Nonalcoholic fatty liver disease (NAFLD) is defined as excessive deposition of triglycerides in the hepatocytes, occurring in the absence of other conditions that may lead to hepaticsteatosis, such as alcoholic liver disease, viral hepatitis, auto-immune hepatitis and hemochromatosis [1–4]. Commonlyused diagnostic methods include abnormal alanine amino-transferase (ALT) levels, hepatic ultrasound and liver biopsy. Patients with NAFLD may develop nonalcoholic steatohepatitis-tis, a progressive inflammatory liver disease, which mayresult in cirrhosis [5] and increased risk of hepatocellular carcinoma [6–8].NAFLD is the most common chronic liver disease in theworld [1,9]. The prevalence varies due to different definitions of the disease and depending on the geographicalregion. A meta-analysis from 2016 estimated a pooled global prevalence of NAFLD of 25.2%, with an average prevalence in Europe of 23.7%, varying between 5% and 44%[10]. However, population-based prevalence data aresparse [11, 12].The association between NAFLD and the metabolic syndrome is well documented, and patients with NAFLD tend tohave certain elements of the metabolic syndrome such asobesity, hypertension, diabetes mellitus and dyslipidemias [2, 13, 14]. Given the rise of obesity across most western countries, the burden of NAFLD will most certainly increase in thenear future [11]. To estimate the prevalence, risk factors and clinical profile of NAFLD of nonalcoholic fatty liver disease (NAFLD) among type 2 diabetes mellitus (T2DM) patients at a tertiary care center in Madhubani Medical College of  Madhubani district of Bihar, India.

Risk Factors

Although the cause of nonalcoholic fatty liver disease is unclear, the condition is associated with many risk factors. The three most important ones are closely related to metabolic syndrome and insulin resistance:

Overweight and obesity - Your risk increases with every pound of excess weight. More than 70 percent of people with nonalcoholic steatohepatitis (NASH) are obese. Overweight is defined as having a body mass index between 25 and 29.9; obesity is defined as having a body mass index of 30 or higher.

Diabetes - When your body becomes resistant to the effects of insulin or your pancreas doesn't produce enough insulin to maintain a normal blood sugar (glucose) level, this can damage many organs in your body, including your liver. As many as three in four people with NASH also have diabetes.

Hyperlipidemia - High cholesterol levels and elevated triglycerides are common in people who develop NASH. It's estimated that up to 80 percent of people with NASH have hyperlipidemia.

Other Risk Factors Include

Abdominal surgery - Operations to remove large sections of the small intestine (small bowel resection), treat obesity (gastric bypass) or bypass parts of the small intestine often lead to rapid weight loss, which may increase your risk of nonalcoholic fatty liver disease.

Medications - These include oral corticosteroids (prednisone, hydrocortisone, others), synthetic estrogens for menopause, amiodarone for heart arrhythmias, tamoxifen for breast cancer and methotrexate, an immune-suppressing medication for rheumatoid arthritis.

AIMS AND OBJECTIVE:

To estimate the prevalence, risk factors and clinical profile of NAFLD of nonalcoholic fatty liver disease (NAFLD) among type 2 diabetes mellitus (T2DM) patients at a tertiary care center in Madhubani Medical College of Madhubani district of Bihar, India.

MATERIAL AND METHODS:

The study was done after approval from ethical committee of the institute. ALT and lipids were analyzed, anthropometric measures done, and comorbidity and risk factors reported. Elevated ALT was used to define NAFLD and participants with other diagnosed liver diseases and excessive alcohol consumption were excluded. Multivariable logistic regression reporting odds ratio (OR) and 95% confidence interval (CI) was used to assess risk factors.

Study Design:Cross-sectional study.

Study Period: The study was done for a period of one year from June 2023 toMay 2024 

Participants:  Already diagnosed type 2 diabetes mellitus (T2DM) patients coming to OPD in the department of Medicine.

Inclusion and Exclusion criteria:

Inclusion Criteria was age 18 to 65 years, BMI ≤23 and Ultrasound of hepatobiliary system showed fatty liver whereas exclusion criteria was Ultrasound of hepatobiliary system suggestive of chronic liver disease, BMI ≥23,

STATISTICAL ANALYSIS:

The prevalence of NAFLD was estimated by dividing the number of participants with ALT above the cutoff, excluding the participants with other possible causes of elevated ALT, with the total number of participants in HUNT3 with avail-able ALT measurements.The data were entered and analyzed using computer program SPSS-20.

