European Journal of Cardiovascular Medicine

Non-alcoholic fatty liver disease (NAFLD) represents a spectrum of hepatic disorders ranging from simple steatosis to non-alcoholic steatohepatitis (NASH), fibrosis, and cirrhosis, in the absence of significant alcohol intake. It is increasingly recognized as a common comorbidity in individuals with Type 2 Diabetes Mellitus (T2DM), with insulin resistance and metabolic dysregulation playing central roles in its pathogenesis [1]. The bidirectional relationship between NAFLD and T2DM significantly heightens the risk for both hepatic and cardiovascular complications, making early detection vital.

Globally, the prevalence of NAFLD in T2DM patients is alarmingly high, with studies reporting rates ranging from 50% to over 70% depending on diagnostic methods and population characteristics [1,2]. In India, this burden is similarly significant. A study among Indian women with a history of gestational diabetes revealed a high prevalence of NAFLD, emphasizing the ongoing metabolic risk in this subgroup [2]. Moreover, although NAFLD is traditionally considered an adult disease, evidence has shown its emergence even in children and adolescents with type 1 diabetes, indicating a broader at-risk population due to underlying metabolic dysfunction [3].

Various risk factors have been associated with NAFLD in diabetic populations, including obesity, poor glycemic control, dyslipidemia, and elevated liver enzymes [4,5]. However, the magnitude and interplay of these risk factors may vary by region, ethnicity, and access to healthcare. Given the limited regional data from Telangana, this study was undertaken to estimate the prevalence of NAFLD among T2DM patients and identify associated clinical and biochemical risk factors in a tertiary care setting.

This study was conducted to determine the prevalence of NAFLD among patients with T2DM in a tertiary care hospital setting and to identify associated clinical and biochemical risk factors in this population.

Study Design and Duration:
A hospital-based cross-sectional study was conducted over a 10-month period from July 2023 to April 2024.

Study Setting:
The study was carried out in the Department of General Medicine at Government Medical College (GMC), Mahabubabad, a tertiary care teaching hospital in Telangana, India.

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 departments during the study period.

Inclusion Criteria:

Patients with T2DM diagnosed based on American Diabetes Association (ADA) criteria.

Age ≥18 years.

Patients who consented to participate in the study.

Exclusion Criteria:

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

Known chronic liver diseases of other etiology (e.g., viral hepatitis, autoimmune hepatitis).

Use of hepatotoxic medications.

Pregnancy.

Sample Size:
A total of 100 eligible T2DM patients were recruited using a purposive sampling technique.

Data Collection:
A pre-designed, structured proforma was used to record demographic data, duration of diabetes, anthropometric measurements (height, weight, BMI), and clinical history. Laboratory investigations included fasting blood glucose, HbA1c, lipid profile, and liver function tests. Ultrasonography of the abdomen was performed by a trained radiologist to diagnose NAFLD based on echogenicity patterns.

Operational Definition of NAFLD:
NAFLD was diagnosed based on the presence of increased hepatic echogenicity on ultrasound, in the absence of other causes of chronic liver disease or significant alcohol consumption.

Statistical Analysis:
Data were entered into Microsoft Excel and analyzed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation (SD), and categorical variables as percentages. Group comparisons were performed using independent sample t-tests and chi-square tests. Multivariate logistic regression analysis was applied to identify independent risk factors for NAFLD. A p-value of <0.05 was considered statistically significant.

A total of 100 patients with Type 2 Diabetes Mellitus (T2DM) were included in the study. The mean age of participants was 53.6 ± 9.4 years, with a male predominance (55 males, 45 females). The mean body mass index (BMI) was 27.8 ± 4.1 kg/m² and the mean glycated hemoglobin (HbA1c) level was 7.7 ± 1.3% (Table 1).

Table 1: Demographic and Clinical Characteristics of Study Participants (n = 100)

The overall prevalence of Non-Alcoholic Fatty Liver Disease (NAFLD) among the study population was 62%. NAFLD was more prevalent in males (67.3%) compared to females (55.6%), although the difference was not statistically significant. The highest prevalence was observed in the age group of 51–60 years (68.4%), followed by the 41–50 years age group (61.5%) (Table 2).

