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. 2022 Jul;12(Suppl 1):S15–S18. doi: 10.5005/jp-journals-10018-1362

Comparison of Clinical, Biochemical, and Histopathologic Profiles between NAFLD in Asian-Indians and United States Adults

Shivaram P Singh 1,✉, Manas K Panigrahi 2, Anish Patel 3, Lavanya Viswanathan 4, Mitali M Rath 5, Sanjib K Kar 6, Stephen A Harrison 7
PMCID: PMC9681572  PMID: 36466104

Abstract

Background and aims

Nonalcoholic fatty liver disease (NAFLD) is very common in both Asian and Western countries. Geographic variation leads to differences in epidemiological and demographic characters of NAFLD patients. Studies conducted upon different ethnic groups in the United States (US) show a higher prevalence of NAFLD in Hispanics and African-Americans. There is however, a paucity of studies involving Asians. It has been observed that Asian-Indian NAFLD patients have unique characteristics compared to their counterparts in the West. This study is the first attempt at comparing the characteristics of Asian-Indian and US NAFLD patients.

Materials and Methods

A retrospective analysis of clinical, biochemical, and histological data was performed for 633 Asian-Indian NAFLD patients and 451 US NAFLD patients. Clinical parameters [age, gender, body mass index (BMI), diabetes, hypertension, etc.], biochemical tests (liver function tests, lipid profile, and fasting blood sugar), hepatic ultrasound and hepatic histology were compared between the two cohorts.

Results

Eighty-two percent of US NAFLD patients were more than 40 years of age compared to 51.3% of Asian-Indian patients (p <0.01). US (male 56.3%) and Asian-Indian (male 81.7%) (p <0.01) patients differed from each other as regards gender prevalence. Rates of obesity were greater in the US patients compared to Asian-Indians (BMI 32.6 ± 5.3 kg/m2 vs 26.2 ± 3.4 kg/m2). There was a higher prevalence of both diabetes and hypertension (diabetes 42.1% vs 33%, and hypertension 56.8% vs 29.7%, p ≤0.01) in US patients. ALT levels were also significantly higher in US NAFLD patients compared to Asian-Indians (ALT 82.78 ± 71.30 vs 53.66 ± 37, p ≤0.01). A higher proportion of US patients were found to have the more advanced liver disease at the time of diagnosis compared to Asian-Indians (Stage 3 fibrosis 10.42% vs 0%, and Stage 4 fibrosis 2.66% vs 0%, p <0.01).

Conclusion

Asian-Indian and US NAFLD patients differ significantly on several parameters. Further studies need to be carried out to understand the mechanistic basis of these differences better.

How to cite this article

Singh SP, Panigrahi MK, Patel A, et al. Comparison of Clinical, Biochemical, and Histopathologic Profiles between NAFLD in Asian-Indians and United States Adults. Euroasian J Hepato-Gastroenterol 2022;12(Suppl 1):S15–S18.

Keywords: Epidemiology, Ethnicity, Ethnology, NAFLD, Nonalcoholic fatty liver disease, Nonalcoholic steatohepatitis

Introduction

Nonalcoholic fatty liver disease is a common liver disorder in both Asian and Western countries. With the epidemic of metabolic syndrome (MS) spiraling upwards, there has been a heightened awareness and early recognition of asymptomatic patients with raised transaminases and NAFLD has become a common cause of referrals to hepatology clinics.1 Traditionally NAFLD was considered relatively benign; however, it has now been clearly shown to progress to cirrhosis, liver failure, and hepatocellular carcinoma.

