in 30 obese patients with BMI BMI >40 undergoing bariatric surgery. Kleiner's classification was used to determine non-alcoholic steatohepatitis (NAS) activity score, non-alcoholic steatohepatitis (NASH) and liver fibrosis. The periodontal condition was classified following the recent AAP/EFP classification. Patients were divided into periodontitis (PG) and non-periodontitis groups (NPG). Data on systemic health parameters were collected from patients' medical records. Descriptive statistics and simple statistical tests were used to determine the differences between the two groups.

RESULTS

The prevalence of NASH in the sample was 43% (13/30), borderline NASH 37% (11/30), while fibrosis stage 1 was most common (72%, [22/30]). Periodontitis prevalence was 67% (20/30), while all non-periodontitis patients (33%; 10/30) exhibited gingivitis. PG and NPG did not differ in NAS or NASH prevalence (p > 0.05). However, the periodontitis group showed higher C-reactive protein levels, while NPG showed higher gamma-glutamyl transpeptidase levels (p < 0.05).

CONCLUSION

The study results suggest the considerable prevalence of MAFLD, periodontitis and gingivitis in obese patients with BMI >40 undergoing bariatric surgery. Patients with periodontitis had higher CRP levels, while those with gingivitis presented higher gamma-glutamyl transpeptidase levels.

eHealth interventions targeting poor diet, alcohol use, tobacco smoking and vaping among disadvantaged youth: A systematic review protocol (Preprint)

Background

Chronic disease burden is higher among disadvantaged populations. Preventing lifestyle risk behaviors such as poor diet, alcohol use, tobacco smoking, and vaping in adolescence is critical for reducing the risk of chronic disease and related harms in adolescence and adulthood. Although eHealth interventions are a promising prevention approach among the general population, it is unclear whether they adequately serve adolescents from disadvantaged backgrounds such as those living in geographically remote or lower socioeconomic areas.

Objective

This is the first systematic review to identify, evaluate, and synthesize evidence for the effectiveness of eHealth interventions targeting adolescents living in geographically remote or lower socioeconomic areas in preventing poor diet, alcohol use, tobacco smoking, and vaping.

Methods

A systematic search will be conducted in 7 electronic databases: the Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PROSPERO, MEDLINE (Ovid), Embase (Ovid), Scopus, and PsycInfo (Ovid). The search will be limited to eHealth-based experimental studies (ie, randomized controlled trials and quasi-experimental studies) targeting diet, alcohol use, tobacco smoking, and vaping among adolescents (aged 10-19 years). Eligible studies will be those reporting on at least one marker of socioeconomic status (eg, social class, household income, parental occupation status, parental education, and family affluence) or geographical remoteness (eg, living in rural, regional, and remote areas, or living outside major metropolitan centers). One reviewer will screen all studies for eligibility, of which 25% will be double-screened. Data will be extracted and summarized in a narrative synthesis. Risk of bias will be assessed using the Cochrane Revised Risk of Bias Tool.

Results

As of December 2021, the title and abstract screening of 3216 articles was completed, and the full-text review was underway. The systematic review is expected to be completed in 2022.

Conclusions

This systematic review will provide an in-depth understanding of effective eHealth interventions targeting poor diet, alcohol use, tobacco smoking, and vaping among adolescents living in geographically remote or lower socioeconomic areas and the factors that contribute to their effectiveness. This in turn will provide critical knowledge to improve future interventions delivered to these populations.

Trial Registration

PROSPERO CRD42021294119; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=294119

International Registered Report Identifier (IRRID)

PRR1-10.2196/35408