Open Access Original

Article DOI: 10.7759/cureus.47896

Prevalence of Nonalcoholic Fatty Liver Disease at

a Tertiary Care Center in Saudi Arabia
Review began 10/17/2023
Ghada Hussein 1 , Aljoharah A. Al Saud 2 , Abdulelah A. Bashandi 2 , Mohammed M. Almousallam 2 , Reem
Review ended 10/22/2023 M. AlShihri 2 , Osama M. Almousallam 2 , Ibrahim M. Binsalamah 2 , Yaser Alendijani 3
Published 10/29/2023

© Copyright 2023 1. Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, SAU 2. Family Medicine and
Hussein et al. This is an open access article Polyclinics, Alfaisal University College of Medicine, Riyadh, SAU 3. Family Medicine and Polyclinics, King Faisal
distributed under the terms of the Creative Specialist Hospital and Research Centre, Riyadh, SAU
Commons Attribution License CC-BY 4.0.,
which permits unrestricted use, distribution,
and reproduction in any medium, provided
Corresponding author: Ghada Hussein, [email protected]
the original author and source are credited.

Abstract
Objectives: To determine the prevalence of nonalcoholic fatty liver disease (NAFLD) in patients who
received abdominal imaging and to assess the clinical and metabolic characteristics of NAFLD.

Methods: This is a retrospective study of 500 family medicine patients (aged 18 years and older) who
completed abdominal imaging at King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia,
from January 2016 through June 2020.

Results: The patients enrolled had a mean age of 49.41 ± 14.80 years, with 300 females and 349 of Saudi
nationality. The mean body mass index (BMI) was 29.43 ± 6.61 kg/m2, while 373 of the enrolled subjects were
either overweight or obese. Half of our patients had some form of fatty liver in the imaging results.
Regarding chronic medical conditions, 33.4%, 31.4%, and 29.4% had a history of hypertension, type 2
diabetes mellitus (DM2), and dyslipidemia, respectively. The mean Fibrosis-4 (FIB-4) index was 0.94 ± 0.72.
Body mass index was higher among fatty liver patients (p = 0.001). Hypertension, coronary artery disease,
dyslipidemia, and DM2 were more common in the fatty liver group.

Conclusion: Our findings reiterate the significance of obesity and the coexistence of cardiovascular risk
factors in NAFLD. Further studies are needed to corroborate and expand our findings, enabling more refined
strategies for the prevention, risk prediction, early detection, and management of NAFLD.

Categories: Endocrinology/Diabetes/Metabolism, Family/General Practice, Internal Medicine

Keywords: nonalcoholic fatty liver disease (nafld), obesity, family medicine, fatty liver, fib-4, nafld

Introduction
Nonalcoholic fatty liver disease (NAFLD) is defined as the accumulation of excess fat in the liver in the
absence of other causes [1]. The spectrum of NAFLD encompasses fatty liver changes on abdominal imaging,
some normal liver function tests, and elevated liver function tests, which are associated with advanced liver
cirrhosis [2].

The worldwide prevalence of NAFLD is 25% [1], with the highest prevalence being in the Middle East at 32%
[3]. The most important risk factors for NAFLD are being overweight, obesity, and type 2 diabetes (DM2) [4].
One-third of the Middle East is obese, and the prevalence of DM2 is increasing rapidly in Saudi Arabia [2].
Therefore, diagnosing NAFLD early and initiating prompt treatment is critical for decreasing complications
and mortality [5].

Nonalcoholic fatty liver disease is associated with morbidity and mortality. Death due to cardiovascular
disease is attributed to NAFLD [5]. Nonalcoholic fatty liver disease can lead to liver-related mortality and
morbidity due to hepatocellular carcinoma with or without cirrhosis [3].

A nonalcoholic fatty liver disease diagnosis can be confirmed through invasive or noninvasive testing. Liver
biopsies are the gold standard for assessing liver fibrosis; however, they are not recommended for all patients
with NAFLD due to the risk of complications. Indeed, many patients are unwilling to undergo these
procedures [3]. Increased liver fat is usually seen on an abdominal ultrasound (US) when more than 20% of
the hepatocytes are affected, while non-contrast computerized tomography (CT) is more specific than the US
for NAFLD [6]. Magnetic resonance imaging (MRI) is the most sensitive modality for evaluating hepatic
steatosis. As little as 5% steatosis can be detected [6]. Furthermore, biochemical markers-aminotransferases,
bilirubin, and ferritin-and metabolic markers-glycated hemoglobin (HbA1C) and lipids [3]-are used as
predictors of NAFLD diagnoses [5].

