Nonalcoholic Fatty Liver Disease Status and Its Associated Factors Among Patients With Type 2 Diabetes Mellitus in Adama Hospital Medical College, South Eastern Ethiopia: A Cross‐Sectional Study

ABSTRACT

Background and Aims

Nonalcoholic fatty liver disease (NAFLD) is a condition of fat accumulation in hepatocytes, not because of excess alcohol intake and disease‐causing etiology. The disease occurrence is increased among patients with type 2 diabetes mellitus (T2DM) because of a strong pathophysiological link. Therefore, the aim of this study was to assess the NAFLD status and its associated factors among patients with T2DM in Adama Hospital Medical College, South Eastern Ethiopia, 2022.

Methods

Systematic random sampling was used in an institution‐based cross‐sectional study design from March to June 2022. Sociodemographic, behavioral, and clinical data were assessed using a structured questionnaire. Fatty liver was diagnosed using ultrasonography. About 5 mL of blood sample was collected for testing liver enzyme, fasting blood glucose, and lipid profile tests using the Cobas C 311 analyzer. EpiData version 3.1 was used for data input, and Stata version 17 for analysis. Binary and multivariable logistic regression were used to show the association of sociodemographic and clinical variables, and one‐way ANOVA with post hoc Bonferroni test was used to show significant mean differences among different liver status grading. p < 0.05 was taken as statistically significant.

Results

The prevalence of NAFLD among patients with T2DM was 85.57% (95% CI: 79.8–89.8). Being female and having a longer duration of diabetes had higher odds of having NAFLD. Fasting blood glucose, alanine transaminase, direct bilirubin, total cholesterol, and triglyceride showed a significant mean difference among different NAFLD status as compared to patients with T2DM without NAFLD.

Conclusion

The prevalence of NAFLD was found high. T2DM patients with longer duration of the diabetes and females were found to have a greater risk for NAFLD.

Abbreviations

ALT

alanine transaminase

AST

aspartate transaminase

BMI

body mass index

BP

blood pressure

DB

direct bilirubin

DM

diabetes mellitus

FBS

fasting blood sugar

FFA

free fatty acid

HCC

hepatocellular carcinoma

MS

metabolic syndrome

NAFL

nonalcoholic fatty liver

NAFLD

nonalcoholic fatty liver disease.

NASH

nonalcoholic steatohepatitis

T2DM

type 2 diabetes mellitus

TB

total bilirubin

TC

total cholesterol

TG

triglyceride

TP

total protein

VLDL

very low‐density lipoprotein

1. Introduction

Diabetes mellitus (DM) can be characterized by a significant increase in glucose in the plasma because of either the body's inability to utilize insulin efficiently or secrete sufficient insulin hormone [1]. The distinctive feature of nonalcoholic fatty liver disease (NAFLD) is hepatic fat accumulation (steatosis) without alcohol consumption above 30 g/day for males and 20 g/day for females, and with no disease causative agent [2]. NAFLD represents a range of progressive liver diseases that start with nonalcoholic fatty liver (NAFL), which is isolated intrahepatic triglyceride (TG) accumulation, to nonalcoholic steatohepatitis (NASH), which progresses to fibrosis or cirrhosis, and possibly hepatocellular carcinoma (HCC), which is marked by inflammation and hepatocyte injury [3].

Although NAFLD pathophysiology is still not fully understood, insulin resistance appears to be a significant contributing factor that is commonly associated with DM. Skeletal muscle, liver, and adipose tissue are the key sites of insulin action and resistance [4]. Insulin resistance enhances hormone‐sensitive lipase's ability to break down TG in adipose tissue. Complementary hyperinsulinemia, relative hyperglycemia, and impaired metabolism of free fatty acid (FFA) via oxidation all enhance diminished oxidative catabolism of FFA, liver de novo lipogenesis, and increase production of cholesterol [5].

NAFLD has emerged as a significant challenge due to its rising prevalence, tough diagnosis, as its gold standard diagnostic method is liver biopsy, multifaceted pathogenesis, and not having an approved intervention [6]. The overall prevalence of NAFLD is 25% among the adult population [7]. A study conducted globally estimated that about one‐third to two‐thirds of patients with DM have NAFLD [8]. It has been estimated that more than 24% of obese individuals with type 2 diabetes mellitus (T2DM) also have NAFLD [9].

