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Prevalence, characteristics, and mortality outcomes of obese and nonobese MAFLD in the United States

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Abstract

Background and aims

Metabolic dysfunction-associated fatty liver disease (MAFLD) establishes new criteria for diagnosis of fatty liver disease independent of alcohol intake. We aimed to describe the prevalence and compare characteristics and mortality outcomes of persons with nonobese and obese MAFLD.

Methods

Using data from 13,640 participants from the third National Health and Nutrition Examination Survey (NHANES III) 1988–1994, we identified participants with fatty liver on ultrasound who had MAFLD and analyzed them by the presence of obesity.

Results

Overall prevalence of MAFLD was 19%; amongst those, 54% were obese and 46% were nonobese. Nonobese MAFLD was more common in participants older than 65 than in younger participants (56.8% vs. 43.2%, p < 0.0001). Nonobese MAFLD was more common in males (63.2% vs. 48.3%, p < 0.0001). Obese MAFLD was more common in females (51.7% vs. 48.3%, p < 0.0001). After adjusting for several demographic factors and alcohol use, older age [adjusted odds ratio (aOR) 1.02, 95% CI 1.00–1.02, p = 0.003] and being male (aOR: 1.65, 95% CI 1.25–2.17, p = 0.001) were independent risk factors for nonobese MAFLD. Nonobese MAFLD participants had a higher 20-year cumulative incidence for all-cause mortality compared to obese MAFLD participants (33.2% vs. 28.8%, p = 0.0137). However, nonobese MAFLD was not independently associated with mortality after adjusting for relevant confounders, while FIB-4 > 1.3 and cardiovascular disease were the strongest risk factors associated with increased mortality [adjusted hazard ratio (aHR)  > 2.7 for both, p < 0.0001 for both].

Conclusions

Nonobese MAFLD constitutes about half of the MAFLD in the United States, especially among males and the elderly. Notably, nonobese MAFLD carries higher mortality than obese MAFLD. Screening and diagnosis of MAFLD should be considered in nonobese populations.

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Abbreviations

aHR:

Adjusted hazard ratio

aOR:

Adjusted odds ratio

ALT:

Alanine transaminase

AST:

Aspartate aminotransferase

BMI:

Body mass index

CI:

Confidence interval

FIB-4:

Fibrosis-4

GGT:

Gamma-glutamyl transferase

HBA1C:

Hemoglobin A1C

HDL-C:

High-density lipoprotein cholesterol

HOMA-IR:

Homeostatic model assessment of insulin resistance

LDL-C:

Low-density lipoprotein cholesterol

MAFLD:

Metabolic dysfunction-associated fatty liver disease

MetS:

Metabolic syndrome

NAFLD:

Nonalcoholic fatty liver disease

NHANES:

National Health and Nutrition Examination Survey

T2DM:

Type 2 diabetes mellitus

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Funding

The authors did not receive support from any organization for the submitted work.

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Author notes

  1. Allen D. Dao and Vy H. Nguyen have contributed equally.

Authors and Affiliations

  1. Division of Gastroenterology and Hepatology, Stanford University Medical Center, 780 Welch Road, CJ250K, Palo Alto, CA, 94304, USA

    Allen D. Dao, Vy H. Nguyen, Ramsey Cheung & Mindie H. Nguyen

  2. Santa Clara University, Santa Clara, CA, USA

    Allen D. Dao

  3. Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan

    Takanori Ito

  4. Division of Gastroenterology, Palo Alto VA, Palo Alto, CA, USA

    Ramsey Cheung

  5. Department of Epidemiology and Population Health, Stanford University Medical Center, Palo Alto, CA, USA

    Mindie H. Nguyen

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Contributions

Guarantor of the article: MHN. Specific author contributions: Study design: ADD, VHN, MHN. Data collection: ADD, VHN. Data analysis: ADD, VHN, MHN. Drafting of the article: ADD, VHN, MHN. Data interpretation, review and/or revision of the manuscript: All authors. Study concept and study supervision: MHN.

Corresponding author

Correspondence to Mindie H. Nguyen.

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Conflict of interest

Mindie H. Nguyen: Research support: Pfizer, Enanta, Gilead, Exact Sciences, Vir Biotech, Helio Health, National Cancer Institute, Glycotest, B. K. Kee Foundation; Consulting and/or Advisory Board: Intercept, Exact Science, Gilead, GSK, Eli Lilly, Laboratory of Advanced Medicine, Janssen. Ramsey Cheung: Research support: Gilead. Allen D. Dao, Vy H. Nguyen and Takanori Ito have no relevant financial or non-financial interests to disclose.

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Dao, A.D., Nguyen, V.H., Ito, T. et al. Prevalence, characteristics, and mortality outcomes of obese and nonobese MAFLD in the United States. Hepatol Int 17, 225–236 (2023). https://doi.org/10.1007/s12072-022-10436-2

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