Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Indian Journal of Gastroenterology
Published in: Indian Journal of Gastroenterology 1/2020

01-02-2020 | Obesity | Review Article

Epidemiology of non-alcoholic fatty liver disease in Asia

Authors: Sui-Weng Wong, Wah-Kheong Chan

Published in: Indian Journal of Gastroenterology | Issue 1/2020

Login to get access

Abstract

The growing burden of non-alcoholic fatty liver disease (NAFLD) parallels the increasing prevalence of obesity in Asia. The overall prevalence of NAFLD in Asia is now estimated to be 29.6% and may have surpassed that in Western populations. NAFLD increases with increasing age and is closely associated with metabolic syndrome. Ethnic differences exist in the prevalence of NAFLD, but the underlying factors are unclear. There were initial concerns about lean NAFLD being associated with more severe liver disease and increased mortality, but subsequent studies suggested otherwise. Only some NAFLD patients progress to develop advanced liver fibrosis and cirrhosis, while the liver status remains unchanged in the majority; fibrosis stage is the most important predictor of disease-specific mortality in NAFLD. Surveillance for hepatocellular carcinoma (HCC) remains a challenge due to undiagnosed cirrhosis and the development of HCC in non-cirrhotic NAFLD patients. Diabetes mellitus shares a bidirectional relationship with NAFLD; NAFLD is highly prevalent among patients with diabetes mellitus, and diabetes mellitus is associated with more severe NAFLD. Chronic hepatitis B (CHB) is a major cause of chronic liver disease in Asia; NAFLD and CHB are increasingly observed together because of the increasing prevalence of NAFLD. Despite studies reporting favorable virologic outcome in CHB patients with NAFLD, NAFLD has been found to be independently associated with fibrosis progression and poorer prognosis in CHB patients. Therefore, NAFLD in CHB patients should be given more attention.
Appendix
Available only for authorised users
Literature
1.
Younossi ZM, Koenig AB, Abdelatif D, et al. Global epidemiology of nonalcoholic fatty liver disease-meta-analytic assessment of prevalence, incidence, and outcomes. Hepatology. 2016;64:73–84. 
2.
EASL-EASD-EASO Clinical Practice Guidelines for the management of non-alcoholic fatty liver disease. J Hepatol. 2016;64:1388–402.
3.
Younossi Z, Anstee QM, Marietti M, et al. Global burden of NAFLD and NASH: trends, predictions, risk factors and prevention. Nat Rev Gastroenterol Hepatol. 2018;1:11–20. 
4.
Wong SW, Ting YW, Chan WK. Epidemiology of non-alcoholic fatty liver disease-related hepatocellular carcinoma and its implications. JGH Open. 2018;2:235–41.
5.
Wong RJ, Cheung R, Ahmed A. Nonalcoholic steatohepatitis is the most rapidly growing indication for liver transplantation in patients with hepatocellular carcinoma in the U.S. Hepatology. 2014;59:2188–95. 
6.
Wah-Kheong C, Khean-Lee G. Epidemiology of a fast emerging disease in the Asia-Pacific region: non-alcoholic fatty liver disease. Hepatol Int. 2013;7:65–71.
7.
Li J, Zou B, Yeo YH, et al. Prevalence, incidence, and outcome of non-alcoholic fatty liver disease in Asia, 1999-2019: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol. 2019;4:389–98. 
8.
Li Z, Xue J, Chen P, et al. Prevalence of nonalcoholic fatty liver disease in mainland of China: a meta-analysis of published studies. J Gastroenterol Hepatol. 2014;29:42–51. 
9.
Kojima S, Watanabe N, Numata M, et al. Increase in the prevalence of fatty liver in Japan over the past 12 years: analysis of clinical background. J Gastroenterol. 2003;38:954–61. 
10.
Kanwal F, Kramer JR, Duan Z, et al. Trends in the burden of nonalcoholic fatty liver disease in a United States cohort of veterans. Clin Gastroenterol Hepatol. 2016;14:301–8.e82. 
11.
Bedogni G, Miglioli L, Masutti F, et al. Incidence and natural course of fatty liver in the general population: the Dionysos study. Hepatology. 2007;46:1387–91.
12.
Al-Dayyat HM, Rayyan YM, Tayyem RF. Non-alcoholic fatty liver disease and associated dietary and lifestyle risk factors. Diabetes Metab Syndr. 2018;12:569–75.
13.
14.
Asrani SK, Devarbhavi H, Eaton J, Kamath PS. Burden of liver diseases in the world. J Hepatol. 2019;70:151–71. 
15.
WHO Expert Consultation. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. Lancet. 2004;363:157–63.
16.
Yoon KH, Lee JH, Kim JW, et al. Epidemic obesity and type 2 diabetes in Asia. Lancet. 2006;368:1681–8.
17.
