Serum testosterone and non-alcoholic fatty liver disease in men and women in the US

Endurance Training Alleviates Metabolic-Associated Fatty-Liver Disease (MAFLD)-Related Testicular Impairments via Endoplasmic Reticulum Stress Regulation

BACKGROUND

Metabolic-associated fatty liver disease (MAFLD), the most prevalent liver disorder globally, affects 20%-40% of the population and presents significant health challenges. Studies link MAFLD to male reproductive dysfunction, highlighting the need for effective interventions. This study investigates the impact of MAFLD on testicular function and evaluates the protective role of endurance training, with a focus on the GRP78-IRE-1α-ATF6 signaling pathway.

METHODS

Forty-four rats were allocated into two dietary groups (n = 22 each): a standard diet control group (C) and a high-fat diet supplemented with fructose water group (FL). After 17 weeks, histological analysis confirmed MAFLD development in the FL group, while the control group showed no pathological changes. Each dietary group was further subdivided into sedentary and endurance-trained (T) subgroups (n = 10 per subgroup), resulting in four experimental groups: C, C + T, FL + T, and FL. At the end of the research, thyroid stimulating hormone (TSH), sex hormones (testosterone), tumor necrosis factor-alpha (TNF-a) as well as GRP78, IRE-1α, and AFT6 expression were assessed.

RESULTS

Our results indicated that MAFLD led to significant weight gain, disrupted serum levels of thyroid-stimulating hormone, and impaired sex hormone profile. Additionally, MAFLD triggered ER stress, evidenced by dysregulated expression of genes in the GRP78-IRE-1α-ATF6 pathway. Remarkably, endurance training mitigated these adverse effects by normalizing hormonal profiles and restoring the expression of ER stress-related genes. These findings highlight the critical role of ER stress in MAFLD-induced male reproductive dysfunction.

CONCLUSION

Overall, the present study suggests endurance training as a promising treatment strategy for addressing MAFLD and its associated reproductive complications.

Sex Hormone: A Potential Target at Treating Female Metabolic Dysfunction-Associated Steatotic Liver Disease?

The global prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) is rising due to rapid lifestyle changes. Although females may be less prone to MASLD than males, specific studies on MASLD in females should still be conducted. Previous research has shown that sex hormone levels are strongly linked to MASLD in females. By reviewing a large number of experimental and clinical studies, we summarized the pathophysiological mechanisms of estrogen, androgen, sex hormone-binding globulin, follicle-stimulating hormone, and prolactin involved in the development of MASLD. We also analyzed the role of these hormones in female MASLD patients with polycystic ovarian syndrome or menopause, and explored the potential of targeting sex hormones for the treatment of MASLD. We hope this will provide a reference for further exploration of mechanisms and treatments for female MASLD from the perspective of sex hormones.

Mechanism investigation of anti-NAFLD of Shugan Yipi Granule based on network pharmacology analysis and experimental verification

As a classical traditional Chinese patent medicine, Shugan Yipi Granule is widely used in China to treat non-alcoholic fatty liver disease (NAFLD) recently. Our previous study confirmed that Shugan Yipi Granule are effective in NAFLD. However, its underlying mechanism is still unknown. This study aims to investigate the mechanism of Shugan Yipi Granule on NAFLD based on network pharmacology prediction, liquid chromatography-mass spectrometry (LC-MS) analysis and in vitro verification. We obtained the active ingredients and targets of Shugan Yipi Granule and NAFLD from 6 traditional Chinese medicine databases, and the crucial components and targets screened by protein-protein interaction (PPI) network were used for molecular docking. Plasma metabolomics of NAFLD patients treated with Shugan Yipi Granule for one month was analyzed using LC-MS methods and MetaboAnalyst 4.0 to obtain significant differential metabolites and pathways. Finally, free fatty acid (FFA) induced HepG2 cells were treated with different concentrations of quercetin and kaempferol, then oil red o (ORO) and triglyceride (TG) level were tested to verify the lipid deposition of the cell. Network pharmacology analysis showed that the main active ingredients of Shugan Yipi Granule include quercetin, kaempferol and other 58 ones, as well as 188 potential targets. PI3K/Akt signaling pathway was found to be the most relevant pathway for the treatment of NAFLD. Non-targeted metabolomics showed that quercetin and kaempferol were significantly up-regulated differential metabolites and were involved in metabolic pathways such as thyroid hormone signaling. In vitro results showed that quercetin, kaempferol were effective in reducing lipid deposition and TG content by inhibiting cellular fatty acid uptake. Ultimately, with the network pharmacology and serum metabolomics analysis, quercetin and kaempferol were found to be the important active ingredients and significantly up-regulated differential metabolites of Shugan Yipi Granule against NAFLD, which we inferred that they may regulate NAFLD through PI3K/Akt signaling pathway and thyroid hormone metabolism pathway. The in vitro experiment verification results showed that quercetin and kaempferol attenuated the lipid accumulation and TG content by inhibiting the fatty acid uptake in the FFA-induced HepG2 cell. Current study provides the necessary experimental basis for subsequent in-depth mechanism research.

