Hepatic Steatosis and Stiffness in Adolescent Obesity are Linked to Androgenemia, Insulin Sensitivity, and Inflammation

Abstract

Introduction:

Metabolic dysfunction-associated steatotic liver disease (MASLD) is driven by obesity and is common among girls with polycystic ovary syndrome (PCOS). Higher testosterone concentrations are associated with more severe histological MASLD features in girls, but less severe in boys. This proof-of-concept study tested the hypotheses that MRI-based hepatic fat and stiffness are higher among girls with PCOS versus girls without PCOS but not boys and are associated with testosterone concentration (differing by sex), insulin sensitivity, and inflammation.

Methods:

This proof-of-concept cross-sectional study at an academic pediatric center included pubertal girls (n=25; 10 without PCOS, 15 with PCOS) and boys (n=10) with obesity, ages 12–18 years. Outcomes were (primary) MRI hepatic fat fraction (HFF %) and stiffness and (secondary) insulin sensitivity index (ISI), 2-hour OGTT and inflammatory markers.

Results:

HFF was higher in girls with PCOS versus those without but not different from boys. Stiffness did not differ by group. HFF and stiffness were both directly associated with OGTT 2-hour glucose and inversely with ISI. Stiffness was directly associated with testosterone (total, free) in girls without PCOS and with interleukin (IL)-6 and IL-18 in the full cohort.

Conclusions:

HFF was higher in girls with PCOS versus those without, but not different from boys. While stiffness did not differ by group, its association with testosterone concentrations in girls without PCOS may be an additional risk biomarker for MASLD in addition to inflammation and insulin resistance. Future larger, longitudinal studies should determine if addressing these alterations, separately or collectively, in youth with obesity could improve hepatic outcomes.

Introduction

Metabolic dysfunction-associated steatotic liver disease (MASLD), previously termed non-alcoholic fatty liver disease [1] is a growing health threat to children with obesity [2] and is the most common liver disease in children [3]. The prevalence of MASLD is higher in the setting of insulin resistance [4, 3], polycystic ovary syndrome (PCOS), and type 2 diabetes. Among adult women with PCOS versus those without, the prevalence of MASLD is estimated at approximately 52% versus 30% [5], while among adolescent girls with obesity and PCOS versus without PCOS, the difference in prevalence is even larger, 49% versus 14%.[6] Among adolescents with biopsy-confirmed MASLD, higher testosterone in girls is associated with greater steatosis severity but related to improved features in boys [7]. Androgenemia, insulin resistance, and MASLD appear to be tightly linked in both youth and adults with obesity [8, 9].

Interest regarding the role of inflammation in MASLD is increasing. Inflammatory markers including C-reactive protein (CRP), interleukin (IL)-6, and tumor necrosis factor (TNF)-alpha have been found to be associated with MASLD in adults [10], while IL-18 [11], TNF-alpha [12], growth differentiation factor (GDF)-15 [13–15] were associated with MASLD in youth and in adults with advanced liver disease. The role of potentially protective, anti-inflammatory, fibroblast growth factor (FGF)-21 and adipokines, leptin and adiponectin, have also been investigated and have been variably associated with hepatic fat content in youth with obesity [16–19].

Given the interrelated roles of insulin resistance and the metabolic syndrome in adolescents with obesity, and the sex-related differential impact of androgenemia on hepatic health [20], we hypothesized that a) hepatic fat content and stiffness (measured by magnetic resonance imaging (MRI) [3]) are worse in girls with PCOS versus without PCOS but not different from boys, b) hepatic fat and stiffness are associated with testosterone concentrations in girls but not boys, and c) hepatic fat and stiffness would be more severe among youth with greater degrees of insulin resistance and inflammation. Therefore, in this cross-sectional proof-of-concept study, we evaluated adolescent girls with obesity with or without PCOS and adolescent boys with obesity, of similar age and pubertal stage, and examined the associations between hepatic fat and stiffness, insulin sensitivity, and inflammation in the context of varying degrees of androgenemia.

