for many years , alcoholic liver disease and viral hepatitis - induced liver disease were considered the main causes of liver disease morbidity and mortality . however , with the dramatic increase in the prevalence of obesity , nonalcoholic fatty liver disease ( nafld ) has become the most common chronic liver disease and is now receiving greater attention globally .
nafld describes a pathologic condition characterized by significant lipid deposition in the hepatocytes of the liver parenchyma in patients with no history of excessive alcohol consumption .
the spectrum of nafdl includes hepatic steatosis , nonalcoholic steatohepatitis , chronic fibrosis and cirrhosis .
the true incidence and prevalence of the disease is difficult to ascertain accurately due to lack of effective screening tests that can be applied to the entire population .
population - based epidemiological studies using ultrasound imaging as a diagnostic modality have detected the presence of fatty liver in 13% to 22% of the population of lean nonalcoholic subjects .
estimates in the united states population suggest that up to 30% of adults may have nafld .
the prevalence estimates from several other countries are quite variable , but depict a highly prevalent condition , with ~20% of the adult population with ultrasound - defined nafld .
the prevalence of nafld increases to 5055% in type-2 diabetics and patients with hypertriglyceridemia , and to 75% in obese persons .
increasing evidence indicates that nafld is the hepatic component of a systemic metabolic syndrome   that includes obesity , insulin resistance , hyperlipidemia , and hypertension .
approximately 90% of patients with nafld have 1 characteristic features of metabolic syndrome and about 33% have the complete diagnosis . in individuals with nafdl
, the prevalence of metabolic syndrome increases with increasing body mass index , from 18% in normal - weight subjects to 67% in obese subjects .
furthermore , with the addition of each of the components of the metabolic syndrome , the risk of steatosis increases exponentially .
criticism has been leveled at the syndrome in part because of varying and incomplete definitions and the lack of a unifying mechanism .
in addition , the individual components of the metabolic syndrome themselves are adequate to predict the risk of cardiovascular disease or diabetes .
although the clinical usefulness of metabolic syndrome has been questioned , it is still considered useful as an educational concept [ 1114 ] .
the metabolic syndrome is estimated to affect about 20% of the lithuanian middle - aged urban population [ 1517 ] . in this study
we aimed to assess the prevalence of the following metabolic risk factors among men and women with nafld : obesity , hypertension , dyslipidemia , and diabetes .
the study was conducted in accordance with the recommendations laid down by the 18 world medical assembly ( helsinki , 1964 ) and all applicable amendments .
this was an epidemiologic study . in order to ensure that the data reflect the health status of patients living in urban as well as rural areas , randomly selected family physicians throughout lithuania
the regions covered included anykiai , elektrnai , jonava , jurbarkas , kaunas , kdainiai , klaipda , kretinga , marijampol , maeikiai , palanga , panevys , plung , prienai , radvilikis , raseiniai , iauliai , ilal , taurag , utena , and vilnius .
every patient fulfilling the inclusion criteria who visited the physician on a working day for any reason was asked to take part in the study .
patients included in the study had to be outpatients with nafld , aged 1880 years old .
the diagnosis of nafld had to be confirmed during previous consultations by means of ultrasonography , liver biopsy , computed tomography or magnetic resonance imaging   and documented in the patient s record .
the following exclusion criteria were applied : pregnancy , alcoholic liver disease ( established diagnosis of alcoholic liver disease or confirmed alcohol intake in daily doses 40 g for men and 20 g for women ) , known or evidenced virus hepatitis , autoimmune hepatitis , toxic liver damage , gene pathology , and confirmed absence of liver pathology .
the following data were collected during a single patient visit : weight , height , waist circumference , body mass index ( bmi ) , age , sex , leisure - time physical activity , concomitant diseases , and use of antioxidants , cytoprotective agents , insulin secretagogues , and lipid - lowering agents .
demographic and medical data were retrieved from patients cards , while anthropometric parameters ( height , weight , bmi and waist circumference ) were measured during the study visit .
height ( cm ) and weight ( kg ) were measured with indoor clothing and without shoes .
the waist circumference ( cm ) was measured at the level of the umbilicus , with the participant standing and breathing normally .
hypertension was defined as elevated blood pressure at or above 140/90 mm hg ( 130/80 mm hg for diabetics ) or a history of hypertension and use of antihypertensive medication .