Associations of sex-related and thyroid-related hormones with risk of metabolic dysfunction-associated fatty liver disease in T2DM patients

BACKGROUND

We aimed to examine sex-specific associations between sex- and thyroid-related hormones and the risk of metabolic dysfunction-associated fatty liver disease (MAFLD) in patients with type 2 diabetes mellitus (T2DM).

METHODS

Cross-sectional analyses of baseline information from an ongoing cohort of 432 T2DM patients (185 women and 247 men) in Xiamen, China were conducted. Plasma sex-related hormones, including estradiol (E2), follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin (PRL), progesterone, and total testosterone (TT), and thyroid-related hormones, including free triiodothyronine (FT3), free thyroxine (FT4), thyroid-stimulating hormone (TSH), and parathyroid hormone (PTH), were measured using chemiluminescent immunoassays. MAFLD was defined as the presence of hepatic steatosis (diagnosed by either hepatic ultrasonography scanning or fatty liver index (FLI) score > 60) since all subjects had T2DM in the present study.

RESULTS

Prevalence of MAFLD was 65.6% in men and 61.1% in women with T2DM (P = 0.335). For men, those with MAFLD showed significantly decreased levels of FSH (median (interquartile range (IQR)):7.2 (4.9-11.1) vs. 9.8 (7.1-12.4) mIU/ml) and TT (13.2 (10.4-16.5) vs. 16.7 (12.8-21.6) nmol/L) as well as increased level of FT3 (mean ± standard deviation (SD):4.63 ± 0.68 vs. 4.39 ± 0.85 pmol/L) than those without MAFLD (all p-values < 0.05). After adjusting for potential confounding factors, FSH and LH were negative, while progesterone was positively associated with the risk of MAFLD in men, and the adjusted odds ratios (ORs) (95% confidence intervals (CIs)) were 0.919 (0.856-0.986), 0.888 (0.802-0.983), and 8.069 (2.019-32.258) (all p-values < 0.05), respectively. In women, there was no statistically significant association between sex- or thyroid-related hormones and the risk of MAFLD.

CONCLUSION

FSH and LH levels were negative, whereas progesterone was positively associated with the risk of MAFLD in men with T2DM. Screening for MAFLD and monitoring sex-related hormones are important for T2DM patients, especially in men.

Association of sex hormones with non-alcoholic fatty liver disease: An observational and Mendelian randomization study

BACKGROUND AND AIMS

Sex-specific associations of sex hormone-binding globulin (SHBG) and bioavailable testosterone (BAT) with NAFLD remain indeterminate. We aimed to explore observational and genetically determined relationships between each hormone and NAFLD.

METHODS

We included 187 395 men and 170 193 women from the UK Biobank. Linear and nonlinear Cox regression models and Mendelian randomization (MR) analysis were used to test the associations.

RESULTS

During 12.49 years of follow-up, 2209 male and 1886 female NAFLD cases were documented. Elevated SHBG levels were linearly associated with a lower risk of NAFLD in women (HR (95% CI), .71 (.63, .79)), but not in men (a "U" shape, pnon-linear < .001). Higher BAT levels were associated with a lower NAFLD risk in men (HR (95% CI), .81 (.71, .93)) but a higher risk in women (HR (95% CI): 1.25 (1.15, 1.36)). Genetically determined SHBG and BAT levels were linearly associated with NAFLD risk in women (OR (95% CI): .57 (.38, .87) and 2.21 (1.41, 3.26) respectively); in men, an "L-shaped" MR association between SHBG levels and NAFLD risk was found (pnon-linear = .016). The bidirectional MR analysis further revealed the effect of NAFLD on SHBG and BAT levels in both sexes.