Materials and Methods

Participants

The sample included 35 adolescents ages 12–18 years with obesity (body mass index [BMI] ≥95^th percentile for age/sex using U.S. Centers for Disease Control and Prevention growth charts), Tanner stage 3 puberty or higher and post-menarche for females. Recruitment was stratified to include 15 girls with obesity and clinically diagnosed PCOS (clinical hyperandrogenism and/or biochemical hyperandrogenemia in the presence of persistent oligomenorrhea), 10 girls with obesity without PCOS, and 10 boys with obesity. Exclusion criteria included pregnancy; use of medications or presence of diseases that alter glucose, lipid, or androgen metabolism; previously diagnosed diabetes mellitus; and anemia. Participants were recruited from the UPMC Children’s Hospital of Pittsburgh PCOS Center within the Center for Pediatric Research in Obesity and Metabolism, Division of Pediatric Endocrinology, and from the general pediatric endocrinology clinic and the obesity management clinic. The study was approved by the University of Pittsburgh Institutional Review Board. Informed consent and child assent (for participants younger than 18 years) were obtained from each participant and accompanying legal guardian.

Clinical examination

All participants underwent medical history and physical examination prior to laboratory tests to confirm absence of health condition exclusions and alcohol use. Study visits took place at the Pediatric Clinical and Translational Research Center at UPMC Children’s Hospital of Pittsburgh. Urine pregnancy test was obtained for all female participants. Height and weight were measured to determine BMI. BMI Z-score was determined using pediatric growth curves from the U.S. Centers for Disease Control and Prevention [21]. Pubertal development was assessed by a pediatric endocrinologist using Tanner criteria [22, 23]. An intravenous catheter was placed in all participants to obtain fasting blood samples followed by an oral glucose tolerance test (OGTT) as below.

Oral glucose tolerance test

After an overnight fast of at least 10 hours, fasting blood was obtained for glucose and insulin, alanine and aspartate aminotransferases (ALT, AST), inflammatory markers, adipokines, and androgens as listed below. This was followed by a 2-hour OGTT performed according to the American Diabetes Association (ADA) criteria. Participants ingested a dextrose solution of 75g over a period of less than 5 minutes. Venous blood samples for glucose and insulin concentrations were drawn 15 minutes prior to ingestion, immediately before ingestion (time 0), and at 15, 30, 60, 90, and 120 minutes after ingestion. Impaired fasting glucose (time 0 glucose = 100–125 mg/dL), impaired glucose tolerance (time 120 glucose = 140–199 mg/dL), and diabetes (time 0 glucose ≥126 mg/dL or time 120 glucose ≥200mg/dL) were defined per ADA criteria [24]. Due to lab error leading to missing glucose data at time 0, the negative 15-minute timepoint was used to replace the missing fasting glucose value for one girl with PCOS. Insulin at time 0 was used to calculate insulin sensitivity index (ISI), the inverse of fasting insulin, a marker of insulin sensitivity [25] which is strongly correlated with clamp-measured insulin sensitivity in youth with obesity across the glycemic spectrum [25].

Biochemical measurements

Analysis of the samples was completed using commercially available multiplex kits (Millipore Sigma, Burlington, MA, USA). IL-6 and TNF-alpha were analyzed with the Human Adipocyte Magnetic Bead Panel. GDF-15, IL-18, FGF-21, adiponectin, and leptin were analyzed with the Human Aging Magnetic Panel. All samples were stored at −80°C following processing by the staff at the Pediatric Clinical and Translational Research Center. Samples were kept frozen until analyzed and were only thawed one time for analysis. The number of samples was sufficient to run the entire study on one plate per assay.

Insulin was analyzed with a commercially available Human Insulin ELISA kit (Millipore Sigma, Burlington, MA, USA) with an intra-assay CV less than 2.24% and an inter-assay CV <10%. Triglycerides, ALT, and AST were analyzed in the UPMC Children’s Hospital of Pittsburgh clinical laboratory. To evaluate androgenemia, fasting serum samples were analyzed by LabCorp using direct analog enzyme immunoassay (free testosterone) or electrochemiluminescence immunoassay (total testosterone, sex-hormone binding globulin [SHBG]).

MRI measurement of liver fat and fibrosis

Following the OGTT, participants were transferred to the radiology department to obtain MRI of the abdomen without contrast following liver elastography and IDEAL-IQ protocol on a 3 Tesla GE magnet utilizing a dedicated phased array coil. MR elastography was performed utilizing an external pneumatic driver and MR TOUCH encoding with color wave and stiffness maps provided. MR outcomes were hepatic fat fraction (HFF) measured as proton density fat fraction (%) and liver stiffness (kPa). Reference ranges for interpretation of proton density fat fraction were based on Tang et al, with <6.4% interpreted as normal, 6.4–17.3% grade 1, 17.4–22.0% grade 2, and ≥22.1% grade 3 steatosis.[26] MR elastography results were based on findings from Kim D et al, with < 2.5 kPa normal, 2.5–2.9 kPa either normal or inflammation, 2.9–3.5 kPa Stage 1–2 fibrosis, 3.5–4.0 kPa Stage 2–3 fibrosis, 4.0–5.0 kPa Stage 3–4 fibrosis, and >5.0 kPa Stage 4 or cirrhosis [27]. Images were read by the collaborating pediatric MR radiologists at UPMC Children's Hospital of Pittsburgh.