dyslipidemia was defined as abnormal fasting lipid profile ( total cholesterol > 5.0 mmol / l or low - density lipoprotein ( ldl ) cholesterol > 3.0 mmol / l or high - density lipoprotein ( hdl ) cholesterol
leisure - time physical activity was classified into 3 categories : ( 1 ) low ( almost completely inactive , e.g. , reading , watching television , housework , etc . ) , ( 2 ) moderate ( some physical activity for > 4 hours per week ( eg , walking , cycling , light exercising , light gardening , etc . ) , and ( 3 ) high ( vigorous physical activity for > 3 hours per week , e.g. , running , jogging , swimming , heavy gardening , or regular exercise or competitive sports several times per week ) .
bmi was calculated by dividing the individual s body weight by the square of his / her height : bmi = weight ( kg)/height ( m ) .
abdominal obesity was defined as waist circumference > 102 cm in men and > 88 cm in women .
sample size was calculated based on the following assumptions : anticipated prevalence of nafdl is 20% ( p=0.2 ) , its absolute precision is 3% ( d=0.03 ) , and confidence level is 95% . for sample size calculation
the following equation was used : based on the above assumptions , the minimum sample size for this study was calculated to be 780 patients .
parametric student s t - test test or non - parametric wilcoxon test was applied to test the difference between continuous data .
in total , 804 patients were recruited in the study and of these 798 were included in the analysis ( 6 patients were protocol violations ) . there were 298 ( 37.3% ) men and 500 ( 62.7% ) women among the study participants .
the mean (  standard deviation [ sd ] ) age of patients was 58.1 ( 10.7 ) years ; range , 23 to 80 years .
women were slightly older than men ( mean age , 60.29.6 vs. 54.511.4 years ; p<0.05 ) .
the prevalence of obesity ( bmi > 30 kg / m ) was 69.9% among study patients and it was significantly higher among women compared to men ( 75.4% vs. 60.7% , p<0.05 ) ; 62.4% of the men and 89.2% of the women
hypertension and dyslipidemia were also highly prevalent in this group of nafdl patients , and metabolic risk factors were more prevalent among women ( table 1 ) .
the prevalence of diabetes was similar in both men and women ; 21.9% of patients had diabetes ; all except 1 were cases of type 2 diabetes mellitus .
the prevalence of metabolic risk factors was compared in different age groups ( 60 years and > 60 years ) separately in men and in women .
there were no differences in the mean bmi in the proportion of men or women with bmi > 30 kg / m or central obesity in the 2 age groups ( table 2 ) .
the proportion of patients with diabetes was also significantly higher among elderly men and was numerically higher among elderly women .
dyslipidemia was more common among women aged > 60 years , while no such age - related differences were observed in men .
very few nafdl patients ( 3.1% ) reported high leisure - time physical activity ( regular vigorous exercise , competitive sports or similar physical activity for at least 3 hours per week ) . among women ,
the proportion of subjects reporting low leisure - time physical activity was higher than that among men ( 45.8 vs. 29.2% ; p<0.05 ) .
consequently , there were more men than women with moderate physical activity ( 66.1 vs. 52.0% ; p<0.05 ) . in both sexes , the level of leisure - time physical activity was lower in older patients ( table 3 ) .
the most common medicines were cytoprotective agents , ursodeoxycholic acid , pentoxifylline , betaine or phospholipid preparations ( 24.9% ) , lipid - lowering drugs ( 21.3% ) , and antioxidants  vitamin e , n - acetylcysteine , selenium , or beta - carotene ( 19.1% ) .
insulin secretagogues ( metformin , pioglitazone or rosiglitazone ) were used by 11.7% of patients .
almost 30% of patients received combined treatment and the most frequent combination was a lipid - lowering drug and a cytoprotective agent ( 10.6% ) .
in this study we found that metabolic risk factors were highly prevalent in patients with nafld .
more than two - thirds of patients were obese , and similar proportions of patients had hypertension or dyslipidemia .
an italian study showed that nafld was associated with most of the features of the metabolic syndrome  obesity , hyperglycemia , hyperinsulinemia , hypertriglyceridemia , and systolic hypertension .
several studies reported that nafld is 3 to 5 times more common in men than in women [ 2123 ] , while others stated that the risk of this disease is greater among women .
we did not evaluate the prevalence of nafld ; however , the number of female patients in our study was approximately 1.5-fold higher than the number of males . besides , most of metabolic risk factors , which are also generally considered as nafdl risk factors ( obesity , hypertension , dyslipidemia ) , were more prevalent among women compared to men .
since the women in this study population were significantly older than the men , we conducted a further analysis to determine if these differences could have been caused by age rather than sex .
the distribution of obesity parameters ( mean bmi , proportion of patients with bmi > 30 kg / m or central obesity ) was similar in the 2 age groups , thus the difference observed in men and women was most likely determined by sex .
contrarily , the differences in the prevalence of arterial hypertension and diabetes seemed to be related to advanced age , as the prevalence of these diseases was higher among older men and women .
published data on the prevalence of metabolic syndrome among lithuanian men and women are inconsistent .
a study that used the definition of international diabetes federation , reported that the prevalence of metabolic syndrome was almost two - fold higher among men compared to women ( 28.1% vs. 16.6% ) ( 15 ) .
other studies , which employed world health organization or national cholesterol education program  adult treatment panel iii criteria , reported opposite results , showing higher prevalence among women .
one lithuanian study also reported some sex - related differences in the prevalence of metabolic syndrome components in patients with acute ischemic syndromes . in this study women were significantly older than men ; however , the potential confounding effect of age was not analyzed .
there is no specific therapy for nafld that has clearly been proven effective ; however several pharmacological options , including antioxidants , lipid lowering agents , hepatoprotective agents , and insulin secretagogues , have been tried with some successes . in our study ,
the most common medicines being cytoprotective agents , followed by lipid - lowering drugs and antioxidants .
it is recommended to initiate pharmacological treatment only when there is no change in the course of disease after adequate lifestyle changes have been undertaken .
the published results of several studies in nafld populations have reported that short - term moderate weight loss with regular physical activity leads to improvement in liver biochemical tests and to resolution of hepatic steatosis .
however , available information on leisure - time physical activity suggests that lifestyle - related therapeutic modalities were not fully utilized in this group , especially among women .
the physicians who participated in the study constituted only about 3% of the family physicians in lithuania . although almost half of lithuanian administrative regions were covered and efforts were made to invite physicians working in urban as well as rural areas , it is possible that the study population was not representative of the general population .
second , the enrollment of a greater proportion of women into the study , and the fact that they were older than men , may have biased the results .
the effect of this potential bias was reduced by applying stratification by sex and age .
further studies involving a control group are needed for a better understanding of true prevalence of metabolic risk factors in the population of patients with nafdl in lithuania .
obesity , arterial hypertension , and dyslipidemia were more prevalent among women compared to men ; however , the differences in the prevalence of hypertension seemed to be determined by advanced age .
 summarybackgroundnonalcoholic fatty liver disease ( nafld ) is the most common chronic liver disease ; there is growing evidence that it is a hepatic manifestation of a metabolic syndrome . 
 this study aimed to assess the prevalence of metabolic risk factors among patients with nafld.material/methodsoutpatients with nafld were recruited into the study . 
 family physicians recorded patients demographic and anthropometric data , leisure - time physical activity , concomitant diseases , and pharmacological treatment for nafld into standardized case report forms.resultsin total , data on 798 patients were analyzed . 
 most patients were women and they were older than the men ( mean age , 60.29.6 vs. 54.511.4 years ; p<0.05 ) . 
 metabolic risk factors ( obesity , arterial hypertension , dyslipidemia ) were highly prevalent in the study patients , and these factors were more prevalent among women . there were no differences in the mean body mass index ( bmi ) , in the proportion of men or women with bmi > 30 kg / m2 or central obesity in the 2 age groups ( 60 years and > 60 years ) . 
 hypertension and diabetes were more prevalent among older men and women . 
 dyslipidemia was more common among older women . 
 the level of leisure - time physical activity was lower in women and in older patients . 
 the most frequently prescribed pharmacological agents were cytoprotective agents , lipid - lowering drugs , and antioxidants.conclusionsmetabolic risk factors were highly prevalent among patients with nafld . 
 obesity , hypertension , and dyslipidemia were more prevalent among women . 
 the differences in the prevalence of hypertension seemed to be influenced by older age of women . 
Background
Material and Methods
Results
Discussion
Conclusions