Nonalcoholic fatty liver disease (NAFLD) has become the most common form of chronic liver disease in the USA. Interestingly, most patients with NAFLD are unaware of having any liver disease (LD). We aimed to assess the awareness of suspected NAFLD and factors associated with being aware of LD.
Adult subjects with suspected NAFLD (BMI > 25) with elevated ALT in the absence of secondary causes of LD who participated in the continuous national health and nutrition examination survey (NHANES) during 2001–2016 were identified and analyzed. Trends of NAFLD awareness were then assessed in periods of 4 years each. Multivariable logistic regression analysis was performed to assess factors associated with LD awareness.
A total of 7033 subjects were included in the final analysis (1731, 1757, 1711, and 1834 subjects for the periods of 2001–2004, 2005–2008, 2009–2012, and 2013–2016, respectively). Over the study duration, an increase in BMI, waist circumference, diabetes, and HbA1c; and a decrease in the number of smokers, platelets count, bilirubin, total cholesterol, and LDL level were noticed (p < 0.001). Awareness of having LD across study periods has increased over time from 1.5% in the 2001–2004 periods to 3.1% in the 2013–2016 periods. Multivariable logistic regression analysis showed that older age, ethnicity (non-black), having fewer drinks/week, metabolic syndrome, higher ALT, ALP, and GGT were associated with being aware of having LD.
Awareness of having LD among subjects with suspected NAFLD has increased over the last two decades, but more than 95% of these patients are still unaware of having LD. Educational programs to increase awareness of LD and risk factors for NAFLD should be implemented on a large scale.
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AST to platelet ration index
Body mass index
Centers for disease control and prevention
End-stage liver disease
Hepatic steatosis index
International diabetes federation
“Medical conditions” questionnaire
National health and nutrition examination survey
Nonalcoholic fatty liver disease
NAFLD fibrosis score
National center for health statistics
Upper limit of normal
Younossi ZM, Koenig AB, Abdelatif D, Fazel Y, Henry L, Wymer M. Global epidemiology of nonalcoholic fatty liver disease-Meta-analytic assessment of prevalence, incidence, and outcomes. Hepatology (Baltimore, Md).. 2016;64:73–84.
Wong RJ, Liu B, Bhuket T. Significant burden of nonalcoholic fatty liver disease with advanced fibrosis in the US: a cross-sectional analysis of 2011–2014 National Health and Nutrition Examination Survey. Aliment Pharmacol Ther. 2017;46:974–980.
Kabbany MN, Conjeevaram Selvakumar PK, Watt K, et al. Prevalence of nonalcoholic steatohepatitis-associated cirrhosis in the United States: an analysis of national health and nutrition examination survey data. Am J Gastroenterol. 2017;112:581–587.
Noureddin M, Vipani A, Bresee C, et al. NASH leading cause of liver transplant in women: updated analysis of indications for liver transplant and ethnic and gender variances. Am J Gastroenterol. 2018;113:1649–1659.
Marchesini G, Brizi M, Bianchi G, et al. Nonalcoholic fatty liver disease: a feature of the metabolic syndrome. Diabetes. 2001;50:1844–1850.
Wieland AC, Mettler P, McDermott MT, Crane LA, Cicutto LC, Bambha KM. Low awareness of nonalcoholic fatty liver disease among patients at high metabolic risk. J Clin Gastroenterol. 2015;49:e6–e10.
Mozumdar A, Liguori G. Persistent increase of prevalence of metabolic syndrome among U.S. adults: NHANES III to NHANES 1999–2006. Diabetes Care. 2011;34:216–219.
Adams LA, Lymp JF, St Sauver J, et al. The natural history of nonalcoholic fatty liver disease: a population-based cohort study. Gastroenterology. 2005;129:113–121.
Sanna C, Rosso C, Marietti M, Bugianesi E. Nonalcoholic fatty liver disease and extra-hepatic cancers. Int J Mol Sci. 2016;17:717.
Yasui K, Sumida Y, Mori Y, et al. Nonalcoholic steatohepatitis and increased risk of chronic kidney disease. Metab Clin Exp. 2011;60:735–739.
Yan LH, Mu B, Guan Y, et al. Assessment of the relationship between nonalcoholic fatty liver disease and diabetic complications. J Diabetes Investig. 2016;7:889–894.
Leung CM, Lai LS, Wong WH, et al. Nonalcoholic fatty liver disease: an expanding problem with low levels of awareness in Hong Kong. J Gastroenterol Hepatol. 2009;24:1786–1790.
