1) This study analyzed electronic medical records of over 171,000 patients with diabetes across India to assess the prevalence of nonalcoholic fatty liver disease (NAFLD). 2) The overall prevalence of NAFLD among patients with diabetes was found to be 44.48%, with higher rates in males compared to females. 3) Certain states had prevalence rates over 50%, with the highest in Telangana (54.54%) and Chhattisgarh (53.76%). Younger patients, those who were obese, had dyslipidemia, or poor glycemic control had significantly higher odds of NAFLD.

1. ASSESSMENT OF PREVALENCE AND ASSOCIATED
RISK FACTORS OF NAFLD IN PEOPLE LIVING WITH
DIABETES IN INDIA: A RETROSPECTIVE,
MULTICENTER, ELECTRONIC MEDICAL RECORDS
BASED STUDY
PRESENTER: DR. ANUPAM ANAND
MODERATOR: DR. DEEPIKA SAINI

2. INTRODUCTION
- Nonalcoholic fatty liver disease has become the leading cause of liver disease worldwide.1 It is a
common hepatic disorder characterized by more than 5% of the accumulation of fat in the liver and
refers to a spectrum of diseases ranging from pure steatosis to nonalcoholic steatohepatitis (NASH) and
cirrhosis, in the absence of excessive or moderate alcohol consumption.
- Nonalcoholic fatty liver disease in T2DM is a risk factor for the development of cardiovascular disease
and other vascular complications, irrespective of other known risk factors.12,13 In addition to the
presence of diabetes, age (>45 years), obesity [body mass index (BMI) >30 kg/m2 ], insulin resistance,
elevated levels of ferritin, and hypertension are other clinical risk factors that contribute to higher risk of
NAFLD progression.10,14 There is a strong relationship between metabolic syndrome components and
NAFLD prevalence.

3. The prevalence of NAFLD in India was found to be 44–72% in T2DM.The SPRINT
report in 2014, one of the large-scale multicentric surveys from 101 cities across India
concluded the overall prevalence of NAFLD to be 56.5% among 924 type 2 diabetes
patients aged between 25 and 84 years.
The prevalence was lowest in western India (44.1%) as compared to the northern states
of India (72.4%).6,10 A study by Gupta et al. in 2017 reported the prevalence of NAFLD
to be 69.3% in the patients with T2DM and the severity of NAFLD increased with
increasing age.
It is important to understand the prevalence of NAFLD along with the associated risk
factors in patients living with diabetes in Indian context. This study aims to understand
NAFLD prevalence patterns among T2DM patients across age, gender, states, and
comorbidities, and to assess high risk categories for NAFLD in Indian patients living with
diabetes based on EMRs.

4. Material and Methods
- Study Settings
- It is a retrospective, observational study based on data retrieved from
EMRs of patients living with diabetes from over 250+ individual
diabetes centers located in 30+ cities across 14 states in India.
Medical records of 171,996 adult patients living with diabetes (age>18
years) were included in the analysis. Only first visit details were
included from multiple visits to maintain uniformity across the analysis.

5. Inclusion Criteria
Adult patients (age>18 years) with diabetes mellitus (DM) as per the EMR records,
availability of at least one liver function test (LFT) report in medical records of patients
were included and in case more than one data points were present for a subject, the first
recorded LFT and concomitant lab parameters were used for the analysis.
Based on LFT algorithm (mentioned below), patients living with diabetes were
categorized as with or without NAFLD.
The algorithm used for identifying NAFLD patients with diabetes is given below: Serum
glutamate pyruvate transferase (SGPT) or ALT levels between 25 and 150 IU/L, and
Serum glutamic oxaloacetic transaminase (SGOT):SGPT (AST:ALT) ratio of less than 1.

6. Nonalcoholic fatty liver disease prevalence rates across the following categories were
assessed.
Age categories: 18– 40, 40 – 60, and >60 years.
Body mass index categories: <23, 23–25 (overweight), and >25 kg/m2 (obese).
Hypertension—systolic blood pressure >140 mm Hg and/or diastolic blood pressure
>90mmHg.
Dyslipidemia—TG >150 and/or low-density lipoprotein (LDL) >130 and/or total
cholesterol (TC) >200 and/or high-density lipoprotein (HDL) <40 mg/dL.
If any of the criteria is positive (LDL or HDL or TC or TG).
Hypertriglyceridemia >200 mg/dL.
Duration of diabetes—less than 4 years, 4–<8 years, 8–<14 years, and 14 years and

7. Results
- Electronic medical records of 171,996 patients living with diabetes with average age of 53.18 years (SD:
12.51) were taken for the analysis. Baseline clinical and diagnostic parameters were compared .
- Overall, 44.48% of the patients living with diabetes were found to have NAFLD. A significantly higher
proportion of males (58.64%) in the study had NAFLD compared to females (36.91%) (p<0.001) (Fig. 1).
As shown in Table 2, NAFLD prevalence was >50% in seven of the states.
- The highest prevalence was seen in Telangana (54.54%) and Chhattisgarh (53.76%). Haryana (58.14%)
had the highest prevalence although, the sample size for this was very small .
- Patients living with diabetes with NAFLD had a significantly higher BMI (27.54 vs 27.13, p<0.001) though
duration of diabetes (7.98 vs 10.10, p<0.001) was significantly lower in these patients in comparison to
patients living with diabetes without NAFLD.
- These patients also had significantly higher levels of mean serum TGs (169.38 vs 144.09, p<0.001), LDL
(108.66 vs 104.33, p< 0.001), and TC (176.73 vs 170.47, p<0.001) and significantly lower mean levels of
HDL (40.37 vs 42.93, p<0.001).

8. The prevalence of NAFLD was significantly high in obese patients with dyslipidemia and hypertriglyceridemia.
A higher prevalence of NAFLD was seen in the younger patients living with diabetes (18–40 years) in comparison to
older adults (40–60 years) and elderly (>60 years) (58.35 vs 54.92% and 39.62%, p<0.001).
Patients living with diabetes with both dyslipidemia and hypertension had a significantly higher prevalence of NAFLD
(p<0.001) in comparison to those without. Similarly, patients living with diabetes with poor control had a significantly
higher prevalence of NAFLD compared to patients with good control (54.26 vs 49.54%, p<0.001).
A comparison of prevalence of NALFD among patients living with diabetes based on duration of diabetes showed that
those with shorter duration of diabetes had a significantly higher prevalence compared to those with longer diabetes
duration (60.52 vs 42.75%, p<0.001) of having NAFLD.
Hypertension was not found to be significantly associated with NAFLD
Obese and overweight individuals had significantly (57.1 and 33.5%) higher odds of having NAFLD among patients
living with diabetes.
Presence of dyslipidemia (59.1%) and hypertriglyceridemia (42.3%) among patients living with diabetes also had
significantly higher odds of NAFLD.
Among other major factors that had significantly higher odds of being associated with NAFLD were male gender,
young age, poor glycemic control, and shorter duration of diabetes

17. Conclusion
The current study is one of the biggest real world evidence studies,
based on EMR data of diabetes patients in India. An assessment of
NAFLD using LFT-based screening was done. The study
comprehensively evaluates various epidemiological characteristics of
the NAFLD in diabetes patients in India which have hitherto, not been
done so extensively. This study highlighted high-risk categories of
diabetes patients for NAFLD, such as young, obese, with
hypertriglyceridemia, poor glycemic control, etc. This information will
help health care providers in prioritizing screening among high-risk
diabetes populations.