The prevalence of NAFLD has been found to be 15–46% in the West2–4 and 8–40% in Asian countries.5–9 The prevalence of NAFLD varies with different geographical locations but even in the same location, some races are more prone to develop NAFLD and nonalcoholic steatohepatitis (NASH). Weston et al.10 looked at the prevalence of NAFLD in different ethnic groups of patients in the USA who had been newly diagnosed as having chronic liver disease (CLD). In this study, they found that Hispanics had disproportionately higher representation in the NAFLD group compared to the base population while Caucasians and African-Americans had lower representation. Another study from Italy found that in spite of having a lower BMI, Asian-Indians had the highest levels of fasting serum insulin and insulin resistance (IR) estimated by homeostasis model assessment for IR (HOMA-IR) compared to Eastern Asians, Caucasians, African-Americans, and Hispanics.11 Asian-Indians also had higher hepatic triglyceride (TG) content in comparison with Caucasians. This inter-ethnic difference in the prevalence of NAFLD and NASH is believed to be related not only to different lifestyles but also to a strong genetic predisposition.

The pathophysiology of NAFLD has also not been completely understood yet. It is evident that multiple factors are at play - lifestyle, diet, environmental factors, genes, bile acids, gut microbiota - and these could significantly vary across ethnicities and populations. Madan et al.12 in their study concluded that North-Indian NAFLD patients have mild histological disease at presentation. Another study from coastal Eastern India showed that Indian subjects with NAFLD were younger, had lower BMI, lower prevalence of diabetes mellitus and MS, but similar necro-inflammatory activity score and fibrosis compared to patients in the West.13

This study is the first attempt at comparing the characteristics of Asian-Indian and US NAFLD patients.

Materials and Methods

Study Design

It was a retrospective study comparing clinical, biochemical, and histopathologic profiles of NAFLD between Asian-Indian patients and patients from the US. The study was approved by the ethics committees of both centers.

Patients

Data of NAFLD patients were collected from the data bank of the Department of Gastroenterology, SCB Medical College, Cuttack, India, and the Division of Gastroenterology and Hepatology, Brooke Army Medical Center, Fort Sam Houston, Texas, US. The study cohort included 633 Asian-Indian NAFLD patients and 451 US NAFLD patients.

Methods

Comparisons between the study cohorts included clinical (age, sex, BMI, diabetes, hypertension, etc.), biochemical tests (liver function tests, lipid profile, and fasting blood sugar), hepatic ultrasound and hepatic histology. Statistical analysis was performed using SPSS 17.0 software. The results were expressed as median (range) for continuous variables and as frequencies (proportions) for categorical variables. Independent sample t test and Chi-square test were used to compare the variables. A “p” value of less than 0.05 was considered statistically significant.

Results

The mean age of Asian-Indian NAFLD patients in the study cohort was 42.3 ± 10.1 years (range 17–80 years) whereas the mean age of US NAFLD patients was 49.7 ± 10.6 (range 20–75 years). The majority of US NAFLD patients (82.3%) were more than 40 years of age compared to half (51.3%) of Asian-Indian patients (χ2 = 109.551, p ≤0.01) (Fig. 1). There was a difference in gender prevalence in the US (male 56.3%) and Asian-Indian (male 81.7%) (χ2 = 82.442, p ≤0.01 value) patients. When a cutoff BMI ≥30 kg/m2 was defined as obesity, 71.2% of US NAFLD patients turned out to be obese whereas only 11.2% of Asian-Indian were obese but if obesity as per Asian standard (BMI ≥25 kg/m2) was considered, 63.7% of Asian-Indians were found to be obese. US patients had higher rates of obesity as compared to Asian-Indian patients. (BMI 32.6 ± 5.3 kg/m2vs 26.2 ± 3.4 kg/m2) (Table 1).

Fig. 1.

Fig. 1

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Age and sex distribution of NAFLD population by country

Table 1.

