Influence of Non-alcoholic Fatty Liver Disease on the Development of Diabetes Mellitus

Anuradhani Kasturiratne; Sanjaya Weerasinghe; Anuradha S Dassanayake; Shaman Rajindrajith; Arjuna P de Silva; Norihiro Kato; A Rajitha Wickremasinghe; H Janaka de Silva


J Gastroenterol Hepatol. 2013;28(1):142-147. 

In This Article

Abstract and Introduction


Background and Aim Non-alcoholic fatty liver disease (NAFLD) is linked to metabolic syndrome, and is known to be associated with impaired fasting glycemia and diabetes mellitus. This prospective community-based study was conducted to determine the association between NAFLD and incidence of diabetes mellitus in an urban adult population in Sri Lanka.

Methods Participants of the Ragama Health Study cohort were assessed for NAFLD using established ultrasound criteria in 2007. Those who were free of diabetes at baseline were followed up for 3 years. Incidence rates of diabetes mellitus were compared between subjects with and without NAFLD at baseline.

Results Out of 2984 subjects, 926 had NAFLD and 676 had diabetes in 2007. Of the 2276 subjects who were free of diabetes in 2007, 1914 were re-assessed in 2010. After 3 years, 104 out of 528 subjects with NAFLD and 138 out of 1314 subjects without NAFLD had developed diabetes mellitus de novo. Incidence rates of diabetes were respectively 64.2 and 34 per 1000 person-years of follow up for those with and without NAFLD. NAFLD was an independent predictor of developing diabetes mellitus. Other independent predictors were impaired fasting glycemia and dyslipidemia.

Conclusions Subjects with ultrasonically diagnosed NAFLD have an increased risk of developing diabetes mellitus. Intervention for NAFLD through lifestyle modification may prevent progression of the current diabetes epidemic.


Non-alcoholic fatty liver disease (NAFLD) is considered the hepatic component of metabolic syndrome.[1] Metabolic abnormalities associated with a sedentary lifestyle are known to cause insulin resistance and subsequently type 2 diabetes mellitus. Sedentary lifestyle is also associated with increased adiposity and abnormalities of visceral fat distribution leading to development of NAFLD.[2]

Previous studies have suggested that NAFLD may predict the future development of diabetes mellitus.[3] However, most of these studies were retrospective and based on health check-up data of healthy volunteers, and the diagnosis of NAFLD was based on alanine transaminase (ALT) levels and, in some studies, clinical scoring systems.[4,5,6,7] While liver biopsy is the gold standard in the diagnosis of NAFLD, diagnosis based on established ultrasound criteria is considered the most feasible method of diagnosing NAFLD for epidemiological purposes. Because of its relatively high sensitivity and specificity for detecting NAFLD in situations where there is significant hepatic steatosis,[8] hepatic ultrasound is now widely used as a diagnostic test for NAFLD.

Parallel to rapidly increasing rates of obesity and type 2 diabetes, NAFLD is being increasingly diagnosed in the Asia-Pacific region, and prevalence rates of 5–40% have been reported.[9] Recent population based studies from Sri Lanka have reported a NAFLD prevalence of 32.6% in an urban community[10] and 18% in a predominantly Indian Tamil, rural, physically active, economically deprived estate worker community.[11] Sri Lanka is currently experiencing a surge in non-communicable diseases as a result of the epidemiologic and demographic transitions that have interacted with lifestyle changes. There is a high prevalence of diabetes mellitus, 17.5% in men and 15.7% in women, in the predominantly urban Western Province.[12]

This prospective, community cohort follow-up study in an urban adult population in Sri Lanka was performed to determine the risk of incident diabetes mellitus in people with NAFLD.