European Journal of Cardiovascular Medicine

Non-alcoholic fatty liver disease (NAFLD) represents a spectrum of hepatic disorders ranging from simple steatosis to non-alcoholic steatohepatitis (NASH), fibrosis, and even cirrhosis, occurring in the absence of significant alcohol consumption or other secondary causes of liver fat accumulation [1]. It is now recognized as the most common chronic liver disease globally, especially in individuals with metabolic disorders such as Type 2 Diabetes Mellitus (T2DM) [2].

Type 2 diabetes mellitus is a chronic metabolic disorder characterized by insulin resistance and impaired insulin secretion, leading to persistent hyperglycemia. It is increasingly associated with multiple systemic complications, of which hepatic involvement in the form of NAFLD has emerged as a significant concern [3]. Insulin resistance plays a pivotal role in hepatic fat accumulation by increasing lipolysis in adipose tissue, promoting hepatic de novo lipogenesis, and impairing lipid oxidation [4].

Globally, the estimated prevalence of NAFLD in the general population ranges from 25% to 30%, while in patients with T2DM, it is reported to be as high as 50% to 70%, highlighting the substantial overlap between these two metabolic disorders [5,6]. In India, the burden of NAFLD among diabetics appears to be rapidly increasing, with recent urban cohort studies reporting prevalence rates between 45% and 65% [7]. Regional studies from western India have indicated similar trends, with a strong correlation between poor glycemic control and higher grades of fatty liver on ultrasonography [8].

The silent progression of NAFLD, especially in diabetic patients, poses a significant clinical challenge as many patients remain asymptomatic until advanced liver disease develops. Furthermore, NAFLD not only increases the risk of liver-related morbidity and mortality but also acts as an independent risk factor for cardiovascular events [9].

Despite increasing awareness, routine screening of NAFLD among diabetics is still suboptimal in many clinical settings. There is limited regional data on the actual prevalence of NAFLD in diabetics and its association with glycemic control, especially in the western part of India. This underlines the need for context-specific research to determine the burden of NAFLD among diabetics and guide early intervention strategies [10].

Therefore, this study aims to estimate the prevalence of NAFLD in patients with Type 2 Diabetes Mellitus and assess its correlation with glycemic control (as measured by HbA1c), with the ultimate goal of improving early detection and clinical management of hepatic complications in diabetic patients.

This was a cross-sectional observational study conducted at a private referral hospital located in Dhanera, a semi-urban region in northern Gujarat. The study aimed to assess the prevalence of non-alcoholic fatty liver disease (NAFLD) in patients diagnosed with Type 2 Diabetes Mellitus (T2DM) and to explore its correlation with glycemic control using HbA1c levels.

The study was conducted over a period of 12 months, from 20th August 2023 to 11th August 2024. A total of 25 adult patients diagnosed with T2DM attending the outpatient or inpatient services of the hospital were enrolled in the study based on a predefined selection criteria.

Inclusion criteria included patients aged ≥30 years with a known history of Type 2 Diabetes Mellitus of at least one year duration and who provided informed written consent for participation. Patients were selected consecutively as per convenience sampling until the sample size was reached.

Exclusion criteria were patients with significant alcohol intake (>20 g/day for women and >30 g/day for men), known chronic liver diseases (such as viral hepatitis B/C, autoimmune hepatitis, or Wilson’s disease), use of hepatotoxic medications (like amiodarone, methotrexate), or any history of malignancy or chronic kidney disease.

After obtaining ethical clearance and informed consent, a detailed clinical history and examination were carried out. Demographic information, BMI, duration of diabetes, and treatment details were recorded. Liver ultrasonography was performed in all patients to identify hepatic steatosis and classify the grade of NAFLD. HbA1c levels were measured using standardized laboratory methods to assess glycemic control.

All collected data were entered in Microsoft Excel and analyzed using SPSS version 26.0. Descriptive statistics were used for demographic and clinical characteristics. The prevalence of NAFLD was expressed in percentage, and the correlation between HbA1c levels and presence of NAFLD was analyzed using Chi-square test and Pearson’s correlation coefficient. A p-value of <0.05 was considered statistically significant.

In this cross-sectional study conducted at a private referral hospital in Dhanera, Gujarat, a total of 25 patients with Type 2 Diabetes Mellitus were evaluated for the presence of Non-Alcoholic Fatty Liver Disease (NAFLD) and its association with glycemic control. The majority of participants belonged to the 50–59 years age group (36%), followed by the 40–49 years group (28%). Males constituted 56% of the sample, and females 44%. With respect to the duration of diabetes, 40% of patients had diabetes for 6–10 years, while 36% had a duration exceeding 10 years. Regarding body mass index (BMI), 40% of the patients were overweight (BMI 25–29.9 kg/m²), and 32% were classified as obese (BMI ≥30 kg/m²), suggesting a significant burden of excess weight in this diabetic cohort.

