title: High Prevalence of Nonalcoholic Fatty Liver Disease in Patients With Type 2 Diabetes Mellitus and Normal Plasma Aminotransferase Levels.
abstract: OBJECTIVE
  Nonalcoholic fatty liver disease (NAFLD) and its more severe form with steatohepatitis (NASH) are common in patients with type 2 diabetes mellitus (T2DM). However, they are usually believed to largely affect those with elevated aminotransferases. The aim of this study was to determine the prevalence of NAFLD by the gold standard, liver magnetic resonance spectroscopy ((1)H-MRS) in patients with T2DM and normal aminotransferases, and to characterize their metabolic profile.
  
  
  METHODS
  We recruited 103 patients with T2DM and normal plasma aminotransferases (age, 60 ± 8 y; body mass index [BMI], 33 ± 5 kg/m(2); glycated hemoglobin [A1c], 7.6 ± 1.3%). We measured the following: 1) liver triglyceride content by (1)H-MRS; 2) systemic insulin sensitivity (homeostasis model assessment-insulin resistance); and 3) adipose tissue insulin resistance, both fasting (as the adipose tissue insulin resistance index: fasting plasma free fatty acids [FFA] × insulin) and during an oral glucose tolerance test (as the suppression of FFA).
  
  
  RESULTS
  The prevalence of NAFLD and NASH were much higher than expected (50% and 56% of NAFLD patients, respectively). The prevalence of NAFLD was higher in obese compared with nonobese patients as well as with increasing BMI (P = .001 for trend). Higher plasma A1c was associated with a greater prevalence of NAFLD and worse liver triglyceride accumulation (P = .01). Compared with nonobese patients without NAFLD, patients with NAFLD had severe systemic (liver/muscle) and, particularly, adipose tissue (fasting/postprandial) insulin resistance (all P < .01).
  
