European Journal of Cardiovascular Medicine

Non-alcoholic fatty liver disease (NAFLD) has become a significant public health concern in recent years.   It is defined by the accumulation of ≥5% of fat in the liver without any underlying causes and is a diagnosis of exclusion ¹. The progression of NAFLD can vary from basic fat buildup to inflammatory conditions like NASH (Non-Alcoholic Steato Hepatitis) and ultimately to liver fibrosis, cirrhosis, and in rare instances, hepatocellular carcinoma (HCC) ².  NAFLD has been found to be linked with numerous conditions including Type 2 diabetes mellitus, hypertension, dyslipidemia, obesity, and Metabolic Syndrome ³. The prevalence of NAFLD and NASH is anticipated to rise rapidly on a global scale as the prevalence of all predisposing factors continues to climb ⁴.   

The Ministry of Health and Family Welfare, India has included NAFLD in the National Program for prevention and control of non-communicable diseases (NP-NCD), due to its high prevalence rate ⁵. 

  The frequency of NAFLD varies from 7% in the United States to as high as 25% in certain Asian nations ⁶. Within India, the prevalence of NAFLD ranges from 9 to 32% ⁷. Specifically in the Indian population, a higher prevalence of NAFLD has been observed in obese individuals and those with insulin resistance and diabetes ⁸. Due to the lack of research documenting the characteristics of NAFLD cases and the wide variability within the country, it is imperative to conduct studies on the local population.   

Hence, the objective of this research was to determine the extent of NAFLD and analyze the impact of different factors, including demographic traits, anthropometric measures, and other key variables. 

This is an analytical cross-sectional study. The target population included patients in the age group of 20 - 40 years undergoing abdominal imaging from October 2021 to November 2022 at a Tertiary care centre in Guntur, Andhra Pradesh. Based on the inclusion criteria for selection, the study consisted of 457 consecutive patients who do not consume alcohol and who had no history of any liver disease, renal impairment and other chronic hepatic diseases.  After obtaining approval from the institutional ethics committee, a consecutive group of patients who were planning to have abdominal imaging for different reasons was established. 

Structured questionnaires were utilized to collect demographic and medical data after obtaining informed consent. Data was gathered from participants who were willing to participate in the study.   The information collected from the study participants included demographic details like age, gender, family history, and medical history.

In addition, measurements of anthropometric parameters such as height, weight, and Body Mass Index (BMI) were recorded.   The participants underwent ultrasound scans to determine the presence of non-alcoholic fatty liver disease (NAFLD).  Based on the ultrasonogram features of fatty liver, NAFLD was labeled from grades 0 to 3 ⁹.

The data collected was analyzed with SPSS software version 19.0. The descriptive statistics included percentages, mean, and standard deviation. For qualitative variables, bivariate analysis was performed using chi-square test or Fisher’s exact test. A p- value <0.05 was considered statistically significant for all tests. 

The overall prevalence of NAFLD In the present study was found to be 46% [Table no.1].  In terms of Ultrasonogram grading of fatty liver, it was found that 33.9% of individuals had grade 1, 19.8% had grade 2, and 0.3% had grade 3 fatty liver. 

Table 1: Ultrasound findings

Table 2: Demographic characteristics

It was observed that the prevalence NAFLD varied significantly by age, with more individuals affected in older age groups (p<0.05), while gender distribution showed no significant difference (p>0.05); socioeconomic status also showed variability, but not significantly different between groups (p>0.05). [Table no.2].

Table 3: Comparison of anthropometric parameters

Individuals with NAFLD had significantly higher weight, BMI, waist circumference, hip circumference, and waist-to-hip ratio (p<0.05) compared to those with normal liver findings, with no significant difference in height (p>0.05). [Table no.3].

