European Journal of Cardiovascular Medicine

Non-alcoholic fatty liver disease (NAFLD) has emerged as the most common chronic liver disorder worldwide, encompassing a spectrum of liver abnormalities ranging from simple hepatic steatosis to non-alcoholic steatohepatitis (NASH), fibrosis, and cirrhosis in individuals with little or no alcohol intake^1,2. NAFLD is increasingly recognized as the hepatic manifestation of metabolic syndrome and is closely linked with obesity, insulin resistance, dyslipidemia, and particularly Type 2 Diabetes Mellitus (T2DM)³.

The global prevalence of NAFLD is estimated to be around 25%, but this figure rises significantly among patients with T2DM, reaching up to 55–70% in various studies. T2DM accelerates the progression of NAFLD, increasing the risk of advanced fibrosis, cirrhosis, and hepatocellular carcinoma⁴. The bidirectional relationship between NAFLD and T2DM not only complicates metabolic control but also increases cardiovascular morbidity and all-cause mortality^5,6.

Despite the growing burden of NAFLD in diabetic populations, it remains underdiagnosed, especially in resource-limited settings, due to the absence of overt symptoms and limited use of imaging in routine diabetic care. Identifying patients at risk using non-invasive methods like abdominal ultrasonography and evaluating associated risk factors are vital steps toward early detection, lifestyle modification, and prevention of long-term hepatic complications.

This study was undertaken to determine the prevalence of NAFLD in patients with T2DM attending a tertiary care hospital and to identify clinical and biochemical risk factors associated with its occurrence. The findings aim to contribute to improved screening protocols and patient education in diabetic care.

Study Design and Setting:
This was a hospital-based, cross-sectional observational study conducted in the Department of General Medicine at Government Medical College (GMC), Suryapet. The study was carried out over a period of nine months, from May 2024 to January 2025.

Study Population:
The study included adult patients (aged ≥18 years) with a confirmed diagnosis of Type 2 Diabetes Mellitus (T2DM) attending the outpatient and inpatient services of GMC Suryapet during the study period.

Inclusion Criteria:

Patients diagnosed with T2DM for at least one year.

Age ≥18 years.

Patients who gave written informed consent.

Exclusion Criteria:

History of significant alcohol consumption (>20 g/day for men, >10 g/day for women).

Known chronic liver diseases (viral hepatitis, autoimmune hepatitis, Wilson’s disease, etc.).

Use of hepatotoxic drugs (e.g., methotrexate, tamoxifen, amiodarone).

Pregnancy.

Patients with Type 1 Diabetes Mellitus.

Sample Size:
A total of 100 eligible patients with T2DM were included in the study by convenient sampling.

Data Collection:
Demographic and clinical data including age, gender, BMI, duration of diabetes, and presence of comorbidities (hypertension, dyslipidemia) were recorded. Laboratory parameters such as fasting blood glucose, postprandial glucose, HbA1c, lipid profile, and liver function tests were documented.

Diagnosis of NAFLD:
NAFLD was diagnosed using abdominal ultrasonography, performed by an experienced radiologist. The diagnosis was based on characteristic features of hepatic steatosis, including increased echogenicity of the liver parenchyma with posterior beam attenuation and loss of visualization of intrahepatic vessels.

Statistical Analysis:
Data were entered in Microsoft Excel and analyzed using SPSS version 25. Descriptive statistics were used for demographic variables. Associations between NAFLD and risk factors were assessed using Chi-square test for categorical variables and independent t-test for continuous variables. Multivariate logistic regression was performed to identify independent predictors of NAFLD. A p-value <0.05 was considered statistically significant.

Ethical Considerations:
The study was approved by the Institutional Ethics Committee of Government Medical College, Suryapet. Written informed consent was obtained from all participants prior to inclusion.

Out of the 100 patients with Type 2 Diabetes Mellitus (T2DM) enrolled in the study, 56% were diagnosed with Non-Alcoholic Fatty Liver Disease (NAFLD) based on ultrasonographic findings. The prevalence was higher among males (62.5%) compared to females (50.0%) (Table 1).

Table 1: Prevalence of NAFLD by Gender

Body Mass Index (BMI) showed a strong association with NAFLD. Among patients with BMI ≥25 kg/m², the prevalence of NAFLD was significantly higher (66.2%) compared to those with BMI <25 kg/m² (26.9%) (Table 2). This difference was statistically significant and suggests that overweight and obesity are major contributing factors to hepatic fat accumulation.

