Non-alcoholic fatty liver disease has emerged as a significant public health challenge, with its prevalence rising globally alongside trends in obesity and metabolic disorders. While NAFLD affects individuals across the world, India faces a particularly concerning burden. Estimates suggest that the prevalence of NAFLD in India ranges from 6.7 % to 55.1 % of all the cases making it a leading cause of chronic liver disease in the country. [1,2] This condition, characterized by the accumulation of fat in the liver without the influence of alcohol consumption [3], it is increasingly recognized as a major contributor to liver-related morbidity and mortality. The increased prevalence is typically linked to those who are overweight, obese, and have type 2 diabetes mellitus.[4] The rise in NAFLD cases correlates closely with lifestyle changes, including poor dietary habits and sedentary behavior, which have become prevalent in urban and rural settings. The spectrum of NAFLD ranges from simple steatosis to more severe forms such as non-alcoholic steatohepatitis (NASH), which can progress to liver fibrosis, cirrhosis, and even hepatocellular carcinoma [5] As a result of the current obesity epidemic, which is predicted to worsen liver disease, the prevalence of non-alcoholic fatty liver disease (NAFLD) is rising along with diabetes and other risk factors (1 in 14 people in India have diabetes and 1 in 29 people are obese).[6] Accurately identifying individuals at risk and recognizing NAFLD early on could provide substantial benefits in terms of diagnosis, prevention, and treatment. The alarming prevalence of NAFLD in India highlights the urgent need for public health initiatives aimed at early detection and management. Understanding the prevalence and factors contributing to NAFLD in the Indian adult population seeking tertiary care is crucial for developing targeted interventions and improving patient outcomes. By shedding light on these aspects, this research aims to contribute valuable insights for healthcare professionals and policymakers in their efforts to address the growing challenge of NAFLD in India, in this regard present study aimed to estimate the prevalence of NAFLD and factors associated with it among the patients attending tertiary care centre. 

Study Design:  Observational Cross-Sectional study.

Study Population: Adult patients, either inpatient or outpatient, who were referred to the Radiology Department of the Government General Hospital in Rajamahendravaram, Andhra Pradesh, for an abdominal ultrasound, made up the study population.

Sample size and sampling technique:

By taking the prevalence of NAFLD as 38.6 per cent as pooled prevalence among adults from a metanalysis study done by Shalimar et al [7] with a 95 per cent confidence interval, an allowable error of 7 per cent, a non-response rate of 10 per cent, the minimum sample size came to 193 and it was rounded off to 200 subjects. A total of 200 subjects were selected by using simple random sampling from the list of daily registered patients for ultrasound in the radiology department.

Inclusion Criteria:

• Males and females in the age group of 18 years to 60 years
• Patients who gave written and informed consent

Exclusion Criteria:

• Patients who had overt cirrhosis, previously diagnosed Hepatitis B virus or Hepatitis C virus infection and biliary diseases.
• Patients with Alcohol abuse, ascites, Chronic drug abuse and malignant liver cancer

Study period

The study was carried out for 6 months from October 2022 to March 2023

Study Instruments and Variables

A pretested validated questionnaire was utilised to gather data on age, gender, lifestyle risk factors, body mass index, waist circumference, waist/hip ratio, and ultrasound results. Furthermore, comprehensive data regarding lifestyle practices, and food patterns were recorded.

Ethical considerations

Institutional Ethics Committee approval was obtained before conducting the study.

Data collection: Following the acquisition of informed consent, a pretested validated case record form was employed to gather data from eligible subjects concerning demographic information, co-morbidities, dietary habits, and anthropometric measurements. Anthropometric measurements included Body Mass Index (BMI) and waist-hip ratio. All individuals underwent an ultrasound examination conducted by a radiologist. Furthermore, data regarding lifestyle practices was collected.

Statistical Analysis: After data collection, the acquired data were double-checked and entered in to Microsoft Excel. Data was analysed using SPSS software (version 21.0). Before conducting statistical tests, the normality of continuous variables was evaluated. Chi-square test was to find the association for qualitative variables. A P value below 0.05 was deemed statistically significant. Ninety-five percent confidence intervals (95% CI) for the measures of association were computed and documented.

The present study was conducted among 200 study participants. The prevalence of NAFLD was found to be 38%. The mean age was 38.4 ± 10.2 years, and the mean weight was 66.2 ± 9.2. Out of 200 study participants, 120 (60%) were males and the rest 80 (40%) were females. The mean BMI of the sample population was 25.6 ±4.4. The mean waist-hip ratio was 0.92±0.18 cm.