Statistical analysis

Continuous data were summarized using mean and standard deviation (SD). Non-parametric continuous data were log-transformed for analysis. Categorical variables were summarized using frequencies and percentages. Differences in log-transformed continuous variables were assessed using ANOVA with post-hoc pairwise comparisons between female group (PCOS versus non-PCOS) and between male versus female subgroups evaluated using Bonferroni’s procedure. Differences in categorical variables were assessed using the chi-square test. Pearson correlation of log-transformed continuous variables was used to assess for associations between HFF or stiffness and testosterone (total and free) and SHBG as continuous variables, stratified by category (girls with PCOS, girls without PCOS, boys). To evaluate associations between HFF or stiffness and inflammation or insulin resistance, Pearson correlation was repeated with the entire sample of subjects without stratification by sex. Statistical significance was set at p<0.05. For comparisons of hepatic outcomes among girls with versus without PCOS, one-sided p-values were used due to the pre-specified hypotheses stated above that hepatic fat and stiffness will be worse among girls with PCOS versus without PCOS. Stata 18 was used for statistical analysis.

Results

Participant characteristics

Participant characteristics are summarized in Table 1 by group (girls with PCOS, girls without PCOS, boys), with ANOVA statistical significance among the three groups and pairwise post-hoc comparisons shown. Age, race-ethnicity, BMI Z-scores, leptin and adiponectin did not differ among the groups, nor did measures of glucose or insulin sensitivity. HDL cholesterol was lower in girls with PCOS versus without (p = 0.001). Consistent with participants’ clinical diagnosis, girls with PCOS had significantly higher total and free testosterone than girls without PCOS (p<0.001 for each). As shown in Figure 1A, HFF was significantly higher in girls with PCOS than those without PCOS. No difference was found between boys and girls with or without PCOS (Table 1). Using the HFF thresholds of Tang et al[26] and dichotomizing into grade 0 steatosis versus grade 1 or above, girls with PCOS had a higher prevalence of grade 1 or higher steatosis (n=10/15, 67%) than girls without PCOS (n=3/10, 30%) (chi-squared p = 0.03, one-sided based on prespecified hypothesis of higher steatosis in girls with PCOS). Girls with PCOS were also the only group with grade 3 steatosis (n=3/15, 20%). Stiffness did not differ across the three groups (as shown in Fig. 1B). With the exception of CRP, ALT, AST, GGT, inflammatory markers, GDF-15 and FGF-21 did not differ across the three groups (Table 1).

Table 1.

Participant characteristics by group.

