This study examined the relationship between subclinical hypothyroidism and non-alcoholic fatty liver disease among 190 working women in Kolkata over one year. In the first six months with levothyroxine therapy, most women had mild hypothyroidism and pre-obesity, and over half had mild NAFLD risk. In the second six months without medication and following a hypothyroid diet, most women had subclinical hypothyroidism, were pre-obese, and all had low or no NAFLD risk, showing an association between improved thyroid function and liver health through dietary changes alone.

1. 2nd National Conference of Indian Society of Clinical Nutrition (INSCN)
Nutritional Management of Gastroenterology, Surgical & Critically-ill patients: Consensus and Controversies
JOINTLY ORGANIZED BY
Indian Society of Clinical Nutrition, Departments of Gastroenterology & HNU and Surgical Disciplines,
AIIMS Gastroenterology Research and Education Society, AIIMS.
A STUDY ON RELATIONSHIP BETWEEN SUBCLINICAL HYPOTHYROIDISM & NON-
ALCOHOLIC FATTY LIVER DISEASE AMONG WORKING WOMEN IN KOLKATA.
Presented By : Swapan Banerjee
Research Scholar, Department of Nutrition, Seacom Skills University ,Kolkata
[ Certified by – FSSAI , DGET , IRCA ]
Email – sbanerjee90@gmail.com
Date of Presentation : 31-08-2018

2. INTRODUCTION - HYPOTHYROIDISM & NAFLD
• In a clinical aspect, subclinical hypothyroidism (SCH) has been associated with
metabolic syndrome, disorders of cardiovascular & lipid metabolism.
• Hypothyroidism is anticipated as an independent risk factor for developing
NAFLD/NASH and that due to lower free T4 (FT4) & increased serum levels of
thyroid stimulating hormone (TSH).
• Liver biopsy and the NAFLD activity score to distinguish NASH from NAFLD
specifies the seriousness of NAFLD and hypothyroidism. [Pagadala et al , 2012]
• The other theory is based on hepatic damage through mitochondrial dysfunction,
oxidative stress, and reactive oxygen species (ROS) production. [Mazo et al . 2011]

3. HEALTHY LIVER INFLAMMATION NAFLD CIRRHOSIS

4. NAFLD – ONE OF THE CAUSE OF HYPOTHYROIDISM (VICE VERSA)
• A
Source : JJCDC: April 01, 2015

5. TSH IN HYPOTHYRODISM STATE
Source : Martin I. Surks, and Joseph G. Hollowell J Clin Endocrinol Metab

6. PREVALENCE OF HYPOTHYROIDISM
60% Hypothyroidism = 40% Subclinical Hypothyroidism & 20% Mild To Overt Hypothyroidism (out of total study population)
Source : Stanley Medical Journal, Vol 4 | Issue 2 | April-June | 2017

7. RESEARCH GAP & SCOPE
In this study context, there are lack of sufficient data or scanty research found so far .
So these two variables are taken synergistically in this study because these two health issues
are very common & expected to be closely related at urban areas mostly among women.
So finding the research gap & seeing the wide scope for research on
relationship & recovery.

8. RESEARCH PROBLEM
Working women in India are mostly leading sedentary lifestyles & consuming more junk foods
but no such exercises to balance the excess body fat. These altogether result in obesity which is
further the reasons for non-communicable diseases like DM, HTN,CVD, CKD,CLD &
endocrinological disorders including hypothyroidism or SCH.
Although some other major reasons for hypothyroidism or SCH are Iodine imbalance & genetic
or congenital (autoimmune disorder).
So, obese women due to improper eating habits & lack of sufficient physical activities or may be
infections/inflammation etc , The liver is affected & ultimately healthy liver develop NAFLD
which is concerned here.
Hence, this study is mainly designed to understand the relationship or a link between these
two health issues commonly seen nowadays almost at every family among the working women
living in Kolkata at the age group 30-40 years.

9. CAUSES - HYPOTHYROIDISM & SUBCLINICAL HYPOTHYROIDISM (SCH)
Iodine deficiency
Chronic Illness
Gluten rich foods
Autoimmune disease
Some medications
Radiation therapy
Thyroid gland surgery
Pituitary gland disorder
Overwork and under sleep
Poor conversion of T4 to T3
Stress & psychological disorders
During Pregnancy or postpartum

10. OBJECTIVE - OF THIS STUDY
• To determine whether a relationship exists between Subclinical
Hypothyroidism & NAFLD among the obese working women leading
unhealthy eating habits.
• Assessments of other relationships among BMI, TSH with hypothyroidism
& NAFLD Score (N.F.S)
• To find out the impact of the tentative hypothyroidism diet plan.

