Prevalence of Non-Alcoholic Fatty Liver Disease in Urban Adult Population in a Tertiary Care Center, Chennai

Abstract

Background:

Non-alcoholic fatty liver disease (NAFLD) is becoming one of the most common liver diseases among the Indian population. The predisposing factors for NAFLD are diet, lifestyle modifications, and lack of exercise. There is a paucity of research on NAFLD in the South Indian population. Hence, the present study aimed to assess the prevalence of NAFLD among the urban adult population in Chennai.

Material and Methods:

This analytical cross-sectional study was conducted in General Medicine outpatient departments at a tertiary care center in Chennai. The study included 510 non-alcoholic adults (both male and female) aged between 21 and 40 years. Ultrasonography was performed to rule out fatty liver in all participants. All the results obtained were statistically analyzed using SPSS software version 22.0. The frequency was given in percentage.

Results:

The proportion of participants who screened positive for NAFLD was 61.5%. The participants with higher body mass index (BMI) were found to be significantly 23.09 times higher risk of developing NAFLD. An increase in age was also found to be a predictor of NAFLD. This study also supports that males are more prone to develop NAFLD and are at a 1.59% higher risk of developing the disease than females.

Conclusion:

Fatty liver has become one of the common non-communicable diseases in India, the high prevalence of NAFLD in the present study supports it. Therefore, people should have regular screening and diagnosis to rule out fatty liver disease. Proper diet patterns and exercise must be followed to prevent fatty liver.

INTRODUCTION

Non-alcoholic fatty liver disease (NAFLD) is the leading cause of liver disease globally and also the most common liver disease affecting the Indian population. NAFLD can be defined as macrovascular steatosis that is found in >4% of hepatocytes in the absence of secondary causes such as alcohol or drugs that are associated with fatty liver.[1] The prevalence of NAFLD is found to be more than 25% globally and 9% to 32% in the general Indian population. The higher prevalence is usually associated with individuals who are overweight, obese, and diabetic (type 2 diabetes mellitus).[2]

NAFLD includes a wide range of diseases from NAFLD to non-alcoholic steatohepatitis (NASH), fibrosis, liver cirrhosis, and finally results in hepatic carcinoma.[3] Non-alcoholic fatty liver disease has been included in the National Health Program for the prevention and control of various diseases, such as diabetes, cancer, cardiovascular diseases, and stroke, by the Ministry of Health and Family Welfare due to its high prevalence rate.[4]

Non-alcoholic fatty liver disease is associated with various risk factors such as diabetes mellitus (insulin resistance type 2 DM), obesity, dyslipidemia, and metabolic syndrome.[5] It is found that cardiovascular disease is the leading cause of death among NAFLD, where NAFLD acts as an independent cause of the increased risk of heart disease.[6]

To characterize the degree and the nature of obesity, body mass index (BMI) and waist circumference have to be calculated.[7] Because insulin resistance is commonly associated with NAFLD, non-diabetic patients should be assessed for insulin resistance by calculating homeostasis model assessment-insulin resistance (HOMA-IR).[8]

The treatment strategy for non-alcoholic fatty liver disease may include proper diet, exercise for weight reduction, and drugs such as pentoxifylline, ursodeoxycholic acid, vitamin E, and metformin.[9] Studies have shown among the Indian population that these drugs improve inflammation and hepatic steatosis and are also effective in regularizing transaminase enzymes.[3]

Because there is a raise in the current obesity epidemic with an increase in diabetes and other risk factors (1 in 29 individuals are obese and 1 in 14 are diabetic in India), along with the quantity of those risk factors, there is an increase in the prevalence of NAFLD that is predictable to advance liver disease.[10] Hence, NAFLD can create an adverse impact on global health that is reflected in the cost of healthcare hepatologist follow up and liver management, for the close-coming non-alcoholic steatohepatitis, which is the most common indication. NAFLD increases adverse outcomes such as an increase in liver-specific morbidity and mortality.[11]

Therefore, the aim of the present study is to assess the prevalence of NAFLD among patients attending a tertiary care center in Chennai and associate it with the basic demographic and anthropometric measurements that act as the primary risk factor for NAFLD. This study is performed to promote regular screening and diagnosis of patients for NAFLD and initiate early treatments and prevention measures to minimize the prognosis of the disease.

MATERIALS AND METHODS

Study setting and participants

This analytical cross-sectional study was conducted on 510 adults including both males and females aged between 21 and 40 years attending the General Medicine outpatient department at a tertiary care center in Chennai, Tamil Nadu, from November 2021 to January 2022. The eligibility criteria included non-alcoholic adults between the age group of 21 and 40 years and without a history of any liver disease, renal impairment, diabetes, and thyroid disorders.

Ethical clearance

The groundwork for the study was started after getting clearance from the research committee and the institutional human ethical committee (reference number for approval: 002/SBMC/IHEC/2021/1662).

Data collection

A patient information sheet that explains the nature and purpose of the study was issued to the willing participants, and after obtaining informed and written consent, the demographic profile such as age, gender, family, and medical history was recorded. Anthropometric measurements such as height, weight, and BMI were calculated. Ultrasonography was performed to rule out NAFLD among the willing participants.