Table 2: Association of NAFLD with Body Mass Index (BMI)

Duration of diabetes also demonstrated a notable relationship with NAFLD. Patients with a diabetes duration of ≥10 years exhibited a higher prevalence of NAFLD (68.1%) compared to those with <10 years of disease (45.3%) (Table 3).

Table 3: NAFLD Prevalence by Duration of Diabetes

This indicates that chronicity of hyperglycemia may exacerbate hepatic steatosis over time.

In terms of glycemic control, NAFLD was more prevalent in patients with poor glycemic status (HbA1c ≥7%), with a prevalence of 61.8%, compared to 37.5% in those with HbA1c <7% (Table 4). This supports the hypothesis that persistent hyperglycemia is a significant contributor to the development of hepatic fat accumulation.

Table 4: Association of HbA1c with NAFLD

On multivariate logistic regression analysis, three variables emerged as statistically significant independent predictors of NAFLD: BMI ≥25 kg/m² (OR: 3.6; 95% CI: 1.5–8.6; p=0.004), HbA1c ≥7% (OR: 2.9; 95% CI: 1.2–6.9; p=0.014), and duration of diabetes ≥10 years (OR: 2.4; 95% CI: 1.0–5.8; p=0.041) (Table 5).

Table 5: Multivariate Logistic Regression Analysis of Risk Factors for NAFLD

These findings highlight the multifactorial nature of NAFLD in patients with T2DM, with obesity, poor glycemic control, and longer disease duration being the primary determinants in this cohort.

In this cross-sectional study conducted at Government Medical College, Suryapet, we found that 56% of patients with Type 2 Diabetes Mellitus (T2DM) had sonographic evidence of Non-Alcoholic Fatty Liver Disease (NAFLD). This prevalence aligns with findings from earlier studies which report NAFLD prevalence rates of 50–70% among diabetic populations. The high burden observed in our study reinforces the strong interrelationship between hepatic steatosis and T2DM.

Male predominance in NAFLD prevalence (62.5%) is consistent with prior literature, possibly due to gender-related differences in visceral adiposity and hormonal profiles. Obesity emerged as a major risk factor, with 66.2% of overweight/obese patients (BMI ≥25 kg/m²) showing evidence of NAFLD. This corroborates existing evidence that insulin resistance associated with obesity plays a central role in hepatic fat accumulation^7,8.

We also observed a significantly higher prevalence of NAFLD in patients with longer duration of diabetes (≥10 years) and those with poor glycemic control (HbA1c ≥7%), findings echoed by studies such as those by Leite et al. and Targher et al., where prolonged hyperglycemia and insulin resistance have been implicated in the pathogenesis and progression of NAFLD⁹.

Our multivariate logistic regression analysis confirmed BMI ≥25 kg/m², HbA1c ≥7%, and diabetes duration ≥10 years as independent predictors of NAFLD. These factors should prompt clinicians to actively screen for hepatic involvement in T2DM patients even in the absence of clinical symptoms¹⁰.

The non-invasive and cost-effective utility of ultrasonography makes it a practical tool in routine diabetic care, particularly in low-resource settings like ours. Early identification can allow for lifestyle interventions and pharmacologic strategies to reverse or arrest disease progression¹¹.

Limitations of this study include its single-center design and relatively small sample size, which may affect generalizability. Additionally, ultrasonography, though practical, is operator-dependent and less sensitive for early or mild steatosis compared to MRI or liver biopsy.

This cross-sectional study highlights a high prevalence of Non-Alcoholic Fatty Liver Disease (NAFLD) among patients with Type 2 Diabetes Mellitus (T2DM), with more than half of the studied population affected. Obesity, poor glycemic control (HbA1c ≥7%), and longer duration of diabetes (≥10 years) were identified as significant and independent risk factors. These findings underscore the need for routine screening of NAFLD in diabetic patients, especially those with additional metabolic risk factors. Early detection through ultrasonography can facilitate timely lifestyle modifications and appropriate interventions, potentially reducing the burden of hepatic and cardiovascular complications. Integration of NAFLD assessment into diabetic care protocols is strongly recommended.

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