Obesity and T2DM have increased dramatically over the past few decades as a result of lifestyle modifications brought on by increasing urbanization [10]. According to the International Diabetes Federation, in 2021, nearly 536.6 million people worldwide had diabetes, with ~90% having T2DM, and this number is expected to be projected to 643 million in 2030 [1]. There is growing evidence that people with NASH who are diabetic have an increased risk of developing cirrhosis and HCC in addition to extrahepatic problems. Furthermore, having NAFLD raises the chance of DM progression and severity [11, 12].

There is an indication that NAFLD may increase the chance of cardiovascular disease, with its co‐occurrence with diabetes and MS, and it could also be a contributing factor in diabetic microvascular complications [13]. In a study with more than 2000 people with T2DM and 6.5 years of follow‐up, NAFLD was shown to be related to a nearly two‐fold higher risk of cardiovascular disease [14]. It is possible that NAFLD is a distinct risk factor for diabetic retinopathy and chronic kidney disease [15, 16]. In its more complex cases, NAFLD may affect the balance of gut flora and disrupt iron metabolism [17].

In Ethiopia, there is a lack of routine screening of DM patients for NAFLD status. Evidence from the literature suggests that studies on NAFLD status and associated factors in patients with T2DM have not been carried out in Ethiopia. Therefore, the study aims to assess the NAFLD status of patients with T2DM and identify its associated factors, which may offer insight into the state of the disease and its adverse outcomes.

2. Materials and Methods

2.1. Study Design, Period, Area, and Setting

This study was conducted at Adama Hospital Medical College, located in Adama City, found in the Oromia region, East Shewa Zone, which is located 99 km south‐east of the capital city of Ethiopia, Addis Ababa. An institution‐based cross‐sectional study was conducted to determine the NAFLD status and identify associated factors in patients with T2DM at Adama Hospital Medical College, South Eastern Ethiopia, from March 10 to June 15, 2022.

2.2. Study Population

The study population comprised patients with T2DM who visited the DM clinic during the study period and who fulfilled the eligibility criteria.

2.3. Eligibility Criteria

2.3.1. Inclusion Criteria

All adult patients with T2DM who had a follow‐up and visited the DM clinic of Adama Hospital Medical College during the study period without an alcohol drinking habit and a fatty liver checkup before.

2.3.2. Exclusion Criteria

People with known hepatic disease or inflammation and drug users that can cause liver toxicity and registered on their charts including statins, antifungal, steroids, allopurinol, antiviral, and arthritis drugs were omitted reviewed from the medical charts. People who tested positive for hepatitis B and hepatitis C viruses were excluded from the study. In addition, women tested positive for pregnancy were not included in the study.

2.4. Sample Size Determination and Sampling Technique

According to research in Ethiopia [18], 73% of patients with T2DM have been reported to have NAFLD. The sample size was calculated using a single population proportion formula with a 95% confidence level and a 5% marginal error. The calculated sample size was 303, and after accounting for a 10% nonresponse rate, it rose to 334. However, a finite population correction formula was used to correct the sample size since there are 462 registered patients with T2DM in the center. This gave a final sample size of 194. The study participants were chosen using a systematic random sampling technique. The calculated interval for the systematic random sampling was 2. Therefore, study participants were interviewed at every second interval, which the first participant chosen by the lottery method.

2.5. Study Variables

2.5.1. Outcome Variable

• NAFLD

• Liver function test

• Lipid profile

• Fasting blood glucose

2.5.2. Independent Variables

• Sociodemographic characteristics such as age, sex, marital status, and occupational status.

• Anthropometric measurements such as BMI, clinical factors, and history, such as duration of DM and blood pressure.

• Behavioral characteristics such as exercise habits and smoking habits.

2.6. Data Collection Process and Laboratory Methods

Patients with T2DM aged 18 years and above were recruited after the purpose of the study had been explained to them and they provided written informed consent. Experienced nurses conducted face‐to‐face interviews with study participants to gather their sociodemographic data using a structured questionnaire. Clinical data were also collected by experienced nurses from the chronic case unit OPD by looking at their charts and measuring BP. BP was measured using a mercury sphygmomanometer from the left upper arm and positioned at the heart level. The research participants' height and weight were measured using a stadiometer and a weighing scale. The participants were directed to stand straight on the stadiometer floorboard with their backs to the perpendicular backboard. The soles of the feet were brought together and in contact with the vertical board's base. Shoes and hats were removed from the participant before the height assessment. The height was reported within 0.1 cm.