  
  CONCLUSIONS
  The prevalence of NAFLD is much higher than previously believed in overweight/obese patients with T2DM and normal aminotransferases. Moreover, many are at increased risk of NASH. Physicians should have a lower threshold for screening patients with T2DM for NAFLD/NASH.
authors.affiliation: Division of Endocrinology, Diabetes and Metabolism (P.P.S., F.B., M.M., R.L., S.S., K.C.), University of Florida, Gainesville, Florida 32610; Division of Endocrinology, Diabetes and Metabolism (P.P.S., F.B., M.M., D.B., S.S., K.C.), Malcom Randall Veterans Administration Medical Center (VAMC), Gainesville, Florida 32608; Division of Diabetes (B.O., J.H., K.C.), the University of Texas Health Science Center at San Antonio, San Antonio, Texas 78229; and Division of Diabetes (B.O., J.H., K.C.), and Division of Hepatology (A.W.), Audie L. Murphy VAMC, San Antonio, Texas 78229.
authors.forename: Paola
authors.initials: P
authors.lastname: Portillo-Sanchez
authors.affiliation: Division of Endocrinology, Diabetes and Metabolism (P.P.S., F.B., M.M., R.L., S.S., K.C.), University of Florida, Gainesville, Florida 32610; Division of Endocrinology, Diabetes and Metabolism (P.P.S., F.B., M.M., D.B., S.S., K.C.), Malcom Randall Veterans Administration Medical Center (VAMC), Gainesville, Florida 32608; Division of Diabetes (B.O., J.H., K.C.), the University of Texas Health Science Center at San Antonio, San Antonio, Texas 78229; and Division of Diabetes (B.O., J.H., K.C.), and Division of Hepatology (A.W.), Audie L. Murphy VAMC, San Antonio, Texas 78229.
authors.forename: Fernando
authors.initials: F
authors.lastname: Bril
authors.affiliation: Division of Endocrinology, Diabetes and Metabolism (P.P.S., F.B., M.M., R.L., S.S., K.C.), University of Florida, Gainesville, Florida 32610; Division of Endocrinology, Diabetes and Metabolism (P.P.S., F.B., M.M., D.B., S.S., K.C.), Malcom Randall Veterans Administration Medical Center (VAMC), Gainesville, Florida 32608; Division of Diabetes (B.O., J.H., K.C.), the University of Texas Health Science Center at San Antonio, San Antonio, Texas 78229; and Division of Diabetes (B.O., J.H., K.C.), and Division of Hepatology (A.W.), Audie L. Murphy VAMC, San Antonio, Texas 78229.
authors.forename: Maryann
authors.initials: M
authors.lastname: Maximos
authors.affiliation: Division of Endocrinology, Diabetes and Metabolism (P.P.S., F.B., M.M., R.L., S.S., K.C.), University of Florida, Gainesville, Florida 32610; Division of Endocrinology, Diabetes and Metabolism (P.P.S., F.B., M.M., D.B., S.S., K.C.), Malcom Randall Veterans Administration Medical Center (VAMC), Gainesville, Florida 32608; Division of Diabetes (B.O., J.H., K.C.), the University of Texas Health Science Center at San Antonio, San Antonio, Texas 78229; and Division of Diabetes (B.O., J.H., K.C.), and Division of Hepatology (A.W.), Audie L. Murphy VAMC, San Antonio, Texas 78229.
authors.forename: Romina
authors.initials: R
authors.lastname: Lomonaco
authors.affiliation: Division of Endocrinology, Diabetes and Metabolism (P.P.S., F.B., M.M., R.L., S.S., K.C.), University of Florida, Gainesville, Florida 32610; Division of Endocrinology, Diabetes and Metabolism (P.P.S., F.B., M.M., D.B., S.S., K.C.), Malcom Randall Veterans Administration Medical Center (VAMC), Gainesville, Florida 32608; Division of Diabetes (B.O., J.H., K.C.), the University of Texas Health Science Center at San Antonio, San Antonio, Texas 78229; and Division of Diabetes (B.O., J.H., K.C.), and Division of Hepatology (A.W.), Audie L. Murphy VAMC, San Antonio, Texas 78229.
authors.forename: Diane
authors.initials: D
authors.lastname: Biernacki
authors.affiliation: Division of Endocrinology, Diabetes and Metabolism (P.P.S., F.B., M.M., R.L., S.S., K.C.), University of Florida, Gainesville, Florida 32610; Division of Endocrinology, Diabetes and Metabolism (P.P.S., F.B., M.M., D.B., S.S., K.C.), Malcom Randall Veterans Administration Medical Center (VAMC), Gainesville, Florida 32608; Division of Diabetes (B.O., J.H., K.C.), the University of Texas Health Science Center at San Antonio, San Antonio, Texas 78229; and Division of Diabetes (B.O., J.H., K.C.), and Division of Hepatology (A.W.), Audie L. Murphy VAMC, San Antonio, Texas 78229.
authors.forename: Beverly
authors.initials: B
authors.lastname: Orsak
authors.affiliation: Division of Endocrinology, Diabetes and Metabolism (P.P.S., F.B., M.M., R.L., S.S., K.C.), University of Florida, Gainesville, Florida 32610; Division of Endocrinology, Diabetes and Metabolism (P.P.S., F.B., M.M., D.B., S.S., K.C.), Malcom Randall Veterans Administration Medical Center (VAMC), Gainesville, Florida 32608; Division of Diabetes (B.O., J.H., K.C.), the University of Texas Health Science Center at San Antonio, San Antonio, Texas 78229; and Division of Diabetes (B.O., J.H., K.C.), and Division of Hepatology (A.W.), Audie L. Murphy VAMC, San Antonio, Texas 78229.
authors.forename: Sreevidya
authors.initials: S
authors.lastname: Subbarayan
authors.affiliation: Division of Endocrinology, Diabetes and Metabolism (P.P.S., F.B., M.M., R.L., S.S., K.C.), University of Florida, Gainesville, Florida 32610; Division of Endocrinology, Diabetes and Metabolism (P.P.S., F.B., M.M., D.B., S.S., K.C.), Malcom Randall Veterans Administration Medical Center (VAMC), Gainesville, Florida 32608; Division of Diabetes (B.O., J.H., K.C.), the University of Texas Health Science Center at San Antonio, San Antonio, Texas 78229; and Division of Diabetes (B.O., J.H., K.C.), and Division of Hepatology (A.W.), Audie L. Murphy VAMC, San Antonio, Texas 78229.
authors.forename: Amy
authors.initials: A
authors.lastname: Webb
authors.affiliation: Division of Endocrinology, Diabetes and Metabolism (P.P.S., F.B., M.M., R.L., S.S., K.C.), University of Florida, Gainesville, Florida 32610; Division of Endocrinology, Diabetes and Metabolism (P.P.S., F.B., M.M., D.B., S.S., K.C.), Malcom Randall Veterans Administration Medical Center (VAMC), Gainesville, Florida 32608; Division of Diabetes (B.O., J.H., K.C.), the University of Texas Health Science Center at San Antonio, San Antonio, Texas 78229; and Division of Diabetes (B.O., J.H., K.C.), and Division of Hepatology (A.W.), Audie L. Murphy VAMC, San Antonio, Texas 78229.
authors.forename: Joan
authors.initials: J
authors.lastname: Hecht
authors.affiliation: Division of Endocrinology, Diabetes and Metabolism (P.P.S., F.B., M.M., R.L., S.S., K.C.), University of Florida, Gainesville, Florida 32610; Division of Endocrinology, Diabetes and Metabolism (P.P.S., F.B., M.M., D.B., S.S., K.C.), Malcom Randall Veterans Administration Medical Center (VAMC), Gainesville, Florida 32608; Division of Diabetes (B.O., J.H., K.C.), the University of Texas Health Science Center at San Antonio, San Antonio, Texas 78229; and Division of Diabetes (B.O., J.H., K.C.), and Division of Hepatology (A.W.), Audie L. Murphy VAMC, San Antonio, Texas 78229.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Cusi
mesh_terms: D000368:Aged; D003924:Diabetes Mellitus, Type 2 / Q000097:blood / Q000150:complications / Q000453:epidemiology*; D005234:Fatty Liver / Q000097:blood / Q000150:complications / Q000453:epidemiology; D005260:Female; D006801:Humans; D007333:Insulin Resistance / Q000502:physiology; D008099:Liver / Q000378:metabolism; D008297:Male; D008875:Middle Aged; D065626:Non-alcoholic Fatty Liver Disease / Q000097:blood / Q000150:complications / Q000453:epidemiology*; D009765:Obesity / Q000097:blood / Q000150:complications / Q000453:epidemiology; D015995:Prevalence; D000637:Transaminases / Q000097:blood*; D014280:Triglycerides / Q000378:metabolism
chemical_list: D014280:Triglycerides; D000637:Transaminases