CONCLUSIONS

Consistently, linear associations of lower SHBG and higher BAT levels with increased NAFLD risk were both conventionally and genetically found in women, while in men, SHBG acts in a nonlinear manner. In addition, NAFLD may affect SHBG and BAT levels.

Loss of testosterone induces postprandial insulin resistance and increases the expression of the hepatic antioxidant flavin-containing monooxygenases in mice exposed to intermittent hypoxia

AIM

We tested the hypothesis that low testosterone alters the effects of intermittent hypoxia (IH) on glucose homeostasis, hepatic oxidative stress, and transcriptomic profile in male mice.

METHODS

We used sham-operated or orchiectomized (ORX) mice exposed to normoxia (Nx) or IH for 2 weeks. We performed fasting insulin and glucose tolerance tests and assessed fasting and postprandial insulin resistance with the HOMA-IR. The activity of hepatic prooxidant (NADPH oxidase-NOX), antioxidant enzymes (superoxide dismutase, catalase, and glutathione peroxidase-SOD, Cat, GPx), lipid peroxidation (MDA concentration), and the total concentration of glutathione (GSH) were measured under postprandial conditions. mRNA sequencing and pathway enrichment analyses were used to identify hepatic genes underlying the interactions between IH and testosterone.

RESULTS

In Sham mice, IH improves fasting insulin sensitivity and glucose tolerance, while there are no effects of IH in ORX mice. In ORX mice, IH induces postprandial hyperinsulinemia, insulin resistance, and a prooxidant profile of enzyme activity (low SOD activity) without altering hepatic MDA and GSH content. ORX and IH altered the expression of genes involved in oxidoreductase activities, cytochromes-dependent pathways, and glutathione metabolism. Among the genes upregulated in ORX-IH mice, the flavin-containing monooxygenases (FMO) are particularly relevant since these are potent hepatic antioxidants that could help prevent overt oxidative stress in ORX-IH mice.

CONCLUSION

Low levels of testosterone in male mice exposed to IH induce post-prandial hyperinsulinemia and insulin resistance and determine the mechanisms by which the liver handles IH-induced oxidative stress.

The Metabolic Syndrome, a Human Disease

This review focuses on the question of metabolic syndrome (MS) being a complex, but essentially monophyletic, galaxy of associated diseases/disorders, or just a syndrome of related but rather independent pathologies. The human nature of MS (its exceptionality in Nature and its close interdependence with human action and evolution) is presented and discussed. The text also describes the close interdependence of its components, with special emphasis on the description of their interrelations (including their syndromic development and recruitment), as well as their consequences upon energy handling and partition. The main theories on MS's origin and development are presented in relation to hepatic steatosis, type 2 diabetes, and obesity, but encompass most of the MS components described so far. The differential effects of sex and its biological consequences are considered under the light of human social needs and evolution, which are also directly related to MS epidemiology, severity, and relations with senescence. The triggering and maintenance factors of MS are discussed, with especial emphasis on inflammation, a complex process affecting different levels of organization and which is a critical element for MS development. Inflammation is also related to the operation of connective tissue (including the adipose organ) and the widely studied and acknowledged influence of diet. The role of diet composition, including the transcendence of the anaplerotic maintenance of the Krebs cycle from dietary amino acid supply (and its timing), is developed in the context of testosterone and β-estradiol control of the insulin-glycaemia hepatic core system of carbohydrate-triacylglycerol energy handling. The high probability of MS acting as a unique complex biological control system (essentially monophyletic) is presented, together with additional perspectives/considerations on the treatment of this 'very' human disease.

Endogenous sex hormones and nonalcoholic fatty liver disease in US adults

BACKGROUND AND AIMS

Sex steroid hormones and sex hormone-binding globulin (SHBG) have a role in predisposing individuals to nonalcoholic fatty liver disease (NAFLD), but their effects are known to differ between men and women. The testosterone-to-estradiol ratio (T/E2 ratio) and free androgen index (FAI) were known biomarkers for the hormonal milieu. We investigated whether sex steroid hormones, T/E2 ratio, FAI, and SHBG were associated with NAFLD in US adults.