Anuurad E, Shiwaku K, Nogi A, et al. The new BMI criteria for asians by the regional office for the western pacific region of WHO are suitable for screening of overweight to prevent metabolic syndrome in elder Japanese workers. J Occup Health. 2003;45:335–43. 
18.
Wong VW, Chu WC, Wong GL, et al. Prevalence of non-alcoholic fatty liver disease and advanced fibrosis in Hong Kong Chinese: a population study using proton-magnetic resonance spectroscopy and transient elastography. Gut. 2012;61:409–15.
19.
Wong VW, Wong GL, Yeung DK, et al. Incidence of non-alcoholic fatty liver disease in Hong Kong: a population study with paired proton-magnetic resonance spectroscopy. J Hepatol. 2015;62:182–9. 
20.
Amarapurkar D, Kamani P, Patel N, et al. Prevalence of non-alcoholic fatty liver disease: population based study. Ann Hepatol. 2007;6:161–3.
21.
Singh SP, Nayak S, Swain M, et al. Prevalence of nonalcoholic fatty liver disease in coastal eastern India: a preliminary ultrasonographic survey. Trop Gastroenterol. 2004;25:76–9.
22.
Mohan V, Farooq S, Deepa M, et al. Prevalence of non-alcoholic fatty liver disease in urban south Indians in relation to different grades of glucose intolerance and metabolic syndrome. Diabetes Res Clin Pract. 2009;84:84–91.
23.
Das K, Das K, Mukherjee PS, et al. Nonobese population in a developing country has a high prevalence of nonalcoholic fatty liver and significant liver disease. Hepatology. 2010;51:1593–602. 
24.
Z-w C, L-y C, H-l D, et al. Relationship between alanine aminotransferase levels and metabolic syndrome in nonalcoholic fatty liver disease. J Zhejiang Univ Sci B. 2008;9:616–22. 
25.
Li H, Wang YJ, Tan K, et al. Prevalence and risk factors of fatty liver disease in Chengdu, Southwest China. Hepatobiliary Pancreat Dis Int. 2009;8:377–82.
26.
Hou XH, Zhu YX, Lu HJ, et al. Non-alcoholic fatty liver disease’s prevalence and impact on alanine aminotransferase associated with metabolic syndrome in the Chinese. J Gastroenterol Hepatol. 2011;2:722–30. 
27.
Gao AB, Xiao Q, Li LY, et al. Epidemiological survey of the association between non alcoholic fatty liver disease and metabolic syndrome in civil servants of Chongqing city. Zhonghua Yu Fang Yi Xue Za Zhi. 2008;42:107–10.
28.
Browning JD, Kumar KS, Saboorian MH, Thiele DL. Ethnic differences in the prevalence of cryptogenic cirrhosis. Am J Gastroenterol. 2004;99:292–8.
29.
Romeo S, Kozlitina J, Xing C, et al. Genetic variation in PNPLA3 confers susceptibility to nonalcoholic fatty liver disease. Nat Genet. 2008;40:1461–5.
30.
Goh SC, Ho EL, Goh KL. Prevalence and risk factors of non-alcoholic fatty liver disease in a multiracial suburban Asian population in Malaysia. Hepatol Int. 2013;7:548–54. 
31.
Chan WK, Tan AT, Vethakkan SR, et al. Non-alcoholic fatty liver disease in diabetics--prevalence and predictive factors in a multiracial hospital clinic population in Malaysia. J Gastroenterol Hepatol. 2013;28:1375–83.
32.
Chan WK, Bahar N, Razlan H, et al. Non-alcoholic fatty liver disease in a young multiracial Asian population: a worrying ethnic predilection in Malay and Indian males. Hepatol Int. 2014;8:121–7. 
33.
Zain SM, Mohamed R, Mahadeva S, et al. A multi-ethnic study of a PNPLA3 gene variant and its association with disease severity in non-alcoholic fatty liver disease. Hum Genet. 2012;131:1145–52. 
34.
Ding C, Chan Z, Magkos F. Lean, but not healthy: the ‘metabolically obese, normal-weight’ phenotype. Curr Opin Clin Nutr Metab Care. 2016;19:408–17.
35.
Feldman A, Eder SK, Felder TK, et al. Clinical and metabolic characterization of lean Caucasian subjects with non-alcoholic fatty liver. Am J Gastroenterol. 2017;112:102–10. 
36.
37.
Enjoji M, Yasutake K, Kohjima M, Nakamuta M. Nutrition and nonalcoholic fatty liver disease: the significance of cholesterol. Int J Hepatol. 2012;2012:925807.
38.
Yasutake K, Nakamuta M, Shima Y, et al. Nutritional investigation of non-obese patients with non-alcoholic fatty liver disease: the significance of dietary cholesterol. Scand J Gastroenterol. 2009;44:471–7. 
39.
Musso G, Gambino R, De Michieli F, et al. Dietary habits and their relations to insulin resistance and postprandial lipemia in nonalcoholic steatohepatitis. Hepatology. 2003;37:909–16. 
40.
41.
Wei JL, Leung JC, Loong TC, et al. Prevalence and severity of nonalcoholic fatty liver disease in non-obese patients: a population study using proton-magnetic resonance spectroscopy. Am J Gastroenterol. 2015;110:1306–14; quiz 15.
42.