Ultrasound features for diagnosing fatty liver

Liver to kidney contrast, parenchymal brightness, bright vessel wall, deep beam attenuation, and define gallbladder wall.

Based on the conventional qualitative grades, NAFLD was labeled from grades 0 to 3.

• Grade 0 - Normal

• Grade 1 - Represented by a slight diffused increase in fine echoes in the hepatic parenchyma with normal visualization of the diaphragm and intrahepatic vessel borders (mild)

• Grade 2 - Represented by a moderate diffused increase in fine echoes with slightly impaired visualization of intrahepatic vessels and diaphragm (moderate)

• Grade 3 - Represented by a marked increase in fine echoes with poor or no visualization of the intrahepatic vessel borders, diaphragm, and posterior portion of the right lobe of the liver (severe).

Statistical analysis

After data collection, the obtained data were analyzed using SPSS software version 22.0. The descriptive statistics were presented in percentage, mean, and standard deviation. The mean difference in age and BMI was analyzed between NAFLD and normal participants and for all statistical tests, a P value <0.05 was taken as statistically significant.

RESULTS

Among 510 diagnosed participants, the overall prevalence of NAFLD was 61.5% [Table 1]. According to the Ultrasonogram grading of fatty liver, 38.2% of participants had grade 1, 22.8% had grade 2, and 0.5% had grade 3 fatty liver.

Table 1.

Ultrasound findings on NAFLD

Ultrasound findings	n	%
Normal	196	38.5
NAFLD	314	61.5
Total	510	100

Demographic details

The mean age group for the participants with NAFLD and normal people did not show that statistical differences existed between groups. The age group of 21–40 years was divided into two groups as 21–30 years and 31–40 years. The majority of the population with NAFLD was between the age of 31 and 40 years, which shows that older ones are predominantly present with fatty liver. In this study, both males and females were included, in which males were more likely to develop NAFLD this study shows that 53.6% of males and 46.4% of females had NAFLD.

Anthropometric measurements

The mean BMI of NAFLD and normal patients showed statistical significance between groups. Based on the BMI, the participants were divided into three groups as normal (18.5–24.9), overweight (25–29.9), and obese (≥30). It was found that an increase in weight increased the risk of developing fatty liver.

DISCUSSION

In this analytical cross-sectional study, we found that 61.5% of the population was diagnosed with NAFLD detected using ultrasound. A meta-analysis assessment showed a worldwide prevalence of 25.24% of NAFLD.[12] It is estimated that around 9–32% of the general Indian population suffers from NAFLD.[13] A prevalence rate of 49.8% was reported in coastal south India in a population-based study.[14] Increased burden of NAFLD, which is associated with a high prevalence, should be a concern that may lead to future risk of developing severe liver diseases such as NASH, fibrosis, cirrhosis, hepatocellular carcinoma, and mortality.[3] A community-based prevalence study of NAFLD based on the ultrasound findings estimated that urban Mumbai had 16.6%, urban Chennai had 32%, and rural Haryana had 30.7%.[15,16] The present study reported a marked rise in prevalence among patients attending the general surgery department in a tertiary care hospital in Chennai.

Based on the conventional qualitative grades, NAFLD was labeled from grades 0 to 3.[17] In this study, most of the NAFLD patients were graded 1 (i.e., mild) with 38.2%.

In this study, we found that an increase in the age group was associated with a high risk of NAFLD, about 57.3% of patients were above the age group of 30 years. We observed that patients in the age group >30 years were at 1.37 (Confidence interval: 0.95–1.96) times higher risk of developing NAFLD. A study by Golabi et al.,[18] found that age groups between 60 and 74 years are at an increased risk of mortality with NAFLD. The present study supports that overweight and obese people are more likely to develop NAFLD due to an increase in the deposition of fat. Above 7.3 and 25.2% of overweight and obese people are more likely to develop NAFLD, which is statistically highly significant with 23.09 times higher risk of developing NAFLD. A study by Asadullah et al.,[19] supports our study with an Odds ratio of 1.79 times higher risk of developing NAFLD (95%CI: 1.07–2.98). Therefore, our study concludes that obese persons with an increased age group were at a higher chance of developing NAFLD. Hence, patients with an increase in BMI and age must be monitored regularly to avoid further complications.

CONCLUSION

Fatty liver has become one of the most common non-communicable diseases in India, a prevalence of 61.5% was observed in the present study. It was also found that an increase in age and BMI was associated with a high risk of developing NAFLD. Therefore, from the present study, it was observed that NAFLD is very common among the Indian population, affecting predominantly males. Hence, people should be regularly screened and diagnosed to rule out fatty liver disease with other healthcare facilities provided. Exercise with proper diet patterns must be followed to prevent fatty liver disease.

Authors contribution

This study was performed by Dr. Mary Chandrika Anton under the guidance of Dr. B. Shanthi. Dr. Chaganti Sridevi contributed to the discussion writing.

Ethical standards

The study involved human participants following the ethical standards of the tertiary healthcare institution where the study was conducted.

Limitations of the study

The study population shall be enlarged as it was relatively less.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.