Federation ID. The IDF Consensus Worldwide Definition of the Metabolic Syndrome 2011. https://www.pitt.edu/~super1/Metabolic/IDF1.pdf. Accessed 30 Jan 2019.
Lee JH, Kim D, Kim HJ, et al. Hepatic steatosis index: a simple screening tool reflecting nonalcoholic fatty liver disease. Dig Liver Dis: Off J Ital Soc Gastroenterol Ital Assoc Study Liver. 2010;42:503–508.
Johnson CL, Paulose-Ram R, Ogden CL, et al. National health and nutrition examination survey: analytic guidelines, 1999–2010. Vital Health Stat. 2013;2:1–24.
Kim D, Kim WR. Nonobese Fatty Liver Disease. Clin Gastroenterol Hepatol: Off Clin Pract J Am Gastroenterol Assoc. 2017;15:474–485.
Yilmaz Y. Is nonalcoholic fatty liver disease the hepatic expression of the metabolic syndrome? World J Hepatol. 2012;4:332–334.
Dyson JK, Anstee QM, McPherson S. Nonalcoholic fatty liver disease: a practical approach to diagnosis and staging. Frontline Gastroenterol. 2014;5:211–218.
Lee MJ, Kim EH, Bae SJ, et al. Age-related decrease in skeletal muscle mass is an independent risk factor for incident nonalcoholic fatty liver disease: a 10-year retrospective cohort study. Gut Liver. 2019;13:67–76.
Lazo M, Hernaez R, Eberhardt MS, et al. Prevalence of nonalcoholic fatty liver disease in the United States: the third national health and nutrition examination survey, 1988–1994. Am J Epidemiol. 2013;178:38–45.
Coogan PE, Wise LA, Cozier YC, Palmer JR, Rosenberg L. Lifecourse educational status in relation to weight gain in African American women. Ethn Dis. 2012;22:198–206.
Bergqvist CJ, Skoien R, Horsfall L, Clouston AD, Jonsson JR, Powell EE. Awareness and opinions of nonalcoholic fatty liver disease by hospital specialists. Intern Med J. 2013;43:247–253.
Grattagliano I, D’Ambrosio G, Palmieri VO, et al. Improving nonalcoholic fatty liver disease management by general practitioners: a critical evaluation and impact of an educational training program. J Gastrointestin Liver Dis. 2008;17:389–394.
Polanco-Briceno S, Glass D, Stuntz M, Caze A. Awareness of nonalcoholic steatohepatitis and associated practice patterns of primary care physicians and specialists. BMC Res Notes. 2016;9:157.
Singh Sp MB, Misra D, Pati GK, et al. Awareness and opinion of nonalcoholic fatty liver disease (NAFLD) patients about obesity and its consequences. J Hepatol. 2014;60:S352.
Zelber-Sagi S, Nitzan-Kaluski D, Goldsmith R, et al. Long term nutritional intake and the risk for nonalcoholic fatty liver disease (NAFLD): a population based study. J Hepatol. 2007;47:711–717.
Singh SP, Singh A, Misra D, et al. Risk factors associated with nonalcoholic fatty liver disease in Indians: a case-control study. J Clin Exp Hepatol. 2015;5:295–302.
Modi AA, Feld JJ, Park Y, et al. Increased caffeine consumption is associated with reduced hepatic fibrosis. Hepatology (Baltimore, Md).. 2010;51:201–209.
Kistler KD, Brunt EM, Clark JM, et al. Physical activity recommendations, exercise intensity, and histological severity of nonalcoholic fatty liver disease. Am J Gastroenterol. 2011;106:460–468. quiz 469.
Goldberg RB, Temprosa M, Haffner S, et al. Effect of progression from impaired glucose tolerance to diabetes on cardiovascular risk factors and its amelioration by lifestyle and metformin intervention: the Diabetes Prevention Program randomized trial by the Diabetes Prevention Program Research Group. Diabetes Care. 2009;32:726–732.
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Singh, A., Dhaliwal, A.S., Singh, S. et al. Awareness of Nonalcoholic Fatty Liver Disease Is Increasing but Remains Very Low in a Representative US Cohort. Dig Dis Sci 65, 978–986 (2020). https://doi.org/10.1007/s10620-019-05700-9
- Nonalcoholic fatty liver disease (NAFLD)
- Noninvasive scores
- Liver disease