11. METHODOLOGY
Selection of Subjects :
• Total 190 obese, nondiabetic, non-alcoholic women had a history of SCH & mild
to moderate hypothyroidism within the age group 30-40 years located in Kolkata
were enrolled for this study for six months with Thyroxin tablet (Levothyroxine
therapy) & next six months without this. The study was performed on those
subjects who visited diet chamber or diet camps with the complaints of
overweight, hypothyroidism & fatty liver.
Study Design :
• A qualitative study by purposive sampling method was used for the one year
divided into two stages 1st six months & 2nd six months.

12. TOOLS & TECHNIQUES USED
Data collected through the questionnaires based on : (Primary Data)
Socio-demographic data
Food-frequency
Cooking & eating habits
Anthropometric measurements
Laboratories tests reports were incorporated : ( secondary data )
TSH, T4 ,T3
Routine USG test for liver ( Interval of 3-6 months)
AST (SGOT) - aspartate transaminase
ALT (SGPT) -alanine amino transaminase
ALP - Alkaline phosphatase
LDH - lactate dehydrogenase. (As per data availability)
Bilirubin Level . (As per data availability)

13. OTHER FACTORS
Based on all kind of reports, some factors also considered :
Infection (if any) past or present (like Hepatitis A,B,C,E) – 2 patients
Radiation (If any case) - Nil
Foods habits – Gluten rich diet through wheat products – 38 patients
Family history (Genetically) – 63 patients
Congenital (If any case) - Nil
Due to other medications – 2-5 cases (not specific to say)
Stress ,workload, other psychological issues. – expected more than 25 patients
The common reason is overweight or obesity for every subject, so majority due to for that.
 Note : women who were pregnant not included in this study
 Note : patients or cases were taken here only for record.

14. DIETARY INTERVENTION
A tentative diet plan was designed & applied on average basis to all subjects named as hypothyroid diet plan : (variable some parts person to person )
Tentative Hypothyroidism Diet Plan (Standard/Average)
Weekly & rotational plan : 1-2 days veg menu, rest all days non-veg (Bengali cuisine)
Age – 34 year, Female, Height – 153 cm. & Weight – 68 Kg., BMI – 29.06 (Asian Value)
Diagnosis – NAFLD, Overweight/Obese, Hypothyroidism
(Based on Lab. Reports –LFT, USG, Lipid Profile, TSH, T4 , T3 etc...)
Foods Habits - non vegetarian, Lifestyles - Sedentary
Medication by physician – 50mcg Eltroxin, Pan-D, Duphalac,
Advice – Gluten free hypothyroidism diet plan with low carbs, low fat
Under Observation for 30 days. Monitor weight on every 10day.
Daily Calorie Requirement – 1400kcal/day by foods
Some moderate daily exercises to come down weight by safe method & retain for future.
1. Carbohydrate – 1400kcal x 55% = 770 kcal/4 = 193- 200gm (uncooked measured)
2. Protein - 1400kcal x 25% OR Per Kg Body Weight (max.)= 350 kcal/4 = 88-90gm (Do)
3 .Fat -15% - 1400kcal X 15% = 210kcal /9 = 23-25ml< (only cooking oil 2tsf) –Do-
No Butter, Ghee all high fats etc. as these all are highly restricted for you.)
TENTATIVE DIET PLAN (based on uncooked foods)
6 am – 300ml water with Thyroxine Tablet (As per Physician’s advice)
6.15 am - Some drinking water added with 10gm fenugreek seeds (soaked)
30 Min- Some exercises /walking / yoga at open air/ pollution free zone.
7am – 2 cream cracker biscuits with black tea (avoid green tea)
8am – Breakfast – 50 gm Oats meal / Dalia/ 2 Phulkas (roti) with low oil ,no spicy mix vegetables
should be rich with spinach, lettuce + 1 pinch of iodised salt.
9/10am – Reached at Office/ desk job up to 8 hours or more.
10 am – Drinking water, 1 biscuit, 1 cup green tea
11 am – Fruits (200gm) -1 guava/ berries/pear, apple (except high calorie /high G.I index), 2 almond
or cashew or Brazil nuts can be helpful.
Continued to 2nd
page ….