A weight scale was used to determine each participant's weight. Before beginning the weight measurement, the weight gauge was reset to zero. Participants were instructed to take off any extra layers of clothing, shoes, jewelry, and anything in their pockets before standing with their weight equally spread between both feet, their arms at their sides, palms facing in the direction of their thighs, and their heads up and facing forward. Finally, weights were measured to the nearest 0.1 kg. BMI was then determined by dividing weight in kilograms (kg) by height in meters squared (m²).

After an overnight fast of 8–12 h, an experienced medical laboratory technologist collected 5 mL venous blood from patients with T2DM who visited the chronic care unit of the hospital. The collected blood was poured into a serum separator test tube, then left for 30 min while it clotted. The blood was centrifuged at 3500 rpm for 5 min, and the serum was used for liver function tests, lipid profiles, and FBS tests. To exclude pregnant women, a rapid chromatographic immunoassay test strip was used to check urine human chorionic gonadotropin hormone levels in the study participants, and to exclude hepatitis B and hepatitis C patients, a rapid chromatographic immunoassay test strip was used to check study participants for serum hepatitis B virus surface antigen and hepatitis C virus antibody.

Using the Cobas C 311 chemical analyzer, a skilled laboratory technologist performed the liver function tests, FBS, and lipid profile. This analyzer measures the parameters using a photometric measuring principle that measures the absorbance of the reaction mixture in the cuvettes of the reaction disk at a specific wavelength. A radiologist conducted an ultrasonography examination. The patient was instructed to fast for at least 6 h and was also forbidden to take medications before the ultrasound examination. The parameters that are commonly employed to grade the liver's steatosis include the liver's brightness, the contrast between the liver and kidney, the liver parenchyma, the liver diaphragm, and the appearance of the intrahepatic arteries. NAFLD was classified as normal in individuals when the with a normal echotexture of liver; mild when there is a slight and diffuse increase of liver echogenicity with normal visualization of the diaphragm and of the portal vein wall; moderate when there is increased liver echogenicity with slightly impaired appearance of the portal vein wall and the diaphragm; severe in case of marked increase of liver echogenicity with poor or no visualization of portal vein wall, diaphragm, and posterior part of the right liver lobe.

2.7. Data Quality Assurance

The questionnaire was first prepared in English and then translated into local languages (Affan Oromo and Amharic), and then, to check its consistency, it was translated back into English. Data collectors were trained, and regular supervision was carried out to ensure the quality of the data. The data were checked for completeness and sample labeling, adequacy, proper container, hemolysis, and proper volume. Anthropometric measurements were taken twice, and the average of the two was used. In addition, the weighing scale was tested and validated using standard weights before actual measurement. Finally, at each stage of laboratory analysis (pre‐analytical, analytical, and post‐analytical), the manufacturer's instructions, standard operating procedures, and quality assurance were followed. Needles and tubes were inspected, waste and water levels were checked, temperature and humidity were kept constant, and proper sample preparations were performed primarily. Calibration was performed initially at the startup of using the machine, when the quality control fails, and if any environmental conditions like temperature changed. Calibrators were typically barcoded and placed on the sample disk for automatic recognition. Quality controls were performed every morning before any sample run using manufacturer prepared quality control reagents. All reagents and test kits used were checked for their expiration dates. The findings were carefully documented, transcribed, and evaluated.

2.8. Data Analysis and Interpretation

Data from participants were edited and cleaned manually before being entered into the software. A data entry template was created based on study variables using EpiData v. 3.1, and manually edited data were entered into the software for further editing and analysis using Stata v.17. Descriptive frequencies, percentages, means, and standard deviations were summarized to describe the study population with relevant variables.