Table 1 shows the socio-demographic profile of the subjects. Out of 200 subjects, 120 were male and 80 were female; the majority were Hindu (76%), followed by Christians (18%) and Muslims (6%). Regarding age distribution, 78 subjects were between 18 and 29 years old; 72 were between 30 and 45 years old; and 50 were over 45 years old. The highest proportion of subjects had primary education (35%), followed by secondary education (33%), illiterate (23%), intermediate, and degree holders (9%). Regarding occupation, 51% of the subjects engaged in daily wage and agriculture, while homemakers (30.5%), the unemployed (12%), professionals (6%), technicians (5.5%), and clerks (2.5%) followed.

Figure I:   Distribution of Study Subjects according to gender

Table 1: Distribution of study subjects According to socio-demography (n=200).

(**Yates correction applied)

Table 2:  Association between NAFLD with BMI and Waist Hip ratio among the study subjects

**(yates correction applied) * Statistically Significant

Table 2 shows the BMI and waist-hip ratio measurements. Out of 200 study subjects, 79 (39.5%) had a normal BMI, 34 (17%) were obese, 69 (34.5%) were pre-obese, and 19 (9.5%) were underweight. There was a significant association between increasing BMI and NAFLD in the study population (χ2 = 14.56, p<0.002). There was also a significant association between high waist-hip ratio and NAFLD (χ2 = 43.7, p<0.0001). In terms of comorbidity, 11% had a history of diabetes and 20% had a history of hypertension.

Table 3:  Association of NAFLD with comorbidities and Exercise among study subjects (N = 200)

** (yates correction applied)

Table 3 shows the association of NAFLD with co-morbidities. The results show that there was a significant association between a history of diabetes mellitus (DM) and NAFLD (χ²=24.7, p<0.0001), with a higher prevalence of NAFLD among individuals with a history of DM. The percentage of NAFLD was high among hypertensives compared to non-hypertensives (51.2% vs. 29.8%), and the difference was not found to be significant (χ2 = 0.137, p = 0.07).

Among the study subjects, the proportion of NAFLD cases was higher among those who did not exercise (47.2%) compared to those who regularly exercise for at least 150 minutes per week (10.9%) and the difference was found to be statistically significant. (P < 0.0001)

The study results and referenced research indicate that multiple factors contribute to the development of non-alcoholic fatty liver disease (NAFLD). BMI, gender, waist-hip ratio, and lifestyle factors, including nutrition and exercise, have been recognized as critical risk factors for NAFLD. [9,10 ]

The present study included 200 participants with 120 male and 80 female subjects. Prevalence of NAFLD among the study subjects was 38 %. This study confirms factors associated with NAFLD were high BMI, high Waist hip Ratio, Diabetes , age > 45 years and sedentary habits.

In present study, Prevalence of NAFLD among study subjects using ultrasound was 38%. Similar findings was observed by Pathipaka et al where prevalence of NAFLD was 40% among adult population.[8] our findings were further supported by systematic review and metanalysis conducted by Shalimar et al, where pooled prevalence was 38.6%.[7]

The mean body mass index (BMI) of the sample population was 25.6, categorizing it as overweight, which emerged as a significant factor in this study, with a p-value

of 0.02. This aligns with the results of Anand et al., who indicated a p value of <0.001 for BMI as a risk factor. [11] . similar findings were observed by study  conducted by Pathipaka et al.  Increasing age, and Overweight and obese category of BMI were identified as major risk variables in present study and also other studies.[12,13,14]

The mean waist-hip ratio was 0.92 cm. The waist-hip ratio emerged as a significant factor, with a p-value of 0.000 in the present investigation. This aligns with the findings of the study conducted by Sp Singh et al. [15]and Pathipaka SK, which revealed an elevated waist-to-hip ratio as a risk factor for NAFLD, with a p-value of 0.000.[8]

NAFLD is the predominant chronic liver disease, with an increasing prevalence in India. Various risk factors, such as sedentary lifestyle, overweight, obesity, diabetes, and increased waist-to-hip ratio, were significantly associated with NAFLD. Future research may further explore the impact of dietary and exercise interventions on the prevention and management of NAFLD.

Acknowledgement

We would like to thank the study subjects who actively participated in the study

 Conflict of interest: None declared

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