Prevalence of Metabolic Syndrome among patients with
Nonalcoholic Liver Disease
Peter Latimar L. Andrada M.D., Jose Tan M.D., FPCP, FPSG
Metropolitan Medical Center, Department of Internal Medicine, Section of Gastroenterology
ABSTRACT
Objective: To determine the prevalence of metabolic syndrome
among patients with nonalcoholic fatty liver disease (NAFLD).
Study Design: This is a retrospective study, aiming to describe
the clinical profile of 180 patients with fatty liver findings on
ultrasound. Charts of selected patients seen with in the period
betwwen Aug. 2004 to Aug. 2005 were reviewed.
Participants: 180 patients age 19 years old and above with fatty
liver findings on ultrasound were enrolled to the study. Patients
who strongly denies significant alcoholic intake, intake of
hepatotoxic drugs, with no history of chronic liver disease were
included in the study.
Results: Out of 180 only a total of 109 patients were diagnosed
with NAFLD. The mean age was 47.815.6 with 70 were male
(64.2%) and 39 were female (35.7%). Elevated SGPT was
present in 71/108 (65.7%) subjects whereas elevated SGOT
level was present in 14/42 (33.3%) subjects. Cholesterol above
normal was present in 18 subjects (40.9%) and subjects with
elevated triglyceride were 71 (69.6%). Obesity was the most
prevalent predictor was present in 93 of 106 subjects (85.32%).
Hypertension was present 66.1% (72/109) of subjects. Diabetes
was also an important risk factor, is present in 47.7% (52/109) of
subjects. Insulin resistance an additional risk factor for the
development of NAFLD was noted in 16 out of 19 patients (84%)
using the HOMA-IR index. And 51% (56/109) of the study group
was noted to have Metabolic Syndrome.
Conclusion: The preliminary data presented in the study
showed prevalence of metabolic syndrome among patients with
NAFLD at 51% (56/109) of the study group. Factors associated
with metabolic syndrome among patients with NAFLD includes:
obesity, hypertension, diabetes, hypertriglyceridemia.
Category: Liver
Article: Cross sectional
Keywords: Non-alcoholic fatty liver disease or NAFLD
Metabolic syndrome
I-Introduction:
Fatty Liver is a condition of hepatic steatosis caused by many risk factors and may progress to
liver fibrosis and cirrhosis.1 It is consist of intrahepatic accumulation of lipids and the commonest
liver disease accounting for abnormal function test in the majority of asymptomatic subjects.2 A
common clinical condition frequently encountered on abdominal ultrasound however many
clinicians often considered this as an incidental findings with scarce or no clinical significance.3
Only recently did Ludwig et al, identify a syndrome characterized by the association of fatty liver
and lobular hepatitis and chronically elevated alanine aminotransferase plasma levels in patients
with negligible alcohol intake. Thus the term non-alcoholic steatohepatosis (NASH) was
introduced.4 The original syndrome was described predominantly in obese, 5-7 diabetics,8-10 and
hyperdyslipidemics.8-12
Fatty liver is an increasingly common problem world wide and has been reported in Japan, 13-14
Australia,8 America,15-16 Europe,17 and Middle East.18 According to radiologic surveys; postmortem studies and evidence from the 3rd National Health and Nutrition Examination Survey
(NHANES III), the prevalence of non-alcoholic fatty liver disease (NAFLD) of any type is from
16%-23% and the prevalence of steatohepatitis is from 2%-6% depending on diagnostic method
used, both men and women are equally affected.19
Generally, the diagnosis of fatty liver should be based on the history, clinical manifestation,
laboratory investigation and medical imaging.
Liver biopsy is a useful and effective as a
prognostic indicator but it is an invasive and costly tool that should be taken if necessary.20
However, previous studies in which ultrasound findings were compared to histologic result
indicate that the overall sensitivity and specificity of ultrasonographic examination for the
diagnosis of fatty liver are approximately 80%-95% and 90%-95% respectively.21-23
Retrospective case study was used to analyze the prevalence of metabolic syndrome in nonalcoholic fatty liver diagnosed by ultrasonography in patients admitted in Metropolitan Medical
Center, Department of Internal Medicine.
II- Significance of the study:
The study would like to create awareness among physicians that in patients with
ultrasounds findings of fatty liver, one must further investigate and include work up for metabolic
syndrome. Thus early diagnosis and treatment in this condition would be done in order to prevent
its progression to end stage liver disease.
III- Objectives:
A. General Objective:
The aim of the study is to determine the prevalence Metabolic Syndrome in patients with Non
alcoholic fatty liver disease (NAFLD).
B. Specific Objective:
1. To describe the socio-demographic profile of patients with non-alcoholic fatty liver
disease.