METHODS

A cross-sectional analysis using the 2013-2016 National Health and Nutrition Examination Survey (NHANES) was performed. NAFLD was defined by utilizing the Hepatic Steatosis Index (HSI) and the US fatty liver index (USFLI) without other causes of chronic liver disease.

RESULTS

Out of 8687 subjects (49.5% male), low total testosterone levels were associated with progressively higher odds of NAFLD in men. Increasing T/E2 ratio was inversely associated with higher odds of NAFLD in men. Low serum SHBG levels were independently associated with an increased risk of NAFLD regardless of sex and menopausal status. Increasing FAI was independently associated with NAFLD. When we additionally adjusted for SHBG, T/E2 ratio, not total testosterone, was inversely associated with NAFLD in a dose-dependent manner. Increasing FAI was associated with higher odds of NAFLD in premenopausal women and marginally associated with NAFLD in postmenopausal women.

CONCLUSION

The T/E2 ratio and SHBG were inversely associated with an increased risk of NAFLD in men. In women, increasing FAI was associated with NAFLD, whereas SHBG was inversely associated with NAFLD.

Myosteatosis: Diagnosis, pathophysiology and consequences in metabolic dysfunction-associated steatotic liver disease

Metabolic dysfunction-associated steatotic liver disease (MASLD) is associated with an increased risk of multisystemic complications, including muscle changes such as sarcopenia and myosteatosis that can reciprocally affect liver function. We conducted a systematic review to highlight innovative assessment tools, pathophysiological mechanisms and metabolic consequences related to myosteatosis in MASLD, based on original articles screened from PUBMED, EMBASE and COCHRANE databases. Forty-six original manuscripts (14 pre-clinical and 32 clinical studies) were included. Microscopy (8/14) and tissue lipid extraction (8/14) are the two main assessment techniques used to measure muscle lipid content in pre-clinical studies. In clinical studies, imaging is the most used assessment tool and included CT (14/32), MRI (12/32) and ultrasound (4/32). Assessed muscles varied across studies but mainly included paravertebral (4/14 in pre-clinical; 13/32 in clinical studies) and lower limb muscles (10/14 in preclinical; 13/32 in clinical studies). Myosteatosis is already highly prevalent in non-cirrhotic stages of MASLD and correlates with disease activity when using muscle density assessed by CT. Numerous pathophysiological mechanisms were found and included: high-fat and high-fructose diet, dysregulation in fatty acid transport and ketogenesis, endocrine disorders and impaired microRNA122 pathway signalling. In this review we also uncover several potential consequences of myosteatosis in MASLD, such as insulin resistance, MASLD progression from steatosis to metabolic steatohepatitis and loss of muscle strength. In conclusion, data on myosteatosis in MASLD are already available. Screening for myosteatosis could be highly relevant in the context of MASLD, considering its correlation with MASLD activity as well as its related consequences.

Noninvasive Indices of MASLD Are Associated With Hypogonadism in Male Patients With Type 2 Diabetes Mellitus

CONTEXT

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most prevalent chronic liver disease, affecting one-fourth of the adult population worldwide. Recent data found an association between MASLD and hypogonadism, but this relation in patients with type 2 diabetes mellitus (T2DM) is still unclear.

OBJECTIVE

To evaluate in men with T2DM the association between total testosterone (TT) and noninvasive indices of hepatic steatosis (Fatty Liver Index [FLI], Hepatic Steatosis Index [HSI], Dallas Steatosis Index [DSI]) and fibrosis (AST to Platelet Ratio Index [APRI], Fibrosis-4 Index [FIB-4]), and their predictive cutoff values in identifying hypogonadism.

METHODS

Cross-sectional study on 189 men with T2DM, without history of liver diseases and alcoholism, recruited on an outpatient basis. Interventions were andrological evaluation, metabolic parameters, TT, and liver indices. The main outcome measures were comparison of steatosis and fibrosis indices with testosterone levels and presence of hypogonadism. Receiver operating characteristic curves were used to identify cutoff values of liver indices in predicting low testosterone (<12 nmol/L).