The results were reported as the mean (± standard deviation) for continuous variables and as frequencies (percentages) for categorical variables. Then, categorical variables were analyzed using a binary logistic regression model. Variables with p < 0.25 were considered as significant in bivariable analysis then taken to multivariable regression and variables < 0.05 were taken as statistically significant. Differences among groups of continuous variables were compared with normal patients with T2DM having normal liver (NAFLD) using a one‐way ANOVA to show if there were any significant differences between the group means. The statistically significant groups were subjected to a post hoc Bonferroni test to show which particular groups were significantly different from each other. The differences were considered significant at p ≤ 0.05.

2.9. Ethical Approval and Consent

The study was conducted after obtaining ethical clearance from the University of Gondar, the College of Medicine and Health Science, the School of Biomedical and Laboratory Sciences, and the Ethical Review Committee (Reference Number: 127/2022). A permission letter was also obtained from Adama Hospital Medical College. Study participants were given an information sheet to understand the study, and any questions were welcome. Participants who were willing to participate in the study provided written informed consent before enrollment. Only when a participant was willing and ready to take part in the research did the data collection process start. Additionally, participants were assured that the data obtained from them would be kept confidential and used only for research purposes. Any abnormal laboratory findings during the study period were communicated to the physician for appropriate diagnosis and care. Moreover, all methods were performed in accordance with the relevant guidelines and regulations.

3. Results

3.1. Sociodemographic Characteristics of Study Participants

In this study, 194 patients with T2DM were included, of these 92 (47.42%) were males and the majority of study participants 173 (89.18%) were married. The mean ± SD of age of study participants was 47.63 ± 13.81 years (Table 1).

Table 1.

Sociodemographic characteristics of study participants in Adama Hospital Medical College, South Eastern Ethiopia, 2022 (n = 194).

Variables	Frequency	Percent (%)
Sex
Male	92	47.42
Female	102	52.58
Age (mean)
< 47.63	112	57.73
≥ 47.63	82	42.27
Educational status
Able to read and write	13	6.7
Primary school	32	16.4
Secondary school	67	34.54
Tertiary education	82	42.27
Marital status
Single	3	1.55
Married	173	89.18
Widowed	18	9.28
Residence
Urban	176	90.72
Rural	18	9.28
Occupational status
Merchant	24	12.37
Student	4	2.06
Farmer	15	7.73
Government employer	66	34.02
House wife	58	29.9
Retired	27	13.92

3.2. Behavioral, Anthropometric, and Clinical Characteristics of Study Participants

Table 2 revealed that, of the participants, 132 (68.04%) had no exercise habits, and 163 (84.02%) had normal blood pressure.

Table 2.

Behavioral, anthropometric, and clinical characteristics of study participants in Adama Hospital Medical College, South Eastern Ethiopia, 2022 (n = 194).

Variables	Frequency	Percent (%)
Exercise regularly
Yes	62	31.96
No	132	68.04
Recently smoking habit
Yes	0	0
No	194	100
Diabetes mellitus duration (years)
< 2	51	26.29
2–4	64	32.99
5–7	30	15.46
> 7	49	25.26
Body mass index
18.0–24.9 kg/m2	136	70.1
≥ 25 kg/m2	58	29.9
Blood pressure
Normal	163	84.02
Increased	31	15.98

From 194 study participants, 85.57% (95% CI: 79.8–89.8) of patients with T2DM NAFLD status was positive. In total, 90 (54.21%) had mild, 66 (39.75%) had moderate, and 10 (6.02%) had severe NAFLD (Figure 1).

Figure 1.

Prevalence of different status of NAFLD among patients with T2DM (n = 194).

Table 3 showed the statistical analysis of sociodemographic and clinical variables using binary logistic regression. Females had 7.47 times higher odds of having NAFLD compared to males and the longer the DM duration the increased the odds of having NAFLD.

Table 3.

Binary and multivariable logistic regression analysis of NAFLD status among patients with T2DM (n = 194).

Variables		COR (95% CI)	AOR (95% CI)	p
Age (mean)	< 47.63	I	I	I
	≥ 47.63	0.32 (0.124–0.83)	0.15 (0.38–0.6)	0.07
Sex	Male	I	I	I
	Female	4.01 (1.61–9.96)	7.47 (2.13–12.13)	0.002*
Residency	Urban	I	I	I
	Rural	8.26 (2.9–23.36)	3.34 (0.82–13.63)	0.092
Exercise regularly	Yes	I	I	I
	No	0.34 (0.15–0.773)	1.04 (0.32–3.33)	0.946
DM duration (years)	< 2	I	I	I
	2–5	8.89 (1.9–41.59)	22.47 (3.7–135.1)	0.219
	5–7	2.43 (0.46–12.6)	10.31 (1.45–72.9)	0.088
	> 7	5.87 (1.1–1.75)	4.97 (1.78–15.35)	0.001*

Note: I: reference group.