RESULTS:

A total of 110 diabetic patients were studied. Out of these, 56 (56%) were female and 54 (54%) were male. Mean age of the patients was 47.62 ± 6.56 years. Fifty one (51%) of the diabetic patients were having fatty liver. Out of these 51 patients of fatty liver, 32 (62.74%) were female and 19 (37.25%) were male. Fatigue was seen in 44 (40.0%), generalized weakness in 16 (14.54%), heaviness right upper abdomen in 22 (20.0%) and pain right upper abdomen was seen in 28 (25.45%) of fatty liver patients while these were 41 (37.27%), 38 (34.54%), 17 (15.45%) and 13 (11.81%) in non-fatty liver patients respectively. Itching was noted in 21 (19.09%) patients of fatty liver while it was 24 (21.81%) in non-fatty liver patients. Serum triglyceride level more than 160 mg/dl in 47 (42.72%) patients of fatty liver while serum cholesterol level more than 200 mg/dl was seen in 24 (21.81%). Aspartate amino-transferase (AST) more than 35 u/l was noted in 16 (14.54%), alanine amino-transferase (ALT) more than 40 u/l was noted in 9 (8.18%) fatty liver patients while serum albumin and serum bilirubin were within normal range in all fatty liver and non-fatty liver patients.

DISCUSSION:

Non-alcoholic fatty liver disease (NAFLD) is a common liver disorder. It is mainly seen in obese and diabetic patients. Varying prevalence rates have been reported in various studies. A recent study from Japan in apparently healthy individuals has reported the prevalence of NAFLD as 29%.3 An Italian study reported it to be 20% [15]. The frequency of NAFLD reported in general population of USA is 20% [16]. A study from Karachi, Pakistan conducted by Luxmi et al,2 in 120 diabetic patients described the frequency of NAFLD as 60.8% and Akber et al from Saudi Arabia as 55%6 in type II diabetics and in India it is 49% among diabetics as reported by Gupta et al. [17]. In present study frequency of NAFLD is 51% which is close to the study by Gupta et al and Akber et al.pertinent to say that we have taken abdominal ultrasonography as a tool for detection of NAFLD which can only detect if the fat content of the liver is more than 33% and sensitivity of ultrasonography for detection of fatty liver is poor if the patient has fat content less than 33% of the liver weight. The frequency of NAFLD actually might have been high if we had done liver biopsy for the diagnosis of NAFLD. Various studies describe NAFLD as asymptomatic it may be true in initial phase of NAFLD but patients may present with fatigue and heaviness in right upper abdomen later on.

In present study fatigue was noted as chief complaint in 96 diabetics, out of these 44 (45.83%) were fatty liver patients. Generalized weakness was seen in 96, out of which 46 (47.91%) were of NAFLD. Here it is difficult to say whether these complaints were purely due to NAFLD or underlying diabetes mellitus as our study population was type II diabetic patients. Heaviness right upper abdomen 24 (21.81%) and pain right upper abdomen 22 (20.0%) was seen in fatty liver patients. A study by Wing-kin syn et al described fatigue as an important symptom and pain right upper abdomen in 33% of the patients [18]. Heaviness and pain in right upper abdomen is due to stretching of the liver capsule which is correlated with the amount of fat present in the liver [19,20]. Diabetes mellitus is an important risk factor for NAFLD. It is established that diabetes mellitus through insulin resistance leads to increased free fatty acid load to the liver consequently high triglyceride synthesis and increased secretion of triglyceride rich very low density lipoprotein by the liver. Hyper-triglyceridemia is strongly correlated with NAFLD and our study also supports this. Serum triglycerides were raised in 92.15% of fatty liver patients. Similarly serum cholesterol was raised in 47.05% of patients. The study by Luxmi et al. [21] also reported raised serum triglyceride level in patients with fatty liver and same is the result from our study. Serum alkaline phosphatase was raised in 15.68% of our study patients. Raised Alkaline phosphatase has been described in fatty liver patients especially in old females [22] AST and ALT were raised in our study in only 7 (13.72%) and 6 (11.76%) fatty liver patients respectively, however raised ALT and AST have been reported in significant number of fatty liver patients in other studies [23,24]. Raised ALT level is important finding in fatty liver patients1 while raised ALT was not seen in significant number of NAFLD patients in our study and these findings support the study by Luxmi et al. [21]. Normal ALT has also been reported in NAFLD by other studies [18].Mofrad [25] reported that histologic spectrum is not significantly different in patients with the raised or normal ALT and normal values did not confirm freedom from steato-hepatitis.

Nonalcoholic fatty liver disease (NAFLD) is more commonly seen in type II diabetic patients. Serum triglyceride and serum cholesterol are significantly raised in NAFLD patients. Raised ALT and AST is not a common finding in our NAFLD study patients. Diabetic patients having heaviness or pain right upper abdomen with raised serum triglycerides and cholesterol should be more closely observed for NAFLD and liver complications.

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