Distribution of NAFLD patients as per BMI

Standard of classification BMI class American Indian χ2test "p"
Number % Number %
American Standard Normal 21 4.7 230 36.3 0.000
Over-weight 109 24.2 332 52.4
Obese 321 71.2 71 11.2
Total 451 100 633 100
BMI range (Asian) Normal 9 2 99 15.6 0.000
Over-weight 12 2.7 131 20.7
Obese 430 95.3 403 63.7
Total 451 100 633 100
American Standard for American Cases
Asian Standard for Indian Cases		 Normal 21 4.7 99 15.6 0.000
Over-weight 109 24.2 131 20.7
Obese 321 71.2 403 63.7
Total 451 100 633 100
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With regard to comorbid conditions, US patients had a higher prevalence of both diabetes and hypertension (diabetes 42.1% vs 33%, and hypertension 56.8% vs 29.7%, p ≤0.01). More than three-fourths of US NAFLD patients had elevated transaminases compared to half of the Asian-Indian patients. US NAFLD patients also had significantly higher ALT levels compared to Asian-Indians (ALT 82.78 ± 71.30 vs 53.66 ± 37, p <0.01). Though a higher percentage of US NAFLD patients had dyslipidemia, Asian-Indian NAFLD patients had higher mean TG levels compared to US NAFLD patients. The histological comparison showed that a greater proportion of US patients had the more advanced liver disease at the time of diagnosis compared to Asian-Indians (Stage 3 fibrosis 10.42% vs 0%, and Stage 4 fibrosis 2.66% vs 0%, p <0.01) (Fig. 2).

Fig. 2.

Fig. 2

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Histological comparison of NAFLD patients

Discussion

Worldwide, the overall prevalence of NAFLD ranges from 6.3 to 33% with a median of 20% in the general population. The prevalence also varies with variations in age, gender, geographic location, and ethnicity.14 Studies conducted earlier have pointed out key differences between the phenotypes of NAFLD cohorts in Northern India and those from the West.12 These differences are not surprising, considering the fact that the body fat distribution and risk of adverse cardiovascular events with a similar proportion of body fat differs between Asian-Indians and their Western counterparts. This has even prompted the lowering of BMI and waist-hip ratio (WHR) cutoffs for defining overweight and obesity among Asians.15,16

This study is the first attempt at comparing the characteristics of Asian-Indian and US NAFLD patients. This study demonstrates that Asian-Indian NAFLD patients were younger and had been detected a decade earlier compared to the US NAFLD patients. This may be due to sedentary lifestyle, westernization of dietary habits, and abnormal body fat distribution of Asian-Indians. Indians have a higher percentage of body fat and an adverse pattern of body fat distribution including abdominal adiposity even within BMI ranges considered normal for Caucasians.17In contrast to earlier Western studies which show a higher prevalence of NAFLD among females, this study showed a higher male prevalence both in US and Asian-Indian NAFLD patients.

Though the mean BMI of Asian-Indian NAFLD patients was less than that of the US NAFLD patients, an almost similar percentage of Asian-Indian and US NAFLD patients were found to be obese, if the cutoffs for BMI were considered as per Asian standards. It could possibly be attributed to the fact that Indian patients have a similar body fat percentage as Caucasians even at lower BMI levels. Similar to the study by Duseja et al.,18 the prevalence of diabetes and hypertension were found to be less in Asian-Indian patients in comparison to US NAFLD patients. Misra et al.19 reported that because of body composition and genetic predisposition, Asian-Indians more commonly have atherogenic dyslipidemia (i.e., a combination of hypertriglyceridemia, low level of HDL cholesterol, and high level of LDL cholesterol). In our study, we similarly found that Asian-Indian NAFLD patients have higher mean TG and lower HDL cholesterol in comparison with US NAFLD patients.

The histological comparison showed that a greater proportion of US patients had the more advanced liver disease at the time of diagnosis compared to Asian-Indians (Stage 3 fibrosis 10.42% vs 0%, and Stage 4 fibrosis 2.66% vs 0%, p ≤0.01). Similar histological findings among NASH patients have been reported in other studies from India.12,19

This study shows that Asian-Indian NAFLD patients are younger, have lower BMI, lower transaminases, and have milder histology compared to US NAFLD patients. There have been attempts to homogenize NAFLD without taking into account the significant differences across population groups worldwide. This study clearly shows that significant differences between Asian-Indian and US NAFLD patients exist. Further studies are required to better delineate these differences and understand mechanistically why these differences exist. This would help us in comprehending the pathophysiological details of the entity and help develop preventive and therapeutic strategies to curb the pandemic of NAFLD.

Footnotes

Source of support: Nil

Conflict of interest: None

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