Original article—liver, pancreas, and biliary tract
Independent Association Between Nonalcoholic Fatty Liver Disease and Cardiovascular Disease in the US Population

https://doi.org/10.1016/j.cgh.2011.12.039Get rights and content

Background & Aims

Nonalcoholic fatty liver disease (NAFLD) and cardiovascular diseases (CVDs) have common metabolic risk factors. Despite reports from clinical studies, the association between NAFLD, cardiovascular disease, and cardiovascular mortality are not clear at the population level.

Methods

We analyzed data from the National Health and Nutrition Examination Survey III, conducted from 1988 to 1994, and compared hepatic ultrasound and mortality data. Participants were classified into those with NAFLD (moderate or severe hepatic steatosis, based on ultrasound analysis, without any evidence of other liver disease; n = 2492) and those without (absence of NAFLD or any other chronic liver diseases: controls). The prevalence of CVD was compared between subjects with and without NAFLD. Additional comparisons were made between NAFLD patients who had increased levels of liver enzymes and those who had normal levels. Independent predictors of CVD and cardiovascular mortality also were studied.

Results

During the follow-up period (median, 171 mo), 12.21% of the National Health and Nutrition Examination Survey III participants died; cardiovascular mortality was 3.76%. Regardless of whether levels of liver enzymes were increased or not, individuals with NAFLD were older, predominantly male, more likely to be Hispanic, and less likely to be African American than controls. They also had a higher prevalence of all components of metabolic syndrome and CVD. Regardless of levels of liver enzymes, NAFLD was associated independently with CVD, after adjusting for major demographic, clinical, and metabolic confounders (odds ratio, 1.23; 95% confidence interval, 1.04–1.44). The independent association of NAFLD with cardiovascular mortality was not statistically significant.

Conclusions

NAFLD is associated independently with an increased risk of CVD. However, NAFLD did not increase cardiovascular mortality over a 14-year period.

Section snippets

Study Population

For this study, we used the National Health and Nutrition Examination Survey III (NHANES III) conducted between 1988 and 1994. The survey data were collected by the US National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention via household interviews, physical examination, and laboratory tests, and contains information describing the health and nutritional status of the US population as of the time of the data collection. In addition, the data collections

Results

Of the initial study population (20,050 adult participants from NHANES III), 2492 individuals (18.77% ± 0.76%) fulfilled our clinical and radiologic definition of NAFLD, 426 (15.86% ± 1.15%) of them had NAFLD with increased liver enzyme levels, and 9121 were used as non-NAFLD controls.

The results of the comparison of the NAFLD cohort with the non-NAFLD controls are summarized in Table 1. As expected, individuals with NAFLD were older, more likely to be male or Hispanic, and less likely to be

Discussion

Increasing data suggest an association between NAFLD and cardiovascular diseases that could not be attributable solely to the risk factors common for both of these chronic diseases. A number of cross-sectional studies have confirmed this association and suggested that individuals with diagnosed NAFLD should be assessed for the risk of CVD.4 Other studies have proven that the risk of cardiovascular diseases increases even more when hepatic damage progresses, and described possible molecular

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    Conflicts of interest The authors disclose no conflicts.

    Funding This study was partly supported by the Liver Outcomes Research Fund and Beatty Liver and Obesity Research Fund, Inova Health System, Falls Church, VA.

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