^*Statistically significant p < 0.05.

Table 4 shows there were no significant differences in the mean AST, HDL, LDL, TP, and TB, among different liver statuses with a p > 0.05.

Table 4.

Comparison of mean measured biochemical parameters of patients with T2DM with different NAFLD status (n = 194).

Variables	Liver status	N	Mean (SD)	p
HDL (mg/dL)	Normal	28	40.23 ± 10.69	0.1611
	Mild	90	45.73 ± 33.65
	Moderate	66	37.29 ± 12.36
	Severe	10	36.04 ± 0.17
LDL (mg/dL)	Normal	28	80.12 ± 38.06	0.501
	Mild	90	98.71 ± 26.72
	Moderate	66	83.44 ± 34.12
	Severe	10	141.73 ± 89.07
TP (g/dL)	Normal	28	6.90 ± 0.49	0.6992
	Mild	90	7.08 ± 0.81
	Moderate	66	7.06 ± 0.65
	Severe	10	7.02 ± 0.41
TB (mg/dL)	Normal	28	0.48 ± 0.27	0.1268
	Mild	90	0.36 ± 0.12
	Moderate	66	0.69 ± 0.48
	Severe	10	0.37 ± 0.27
AST (U/L)	Normal	28	0.28 ± 0.22	0.5225
	Mild	90	0.63 ± 0.42
	Moderate	66	0.76 ± 0.12
	Severe	10	0.23 ± 0.17

Abbreviations: AST, aspartate transaminase; HDL, high‐density lipoprotein; LDL, low‐density lipoprotein; TB, total bilirubin; TP, total protein.

After a one‐way ANOVA test, variables that showed significant differences were subjected to post hoc Bonferroni analysis to specifically indicate which specific group is significant. The mean measured ALT of patients with mild NAFLD was significantly lower than mean ALT of those without NAFLD. There were significant differences in the mean DB among patients with T2DM with different NAFLD status (Table 5).

Table 5.

Comparison of mean measured biochemical parameters of patients with T2DM with different NAFLD status (n = 194).

Variables	Liver status	N	Mean (SD)	p
ALT (U/L)	Normal	28	17.10 ± 5.05	—
	Mild	90	12.08 ± 4.57	0.046
	Moderate	66	16.91 ± 13.19	1.000
	Sever	10	15.36 ± 4.96	1.000
FBS (mg/dL)	Normal	28	168 ± 36	—
	Mild	90	220 ± 93	0.065
	Moderate	66	236 ± 109	0.009
	Severe	10	241 ± 99	0.215
TG (mg/dL)	Normal	28	135.18 ± 53.40	—
	Mild	90	162.13 ± 86.62	1.000
	Moderate	66	222.23 ± 14.84	≤ 0.001
	Severe	10	96.78 ± 79.46	1.000
DB (mg/dL)	Normal	28	0.14 ± 0.10	—
	Mild	90	0.08 ± 0.04	< 0.001
	Moderate	66	0.08 ± 0.04	< 0.001
	Severe	10	0.06 ± 0.00	0.001
TC (mg/dL)	Normal	28	133.52 ± 44.51	—
	Mild	90	158.02 ± 34.22	0.078
	Moderate	66	153.33 ± 48.31	0.319
	Severe	10	203.29 ± 92.99	< 0.001

Abbreviations: ALT, alanine transaminase; DB, direct bilirubin; FBS, fasting blood sugar; TC, total cholesterol.TG, triglyceride.