Cruz ACD, Bugianesi E, George J, et al. 379 characteristics and long-term prognosis of lean patients with nonalcoholic fatty liver disease. Gastroenterology. 2014;146:S-909. 
43.
Leung JC, Loong TC, Wei JL, et al. Histological severity and clinical outcomes of nonalcoholic fatty liver disease in nonobese patients. Hepatology. 2017;65:54–64.
44.
Golabi P, Paik J, Fukui N, et al. Patients with lean nonalcoholic fatty liver disease are metabolically abnormal and have a higher risk for mortality. Clin Diabetes. 2018:cd180026.
45.
Chan WK, Ida NH, Cheah PL, Goh KL. Progression of liver disease in non-alcoholic fatty liver disease: a prospective clinicopathological follow-up study. J Dig Dis. 2014;15:545–52.
46.
Wong VW, Wong GL, Choi PC, et al. Disease progression of non-alcoholic fatty liver disease: a prospective study with paired liver biopsies at 3 years. Gut. 2010;59:969–74. 
47.
Fazel Y, Koenig AB, Sayiner M, et al. Epidemiology and natural history of non-alcoholic fatty liver disease. Metabolism. 2016;65:1017–25.
48.
Singh S, Allen AM, Wang Z, et al. Fibrosis progression in nonalcoholic fatty liver vs nonalcoholic steatohepatitis: a systematic review and meta-analysis of paired-biopsy studies. Clin Gastroenterol Hepatol. 2015;13:643–54.e1–9; quiz e39–40.
49.
Angulo P, Kleiner DE, Dam-Larsen S, et al. Liver fibrosis, but no other histologic features, is associated with long-term outcomes of patients with nonalcoholic fatty liver disease. Gastroenterology. 2015;149:389–97.e10.
50.
Ekstedt M, Hagstrom H, Nasr P, et al. Fibrosis stage is the strongest predictor for disease-specific mortality in NAFLD after up to 33 years of follow-up. Hepatology. 2015;61:1547–54. 
51.
Yasui K, Hashimoto E, Komorizono Y, et al. Characteristics of patients with nonalcoholic steatohepatitis who develop hepatocellular carcinoma. Clin Gastroenterol Hepatol. 2011;9:428–33; quiz e50.
52.
Fan JG, Kim SU, Wong VW. New trends on obesity and NAFLD in Asia. J Hepatol. 2017;67:862–73.
53.
Chan WK, Treeprasertsuk S, Goh GB, et al. Optimizing use of nonalcoholic fatty liver disease fibrosis score, fibrosis-4 score, and liver stiffness measurement to identify patients with advanced fibrosis. Clin Gastroenterol Hepatol. 2019;17:2570–80.e37.
54.
Castera L, Friedrich-Rust M, Loomba R. Noninvasive assessment of liver disease in patients with nonalcoholic fatty liver disease. Gastroenterology. 2019;156:1264–81.e4. 
55.
56.
Birkenfeld AL, Shulman GI. Nonalcoholic fatty liver disease, hepatic insulin resistance, and type 2 diabetes. Hepatology. 2014;59:713–23.
57.
Lonardo A, Ballestri S, Guaraldi G, et al. Fatty liver is associated with an increased risk of diabetes and cardiovascular disease - evidence from three different disease models: NAFLD, HCV and HIV. World J Gastroenterol. 2016;22:9674–93.
58.
Fukuda T, Hamaguchi M, Kojima T, et al. The impact of non-alcoholic fatty liver disease on incident type 2 diabetes mellitus in non-overweight individuals. Liver Int. 2016;36:275–83. 
59.
Li Y, Wang J, Tang Y, et al. Bidirectional association between nonalcoholic fatty liver disease and type 2 diabetes in Chinese population: evidence from the Dongfeng-Tongji cohort study. PLoS One. 2017;12:e0174291.
60.
Ogurtsova K, da Rocha Fernandes JD, Huang Y, et al. IDF diabetes atlas: global estimates for the prevalence of diabetes for 2015 and 2040. Diabetes Res Clin Pract. 2017;128:40–50. 
61.
Chan WK, Treeprasertsuk S, Imajo K, et al. Clinical features and treatment of nonalcoholic fatty liver disease across the Asia Pacific region-the GO ASIA initiative. Aliment Pharmacol Ther. 2018;47:816–25. 
62.
Vilar-Gomez E, Martinez-Perez Y, Calzadilla-Bertot L, et al. Weight loss through lifestyle modification significantly reduces features of nonalcoholic steatohepatitis. Gastroenterology. 2015;149:367–78.e5; quiz e14–5.
63.
Tuomilehto J, Lindstrom J, Eriksson JG, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med. 2001;344:1343–50. 
64.
Gillies CL, Abrams KR, Lambert PC, et al. Pharmacological and lifestyle interventions to prevent or delay type 2 diabetes in people with impaired glucose tolerance: systematic review and meta-analysis. BMJ. 2007;334:299.
65.
Younossi ZM, Golabi P, de Avila L, et al. The global epidemiology of NAFLD and NASH in patients with type 2 diabetes: a systematic review and meta-analysis. J Hepatol. 2019;71:793–801. 
66.
Lai LL, Wan Yusoff WNI, Vethakkan SR, et al. Screening for non-alcoholic fatty liver disease in patients with type 2 diabetes mellitus using transient elastography. J Gastroenterol Hepatol. 2019;34:1396–403. 