2. To determine the association of non-alcoholic fatty liver disease and metabolic
syndrome based on its clinical presentations as defined by the NCEP ATP III such as
hypertension, hypertriglyceridemia, decreased serum HDL, impaired fasting glucose and obesity.
(Appendix A)
IV- Methodology:
Study Design:
This is a retrospective study with descriptive cross sectional mode of data analysis
aiming to describe the clinical profile of patients with non-alcoholic fatty liver disease diagnosed
by ultrasonography as seen in Metropolitan Medical Center, with special emphasis on the risk
factors among selected patients.
Study population:
This is a chart review of 256 selected patients age 19 years old and above with fatty liver
over a one year period between August 2004 to August 2005 at Metropolitan Medical Center.
Patients seen as in and out-patient who strongly denies significant alcoholic intake, intake of
hepatotoxic drugs, with no history of chronic liver disease was included in the study. Fatty liver
was diagnosed by ultrasonography using a Hitachi EUB-525 abdominal probe at 3.5 MHz.
Longitudinal, subcostal, ascending and oblique scans were performed. The ultrasonographic
criteria which were used to diagnose a fatty liver included liver and kidney echo discrepancy and
presence of an increased liver echogenicity or “bright liver”, echo penetration into deep portion of
the liver and clarity of the liver’s blood vessel structures.
In most patients’ medical charts serum level of SGPT, SGOT, total cholesterol,
triglyceride, HDL, LDL, albumin, fasting blood sugar, insulin assay and hepatitis profile were
documented. The Body Mass Index (BMI) was calculated as body weight in Kg/ (height in
meter)2, where as
the BMI is more than ≥25 Kg/m2 in obese patient and its ≥23 Kg/m2 in
overweight patients.24 (Appendix B) Insulin resistance was computed using the Homeostatic
Model Assessment index (HOMA).25 A single investigator obtained all these data.
IR= Insulin assay ( microunits/ml) x FBS (mmol/ml)
22.5
The HOMA has been used extensively as a reliable marker measuring insulin resistance
among patients diabetes mellitus and normal subjects. This has been proven by studies made by
Lansang26 and Bonora27 both of which compared HOMA with the more complex glucose clamp
technique and conducted that HOMA can be used reliably as a less expensive alternative for
measuring insulin resistance. A HOMA-IR value of 2.77 was chosen as the threshold for insulin
resistance based on the Bruneck Study.
Exclusion criteria for the study included: primary liver disorders other than fatty liver
disease that could account for steatosis including hepatitis B and C, alcohol intake of > 20
grams/day, history of jaundice for past six months, previous intake of steatogenic drugs such as
amiodarone, estrogen, chemotherapeutic drugs and anti-koch’s medications. Other subjects who
were excluded in the study are patients who were pregnant, with CHF (NYHA class III), with
COPD, with history of sepsis and parenteral nutrition.
Metabolic syndrome also known as Syndrome X was diagnosed according to the new
National Cholesterol Education Program Adult Treatment Panel III (NECP ATP III) report which is
3 or more of the following is present will satisfy the diagnosis: Hypertension (BP130/85 mmHg),
Fasting blood glucose (110-125mg/dl or 6.1mmol/L), Hypertriglyceridemia (150 mg/dl), Low
HDL-C ( < 40 mg/dl for men and < 50 mg/dl for women), Abdominal obesity (waist circumference
of >102cm for men and >88cm for women).28
V- Data Analysis:
Data were expressed as meansSD using Students t test and Chi-square test for
statistical analysis. All data was encoded and presented using the Statistical Package for Social
Sciences (SPSS) version 10. Prevalence of metabolic syndrome will be calculated using the
traditional formula:
Prevalence
= number of patients w/ 3 risk factor
Total population
X 100
VI- Results:
A total of 256 patients with fatty liver findings on ultrasound were selected for the study,
in which only 180 charts were available for reviewed. Out of 180 subjects 71 of which were
excluded due to 52 of them were alcoholic and 19 of them had history of exposure to what was
mentioned in the exclusion criteria. Only a total of 109 patients were enrolled in the study.
The mean age of the entire subject population was 47.815.6 with 70 were male (64.2%)
and 39 were female (35.7%) with male to female ratio of 1:1.7 (Table 1). The age distribution of
study patients is given in Figure 1.
Figure 1. Age distribution of study patients
30.0
25.0
Percent
20.0
15.0
10.0
5.0
0.0
15.0
25.0
35.0
45.0
55.0
65.0
75.0
85.0
Age range
Laboratory Results:
The mean SGPT level was 68.756.05, SGOT level was 34.9115.28. The
values of cholesterol above normal range were present in 18 subjects (40.9%) and subjects with
elevated triglyceride were 71 (69.6%). The mean cholesterol and triglyceride level were
190.4735.04 and 180.5865.52 respectively. The association of hypercholesterolemia and
hypertriglyceridemia in this study were strongly correlated to the incidence of patients with non
alcoholic fatty liver. The serum HDL which is below the normal range was noted in 33 subjects
(35.48%). The mean serum HDL was 49.5011.0. The laboratory data of the study population
were given in Table 2.