4. Discussion

NAFLD is one of the most rapidly increasing chronic diseases worldwide. There is accumulating evidence that diabetic subjects with NASH have numerous difficulties, including increased risk for cardiovascular disease complications, cirrhosis, and HCC [12]. An increase in those risks is also recorded in Ethiopia [19, 20]. This study aimed to assess the status of NAFLD and associated factors among T2DM patients. In this study, the prevalence of NAFLD among T2DM patients was 85.57%. The result was higher than those reported by studies conducted in Saudi Arabia in 2015 and 2018 (47.8% and 72.8%) [21, 22], Sudan in 2015 (50.3%) [23], Ethiopia in 2018 (73%) [18], and Singapore in 2020 (78.2%) [24]. The possible explanation for these differences in reported prevalence may be their sociodemographic characteristics, lifestyles, and cultural differences between countries. Other possible reasons may be due to the method of diagnosis of NAFLD used, lack of attention given to NAFLD by the health sector, and the lack of specific therapeutic regimens due to the complex nature of the disease, as well as the lack of routine liver checkups in health facilities, especially for asymptomatic patients. The logistic regression result revealed that females have a higher odds 7.47 (2.13–12.13) of developing NAFLD compared to males. This finding is consistent with previous studies indicating that females are at greater risk than males. For instance, studies were done in South Africa [25], China [26], and Thailand [27]. However, this finding is not supported by other studies, such as a study conducted in China [28]. This age–gender association is due to the inherent physiological changes in females that increase the risk of visceral fat accumulation, hyperlipidemia, and IR, all recognized risk factors for the onset of NAFLD [29]. Similarly, men and postmenopausal women build visceral adipose tissue more quickly than younger women do with age and weight gain. The changes in the level of sex hormones connected to estrogen are closely correlated with the relationship between aging, being a woman, and the development of NAFLD [27].

Furthermore, this may be because of regional fat distribution, which is controlled by hormones and directly linked to the risk of metabolic diseases and NAFLD. A higher risk is associated with visceral adiposity, which is seen in men, whereas women of reproductive age have a lower risk due to gluteo‐femoral subcutaneous distribution. Estradiol inhibits lipolysis in women of reproductive age and increases the insulin sensitivity of adipose tissue, both of which reduce excess FA being delivered to the liver [30]. Postmenopausal women are no longer safe from NAFLD due to hormonal changes; visceral fat accumulation tends to increase, and women over the age of 50 are more likely to acquire NAFLD. Because estrogen levels diminish throughout menopause, women become more vulnerable to NAFLD [31].

Longer DM duration (> 7 years) has a higher odds 4.97 (1.78–15.35) of developing NAFLD. This outcome is consistent with studies conducted in Ethiopia [18] and China [32]. This may be as a result of increasing DM duration, which increases the risk of DM complications by exacerbating insulin resistance and “de novo” lipogenesis. These factors are vital for the development and increasing severity of NAFLD in patients with T2DM. Increasing FFA, lipolysis, gluconeogenesis reduced immunity and numerous complications are other possible contributory factors [33].

The mean fasting blood sugar of patients with moderate NAFLD was significantly higher than that of patients without NAFLD. These findings agree with studies conducted in Iran [34] and China [28]. This may be due to the pathophysiologic connection between the hyperglycemic state and liver lipid accumulation. In addition, hyperglycemia, mainly caused by insulin resistance, affects the metabolism of lipids. This, in turn, can lead to the development of fatty liver disease and T2DM [35]. Research indicated that saturated fatty acids produce intrahepatic oxidative stress, which further impairs hepatic insulin signaling. Due to this insulin resistance, a significant proportion of NAFLD patients have coronary artery disease and endothelial dysfunction [36].

The mild status of NAFLD showed a significant mean difference of ALT than the patients with T2DM without NAFLD. An increase in the level of ALT in NAFLD‐positive patients with T2DM has been reported by studies conducted in Iran [37] and the USA [38]. The increased ALT levels may indicate an excess of fat being deposited in the liver as a result of NAFLD and represent continuing inflammation that compromises insulin signaling in the liver. As they are released under the state of liver injury, it is increasingly associated with liver abnormalities [39].

Patients with all forms of NAFLD (mild, moderate, and severe) show a significant mean differences of DB compared to the patients with T2DM without NAFLD. This result is similar with study conducted in China [40]. This may be due to serum bilirubin significantly contributing to total antioxidant capacity and anti‐inflammatory effects, as well as acting as scavengers of reactive oxygen species and reducing insulin resistance. Bilirubin offers protection against the risk of NAFLD due to its antioxidant effects. A reduction in bilirubin levels can raise the risk of developing NAFLD by promoting insulin resistance and oxidative stress [41].

