Supplementary Box 1: NAFLD Fibrosis Score (NFS) calculation and accuracy

NFS
can
be
calculated
on
a
free,
easy
to
use
on-line
calculator
(http://NAFLDscore.com).

NFS = -1.675 + 0.037 X age (years) + 0.094 X BMI (kg/m2) + 1.13 X Impaired
fasting glucose/diabetes (yes = 1, no = 0) + 0.99 X AST/ALT ratio + 0.013 X
platelet count (x109/L) - 0.66 X albumin (g/dl).

The low cut-off score (<-1.455) has a negative predictive value (NPV) of 88–93%
and the high cut-off score (>+0.676) has a positive predictive value (PPV) of 79–
90% for the presence of advanced fibrosis in NAFLD in secondary care
populations (13, 22).

Those with an indeterminate score (-1.455 to +0.676) cannot confidently have
advanced fibrosis excluded and require further investigations (i.e. transient
elastography).
Supplementary Box 2: General information on the MDT NAFLD clinic

The MDT NAFLD clinic was started in 2009 at the University Hospitals
Birmingham, UK.

The MDT clinic consists of:
o
2 consultant hepatologists (P.N.N; G.H)
o
1
consultant
endocrinologist
(J.W.T,
with
specialist
interest
in
obesity/NAFLD)

o
2 Diabetes specialist nurses (A.P, L.C)
o
1 specialist dietician with an interest in liver disease (J.J)
o
Rotating clinic research fellows (M.J.A, R.P)
Between 1st January 2010 and 30th December 2010, there were 95 new referrals to
the clinic and 400 patients were reviewed.

In 2012, the clinic had 150 new referrals and 670 patients were reviewed.

The specialist liver tools available include; transient elastography (Fibroscan®) and
Fibrotest (Biopredictive, France). In 2012, the transient elastography service
became nurse-led (M.R).
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Supplementary Box 3: Dietary assessment and guidance
Assessment:
 Weight history, current weight/BMI, and influencing factors
 Lifestyle and exercise via direct questioning (open and closed questions)
 Food intake and eating habits via a 7-day food diary (completed prior to
appointment)
Rationale:
 Discuss rationale for diet and lifestyle advice in relation to the patients underlying
liver disease and severity.
Guidance:
 Tailored to patients lifestyle (i.e. variable working patterns, family members, ability
to exercise etc)
 Aim to reduce energy intake by 250-500 calories per day to promote 1-2kg weight
loss per month
 Rationale for breakfast and suitable choices
 Regular meals advised with rationale (introduced across appointments if very poor
meal patterns i.e. only eat a high calorific evening meal etc)
 Target high sugar/fat intake (especially high sugar drinks i.e. energy drinks)
 Additional advice regarding fibre/vitamins/minerals across appointments
Specialist advice for patients with type 2 diabetes:
 As above
 Additional rationale for complex (vegetables, cereal) vs. simple (e.g. milk, yoghurt
etc) carbohydrates, glycaemic index and fibre.
 Discuss the effects of glucose vs. complex carbohydrates on blood glucose
 Discuss the fact that poor glycaemic control is a driver of fat accumulation in the
liver and rationale for maintaining good control
 Establish clear aims and targets with the patient
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Supplementary Table 1 – Demographics and characteristics of patients with type 2
diabetes screened with the NAFLD Fibrosis Score at the diabetes clinic in HHB, UK
HHB diabetes clinic
(n=64)
Age (years)
Male Sex, % (n)
Ethnicity
- White
- Asian
- Black
- Other/unknown
Metabolic conditions
Obesity (BMI > 30), % (n)
Hypertension, % (n)
Hyperlipidaemia, % (n)
Ischaemic heart disease, % (n)
History of Liver disease, % (n)
Metabolic parameters
Duration of type 2 diabetes (years)
HbA1c % [mmol/mol]
Therapy for type 2 diabetes, % (n)
- Non-insulin dependent
- Insulin dependent
Weight (Kg)
Body Mass Index (Kg/m2)
Systolic Blood Pressure (mmHg)
Diastolic Blood Pressure (mmHg)
Total cholesterol (mmol/L)
Creatinine (µmol/L)
Liver Function Tests
ALT (IU/L)
% (n) patients with abnormal ALT (>43)
AST (IU/L)
% (n) patients with abnormal AST (>41)
GGT (IU/L)
% (n) patients with abnormal GGT (>50)
ALP (IU/L)
% (n) patients with abnormal ALP (>130)
Bilirubin (µmol/L)
% (n) patients with abnormal Bilirubin (>17)
Albumin (g/L)
% (n) patients with abnormal Albumin (<35)
56.5 (48.3-67.0)
65.6 (42/64)
34.4 (22/64)
39.1 (25/64)
3.1 (2/64)
23.4 (15/64)
50.0 (32/64)
64.0 (41/64)
79.7 (51/64)
9.4 (6/64)
0.0 (0/64)
8.5 (5-10)
7.8 (6.8-9.6) [62; 52-81]
62.5 (40/64)
37.5 (24/64)
86.5 (73.5-98.5)
31.5 (27.8-35.1)
134 (121-139)
77.0 (69.8-82.5)
3.9 (3.6-4.8)
82.5 (72.0-95.5)
29.0 (22.0-46.8)
29.7 (19/64)
25.0 (21.0-33.8)
12.5 (8/64)
39.0 (27.0-58.0)
29.7 (19/64)
81.0 (69.0-92.8)
1.6 (1/64)
7.0 (5.0-9.0)
0.0 (0/64)
45 (43-46)
0.0 (0/64)
All values are median values (IQR), unless stated. HHB, Heartlands Hospital Birmingham.
Abnormal ranges for liver function tests are routine laboratory cut-offs (in brackets).
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