Insulin assay was done in 19 subjects (17.43%) in which insulin resistance were noted in
16 subjects (84%) with non alcoholic fatty liver by ultrasound. The mean insulin assay was
14.816.36.
Table 1: Demographic and Clinical characteristics of patients with Nonalcoholic Fatty Liver
Characteristics
Age
BMI
Gender
Male
Female
Diabetics
Hypertensive
n
109
106
109
109
109
Percent
70(64.2%)
39(35.7%)
52(47.7%)
72(66.1%)
MeanSD
47.815.61
28.353.19
Median
48
28.71
Range
23-86
18.83-34.99
Table 2: Laboratory Data of patients with Nonalcoholic Fatty Liver
Laboratory Test
n
MeanSD
Median
Range
SGPT
SGOT
Cholesterol
Triglycerides
HDL
FBS
Insulin assay
108
42
45
102
93
106
19
68.7056.05
34.9115.28
190.4735.04
180.5862.52
49.511.0
129.8349.73
14.816.36
50.6
32.9
190.33
185.22
48
114.88
13.5
17-363.9
12.5-78
121.7-265
49.4-361
28.18-81.3
77.9-373
3.7-33.8
SGPT= 7-41 U/L
SGOT= 10-37 U/L
Cholesterol = 40-200 mg/dL
Triglycerides= 52-201.75 mg/dL
HDL=35-65 mg/dL
FBS= 110-125mg/dL
Insulin assay= < 7.1 microunits/ml
Clinical Conditions:
Obesity was the most prevalent predictor in our study group which was present in 93 of
106 subjects (85.32%). The BMI distribution is given in figure 2. The mean BMI was 28.353.19
Kg/m.2The mean BMI in males was 28.323.33, and in females it was 28.402.96 (p<0.9
between males and females). No significant difference in BMI was noted between male and
female population. Hypertension was present. 66.1% (72/109) in our study group. Diabetes was
also an important risk factor associated in non alcoholic fatty liver which is present in 47.7%
(52/109) of our subjects. The characteristic of the study group is given in Table 1.
Insulin resistance was also noted as an additional for the development of non alcoholic
fatty liver which was detected in 16 out of 19 patients (84%) using the HOMA-IR index.
The prevalence of metabolic syndrome among patients with NAFLD is at 51% (56/109) of
the total study population.
Figure 2: BMI distribution of patients with NAFLD
7%
6%
obese
overwt
normal
87%
VII- Discusssion:
Our data from 109 patients with non-alcoholic fatty liver disease had clinical features
compatib le with the metabolic syndrome. This includes obesity (85.32%), hypertension (66.1%),
diabetes (47.7%), hypertriglyceridemia (69.6%) and low HDL-C (35.48%). It was noted in 51%
(56/109) of our study group had at least 3 or more of the clinical feature suggestive of metabolic
syndrome. Obesity was easily accompanied with fatty liver,29 it is a very common phenomenon in
the developed countries. 60-100% patients of nonalcoholic steatohepatitis (NASH) were prove to
have obesity.30 Hypertension can also be an independent risk factor in patients with NAFLD,
Donati et al31 showed that there is a higher prevalence of NAFLD in non-obese hypertensive.
Type 2 diabetes mellitus usually accompanied insulin resistance. 32,33 Both peripheral and hepatic
insulin resistance were present in almost all patient with nonalcoholic fatty liver disease,
irrespective of the coexistence of related risk factors.32 Above findings, together with the
associated hyperlipidemia, obesity and hypertension, were considered as the manifestation of
the metabolic syndrome that was associated with insulin resistance.33 Insulin resistance was also
noted in 16 out of 19 subjects (84%), recent studies have pointed to hyperinsulinemia and insulin
resistance as pathogenic factors in NAFLD. Marchesini et al34 showed that insulin resistance was
the laboratory finding most closely associated with the presence of NAFLD in a large series of
patients, irrespective of BMI, fat distribution or glucose tolerance. In this study, either type 2
diabetes or elevation of fasting blood glucose was related to fatty liver. It only suggested that
insulin resistance might be a risk factor for fatty liver and metabolic syndrome, since there is only
small sample size was used.