Table 4: Comparison of Lifestyle factors

Lifestyle comparisons revealed that diabetes was significantly more common among individuals with NAFLD (24.3%) compared to those with normal liver findings (7.1%, p < 0.01). Hypertension was comparable among both groups (27.6% vs. 22.3%, p = 0.186). Cooking oil consumption showed no significant difference (p > 0.05). Dietary patterns differed significantly, with fewer vegetarians among NAFLD patients (46.2%) compared to those with normal liver function (56.7%, p <0.05). Physical activity levels were significantly lower in NAFLD patients, with only 11.9% being active compared to 32.4% in the normal group (p <0.05).

This analytical cross-sectional study identified a NAFLD prevalence of 46% based on ultrasound detection which is higher than the global prevalence of 25.24% reported by Zezos P et al in their meta-analysis.¹⁰ In the Indian context, Kalra S et al estimated that NAFLD affects approximately 9–32% of the general population.¹¹ Region-specific studies further highlight variability: Arka De et al reported a prevalence rate of 49.8% in coastal South India ¹², while Amarapurkar D et al found a prevalence of 16.6% in urban Mumbai ¹³ and Majumdar A et al reported 30.7% in rural Haryana ¹⁴. Mohan et al also noted a 32% prevalence rate in Chennai ¹⁵.

Age showed a significant association with NAFLD, with higher prevalence in older age groups (p<0.05) in the present study. Gender distribution and socioeconomic status did not significantly impact NAFLD prevalence (p>0.05). NAFLD patients had significantly higher weight, BMI, waist circumference, hip circumference, and waist-to-hip ratio (p<0.05), with no significant difference in height (p>0.05). Diabetes was significantly more common in NAFLD patients (24.3% vs. 7.1%, p<0.01), while hypertension was comparable between the groups (p=0.186). No significant difference in cooking oil consumption was observed (p>0.05). Dietary patterns revealed that vegetarians had lower rates of NAFLD (46.2% vs. 56.7%, p<0.05), and physical activity levels were significantly lower, with only 11.9% of NAFLD patients being active compared to 32.4% in the normal group (p<0.05).

Khadka B et al found a higher NAFLD prevalence in women (57.1%) and reported that triglycerides and alanine aminotransferase (ALT) levels increased with the severity of fatty liver, while HDL cholesterol decreased. ¹⁶ Overweight and obesity were associated with a significantly increased risk of NAFLD. Chen CH et al identified risk factors including male sex, elevated ALT, obesity, high fasting plasma glucose, and high triglycerides, with an inverse relationship between age ≥65 years and NAFLD.¹⁷

Weiß J et al. found that the NAFLD fibrosis score, which includes factors such as age, body mass index, diabetes status, ASAT, ALAT, platelet count, and albumin level, has a positive predictive value ranging from 82% to 90% and a negative predictive value between 88% and 93%.,¹⁸ Singh SP et al noted higher BMI, waist-hip ratio, and waist-height ratio in NAFLD patients, along with elevated fasting blood sugar and triglycerides. Sedentary lifestyle and specific dietary factors such as non-vegetarian diet, fried food, and spicy foods were associated with NAFLD.¹⁹

In studies done by Zelber-Sagi S et al and Dassanayake A.S et al highlighted the role of high-fat and high-fructose diets in NAFLD, showing an association between fast-food consumption and weight gain. Toshimitsu K et al. also emphasized in their study that a diet high in saturated fats, cholesterol, and carbohydrates is associated with NAFLD.²⁰ Tea consumption patterns also emerged as a factor, while green tea has been linked to improved liver function in NAFLD patients, ²¹ Singh SP et al. observed that drinking tea with milk and sugar was significantly associated with an increased risk of developing NAFLD.¹⁹ 

Additionally, studies done by Bhatt KN et al.,²² and Jawaharlal RK et al.,²³ reported a predominance of NAFLD in females with type 2 diabetes compared to males in non-NAFLD cases. Factors such as waist circumference and BMI were significantly associated with NAFLD, emphasizing the importance of weight management in preventing this condition.

Zelber-Sagi S et al.,²⁴ and Church T.S. et al.,²⁵ found that individuals with lower levels of physical activity are more likely to have NAFLD, which aligns with the findings of the present study.