67.
Kwok R, Choi KC, Wong GL, et al. Screening diabetic patients for non-alcoholic fatty liver disease with controlled attenuation parameter and liver stiffness measurements: a prospective cohort study. Gut. 2016;65:1359–68. 
68.
Kalra S, Vithalani M, Gulati G, et al. Study of prevalence of nonalcoholic fatty liver disease (NAFLD) in type 2 diabetes patients in India (SPRINT). J Assoc Physicians India. 2013;61:448–53.
69.
Guo K, Zhang L, Lu J, et al. Non-alcoholic fatty liver disease is associated with late but not early atherosclerotic lesions in Chinese inpatients with type 2 diabetes. J Diabetes Complicat. 2017;31:80–5.
70.
Lv W-S, Sun R-X, Gao Y-Y, et al. Nonalcoholic fatty liver disease and microvascular complications in type 2 diabetes. World J Gastroenterol. 2013;19:3134–42.
71.
Wong VW, Chan WK, Chitturi S, et al. Asia-Pacific Working Party on Non-alcoholic Fatty Liver Disease guidelines 2017-part 1: definition, risk factors and assessment. J Gastroenterol Hepatol. 2018;33:70–85. 
72.
Global health sector strategy on viral hepatitis 2016-2021. World Health Organization, Geneva. 2016. Accessed 8 October 2019.
73.
Machado MV, Oliveira AG, Cortez-Pinto H. Hepatic steatosis in hepatitis B virus infected patients: meta-analysis of risk factors and comparison with hepatitis C infected patients. J Gastroenterol Hepatol. 2011;26:1361–7.
74.
Wong VW, Wong GL, Chu WC, et al. Hepatitis B virus infection and fatty liver in the general population. J Hepatol. 2012;56:533–40.
75.
Luo B, Wang Y, Wang K. Association of metabolic syndrome and hepatitis B infection in a Chinese population. Clin Chim Acta. 2007;380:238–40.
76.
Jan CF, Chen CJ, Chiu YH, et al. A population-based study investigating the association between metabolic syndrome and hepatitis B/C infection (Keelung Community-based Integrated Screening study No. 10). Int J Obes (Lond). 2006;30:794–9.
77.
Zhong GC, Wu YL, Hao FB, et al. Current but not past hepatitis B virus infection is associated with a decreased risk of nonalcoholic fatty liver disease in the Chinese population: a case-control study with propensity score analysis. J Viral Hepat. 2018;25:842–52. 
78.
Liu PT, Hwang AC, Chen JD. Combined effects of hepatitis B virus infection and elevated alanine aminotransferase levels on dyslipidemia. Metabolism. 2013;62:220–5.
79.
Kang SK, Chung TW, Lee JY, et al. The hepatitis B virus X protein inhibits secretion of apolipoprotein B by enhancing the expression of N-acetylglucosaminyltransferase III. J Biol Chem. 2004;279:28106–12.
80.
Yang MH, Sung J, Gwak GY. The associations between apolipoprotein B, A1, and the B/A1 ratio and nonalcoholic fatty liver disease in both normal-weight and overweight Korean population. J Clin Lipidol. 2016;10:289–98.
81.
Wang MM, Wang GS, Shen F, et al. Hepatic steatosis is highly prevalent in hepatitis B patients and negatively associated with virological factors. Dig Dis Sci. 2014;59:2571–9.
82.
Hui RWH, Seto WK, Cheung KS, et al. Inverse relationship between hepatic steatosis and hepatitis B viremia: results of a large case-control study. J Viral Hepat. 2018;25:97–104.
83.
Seto WK, Hui RWH, Mak LY, et al. Association between hepatic steatosis, measured by controlled attenuation parameter, and fibrosis burden in chronic hepatitis B. Clin Gastroenterol Hepatol. 2018;16:575–83.e2.
84.
85.
Chan AW, Wong GL, Chan HY, et al. Concurrent fatty liver increases risk of hepatocellular carcinoma among patients with chronic hepatitis B. J Gastroenterol Hepatol. 2017;32:667–76.
86.
Gao C, Fang L, Zhao HC, et al. Potential role of diabetes mellitus in the progression of cirrhosis to hepatocellular carcinoma: a cross-sectional case-control study from Chinese patients with HBV infection. Hepatobiliary Pancreat Dis Int. 2013;12:385–93.
87.
Huang YW, Wang TC, Lin SC, et al. Increased risk of cirrhosis and its decompensation in chronic hepatitis B patients with newly diagnosed diabetes: a nationwide cohort study. Clin Infect Dis. 2013;57:1695–702.
88.
Peleg N, Issachar A, Sneh Arbib O, et al. Liver steatosis is a strong predictor of mortality and cancer in chronic hepatitis B regardless of viral load. JHEP Rep. 2019;1:9–16. 
Metadata
Title
Epidemiology of non-alcoholic fatty liver disease in Asia
Authors
Sui-Weng Wong
Wah-Kheong Chan
Publication date
01-02-2020
Publisher
Springer India
Published in
Indian Journal of Gastroenterology / Issue 1/2020
Print ISSN: 0254-8860
Electronic ISSN: 0975-0711
DOI
https://doi.org/10.1007/s12664-020-01018-x