15. DIETARY INTERVENTION
Continued …..
12-1 pm –Lunch (Office /home) – 50 gm brown rice/ 2-3 Phulka roti + 100gm mix veg (less oil
& spices –only homemade), 1pc 50gm fish (preferably sea foods) or 50gm plain paneer , can
add green salad & curd/yoghurt 50gm. Sometime 1 white poultry egg or 100gm chicken leg pc
. (Avoid red meat/much animal/organic foods). Add 2 gm or 1 pinch of iodised salt.
3/4 pm - Tea break/ light snacks at office.
5pm /6pm –evening – Any light calorie meal – Like 30gm Oat/ Poha/ 2 pcs Idly/ veg.
sandwich, puffed rice or rice flakes with salad
8.30pm ( back to home from office)- some water, tea & cream cracker biscuit
9.30 pm – 30gm rice(very less) + 1-2 phulka roti (20gm) , 20gm dal, 1 serving mix veg added
with pumpkin seeds ,curd 50gm can add. OR almost same low calorie diet. (Use some/
negligible iodised salt/ sea foods)
10.30pm – sleep
Foods should avoid [ Goitrins , Thiocyanates, Flavonoids ]
Cruciferous Vegetables - Broccoli, Brussels sprouts, Cabbage, Cauliflower, Kale,
Mustard greens, Rapeseed, Rutabagas, Spinach , Turnips, Sweet potatoes.
Starchy Plants - Cassava, Corn , Lima beans , Linseed, Millet.
Fruits – Peaches, Peanuts, Pears, Pine nuts, Straw berries, Sweet potatoes.
Soy Based Foods - Tofu, Tempeh, Soy milk.
Sources : 1) The Autoimmune Solution: Prevent and Reverse the Full Spectrum of Inflammatory Symptoms
and Diseases Paperback – May 2, 2017, by Amy Myers M.D. (Author)
2) The Thyroid Connection: Why You Feel Tired, Brain-Fogged, and Overweight -- and How to Get Your Life
Back Hardcover – September 27, 2016 by Amy Myers MD (Author)

16. RESULTS - BY DATA ANALYSIS
SPSS-version -22 was used as a statistical tool for data analysis & findings.
1ST Six Month

17. DATA ANALYSIS - 1
Table : 1
Descriptive Statistics (All variables)
N Minimum Maximum Mean
Std.
Deviation
Participants 190 1 118 50.78 31.845
Age 190 30 40 34.96 2.941
Height 190 147 171 156.02 5.897
Weight 190 56 93 70.73 9.601
BMI 190 24 37 28.77 3.625
Weight Status 190 11 13 12.31 .548
TSH 190 4 15 6.98 2.467
FT4 190 1 2 1.49 .330
Hypothyroid Type 190 4 6 4.77 .674
N.F.S 190 1 2 1.38 .486
Table : 3 Hypothyroid Type - at first six month
Observed N Expected N Residual
Subclinical Hypothyroidism
70 63.3 6.7
Mild Hypothyroidism 94 63.3 30.7
Moderate Hypothyroidism
26 63.3 -37.3
Total 190
Table :2 Weight Status - at first six month
Observed N Expected N Residual
Overweight 8 63.3 -55.3
Pre Obesity 115 63.3 51.7
Obesity Class-1 67 63.3 3.7
Total 190

18. DATA ANALYSIS -2
Table :4 Paired Samples Statistics & Correlations
Mean N Std. Deviation Std. Error Mean
Pair 1 Hypothyroid Type & 4.77 190 .674 .049
N.F.S 1.38 190 .486 .035
N Correlation Sig.
Pair 1 Hypothyroid Type &
N.F.S 190 .188 .009
Note : NF.S - NAFLD Fibrosis Score
Table -5 Paired Samples Test : Hypothyroid Type & NF.S
Paired Differences
t df
Sig. (2-
tailed)
Mean
Std.
Deviation
Std. Error
Mean
95% Confidence
Interval of the
Difference
Lower Upper
Pair 1 Hypothyroid Type
& N.F.S
3.389 .753 .055 3.282 3.497 62.042 189 .000
Note : NF.S - NAFLD Fibrosis Score
Table : 6 NAFLD Fibrosis Score
Observed N Expected N Residual
Mild Risk 118 95.0 23.0
High Risk 72 95.0 -23.0
Total 190

