Research Article| Volume 63, ISSUE 2, P486-493, August 2015

Sarcopaenia is associated with NAFLD independently of obesity and insulin resistance: Nationwide surveys (KNHANES 2008–2011)

Published:March 14, 2015DOI:

      Background & Aims

      Although sarcopaenia is associated with obesity-related comorbidities, its influence on non-alcoholic fatty liver disease (NAFLD) or steatohepatitis has not been fully determined. We aimed to investigate the direct relationship between sarcopaenia and NAFLD or steatohepatitis in the general population.


      We conducted a cross-sectional study using nationally representative samples of 15,132 subjects from the Korea National Health and Nutrition Examination Surveys 2008–2011. Subjects were defined as having NAFLD when they had higher scores from previously validated NAFLD prediction models such as the hepatic steatosis index, comprehensive NAFLD score and NAFLD liver fat score. BARD and FIB-4 scores were used to define advanced fibrosis in subjects with NAFLD. The skeletal muscle index (SMI) [SMI(%) = total appendicular skeletal muscle mass (kg)/weight (kg) × 100] measured by dual-energy X-ray absorptiometry was used to diagnose sarcopaenia with cut points of 32.2% for men and 25.5% for women.


      SMI was inversely correlated with all NAFLD predicting scores (Ps <0.001). After stratification, sarcopaenic subjects had an increased risk of NAFLD regardless of obesity (odds ratios [ORs] = 1.55 to 3.02, depending on models; all Ps <0.001) or metabolic syndrome (ORs = 1.63 to 4.00, all Ps <0.001). Multiple logistic regression analysis also demonstrated this independent association between sarcopaenia and NAFLD after adjusting for confounding factors related to obesity or insulin resistance (ORs = 1.18 to 1.22, all Ps <0.001). Furthermore, among the NAFLD population, subjects with lower SMIs were likely to have advanced fibrosis compared with non-sarcopaenic individuals (BARD and FIB-4: ORs = 1.83 and 1.69, respectively; both Ps <0.001). Compared with non-exercised subjects, individuals who exercised regularly had a lower risk of NAFLD (p <0.001), particularly among obese people with well-preserved muscle mass.


      Sarcopaenia is associated with increased risks of NAFLD and advanced fibrosis, independent of obesity or metabolic control.


      NAFLD (Non-alcoholic fatty liver disease), NASH (Non-alcoholic steatohepatitis), KNHANES (Korea National Health and Nutrition Examination Survey), ASM (Appendicular skeletal muscle mass), SMI (Skeletal muscle mass index), SD (Standard deviation), BMI (Body mass index), HSI (Hepatic steatosis index), CNS (Comprehensive NAFLD score), LFS (NAFLD liver fat score), HOMA-IR (Homeostasis model assessment of insulin resistance), AST (Aspartate transaminase), ALT (Alanine transaminase), AOR (Adjusted odds ratio)


      Linked Article

      • Sarcopenia in non-alcoholic fatty liver disease: Targeting the real culprit?
        Journal of HepatologyVol. 63Issue 2
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          There is exponential interest in non-alcoholic fatty liver disease (NAFLD) as a cause of chronic liver disease in the last decade [1]. The epidemic of obesity due to changes in life style and nutritional habits in Western countries has greatly contributed to the rapid increase in prevalence of NAFLD. In addition to obesity, NAFLD is strongly associated with diabetes mellitus and insulin resistance that are believed to be a consequence of low physical activity and increased fat mass as well as the metabolic syndrome [2,3].
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      • The association between sarcopenia and non-alcoholic fatty liver disease: Potential pitfalls in non-invasive prediction models
        Journal of HepatologyVol. 64Issue 2
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          We read with great interest the recent study by Lee et al. published in the Journal of Hepatology [1], which cross-sectionally investigated the association between low skeletal muscle index and non-alcoholic fatty liver disease (NAFLD) in a representative sample of the general Korean population. The main finding of this article was that sarcopenia was significantly associated with increased risk of NAFLD independent of both obesity and metabolic syndrome. Despite these promising results, we have some questions concerning this article.
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      • Reply to “The association between sarcopenia and non-alcoholic fatty liver disease: Potential pitfalls in non-invasive prediction models”
        Journal of HepatologyVol. 64Issue 2
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          We thank Kim et al. for their interest in our article and the several meaningful comments to be discussed. First, due to the definition of sarcopenia which consists of appendicular skeletal muscle mass and body weight [1], subjects with sarcopenia are likely to be more obese, this phenomenon was also reported by several researchers [2,3]. As obesity is closely linked to sarcopenia as well as non-alcoholic fatty liver disease (NAFLD), Kim et al. raised the issue that the effect of obesity should be fully adjusted in the logistic model in order to validate the independent association between sarcopenia and NAFLD [4].
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