The Fibrosis-4 (FIB-4) index is a validated score that estimates liver fibrosis without a biopsy, calculated

How to cite this article

Hussein G, Al Saud A A, Bashandi A A, et al. (October 29, 2023) Prevalence of Nonalcoholic Fatty Liver Disease at a Tertiary Care Center in Saudi
Arabia. Cureus 15(10): e47896. DOI 10.7759/cureus.47896
 from age, serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), and platelet count. The
FIB-4 index should be used as a screening tool for NAFLD in high-risk groups. A person with a FIB-4 index
<1.30 is considered at low risk for developing liver fibrosis [7]. A person is at high risk with a FIB-4 index
>2.67, as per the fibrosis risk stratification, and, thus, should be referred to a liver specialist and
recommended a liver biopsy [7]. Persons of indeterminate risk with a FIB-4 index of 1.3-2.67 need further
assessment of liver stiffness and referral to a liver specialist [7].

According to the American College of Gastroenterology, normal ALT levels should be 29 to 33 U/L for men
and 19 to 25 U/L for women, while elevated levels need further assessment [8]. Hepatocellular injury may be
suggested by elevated AST and/or ALT, alkaline phosphatase, and bilirubin [8]. Alanine aminotransferase is a
more specific marker for hepatocellular cell injury, as it is mainly present in the liver [8].

There is an urgent need for further evaluation of NAFLD since most patients are asymptomatic, and early
detection is warranted for this highly prevalent disease to improve health outcomes. The primary objective
was to assess the prevalence of NAFLD in family medicine patients who received abdominal imaging. The
secondary objective is to evaluate the clinical and metabolic characteristics of NAFLD.

Materials And Methods

The retrospective review included the Integrated Clinical Information System (ICIS) database of the
electronic health records of patients aged 18 or older seen at King Faisal Specialist Hospital and Research
Centre Family Medicine clinics from January 1, 2016-June 30, 2020, who had abdominal imaging (i.e.,
abdominal ultrasound, CT scan of the abdomen, or MRI of the abdomen). The data collected included
demographics, medical history, BMI, tobacco use, blood pressure, and lab results within three months of
imaging, including fasting glucose, HbA1C, AST, ALT, platelet, ALP (alkaline phosphatase), bilirubin, ferritin,
lipid profile, creatinine, GFR (glomerular filtration rate), TSH (thyroid stimulating hormone), uric acid, PT
(prothrombin time), INR (international normalized ratio), and liver imaging findings. The FIB-4 index was
calculated using the formula with lab values and age from the ICIS system.

Patients were excluded if they have coexisting liver disease, hepatitis B or C, alcohol use or history,
autoimmune liver disease, viral hepatitis, pregnancy, hepatocellular carcinoma, secondary causes, or a
history of bariatric surgery. Patients were also excluded if they were taking methotrexate, valproic acid,
amiodarone, and corticosteroids.

All data were analyzed using the IBM SPSS statistical software package, version 20.0 (IBM Corp., Armonk,
NY). Descriptive statistics for the categorical variables were presented as frequencies and percentages. The
continuous variables were summarized as the mean ± standard deviation (SD). Inferential statistics was
performed on continuous variables using the independent t-test to measure the statistical differences
between patients diagnosed with NAFLD and those who were not. Conversely, categorical variables were
compared using the chi-square test and Fisher’s exact test. Univariate logistic regression was performed to
examine the associations between NAFLD and the other factors. The significance level was set at 0.05 with a
95% confidence interval (CI).
Ethical approval was obtained from the Research Ethics Committee at King Faisal Specialist Hospital and
Research Centre, Riyadh, Saudi Arabia, on January 8, 2023 (approval number: RAC 2221264), and a waiver of
signed informed consent was granted.

Results
Five hundred patients were included in the analysis (Table 1).

Variables n (%)

Age, in years (Mean ± SD) 49.41 ± 14.80

< 21 7 (1.4)

21–30 50 (10)

31–40 87 (17.4)

41–50 114 (22.8)

51–60 140 (28)

61–70 61 (12.2)

> 70 41 (8.2)

Gender

2023 Hussein et al. Cureus 15(10): e47896. DOI 10.7759/cureus.47896 2 of 9

 Female 300 (60)

Male 200 (40)

Nationality

Saudi 349 (69.9)

Non-Saudi 150 (30.1)

Marital status

Single 125 (25.2)

Married 345 (69.4)

Divorced 9 (1.8)

Widow/widower 18 (3.6)

BMI (Mean ± SD) 29.43 ± 6.61

Underweight 12 (2.4)

Normal weight 109 (22.1)

Overweight 176 (35.6)

Obese I 114 (23.1)

Obese II 48 (9.7)

Obese III 35 (7.1)

Smoking status

No 445 (90.4)

Yes 47 (9.6)

Fatty liver based on physician diagnosis

No 467 (93.4)

Yes 33 (6.6)

Fatty liver based on imaging results

Normal 248 (49.6)

Fatty liver 67 (13.4)

Mild fatty liver 82 (16.4)

Mild to moderate fatty liver 9 (1.8)

Moderate fatty liver 52 (10.4)

Moderate to severe fatty liver 19 (3.8)

Severe fatty liver 21 (4.2)

Unclear classification 2 (0.4)

Medical history

Hypertension 167 (33.4)

Coronary artery disease or myocardial infarction 20 (4)

Dyslipidemia 147 (29.4)

Type 2 diabetes mellitus 157 (31.4)

Hypothyroidism 67 (13.4)

FIB-4 index (Mean ± SD) 0.94 ± 0.72

Low 409 (81.8)

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 Indeterminate 78 (15.6)

High 13 (2.6)

TABLE 1: Descriptive information of the study population

The mean age of the patient population was 49.41 ± 14.80 years, with 300 (60%) females and 345 (69.4%)
married. The mean body mass index was 29.43 ± 6.61 kg/m2, with the greatest number of patients being
either normal weight or overweight. The majority of patients were non-smokers. Thirty-three (6.6%)
patients had a fatty liver diagnosis that a physician documented in their medical chart under their past
medical history. According to the imaging results, half of our patients had some form of fatty liver. The
prevalence of fatty liver in the studied sample who completed imaging was 50.4% (252). The most common
chronic medical conditions were hypertension, type 2 diabetes mellitus, and dyslipidemia. Most patients had
a low FIB-4 index, with a mean FIB-4 index of 0.94 ± 0.72.

Patients with a fatty liver upon imaging had a statistically significant higher mean age than non-fatty liver
patients. Gender, nationality, and marital status did not differ between the two groups (Table 2).

Fatty liver based on imaging results

Variables p-value
No Yes

Age, in years 47.54 ± 16.17 51.25 ± 13.08 0.005

< 21 5 (2) 2 (0.8)

21–30 36 (14.5) 14 (5.6)

31–40 52 (21) 35 (13.9)

41–50 46 (18.5) 68 (27) 0.004

51–60 61 (24.6) 79 (31.3)

61–70 25 (10.1) 36 (14.3)

> 70 23 (9.3) 18 (7.1)

Gender

Female 149 (60.1) 151 (59.9) 0.971

Male 99 (39.9) 101 (40.1)

Nationality

Saudi 167 (67.6) 182 (72.2) 0.261

Non-Saudi 80 (32.4) 70 (27.8)

Marital status

Single 70 (28.5) 55 (21.9)

Married 163 (66.3) 182 (72.5) 0.368

Divorced 5 (2) 4 (1.6)

Widow/widower 8 (3.3) 10 (4)

BMI 27.28 ± 5.84 31.54 ± 6.65 0.001

Underweight 10 (4.1) 2 (0.8)

Normal weight 80 (32.7) 29 (11.6)

Overweight 97 (39.6) 79 (31.7)

0.001
Obese I 38 (15.5) 76 (30.5)

Obese II 12 (4.9) 36 (14.5)

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 Obese III 8 (3.3) 27 (10.8)

Smoking status

No 216 (87.8) 229 (93.1) 0.137

Yes 30 (12.2) 17 (6.9)

Fatty liver diagnosis placed by physician in medical history

No 246 (99.2) 221 (87.7) 0.001

Yes 2 (0.8) 31 (12.3)

Medical history

Hypertension 59 (23.8) 108 (42.9) 0.001

Coronary artery disease or myocardial infarction 4 (1.6) 16 (6.3) 0.010

Dyslipidemia 40 (16.1) 107 (42.5) 0.001

Type 2 diabetes mellitus 50 (20.2) 107 (42.5) 0.001

Hypothyroidism 32 (12.9) 35 (13.9) 0.746

FIB-4 index 0.94 ± 0.84 0.95 ± 0.58 0.824

Low 206 (83.1) 203 (80.6)

Indeterminate 37 (14.9) 41 (16.3) 0.642

High 5 (2) 8 (3.2)

TABLE 2: Prevalence of sociodemographic factors and medical history among patients with
NAFLD
NAFLD: nonalcoholic fatty liver disease

Body mass index was greater among fatty liver patients (p=0.001). In terms of cardiovascular risk factors,
hypertension, coronary artery disease, dyslipidemia, and type 2 diabetes mellitus were more common in the
fatty liver group. Interestingly, the mean FIB-4 index and FIB-4 risk category were not significantly different
between the two groups.