19. RESULTS - BY DATAANALYSIS
2nd Six Month
No Levothyroxin , only observation by applying diet

20. DATA ANALYSIS - 3
Table -7. Weight Status (2nd
Six Month)
Observed N Expected N Residual
Overweight 12 63.3 -51.3
Pre Obese 110 63.3 46.7
Obesity Class-1 68 63.3 4.7
Total 190
Table -8 Hypothyroid Type (2nd
Six Month)
Observed N Expected N Residual
Subclinical Hypothyroidism,
136 63.3 72.7
Mild Hypothyroidism 46 63.3 -17.3
Moderate Hypothyroidism
8 63.3 -55.3
Total 190
Table -9. NAFLD Fibrosis Score (2nd
Six Month)
Observed N Expected N Residual
No Risk 118 95.0 23.0
Low Risk 72 95.0 -23.0
Total 190
Table -10. Test Statistics
Weight Status Hypothyroid Type N.F.S
Chi-Square 76.337a
136.463a
11.137b
df 2 2 1
Asymp. Sig. .000 .000 .001
a. 0 cells (.0%) have expected frequencies less than 5. The minimum
expected cell frequency is 63.3.
b. 0 cells (.0%) have expected frequencies less than 5. The minimum
expected cell frequency is 95.0.

21. DATAANALYSIS - 4
Table -11. Paired Samples Statistics – 2nd
Six Month
Mean N Std. Deviation Std. Error Mean
Pair 1 Hypothyroid Type
4.33 190 .553 .040
N.F.S 1.38 190 .486 .035
Paired Samples Correlations – 2nd
Six month
N Correlation Sig.
Pair 1 Hypothyroid Type & N.F.S 190 .305 .000
Table -12. Paired Samples Test – For 2nd
Six month
Paired Differences
t df
Sig. (2-
tailed)
Mean
Std.
Deviation
Std. Error
Mean
95% Confidence
Interval of the
Difference
Lower Upper
Pair 1 Hypothyroid Type &
N.F.S
2.947 .615 .045 2.859 3.035 66.065 189 .000
Table -13. Correlations Analysis -2nd
Phase (Mainly concerned variables)
Hypothyroid Type N.F.S
Hypothyroid Type Pearson Correlation 1 .305**
Sig. (2-tailed) .000
N 190 190
N.F.S Pearson Correlation .305**
1
Sig. (2-tailed) .000
N 190 190
**. Correlation is significant at the 0.01 level (2-tailed).

22. DATAANALYSIS – 5
Table : 12 Correlation & Sig. (2-tailed) ,Covariance - Analysis of all variables
Participants Age BMI Hypothyroid Type TSH N.F.S
Participants Pearson Correlation 1 .261**
-.314**
.053 .079 -.351**
Sig. (2-tailed) .000 .000 .464 .276 .000
Sum of Squares and
Cross-products
191662.153 4.616E3 -6.841E3 216.505 1.178E3 -1.
Covariance 1014.085 24.426 -36.194 1.146 6.234 -5.442
Age Pearson Correlation .261**
1 .027 .145*
.096 .047
Sig. (2-tailed) .000 .716 .046 .189 .521
Sum of Squares and
Cross-products
4616.489 1.635E3 53.560 54.379 131.245 12.653
Covariance 24.426 8.649 .283 .288 .694 .067
BMI Pearson Correlation -.314**
.027 1 .200**
.221**
.871**
Sig. (2-tailed) .000 .716 .006 .002 .000
Sum of Squares and
Cross-products
-6840.662 53.560 2.483E3 92.418 372.649 290.334
Covariance -36.194 .283 13.137 .489 1.972 1.536
Hypothyroid Type Pearson Correlation .053 .145*
.200**
1 .905**
.188**
Sig. (2-tailed) .464 .046 .006 .000 .009
Sum of Squares and
Cross-products
216.505 54.379 92.418 85.811 284.427 11.674
Covariance 1.146 .288 .489 .454 1.505 .062
TSH Pearson Correlation .079 .096 .221**
.905**
1 .187**
Sig. (2-tailed) .276 .189 .002 .000 .010
Sum of Squares and
Cross-products
1178.194 131.245 372.649 284.427 1.150E3 42.292
Covariance 6.234 .694 1.972 1.505 6.084 .224
N.F.S Pearson Correlation -.351**
.047 .871**
.188**
.187**
1
Sig. (2-tailed) .000 .521 .000 .009 .010
Sum of Squares and
Cross-products
-1028.463 12.653 290.334 11.674 42.292 44.716
Covariance -5.442 .067 1.536 .062 .224 .237
**. Correlation is significant at the 0.01 level (2-tailed).
*. Correlation is significant at the 0.05 level (2-tailed).