Accordingly NAFLD represent another feature of metabolic syndrome. 35 Since patients
with this syndrome have a 30% increased risk of cardiovascular death in the absence of type 2
DM and a 40-70% increased risk of cardiovascular death in the presence of type 2 DM, 36 patients
with the metabolic syndrome require the treatment of the syndrome regardless of the severity of
any associated non-alcoholic fatty liver disease. However non-alcoholic fatty liver disease may
be an independent disease but more generally it is a lesion of the liver in certain systemic
diseases and can progress from mild steatohepatitis to severe fibrosis and cirrhosis. 10 Although
the etiology of non-alcoholic steatohepatitis is explained extensively. The complicated and
multifactor pathogenesis made it remain poorly understood. Several of the recognized associated
conditions such as intestinal by pass surgery, steroid treatment and total parenteral nutrition, can
cause a metabolic shift favoring lipogenesis rather than lipolysis and lead to steatosis. 30
Recently, a ‘two-hit’ hypothesis for the development of nonalcoholic steatohepatitis has
been proposed. The first hit was insulin resistance which produces steatosis, the second, any
source of oxidative stress that increase the lipid peroxidation and subsequently leads to
increased liver damage.37 Factors which can produce a ‘second hit’ such as alcohol, and drugs
were conspicuously absent in our study group.
At present there is no established therapy for NAFLD based on evidence from large,
RCT’s. Treatment for all patients whatever the severity of their disease, should therefore be
directed at the associated metabolic syndrome risk factors: obesity, type 2 DM, dyslipidemia and
hypertension. This strategy will reduce morbidity and mortality and may also be beneficial to the
liver.38
VIII- Conclusion:
The preliminary data presented in the study showed prevalence of metabolic syndrome
among patients with NAFLD at 51% (56/109) of the study group. The factors associated with
metabolic syndrome among patients with NAFLD includes: obesity, hypertension, diabetes,
hypertriglyceridemia and low HDL-C.
IX- Recommendation:
The researcher/s further recommends comparing the study group to a control. A follow up
research using a prospective study design should be done to the subjects giving emphasis to the
insulin resistance, in which the researcher/s failed to use a bigger sample size.
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Appendix A:
Components of the Metabolic Syndrome (NCEP ATP III recommendations)
Components
Defining level
Fasting Glucose
> 110 mg/dl or  6.1mmol/L
Hypertension
≥130/≥85 mmHg
Abdominal Obesity (waist circumference)
Men > 102 cm or > 40 inches
Women > 88 cm or >35 inches
Triglyceride
≥ 150 mg/dL or ≥ 1.7 mmol/L
HDL-C
Men < 40 mg/dL or < 1.0 mmol/L
Women < 50 mg/dL or < 1.2 mmol/L
Metabolic syndrome is defined by the presence of 3 or more these features
APPENDIX B:
Body Mass Index (BMI) wt. in Kg/ ht. in m2
____________________________________________________________
Classification
BMI score
____________________________________________________________
Underweight
< 18.5
Normal
18.56 – 22.99
Overweight
23- 24.99
Obese 1
25 – 29.99
Obese 2
> 30
____________________________________________________________
The Asia pacific Perspective Obesity and its Treatment WHO
Western Pacific Region-International Association for the Study of Obesity 2004
APPENDIX C
Data Collection Form:
Ultrasound Findings of Fatty Liver among Non- Alcoholic Metabolic
Syndrome Patients
Date ______________
Name_________________________________
A. Vital signs:
BP: ___________
Subject No.__________________
Age/Sex_____________________
CR: ________
RR: __________
B. History:
Alcohol Drinking
>2 bottle of beer/day
>200ml of wine/day
>50ml of 80% proof
Yes
( )
( )
( )
( )
No
( )
( )
( )
( )
Yes
Pregnant
( )
On parenteral nutrition ( )
COPD
( )
Congestive heart failure ( )
History of :
Jaundice
Hepatitis B
Hepatitis C
Hypertension
(
(
(
(
(
(
(
(
Sepsis
Renal Failure
Bowel surgery
Diabetes
(
(
(
(
)
)
)
)
(
(
(
(
)
)
)
)
Anti-Koch’s
Anti-Neoplastic
(
(
)
)
(
(
)
)
)
)
)
)
)
)
)
)
Intake/use of the following medication/s:
Amiodarone
( )
( )
Estrogen
( )
( )
No
( )
( )
( )
( )
C. Anthropometric Measurements:
Weight: (kg) _______ Height: (m) ________
Abdominal Circumference: (cm) ___________
Hip-Waist Ratio: _______________________
BMI: __________
Hip Circumference: (cm) ______________
D. Laboratory Results:
FBS_________
HDL __________
SGPT______ ___U/L
HBs Ag _______
Total Cholesterol___________ Triglyceride _________
LDL ___________
SGOT_______ __U/L
Serum Albumin________
HCV Ab _______
E. Ultrasound of the Liver result: