Awareness of Nonalcoholic Fatty Liver Disease Is Increasing but Remains Very Low in a Representative US Cohort



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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Fig. 1



Advanced fibrosis


Aspartate aminotransferase


Alanine aminotransferase


AST to platelet ration index


Body mass index


Centers for disease control and prevention


End-stage liver disease




γ-Glutamyl transpeptidase


Hepatic steatosis index


High-density lipoprotein


Hemoglobin A1c


International diabetes federation


Low-density lipoprotein


Liver disease


“Medical conditions” questionnaire


Metabolic syndrome


National health and nutrition examination survey


Nonalcoholic fatty liver disease


NAFLD fibrosis score


Nonalcoholic steatohepatitis


National center for health statistics


Upper limit of normal


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Author information




AS, ASD, MG, and NA helped in study concept and design; AS contributed to acquisition of data; all authors helped in analysis and interpretation of data, drafting of the manuscript and critical revision of the manuscript for important intellectual content, and administrative, technical, or material support; RL, AS, and NA contributed to statistical analysis; ASD, SS, AK, AK, MN, WC, AM, and NA contributed to study supervision.

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Correspondence to Amandeep Singh.

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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).

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  • Nonalcoholic fatty liver disease (NAFLD)
  • Noninvasive scores
  • Awareness
  • Liver disease