23. Table – 13. COMPARISON OF TWO STAGES
1st Six Month
1st Six Month - Status
SCH-Subjects BMI Range TSH Level FT4 Level Fast Foods Cooking Oil Use ALT AST ALP NAFLD Risk %
( Participants) Asian Value mIU/l ng/dl Outside/Week At Home/Day U/L *N.F.S N-120
Grp-I-Nos- 118 26-28 4.0-5.0 0.6-1.8 2-3 Serving 50-60ml (5tbsp) 45-60 30-42 110-200 Mild Risk 62
Group -II-No-72 31-37 4.5-5.5 0.6-1.8 3-4 Serving 60ml > (6tbsp) 55-110 38-45 130-250 High Risk 38
2nd Six Month - Status
Grp-I-Nos- 118 26-29 3.8-4.0 0.6-1.8 2-3 Serving 50-60ml (5tbsp) 30-35 28-35 105-140 No Risk 27
Group -II-No-72 31-35 4.0-4.2 0.6-1.8 3-4 Serving 60ml > (6tbsp) 40-75 30-38 120-170 Low Risk 73
Results :NFS :Average -Gr-I -> within -1.2 to -1.0 & Gr-II 0.850 to 1.1 / After Six Month - Progressed>
Progress> -
Gr -1 Absence ; Gr-II - 0.900 to -
Gr-II-> -1.1 to - 0.900
TSH , T4 Ref :value -American Thyroid Association *N.F.S = NAFLD Fibrosis Score (presence > 0.676) and absence < -1.455).
*ALP Ref.value : 100-250 U/L * AllRef.values are for adult 1 tbsp =10ml ALT - Alanine transaminase
* All values are average collected once in a six month period 1 Serving=100gm AST - Aspartate transaminase

24. FINDINGS
• The study showed that 1st six month, 118 Pre-Obese women were consuming
Thyroxine tablets 25 mcg & 72 Obese - I participants 50 mcg tablet per day for SCH
or mild to moderate hypothyroidism due to elevated serum TSH & normal or little
low fT4 .
• During this stage, no diet was being followed except levothyroxine therapy & the
study revealed that 100% of patients were suffering from mild & high-risk NAFLD
(62% & 38%) but next six months, all were with remain same BMI but normal
thyroid level. Tests showed, 73% were mild NFLAD but rest 27% not reported. This
2nd stage was under dietary counseling & all women were under tentative hypothyroid
diet plan.
Note : N.F.S was taken as examination parameter to assess the fatty liver conditions for both the six month stages..

25. NAFLD FIBROSIS SCORE ( N.F.S )
Formula of N.F.S :
-1.675 + 0.037 × age (years) + 0.094 × BMI (kg/m2) + 1.13 × IFG/diabetes (yes = 1,
no = 0) + 0.99 × AST/ALT ratio – 0.013 × platelet (×109/l) – 0.66 × albumin (g/dl)
Assessment of Result :
NAFLD Score < -1.455 = F0-F2
NAFLD Score -1.455 – 0.675 = indeterminate score
NAFLD Score > 0.675 = F3-F4

26. RESULTS BASED ON N.F.S
1st Six Month Stage : ( Average values)
• Group -1 : Score was within -1.2 to -1.0 Mild Risk
• Group -2 Score was within 0.850 to 1.1 High Risk
2nd Six Month Stage : ( Average values)
• Group -1 : score - negligible ( - 0.575 to - 0.675) No Risk
• Group -2 : score within -1.1 to -0.900 Low Risk ( or near mild risk)

27. MAJOR FINDINGS - 1ST SIX MONTH :
•
The Paired Samples Correlation table. no -4 , adds the information that Hypothyroid
Type & N.F.S relationship is significantly positively correlated (r = 0.188, p < 0.001).
• There is a significant average difference between Hypothyroidism & N.F.S [(t189 =
62.04, p < 0.001) ,95% Confidence Interval 3.282 , 3.497].
• As per result , P (α ) value is .009 which is less than .05. Because of this, we can
conclude that there is a statistically significant difference between the mean
hypothyroidism and N.F.S.
• No proper diet plan practiced by the patients, only levothyroxine therapy at this stage.