Characteristic	PCOS Girls	Non-PCOS Girls	Post-hoc P between girls	Boys	3-group P
n	15	10		10
Demographics
Age (years)	15.7 ± 1.5	14.5 ± 1.9	NS	14.9 ± 2.2	NS
Race-ethnicity, n (%)			NS		NS
Black	5 (33%)	2 (20%)		2 (20%)
Biracial (Black, White)	0	1 (10%)		0
Non-Hispanic White	10 (67%)	6 (60%)		8 (80%)
Hispanic	0	1 (10%)		0
Weight (kg)	104.2 ± 13.9	108.6 ± 28.9	NS	99.4 ± 23.9	0.6
Height (cm)	163.7 ± 6.2 a	164.5 ± 9.2	NS	172.6 ± 9.1a	0.03
BMI (kg/m2)	38.9 ± 5.0	40.0 ± 9.5	NS	33.0 ± 5.5	0.04
BMI Z-score	2.3 ± 0.2	2.4 ± 0.4	NS	2.3 ± 0.4	NS
Adiponectin (mcg/mL)	16.1 ± 7.6	20.3 ± 7.4	NS	21.5 ± 9.4	NS
Leptin (ng/mL)	15.2 ± 9.3	20.7 ± 10.2	NS	20.8 ± 12.0	NS
Androgen-Related Measures
Total testosterone (ng/dL)*	51.4 ± 19.5 a	23.0 ± 15.6 b	<0.001	307 ± 129 a,b	<0.001
Free testosterone (pg/mL)*	11.3 ± 5.6 a	3.7 ± 2.8 b	0.001	67.7 ± 34.4 a,b	<0.001
Sex hormone binding globulin (nmol/L) *	19.6 ± 6.8	22.0 ± 17.9	NS	24.2 ± 17.1	NS
Hepatic Outcomes
MRI Proton Density Fat Fraction (%) ^	7.8 (5–20.3)	4.9 (3.6–7.5)	0.03	6.0 (5.0–8.0)	0.057
Steatosis grade[1]
0 (< 6.4%)	5 (33%)	7 (70%)	0.08 across all categories; 0.03 for grade 0 versus grades 1–3	5 (50%)	0.3 across all categories; 0.02 for grade 0 versus grades 1–3
1 (6.4–17.3%)	5 (33%)	3 (30%)		4 (40%)
2 (17.4–22.0)	2 (13%)	0		1 (10%)
3 (≥22.1%)	3 (20%)	0		0
MRI Stiffness, (kPa) ^	2.38 (2.12–2.54)	2.32 (2.17–2.78)	NS	2.25 (1.95–2.6)	NS
ALT (U/L)	57.0 ± 59.8	28.7 ± 9.2	NS	43.2 ± 18.3	NS
AST (U/L)	29.2 ± 23.8	20.0 ± 4.7	NS	24.0 ± 8.5	NS
Metabolic Measures
LDL	86.1 ± 12.4	91.4 ± 22.7	NS	98.4 ± 27.2	NS
HDL	43.5 ± 8.7	34.0 ± 3.9	0.001	38.6 ± 4.1	0.002
Triglycerides	87.4 ± 29.7	111.5 ± 43.4	NS	114.7 ± 43.3	NS
Fasting glucose (mg/dL)	90.5 ± 12.0	87.7 ± 6.0	NS	90.2 ± 5.0	NS
OGTT 2-hour glucose (mg/dL)	131.6 ± 45.9	107.5 ± 21.4	NS	119.4 ± 27.0	NS
Glucose Tolerance Categories
OGTT normal glucose tolerance, n (%)	11 (73%)	9 (90%)	NS	8 (80%)	NS
OGTT impaired glucose tolerance, n (%)	3 (20%)	1 (10%)		2 (20%)
OGTT Diabetes, n (%)	1 (7%)	0		0
Insulin Sensitivity Index (1/insulinF)	0.028 ± 0.018	0.024 ± 0.009	NS	0.026 ± 0.014	NS
Inflammatory Markers
CRP (mg/mL)	1.2 ± 1.7	2.2 ± 1.4	NS	2.7 ± 1.9	0.04
IL-6 (pg/mL)	2.4 ± 1.0	3.0 ± 1.5	NS	2.3 ± 0.6	NS
IL-18 (pg/mL)	241.6 ± 126.9	211.4 ± 137.8	NS	380.7 ± 267.4	NS
TNFa (pg/mL)	1.1 ± 0.6	1.3 ± 0.6	NS	1.4 ± 1.1	NS
GDF15 (pg/mL)	224.3 ± 126.3	301.2 ± 125.4	NS	354.9 ± 235.6	NS
FGF21 (pg/mL)	222.6 ± 75.2	255.4 ± 40.8	NS	253.6 ± 64.7	NS

Data were log-transformed for analysis for skewed distributions, with raw mean ± SD presented above, unless otherwise noted. One-sided p-value used in post-hoc group comparison of MR outcomes.

^*n = 9 for testosterone (total, free) in boys, and n = 12 for SHBG in PCOS girls

^{a, b}Similar letters denote 2 groups that are significantly different with post-hoc analyses.

^{^}Data are presented as raw median and interquartile range

Figure 1.

Box plots of raw data showing median and interquartile ranges of A) hepatic fat fraction and (B) hepatic stiffness by group. Three group comparisons of log-transformed data were performed using ANOVA with post-hoc pairwise Bonferroni’s procedure and one-sided p-values, based on the predefined hypothesis for comparison of hepatic variables for PCOS versus non-PCOS girls.