The severe status of NAFLD showed a significant mean difference of TC as compared to the patients with T2DM without NAFLD, whereas the moderate status of NAFLD showed a significant mean difference of TG as compared to the patients with T2DM without NAFLD. The alteration of lipid profile is in line with studies conducted in Sudan [23] and the United States [42]. This may be because of the key role of lipid toxicity in the progression of NAFLD. The risk of cirrhosis is also increased by hypertriglyceridemia, which is an independent predictor of NAFLD. Fatty liver is significantly associated with hypertriglyceridemia and higher levels of non‐HDL cholesterol [43].

5. Conclusions and Recommendations

The burden of NAFLD among T2DM patients in Adama Hospital Medical College was 85.57%. There were significant differences in mean ALT, FBS, DB, TG, and TC of patients with NAFLD compared to those without NAFLD. In addition, longer DM duration and being female were also significantly associated with NAFLD occurrence. Therefore, health care professionals should routinely screen patients with T2DM for NAFLD to reduce the burden and later complications. Also, to avoid prolonged difficulties, it is desirable to control the blood sugar of patients with T2DM.

In addition, as noncommunicable diseases are highly increasing in this era, policymakers should pay adequate attention to NAFLD regarding its increasing prevalence due to numerous factors. Moreover, researchers should conduct research on a large number of participants with appropriate study designs for a deeper understanding of the pathophysiological mechanisms and impacts of NAFLD on patients with T2DM.

6. Strengths and Limitations of the Study

This study assessed the status of NAFLD and associated factors among patients with T2DM who are enrolled for treatment at the Adama Medical College Hospital. It provides a great insight for the status NAFLD which is not assessed as part of the follow‐up for patients with T2DM, even though it has a great pathophysiological cross‐linkage. The study comprehensively reveals the need of knowing the NAFLD status alongside with biochemical tests. However, the study has some limitations. Using ultrasound for assessing NAFLD as the gold standard is liver biopsy, and the cross‐sectional nature of the study design is also challenging to draw cause–effect relationship.

Author Contributions

Mahider Shimelis Feyisa: conceived, designed, performed the laboratory tests and statistical analysis, interpreted the data, and wrote the draft manuscript. Sintayehu Ambachew: collected the data, performed the laboratory tests and statistical analysis, and wrote the draft manuscript. Alemie Fentie Mebratie: collected the data, performed the laboratory tests and statistical analysis, and wrote the draft manuscript. Bruktawit Eshetu Ali: collected the data, performed the laboratory tests and statistical analysis, and wrote the draft manuscript. Rishan Hadgu Asefa: collected the data, performed the laboratory tests and statistical analysis, and wrote the draft manuscript. Elias Chane Asefa: collected the data, performed the laboratory tests and statistical analysis, and wrote the draft manuscript. Mahder Girma Asmamaw: collected the data, performed the laboratory tests and statistical analysis, and wrote the draft manuscript. Getnet Fetene: collected the data, performed the laboratory tests and statistical analysis, and wrote the draft manuscript. All authors read and approved the final version of the manuscript and the corresponding author (Mahider Shimelis Feyisa) has full access of the data and takes complete responsibility for the integrity of the data and accuracy of the data analysis.

Funding

The authors received no specific funding for this work.

Disclosure

The lead author Mahider Shimelis Feyisa affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Ethics Statement

The study was conducted after obtaining ethical clearance from the University of Gondar, the College of Medicine and Health Science, the School of Biomedical and Laboratory Sciences, and the Ethical Review Committee (Reference Number: 127/2022).

Consent

Participants who were willing to participate in the study provided written informed consent before enrollment.

Conflicts of Interest

The authors declare no conflicts of interest.

Feyisa M. S., Ambachew S., Mebratie A. F., et al., “Nonalcoholic Fatty Liver Disease Status and Its Associated Factors Among Patients With Type 2 Diabetes Mellitus in Adama Hospital Medical College, South Eastern Ethiopia: A Cross‐Sectional Study,” Health Science Reports 9 (2026): 1–9, 10.1002/hsr2.71773.

Data Availability Statement

The authors confirm that the data supporting the findings of this study are available in the article (and/or) its Supporting Materials.