We also compared various laboratory parameters between fatty liver and non-fatty liver patients (Table 3).

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 Fatty liver based on imaging results
Parameters p-value
No Yes

ALT 21.77 ± 20.41 33.32 ± 28.52 0.001

AST 20.99 ± 11.33 26.7 ± 20.06 0.001

Ferritin 98.69 ± 114.3 136.7 ± 173.34 0.081

ALP 75.15 ± 30.29 84.15 ± 45.4 0.010

Triglycerides 1.37 ± 0.8 1.64 ± 0.83 0.003

Cholesterol 4.53 ± 1.04 4.59 ± 0.93 0.588

HDL-C 1.33 ± 0.4 1.27 ± 0.43 0.166

LDL-C 2.97 ± 0.96 3.04 ± 0.86 0.508

Bilirubin 8.68 ± 7.74 8.62 ± 6.82 0.929

Creatinine 70.85 ± 24.86 71.94 ± 26.45 0.642

Uric acid 300.6 ± 96.47 322.16 ± 80.5 0.408

TSH 2.29 ± 2.15 2.47 ± 1.73 0.414

PT 14.25 ± 2.52 14.16 ± 2.48 0.820

INR 1.08 ± 0.21 1.05 ± 0.29 0.460

TABLE 3: The mean difference in laboratory parameters among patients with NAFLD
ALT: alanine aminotransferase; AST: aspartate aminotransferase; ALP: alkaline phosphatase; HDL-C: high-density lipoprotein cholesterol; LDL-C: low-
density lipoprotein cholesterol; TSH: thyroid stimulating hormone; PT: prothrombin time; INR: international normalized ratio; NAFLD: nonalcoholic fatty
liver disease

The ALT, AST, and ALP were statistically higher among fatty liver patients. Lipid profiles did not vary
between fatty liver and non-fatty liver patients, except for triglycerides, which were statistically elevated in
NAFLD patients (p = 0.003). Bilirubin, ferritin, creatinine, uric acid, TSH, PT, and INR levels did not diverge
among the patients.

Stage III obesity was the most predictive factor for NAFLD in our patient population, followed by stage II
obesity and stage I obesity, as shown in Table 4.

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 Variable OR 95% CI p-value

Age 1.017 (1.005–1.03) 0.005

BMI

Underweight 0.552 (0.114–2.669) 0.460

Normal weight Reference

Overweight 2.247 (1.338–3.773) 0.001

Obese I 5.517 (3.101–9.818) 0.001

Obese II 8.276 (3.796–18.041) 0.001

Obese III 9.310 (3.8–22.81) 0.001

Hypertension (Yes/No) 2.403 (1.636–3.528) 0.001

Coronary artery disease or myocardial infarction (Yes/No) 4.136 (1.363–12.551) 0.012

Dyslipidemia (Yes/No) 3.837 (2.52–5.844) 0.001

Type 2 diabetes mellitus (Yes/No) 2.922 (1.962–4.352) 0.001

ALT 1.024 (1.014–1.034) 0.001

AST 1.030 (1.014–1.046) 0.001

ALP 1.007 (1.001–1.013) 0.014

Triglycerides 1.609 (1.159–2.233) 0.004

TABLE 4: Predictor’s factors of NAFLD

ALT: alanine aminotransferase; AST: aspartate aminotransferase; ALP: alkaline phosphatase; NAFLD: nonalcoholic fatty liver disease

The odds ratio of fatty liver disease was 9.3 times higher among stage III obese patients compared to normal-
weight patients. Among cardiovascular risk factors, coronary artery disease, dyslipidemia, type 2 diabetes
mellitus, and hypertension were all predictive of NAFLD. Additionally, increased ALT, AST, ALP, and
triglycerides were notable predictors of NAFLD.

Discussion
This study investigated the demographic, clinical, and laboratory characteristics of a patient population to
determine the potential predictors of NAFLD at a Saudi tertiary center. Studies regarding NAFLD in Saudi
Arabia are limited. A recent meta-analysis by Alenezi et al. included eight studies and found a pooled
prevalence rate of NAFLD of 16.8% in the Kingdom [9]. Additionally, the study reported a prevalence rate of
58% among patients with type 2 diabetes mellitus (9). Hence, it is crucial to identify the predictors of NAFLD
among the Saudi population to allow early prevention and treatment.