Association of hepatic fat and stiffness with testosterone

Hepatic fat did not correlate with testosterone (total or free) or SHBG in any group. However, hepatic stiffness positively correlated with total and free testosterone in girls without PCOS (total: r = 0.84, p = 0.002, Fig. 2B; free: r = 0.66, p = 0.04), but not in girls with PCOS (as shown in Fig. 2A) or in boys (as shown in Fig. 2C), in whom stiffness correlated with SHBG (r = −0.65, p = 0.04). However, in exploratory analysis excluding two visualized outliers, including one girl with PCOS whose stiffness was more than 2 standard deviations below the mean for girls with PCOS, a significant direct relationship was found between stiffness and total testosterone (r = 0.74, p = 0.004), as well as between stiffness and free testosterone (r = 0.62, p = 0.02). Notably, both outlier participants had HFF>20%. These two outliers also had significant obesity, with BMI Z-scores of approximately 2.5 each, versus a mean of 2.3 for girls with PCOS, excluding the outliers.

Figure 2.

Log-transformed MR stiffness versus log-transformed total testosterone by group. (A) PCOS girls, (B) girls without PCOS, and (C) boys. Analysis without the two outliers designated by arrows showed a direct relationship between stiffness and total testosterone (r = 0.74, p = 0.004). Details about the two outliers provided under Results, Association of hepatic fat and stiffness with testosterone.

Association of hepatic fat and stiffness with insulin sensitivity, glycemia and inflammatory markers

In the total cohort, both HFF and stiffness correlated with ISI (HFF: r = −0.38, p = 0.03; stiffness: r = −0.41, p = 0.01) (as shown in Fig. 3A and 3B) and 2-hour glucose (HFF: r = 0.52, p = 0.002; stiffness: r = 0.37, p = 0.03) (as shown in Fig. 3C and 3D). Hepatic stiffness but not HFF correlated with IL-6 (r = 0.36, p = 0.04) and IL-18 (r = 0.37, p = 0.03) (as shown in Fig. 4) with no associations of other inflammatory markers with either stiffness or HFF. Additionally, IL-6 and IL-18 correlated with ISI in the full cohort (r = −0.62, p = 0.0001, and r = −0.54, p = 0.0009 respectively).

Figure 3.

Log-transformed MR outcomes versus log-transformed insulin sensitivity and glycemia outcomes. (A) Hepatic fat fraction (HFF) versus insulin sensitivity index, (B) hepatic stiffness versus insulin sensitivity index, (C) HFF versus 2-hour OGTT glucose, (D) hepatic stiffness versus 2-hour OGTT glucose in the full cohort (PCOS and non-PCOS girls and boys).

Figure 4.

Log-transformed MR stiffness versus log-transformed (A) interleukin-6 and (B) interleukin-18 in the full cohort (PCOS and non-PCOS girls and boys).

Discussion

In this proof-of-concept study of adolescent girls and boys with obesity, hepatic fat fraction was significantly higher in girls with PCOS than girls without PCOS but not different from boys. While stiffness did not differ by group, it was directly associated with testosterone concentrations among girls without PCOS, as well as among girls with PCOS when excluding two outliers. In the full cohort, both HFF and stiffness were associated with glycemia and insulin sensitivity, and stiffness was also associated with IL-6 and IL-8. These findings reflect the spectrum of phenotypic expression of androgenemia [28] and suggest that even among girls without a clinical diagnosis of PCOS, relative hyperandrogenemia may be associated with adverse hepatic outcomes. Furthermore, to our knowledge, our findings relating to MR-based hepatic stiffness are novel in youth, with important implications for future research to elucidate the pathophysiology and treatment options for youth-onset MASLD.

As hypothesized, imaging measures of MASLD showed higher HFF among girls with PCOS than without PCOS with no difference from boys, and grade 3 steatosis was only present among girls with PCOS. Moreover, higher stiffness correlated with higher testosterone concentrations, though only among girls without PCOS. Androgens appear to play an important role in the development of MASLD in adults [29], with lower testosterone in men and higher testosterone in women associated with MASLD [30]. However, results among adolescents have been mixed [31, 6]. Consistent with our findings, in a study of 71 adolescent females with obesity (41 with PCOS, 30 without), Cree-Green and colleagues demonstrated that hepatic fat content was not correlated with total testosterone [6]. On the other hand, in a study of 199 girls with and without PCOS that assessed free rather than total testosterone, Ayonrinde and colleagues found that PCOS was associated with 3-fold odds of MASLD, and girls with moderate-severe steatosis had higher free testosterone than those with mild or absent steatosis [31]. Some of the variability in these findings may be related to varying definitions of MASLD, including imaging modality (i.e., ultrasound- versus MR-based). The sexual dimorphic role of testosterone on MASLD risk has also been demonstrated: In a study of adolescents with biopsy-confirmed MASLD, while greater steatosis severity was associated with lower testosterone for boys, it was associated with higher testosterone in girls [7]. These variable findings suggest the existence of additional factors that influence MASLD risk in adolescents, beyond androgens, such as dietary intake [3] or food insecurity [32], genetic risk [33], or prenatal exposures [34].