28. MAJOR FINDINGS – 2ND SIX MONTH :
• The Paired Samples Correlation table. no – 11, showed that Hypothyroid Type &
N.F.S relationship was significantly positively correlated (r = 0.305, p < 0.001).
• There was a significant average difference between Hypothyroidism & N.F.S [(t189 =
66.07, p < 0.001) , 95% Confidence Interval 2.859 , 3.035]
• P value .000 which is less than .05 (can say p< .001 or P=0.000 means
P<0.0005).Because of this, we can conclude that there is a statistically significant
difference between the mean hypothyroidism and N.F.S.
• Implementation of tentative hypothyroidism diet plan but no levothyroxine therapy.

29. KEY RESULTS
• Both the stages of six-month studies (1st & 2nd ) Hypothyroid Type & N.F.S
relationship was significantly positively correlated. Also, as per statistical
analysis & interpretation, 2nd six month stage showed better results for the
same patients on these two health issues.
• As per study, both hypothyroidism & NAFLD significantly positively
correlated with BMI & TSH range.

30. CONCLUSIONS
The study indicates that there is a positive relationship between
Subclinical Hypothyroidism & NAFLD among middle-aged obese
working women. That means if one increases another one may increase
& vice versa.
Further other variables like weight status (BMI-Asian values), TSH level is
also significantly & positively correlated with both hypothyroidism &
NAFLD.

31. REFERENCES
• 1 .A. Eshraghian and A. H. Jahromi, “Non-alcoholic fatty liver disease and thyroid dysfunction: A systematic review,” World J.
Gastroenterol., vol. 20, no. 25, pp. 8102–8109, 2014.
• 2. Ortiz-Lopez C, Lomonaco R, Orsak B, Finch J, Chang Z, Kochunov VG, Hardies J, Cusi K. Prevalence of prediabetes and
diabetes and metabolic profile of patients with nonalcoholic fatty liver disease (NAFLD) Diabetes Care. 2012;35:873–878
• 3.Yamada T, Fukatsu M, Suzuki S, Wada T, Yoshida T, Joh T. Fatty liver predicts impaired fasting glucose and type 2 diabetes
mellitus in Japanese undergoing a health checkup. J Gastroenterol Hepatol. 2010;25:352–356.
• 4.Raftopoulos Y, Gagné DJ, Papasavas P, Hayetian F, Maurer J, Bononi P, Caushaj PF. Improvement of hypothyroidism after
laparoscopic Roux-en-Y gastric bypass for morbid obesity. Obes Surg. 2004;14:509–513.
• 5. Pucci E, Chiovato L, Pinchera A. Thyroid and lipid metabolism. Int J Obes Relat Metab Disord. 2000;24 Suppl 2:S109–
S112.
• 6. Chung GE, Kim D, Kim W, Yim JY, Park MJ, Kim YJ, Yoon JH, Lee HS. Non-alcoholic fatty liver disease across the
spectrum of hypothyroidism. J Hepatol. 2012;57:150–156.
• 7. Xu C, Xu L, Yu C, Miao M, Li Y. Association between thyroid function and nonalcoholic fatty liver disease in euthyroid
elderly Chinese. Clin Endocrinol (Oxf) 2011;75:240–246.
• 8. Ittermann T, Haring R, Wallaschofski H, Baumeister SE, Nauck M, Dörr M, Lerch MM, Meyer zu Schwabedissen HE,
Rosskopf D, Völzke H. Inverse association between serum free thyroxine levels and hepatic steatosis: results from the Study
of Health in Pomerania. Thyroid. 2012;22:568–574.
• 9. Carulli L, Ballestri S, Lonardo A, Lami F, Violi E, Losi L, Bonilauri L, Verrone AM, Odoardi MR, Scaglioni F, et al. Is
nonalcoholic steatohepatitis associated with a high-though-normal thyroid stimulating hormone level and lower cholesterol
levels? Intern Emerg Med. 2013;8:297–305.
• 11.Angulo P, Hui JM, Marchesini G, et al. The NAFLD fibrosis score: a noninvasive system that identifies liver fibrosis in
patients with NAFLD. Hepatology. 2007;45:846-854.
• 12.Castera L, Vilgrain V, Angulo P. Noninvasive evaluation of NAFLD. Nat Rev Gastroenterol Hepatol. 2013;10:666-675.

32. THANK YOU
Questions ?
Suggestions !