Ultrasonography revealed the presence of NAFLD in 17 out of 25 patients, resulting in a prevalence of 68%. Among these, Grade I fatty liver was the most common (52.9%), followed by Grade II (35.3%) and Grade III (11.8%). In terms of glycemic control, only 20% of patients had HbA1c <7% (good control), whereas 44% had moderate control (HbA1c 7–8.9%) and 36% had poor control (HbA1c ≥9%). A statistically significant association was observed between NAFLD and HbA1c levels (p = 0.031), with the majority of patients with NAFLD exhibiting moderate to poor glycemic control. Specifically, 8 of the 9 patients with HbA1c ≥9% had NAFLD on ultrasonography, highlighting a potential link between worsening glycemic control and hepatic fat accumulation.

These findings suggest that NAFLD is highly prevalent among T2DM patients even in semi-urban settings like Dhanera, and poor glycemic control is significantly associated with its presence.

Table 1: Demographic and Clinical Profile of Study Participants (n = 25)

Table 2: Distribution of NAFLD and Glycemic Control (n = 25)

Table 3: Association Between NAFLD and HbA1c Levels

*p < 0.05 considered statistically significant

Figure 1: Prevalence of NAFLD among T2DM Patients

This study revealed that the prevalence of non-alcoholic fatty liver disease (NAFLD) among patients with Type 2 Diabetes Mellitus (T2DM) was 68%, which is in agreement with global literature showing a strong coexistence of these two metabolic conditions. In this study, a significantly higher proportion of patients with poor glycemic control (HbA1c ≥9%) had NAFLD, supporting the hypothesis that chronic hyperglycemia contributes to hepatic fat accumulation and progression to steatohepatitis.

A comparable prevalence was observed in an international study by Younossi et al., where the global pooled prevalence of NAFLD among diabetics was reported to be around 55%–70% [11]. Their meta-analysis emphasized the metabolic interrelationship between insulin resistance and hepatic steatosis. Similarly, Targher et al. highlighted that NAFLD is almost twice as prevalent in T2DM populations compared to the general population, with poor glycemic control emerging as a key predictor [12].

In the Indian context, a study by Duseja et al. conducted in urban North India reported NAFLD prevalence of 61% among diabetics, with Grade I steatosis being the most common pattern on ultrasound—mirroring the findings of the present study where Grade I constituted over 52% of all NAFLD cases [13]. Another study by Mohan et al. in Chennai noted a NAFLD prevalence of 63.5% in diabetics and confirmed a significant association with higher HbA1c levels and BMI, reiterating the link between poor metabolic control and hepatic involvement [14].

From Gujarat, a study by Patel et al. conducted at a tertiary care center in Ahmedabad reported NAFLD in 66.4% of diabetic patients. They found a significant correlation between HbA1c levels and ultrasonographic grading of fatty liver, especially in patients with BMI >25 kg/m²—findings that align closely with this study where 72% of NAFLD patients were overweight or obese [15].

The present study strengthens the existing evidence that glycemic control plays a vital role in the development and severity of NAFLD. Moreover, the high prevalence observed even in a semi-urban region like Dhanera suggests that NAFLD is no longer confined to urban or affluent populations but is increasingly seen in rural and transitional settings, likely due to dietary shifts, physical inactivity, and delayed diabetes diagnosis.

This study demonstrates a high prevalence (68%) of non-alcoholic fatty liver disease (NAFLD) among patients with Type 2 Diabetes Mellitus in a semi-urban region of northern Gujarat. The majority of these cases were associated with poor glycemic control (HbA1c ≥9%) and elevated BMI. The statistically significant association between HbA1c levels and the presence of NAFLD suggests that chronic hyperglycemia plays a critical role in hepatic fat accumulation and potentially the progression to steatohepatitis or fibrosis. These findings underscore the importance of routine NAFLD screening in diabetic patients, even in rural or semi-urban clinical settings, and integrating glycemic optimization strategies as a central component in NAFLD prevention and management.

Limitations and Recommendations

The primary limitation of this study is its small sample size (n = 25) and single-center design, which may limit generalizability. Ultrasonography, while widely accessible, is less sensitive for detecting early or mild steatosis compared to MRI or liver biopsy. Furthermore, the cross-sectional nature of the study precludes establishing causal relationships between glycemic control and NAFLD severity. Future studies with larger multicentric samples, longitudinal follow-up, and advanced imaging techniques are recommended to validate these associations and explore the reversibility of NAFLD with improved glycemic management.

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