Association between risk factors of non-alcoholic fatty liver with the sonographic findings among adults at Golden Horses Health Sanctuary, Selangor, Malaysia

NAFLD is the most common type of hepatic steatosis, developing through three main stages, from simple hepatic steatosis to non alcoholic steatohepatitis (NASH), that leads to fibrosis and cirrhosis with the end-stage of HCC. It is strongly associated with metabolic syndrome, such as dyslipidemia, T2DM, hypertension and obesity. Therefore, NAFLD is considered an independent risk factor for the development of cardiovascular disease (CVD). The present study was proposed to determine the contributing factors to NAFLD amongst Malaysian adults in the Klang Valley as well as the association between these factors and grading of NAFLD. This study was also designed to assess the differences of hepatic echo-intensity attenuation rate and subcutaneous tissue thickness between NAFLD patients and non-NAFLD subjects. An analytical cross-sectional study design was achieved prospectively amongst Malaysian adults who underwent the routine screening programme at the Golden Horses Health Sanctuary (GHHS) in the Klang Valley for the period from 15th August 2015 until 15th Juanuary 2016. A self-administered questionnaire was adopted as the instrument for data collection. Qualitative ultrasound for diagnosis of NAFLD was performed based on increasing echogenicity of hepatic parenchyma in comparison with echogenicity of the spleen and right renal cortex. In contrast, Quantitative ultrasound for detecting NAFLD was performed by quantifying the hepatic echo-intensity attenuation rate. Moreover, subcutaneous tissue thickness was measured from the skin surface into the liver capsule. A total of 628 subjects were recruited to participate in the study. There were 235 (37.4%) subjects with NAFLD and 393 (62.6%) normal subjects. The mean age of the participants was 54.54 ±6.69 years and the mean BMI was 24.72 ±3.96 kg/m2. The results showed that the peak prevalence of NAFLD involved subjects aged between 53-60 years old. Additionally, the results demonstrated that the prevalence of NAFLD was significantly higher in males, Indians and Malays compared to Chinese, with high BMI (≥ 23.0 kg/m2), high WHR, hypertriglyceridemia, low HDL-C, physical inactivity, DM, and hypertension. Median daily caloric intake of protein, fat, and carbohydrate was also significantly higher in subjects with NAFLD than those without NAFLD. However, when further analysis for percentage of protein intake was done, no association between the daily percentage of protein intake and the prevalence of NAFLD was found. Amongst the NAFLD grades, there was a significant association of high BMI and high WHR with NAFLD grades. Similarly, the median triglyceride was significantly higher amongst NAFLD grade III (2.15 ±1.7 mmol/L) than in grade II (1.50 ±0.70 mmol/L) and grade I (1.40 ±0.80 mmol/L). In the same context, the mean HDL-C was significantly lower amongst NAFLD grade III (1.21 ±0.21 mmol/L) than grade II (1.31 ±0.30 mmol/L) and grade I (1.40 ±0.30 mmol/L). Otherwise, the differences of the mean total cholesterol, LDL-C, median protein, fat, and carbohydrate amongst the NAFLD grades were not reported to be significant. The multiple logistic regression analysis demonstrated that male gender, high BMI, physical inactivity, hypertriglyceridemia, DM, and thickened subcutaneous tissue were independent predictive risk factors for developing NAFLD. However, ages > 60 years old decreased the risk of NAFLD significantly. For the Malay and Indian races, high WHR, low HDL-C, and hypertension were not detected to be significant risk predictors for progression of NAFLD. Interestingly, daily caloric intake of protein, fat, and carbohydrate, were also not found to increase the risk of NAFLD. The differences of mean hepatic echo-intensity attenuation rate and subcutaneous tissue thickness between NAFLD patients and normal subjects were found to be statistically significant. Sonographically, a hepatic echo-intensity attenuation rate of 1.7 dB/cm.MHz and above made the diagnosis of NAFLD more probable. Similarly, subjects with a subcutaneous tissue thickness measuring 2.1 cm and above were more likely to have NAFLD. In conclusion, NAFLD is common in the urban Malaysian population with a higher prevalence amongst Indians and Malays than Chinese. The quantitative ultrasound was valuable to assess NAFLD based on quantifying the hepatic echo-intensity attenuation rate. A large population-based study is recommended to determine prevalence of NAFLD amongst the entire Malaysian population as well as to determine further contributing risk factors of NAFLD.

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