In addition, obesity emerged as a highly significant predictor of NAFLD, with higher levels of obesity
associated with a higher risk of the disease. This corroborates the established literature indicating that
obesity is a prominent risk factor for NAFLD, demonstrating the importance of screening for NAFLD in high-
risk populations and of weight management strategies in the prevention and management of the disease.
Weight loss can improve glycemic control, reduce steatosis, inflammation, and hepatic injury, and enhance
the quality of life in NAFLD patients [10]. Interestingly, a sizable portion of our patient population had a
normal BMI, suggesting that, while obesity is a significant risk factor, NAFLD can occur irrespective of body
weight, underscoring the complexity of the disease’s etiology.

Cardiovascular risk factors, such as hypertension, coronary artery disease, dyslipidemia, and type 2 diabetes
mellitus, were also significantly associated with NAFLD. This concurs with several studies that have
highlighted strong associations between NAFLD and hypertension, diabetes mellitus, and cardiovascular
disease [11]. These associations reinforce the systemic nature of NAFLD and its extensive interplay with
metabolic syndromes, emphasizing the necessity of a comprehensive approach to patient management and
care. The mechanism linking NAFLD to cardiovascular disease is very complex, and both are manifestations
of the end-organ damage of metabolic syndrome [11], so risk modification is recommended. Prospective
studies are also needed to confirm the cause-and-effect relationship between cardiovascular disease and

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 NAFLD.

In contrast to expectations, the FIB-4 index, a measure of liver fibrosis, did not differ between fatty-liver
and non-fatty-liver patients. The FIB-4 index, as a noninvasive marker, can stratify patients with liver
disease and can be used to predict liver-related morbidity and mortality [12]. It is unclear why there was no
distinction between NAFLD and non-NAFLD patients among our patients. Correspondingly, further studies
are needed to confirm our findings in the Saudi population.

Among the examined laboratory parameters, ALT, AST, ALP, and triglyceride levels were elevated in patients
with NAFLD, indicating hepatic inflammation and metabolic abnormalities. This agrees with previous
findings, signifying their importance as markers of liver injury and surrogate measures of NAFLD [13].
Additionally, global guidelines for global gastroenterology suggest that elevated ALT and AST are
independent predictors of progression and mortality in NAFLD [13]. The use of liver enzymes is, therefore,
crucial in both predictive and prognostic capacities in NAFLD.

Our study has several limitations. Due to its retrospective nature, we could not determine the temporality of
the risk factors seen in our patients. Moreover, our patient population is largely homogenous, which may
limit the generalizability of our findings. Our study did not review medications used by the cohort; this
limitation can impact the findings as some medications could lead to hepatic or weight effects. Nevertheless,
NAFLD studies in Saudi Arabia are limited, and our results provide valuable insights into NAFLD prediction
and the risk factors associated with NAFLD for clinicians across the Kingdom.

Conclusions
This study provides valuable insights into the role of obesity and metabolic risk factors in the development
of NAFLD. The findings underscore the importance of weight management and the control of metabolic risk
factors in the prevention and management of NAFLD. Further prospective studies with larger and more
diverse patient cohorts are needed to corroborate and expand the findings, enabling more refined strategies
for the risk prediction, early detection, and management of NAFLD.

Additional Information
Author Contributions
All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the
work.

Concept and design: Ghada Hussein

Acquisition, analysis, or interpretation of data: Ghada Hussein, Aljoharah A. Al Saud, Abdulelah A.

Bashandi, Mohammed M. Almousallam, Reem M. AlShihri, Osama M. Almousallam, Ibrahim M. Binsalamah,
Yaser Alendijani

Drafting of the manuscript: Ghada Hussein, Aljoharah A. Al Saud, Abdulelah A. Bashandi, Mohammed M.
Almousallam, Reem M. AlShihri, Osama M. Almousallam, Ibrahim M. Binsalamah, Yaser Alendijani

Critical review of the manuscript for important intellectual content: Ghada Hussein, Aljoharah A. Al
Saud, Abdulelah A. Bashandi, Mohammed M. Almousallam, Reem M. AlShihri, Osama M. Almousallam,
Ibrahim M. Binsalamah, Yaser Alendijani

Supervision: Ghada Hussein

Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. King Faisal Specialist
Hospital and Research Centre issued approval RAC 2221264. Ethical approval was obtained from the
Research Ethics Committee at King Faisal Specialist Hospital and Research Centre on 08 January 2023 (RAC
2221264). Animal subjects: All authors have confirmed that this study did not involve animal subjects or
tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the
following: Payment/services info: All authors have declared that no financial support was received from
any organization for the submitted work. Financial relationships: All authors have declared that they have
no financial relationships at present or within the previous three years with any organizations that might
have an interest in the submitted work. Other relationships: All authors have declared that there are no
other relationships or activities that could appear to have influenced the submitted work.

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