Consistent with our finding of glycemia and insulin sensitivity being associated with both HFF and stiffness, insulin resistance has also been recognized as both a potential risk factor and a consequence of intrahepatic fat accumulation [35]. D’Adamo and colleagues demonstrated that higher MRI-measured HFF in adolescents with obesity was associated with lower whole-body insulin sensitivity index and glucose disposal rate [36]. Additionally, we previously demonstrated that adolescent girls with PCOS have metabolic inflexibility and insulin resistance [37]. Additional research focusing on the relationship between MASLD and insulin sensitivity in children is needed in order to guide prevention and treatment efforts, such as physical activity and pharmacologic therapy. For example, both aerobic [38] and resistance [39, 40] exercise interventions have been found to improve hepatic insulin sensitivity in adolescents with obesity, though with differences by sex that should be further investigated [40][41]. Currently, pharmacologic options to improve hepatic insulin sensitivity are limited in youth. While thiazolidinediones do improve hepatic insulin sensitivity [42], prolong time to loss of glycemic control in youth with recent-onset type 2 diabetes [43], and improve severity of steatosis and steatohepatitis in adults with prediabetes or type 2 diabetes [44], they are not approved for use in children.

Our findings related to the direct relationship between stiffness and IL-6 and IL-18 are consistent with prior studies linking IL-6 to ultrasonography-diagnosed MASLD in children [45, 46] and adults [10] and IL-18 to ultrasound- and MR proton spectroscopy-based steatosis severity in children [11]. To our knowledge, neither IL-6 nor IL-18 have previously been reported to be associated with MR-measured stiffness in children, though IL-6 has been used to predict Fibroscan-based advanced fibrosis among children with MASLD [46]. One focus of MASLD prevention and treatment is the uncoupling of hepatic insulin resistance and hepatic inflammation [47], amidst the pro-inflammatory state of obesity [48] [49]. Within the liver, chronic inflammation leads to the development of fibrosis and cirrhosis [50]. Overall, our findings add to the growing evidence of the interrelated roles of inflammation, insulin resistance, and androgenemia in adolescent liver health. Further research is needed to investigate these inflammatory markers in larger samples to confirm the identified associations between inflammation and hepatic stiffness.

Our characterization of the multiple potential risk factors for MASLD, including insulin resistance, inflammation, and testosterone concentration within one cohort of adolescents with obesity is a key strength of our study. In place of ultrasound-based measures of liver fat and fibrosis assessment, which often perform poorly in adolescents with obesity, we used MR-elastography for our liver outcome measures. We also acknowledge limitations of our study. The sample size in this proof-of-concept study was small, particularly for males, which thus limited our power to detect relationships between testosterone and MR outcomes. Our primary hepatic outcomes were MRI-based, rather than by biopsy. However, this pragmatic approach was used due to the reliability and increasing acceptance of MRI to define MASLD-related outcomes in youth. We were unable to evaluate potential confounders that may influence MASLD development, including diet, physical activity, or genetic risk factors. Finally, the cross-sectional design did not allow for assessment of causal relationships; a longitudinal study is needed to determine whether hyperandrogenemia directly contributes to MASLD progression in adolescents with and without PCOS.

In conclusion, in this proof-of-concept study of adolescent girls and boys with obesity, we found that hepatic fat fraction was higher among girls with versus without PCOS, and that testosterone concentrations were directly correlated with hepatic stiffness among girls without PCOS. Furthermore, insulin resistance and inflammation were each directly associated with hepatic stiffness. Larger cross-sectional and longitudinal studies would enable the probing of causal relationships and the progression and/or regression of these liver alterations and associated risk factors with current anti-obesity medications.

Data Availability Statement:

Restrictions apply to the availability of some or all data generated or analyzed during this study to preserve patient confidentiality. The corresponding author will on request detail the restrictions and any conditions under which access to some data may be provided.