This analytical cross-sectional study found a NAFLD prevalence of 46% based on ultrasound detection, significantly higher than the global average of 25.24%. In India, prevalence estimates range from 9% to 49.8% across various regions. Age was significantly associated with NAFLD, while gender and socioeconomic status showed no significant impact. NAFLD patients exhibited higher weight, BMI, waist and hip circumferences, and lower physical activity levels, with diabetes being more prevalent in this group. Additionally, lower physical activity levels were linked to increased NAFLD risk. Prioritizing weight management, implementing regular screening for early diagnosis of fatty liver disease, and adopting lifestyle modifications can effectively address NAFLD.

1. Perumpail, B.J., Khan, M.A., Kim, D., et al. "Clinical Epidemiology and Disease Burden of Nonalcoholic Fatty Liver Disease." World Journal of Gastroenterology, 21 Dec. 2017, vol. 23, no. 47, pp. 8263-8276.
2. Sangeetha, A., and K.M. Prabhuswamy. "Prevalence and Profile of NAFLD Among Adults Undergoing Master Health Checkup." International Journal of Contemporary Medical Research, 2019, pp. H31-H34.
3. Bhandari, Roopa Rani, and Sukanya Shetty. "A Study of Non-alcoholic Fatty Liver Disease in a Semiurban Health Facility with Special Reference to Dietary Practice, Socio-economic Factors and Metabolic Syndrome." Accessed from handle.net/10603/285142.
4. Perez, M., Gonzáles, L., Olarte, R., Rodríguez, N.I., Tabares, M., Salazar, J.P., Jaimes, S., García, R.G., and López-Jaramillo, P. "Nonalcoholic Fatty Liver Disease is Associated with Insulin Resistance in a Young Hispanic Population." Preventive Medicine, 1 Feb. 2011, vol. 52, no. 2, pp. 174-177.
5. Government of India. Operational Guidelines for the Integration of Non Alcoholic Fatty Liver Disease (NAFLD) into NPCDCS. National Health Mission, Mar. 2021.
6. Grugrevic, Ivca, Kristian Pudrug, et al. "Natural History of Nonalcoholic Fatty Liver Disease: Implications for Clinical Practice and an Individualized Approach." Canadian Journal of Gastroenterology & Hepatology, vol. 2020, Article ID 9181368, pp. 1-10.
7. Dhamja, Ekta, Shashi Bala Paul, and Saurabh Kedia. "Non-alcoholic Fatty Liver Disease Associated with Hepatocellular Carcinoma: An Increasing Concern." Indian Journal of Medical Research, vol. 149, no. 1, 2019, pp. 9-17.
8. Kara, Sanjay, et al. "Study of Prevalence of NAFLD in Type-2 Diabetics in India (SPRINT)." Journal of the Association of Physicians of India, Jul. 2013.
9. Anton, M.C., Shanthi, B., and Sridevi, C. "Prevalence of Non‑alcoholic Fatty Liver Disease in Urban Adult Population in a Tertiary Care Center, Chennai." Indian Journal of Community Medicine, vol. 48, 2023, pp. 601-604.
10. Zezos, P., and Renner, E.L. "Liver Transplantation and Non‑alcoholic Fatty Liver Disease." World Journal of Gastroenterology, 2014, vol. 20, pp. 15532‑15538.
11. Kalra, S., et al. "Study of Prevalence of Nonalcoholic Fatty Liver Disease (NAFLD) in Type 2 Diabetes Patients in India (SPRINT)." Journal of the Association of Physicians of India, vol. 61, 2013, pp. 448-453.
12. De, A., and Duseja, A. "Nonalcoholic Fatty Liver Disease: Indian Perspective." CLD Review Journal, vol. 18, 2021, pp. 158-163.