Table 2: Prevalence of NAFLD by Demographic Subgroups

Comparison between patients with and without NAFLD revealed significantly higher BMI and HbA1c levels in the NAFLD group (29.8 ± 3.6 kg/m² vs. 24.7 ± 2.9 kg/m², p < 0.001; and 8.1 ± 1.3% vs. 7.2 ± 1.1%, p = 0.004, respectively). Dyslipidemia was observed in 74.2% of NAFLD patients compared to 34.2% in the non-NAFLD group (p < 0.001). Elevated alanine aminotransferase (ALT) levels were significantly more common in the NAFLD group (53.2% vs. 18.4%, p < 0.001) (Table 3).

Table 3: Comparison of Risk Factors Between NAFLD and Non-NAFLD Groups

Multivariate logistic regression analysis identified BMI ≥ 25 kg/m² (OR: 3.8; 95% CI: 1.7–8.5; p = 0.001), HbA1c ≥ 7% (OR: 2.6; 95% CI: 1.1–6.3; p = 0.03), and triglyceride levels ≥ 150 mg/dL (OR: 3.1; 95% CI: 1.3–7.1; p = 0.009) as independent risk factors significantly associated with the presence of NAFLD (Table 4).

Table 4: Multivariate Logistic Regression Analysis of Risk Factors for NAFLD

This study revealed a high prevalence (62%) of Non-Alcoholic Fatty Liver Disease (NAFLD) among patients with Type 2 Diabetes Mellitus (T2DM), reinforcing the growing burden of NAFLD in diabetic populations. Similar findings have been reported across South Asia and globally. A study from Nepal documented a notable co-existence of diabetes in NAFLD patients, emphasizing the clinical interplay between these two metabolic conditions [6]. In a real-world European cohort, Binet et al. found high rates of metabolic dysfunction-associated fatty liver disease (MAFLD) among T2DM patients, further supporting our findings of shared pathophysiological pathways [7].

The high prevalence of NAFLD among T2DM individuals in South Asia is well-established. A meta-analysis involving multiple South Asian countries estimated a pooled prevalence of over 50%, highlighting regional susceptibilities attributed to genetic, dietary, and lifestyle factors [8]. Interestingly, the burden of NAFLD is not limited to type 2 diabetes. Mertens et al. found that even individuals with type 1 diabetes exhibited notable rates of NAFLD, particularly when obesity and metabolic abnormalities coexisted [9].

Our study also identified obesity, elevated HbA1c, and hypertriglyceridemia as independent risk factors for NAFLD. These associations are consistent with previous Indian meta-analytic data showing that poor glycemic control, dyslipidemia, and increased BMI are major contributors to hepatic steatosis [10]. The bidirectional relationship between NAFLD and T2DM, described as the "chicken or egg" dilemma, underscores the role of insulin resistance as a unifying mechanism in both conditions [11].

Additionally, studies from neighboring countries such as Bangladesh have echoed similar findings. Alam et al. observed that age, central obesity, and elevated triglycerides were significantly associated with NAFLD, aligning with the present study’s results [12].

While ultrasonography remains a practical diagnostic tool, it lacks sensitivity for early steatosis and cannot distinguish between NAFLD and NASH. This highlights the need for improved diagnostic strategies and longitudinal follow-up in resource-limited settings. Despite the single-center design and moderate sample size, our study provides valuable insights into the NAFLD burden in diabetic patients in southern India.

This study highlights a high prevalence of Non-Alcoholic Fatty Liver Disease (NAFLD) among patients with Type 2 Diabetes Mellitus (T2DM), with 62% of participants affected. Obesity, poor glycemic control, and hypertriglyceridemia were found to be significant independent risk factors for NAFLD. These findings underscore the importance of routine screening for NAFLD in diabetic patients, especially those with elevated BMI, HbA1c, and triglyceride levels. Early detection and targeted lifestyle or pharmacological interventions can help prevent the progression to advanced liver disease. Integrating hepatic evaluation into diabetes care protocols is essential for improving long-term outcomes and reducing liver- and cardiovascular-related morbidity and mortality.

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