Other articles of this Issue 1/2020

Indian Journal of Gastroenterology 1/2020 Go to the issue

Case Series

Acute exacerbated severe form of nonalcoholic steatohepatitis leading to acute-on-chronic liver failure: A case series

Review Article

Gut microbiota abnormalities, small intestinal bacterial overgrowth, and non-alcoholic fatty liver disease: An emerging paradigm

Original Article

Metabolic syndrome is not uncommon among lean non-alcoholic fatty liver disease patients as compared with those with obesity

Original Article

Natural history, risk factors, and outcome of hepatopulmonary syndrome in pediatric liver diseases

Post-graduate Corner: Research Techniques

Lowering the threshold of statistical significance in gastroenterology trials

Original Article

Body mass index–based controlled attenuation parameter cut-offs for assessment of hepatic steatosis in non-alcoholic fatty liver disease

ACC 2024 Congress Coverage

Heart Failure Video

Year in Review: Heart failure and cardiomyopathies

Watch now

Watch this official video from ACC.24. Dr. Biykem Bozkurt discuss last year's major advances in heart failure and cardiomyopathies.

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

16-04-2024 Type 2 Diabetes News

Incentivised to exercise

11-04-2024 Lifestyle Modifications News

New intervention for STEMI-related cardiogenic shock

10-04-2024 Myocardial Infarction News

» View more highlights on the ACC 2024 congress hub page

Image Credits