13. Amarapurkar, D., Kamani, P., Patel, N., Gupte, P., Kumar, P., Agal, S., Baijal, R., Lala, S., Chaudhary, D., and Deshpande, A. "Prevalence of Non-Alcoholic Fatty Liver Disease: Population-Based Study." Annals of Hepatology, Jul.-Sept. 2007, vol. 6, no. 3, pp. 161-163.
14. Majumdar, A., Misra, P., Sharma, S., Kant, S., Krishnan, A., Pandav, C.S. "Prevalence of Non-Alcoholic Fatty Liver Disease in an Adult Population in a Rural Community of Haryana, India." Indian Journal of Public Health, vol. 60, 2016, pp. 26-33.
15. Mohan, V., Farooq, S., Deepa, M., Ravikumar, R., and Pitchumoni, C.S. "Prevalence of Non-Alcoholic Fatty Liver Disease in Urban South Indians in Relation to Different Grades of Glucose Intolerance and Metabolic Syndrome." Diabetes Research and Clinical Practice, Apr. 2009, vol. 84, no. 1, pp. 84-91.
16. Khadka, B., Shakya, R., and Bista, Y. "Non-Alcoholic Fatty Liver Disease Assessment in Nepal." International Journal of Community Medicine and Public Health, 2016, vol. 15, pp. 1654-1659.
17. Chen, C.H., Huang, M.H., Yang, J.C., Nien, C.K., Yang, C.C., Yeh, Y.H., and Yueh, S.K. "Prevalence and Risk Factors of Non-Alcoholic Fatty Liver Disease in an Adult Population of Taiwan: Metabolic Significance of Non-Alcoholic Fatty Liver Disease in Non-Obese Adults." Journal of Clinical Gastroenterology, Sept. 2006, vol. 40, no. 8, pp. 745-752.
18. Weiß, J., Rau, M., and Geier, A. "Non-Alcoholic Fatty Liver Disease: Epidemiology, Clinical Course, Investigation, and Treatment." Dtsch Arztebl Int, 27 June 2014, vol. 111, no. 26, pp. 447-452.
19. Singh, S.P., Singh, A., Misra, D., Misra, B., Pati, G.K., Panigrahi, M.K., et al. "Risk Factors Associated with Non-Alcoholic Fatty Liver Disease in Indians: A Case-Control Study." Journal of Clinical and Experimental Hepatology, vol. 5, no. 4, 2015, pp. 295-302.
20. Toshimitsu, K., Matsuura, B., Ohkubo, I., and Niiya, T. "Dietary Habits and Nutrient Intake in Non-Alcoholic Steatohepatitis." Nutrition, 2007, vol. 23, pp. 46–52.
21. Sakata, R., Nakamura, T., Torimura, T., Ueno, T., and Sata, M. "Green Tea with High-Density Catechins Improves Liver Function and Fat Infiltration in Non-Alcoholic Fatty Liver Disease (NAFLD) Patients: A Double-Blind Placebo-Controlled Study." International Journal of Molecular Medicine, 2013, vol. 32, pp. 989–994.
22. Bhatt, K.N., Pranav, V., Dipika, Y., Dharmesh, N., Radhika, N., and Arvind, S. "Prevalence of Non-Alcoholic Fatty Liver Disease in Type 2 Diabetes Mellitus and Its Relation with Insulin Resistance in South Gujarat Region." Journal of Mahatma Gandhi Institute of Medical Sciences, 2017, vol. 22, pp. 8.
23. Jawaharlal, R.K., and Mootha, V.K. "Non-Alcoholic Fatty Liver Disease and Type 2 Diabetes Mellitus: A Prospective Observational Study in Coastal Region of Andhra Pradesh." International Journal of Advanced Medicine, 2021, vol. 8, pp. 918-921.
24. Zelber-Sagi, S., Nitzan-Kaluski, D., and Goldsmith, R. "Long-Term Nutritional Intake and the Risk for Non-Alcoholic Fatty Liver Disease (NAFLD): A Population-Based Study." Journal of Hepatology, 2007, vol. 47, pp. 711–717.
25. Church, T.S., Kuk, J.L., Ross, R., Priest, E.L., Biltoft, E., and Blair, S.N. "Association of Cardiorespiratory Fitness, Body Mass Index, and Waist Circumference to Non-Alcoholic Fatty Liver Disease." Gastroenterology, 2006, vol. 130, pp. 2023–2030.