Prevalence of Non-Alcoholic Fatty Liver Disease by Ultrasonographic Assessment in Lean Individuals With Diabetes

BackgroundNon-alcoholic fatty liver disease (NAFLD) is increasingly recognized in individuals with a normal body mass index (BMI), a phenotype termed "lean NAFLD."Data on its prevalence and association with glycemic control among Indian diabetic populations remain limited.This study aimed to determine the prevalence of NAFLD in lean individuals with diabetes (BMI <23 kg/m²) and to evaluate its association with glycated hemoglobin (HbA1c) levels. MethodologyThis hospital-based observational study was conducted in the Department of General Medicine at a tertiary care center between September 2022 and August 2024.One hundred lean diabetes patients (BMI <23 kg/m²), 86 inpatients and 14 outpatients, diagnosed per American Diabetes Association (ADA) criteria, were enrolled; as all participants had type 2 diabetes mellitus, they met at least one cardiometabolic criterion for metabolic dysfunction-associated steatotic liver disease (MASLD), and the terms NAFLD and MASLD are used interchangeably in this report.Clinical parameters, fasting lipid profiles, and HbA1c were recorded, and abdominal ultrasonography was performed prospectively by a single radiologist blinded to clinical history, diabetes treatment, and laboratory results, to diagnose NAFLD and grade its severity (grades 1-3).Associations were assessed using the chi-square test and independent-samples t-test; all analyses were unadjusted bivariate comparisons. ResultsOf the 100 participants, 48 were male and 52 were female.NAFLD was detected in 38% (n=38; 95% CI 29.1-47.8%) of participants, with a higher prevalence in male patients (n = 21/48, 43.8%; 95% CI 30.7-57.7%)than female patients (n = 17/52, 32.7%; 95% CI 21.5-46.2%).Prevalence was similar between inpatients (32/86, 37.2%) and outpatients (6/14, 42.9%; p=0.69).Among affected participants, grade 1 disease was most common (n = 20/38, 52.6%; 95% CI 37.3-67.5%),followed by grade 2 (n = 14/38, 36.8%;95% CI 23.4-52.7%)and grade 3 (n = 4/38, 10.5%; 95% CI 4.2-24.1%).Mean HbA1c did not differ significantly between participants with and without fatty liver (8.75±2.26% vs. 8.94±2.18%;mean difference -0.19%, 95% CI -1.10 to 0.71; p=0.674).Fasting blood glucose >130 mg/dL was significantly more common among participants with fatty liver (OR 5.25, 95% CI 1.12-24.57;p=0.022); the association with elevated serum triglycerides (>149 mg/dL) did not reach statistical significance once the test statistic was corrected (OR 1.50, 95% CI 0.67-3.38;χ²=0.96,p=0.33). ConclusionNAFLD is common among lean Indian diabetes patients and occurred across a broad range of glycemic control.Fasting blood glucose, but not triglycerides or HbA1c, was significantly associated with NAFLD in this unadjusted analysis.These findings highlight the importance of considering NAFLD in lean individuals with diabetes and support further evaluation of targeted ultrasonographic screening in this population.