RESULTS

FLI, HSI, and DSI were negatively related with TT and were higher in the low-testosterone group than in the normal-testosterone group (FLI: 74.1 [61.4-93.5] vs 56.5 [32.1-78.2], P < .001; HSI: 41.5 [39.2-45.9] vs 40.1 [36.6-43.2], P = .005; DSI: 0.45 [-0.08-+1.04] vs -0.07 [-1.02-+0.58], P < .001). FLI and DSI also correlated with clinical symptoms of hypogonadism. No differences between groups were observed for APRI and FIB-4. FLI ≥63 was the best parameter as predictive index of low TT (sensitivity 73%, specificity 64%).

CONCLUSION

We found an association between noninvasive indices of steatosis and hypogonadism in patients with T2DM. These indices could be used to direct the patients to andrological evaluation.

Metabolic syndrome-related factors as possible targets for lower urinary tract symptoms in Korean males

INTRODUCTION

A positive association between benign prostate hyperplasia (BPH)/lower urinary tract symptoms (LUTS) and metabolic syndrome (MetS) was reported in several studies, but studies from Asia often showed conflicting results.

MATERIALS AND METHODS

Medical records were obtained from a health promotion center database between 2021 and 2022. Men without a history of treatment for LUTS were evaluated using the International Prostate Symptom Score (IPSS), Overactive Bladder Symptom Score (OABSS), transrectal ultrasonography.

RESULTS

Of 1345 individuals, 603 (44.8%) had MetS. Older age, higher IPSS values, higher prevalence rates of BPH and overactive bladder, higher triiodothyronine, and lower testosterone and sex-hormone binding globulin were observed in individuals with MetS than in individuals without MetS. The severity of LUTS significantly increased in the individuals with MetS (p = .002). In individuals with MetS, age, HbA1c, and cerebrovascular disease (CVD) were associated with IPSS. For OABSS, age, HbA1c, thyroid-stimulating hormone (TSH), coronary artery occlusive disease, and CVD were identified as predictors.

CONCLUSIONS

We confirmed the positive correlation between MetS and BPH/LUTS in Korean. Factors including TSH and atherosclerosis affected LUTS in individuals with MetS. These findings suggested a potential role of thyroid hormones and atherosclerosis in the etiology and treatment of BPH/LUTS in patients with MetS.

Association between depression and metabolic dysfunction-associated fatty liver disease/significant fibrosis

BACKGROUND

An association between depression and metabolic dysfunction-associated fatty liver disease (MAFLD) appears logical on the basis of previous observations linking depression to nonalcoholic fatty liver disease. We aim to investigate the association between depression and MAFLD and significant fibrosis.

METHODS

This cross-sectional study was conducted on data from National Health and Nutrition Examination Survey, 2017 to March 2020 Pre-pandemic dataset. Depression and depression-related functional impairment were assessed using the Patient Health Questionnaire (PHQ-9). MAFLD, based on the criteria proposed by an international expert panel, and significant fibrosis were defined by transient elastography.

RESULTS

Of the 3327 individuals (mean age: 46.9 years, 50.2 % men), the prevalence of depression and functional impairment due to depression was higher among individuals with MAFLD or significant fibrosis than among those without. Individuals with depression were approximately 70 % more likely to have MAFLD than those without. In multivariable analyses, depression was associated with an increased risk of MAFLD (odds ratio [OR]: 1.77, 95 % confidence interval [CI]:1.33-2.36 for ≥263 dB/m and OR: 1.70, 95 % CI: 1.20-2.41 for ≥285 dB/m). These associations were more pronounced in postmenopausal women than premenopausal women. In terms of significant fibrosis, depression remained an independent predictor of significant fibrosis; however, it attenuated after adjustment for body mass index.

LIMITATIONS

Temporal causality and residual confounders could not be entirely investigated due to the study design.

CONCLUSIONS

Depression was independently associated with MAFLD and significant fibrosis in a nationally representative sample of adults in the US.

Associations between body circumference and testosterone levels and risk of metabolic dysfunction-associated fatty liver disease: a mendelian randomization study

Backgroud

Body circumference and testosterone levels have been reported as associated with metabolic dysfunction-associated fatty liver disease (MAFLD) risk. However, whether body circumference and testosterone levels play a role in the development of MAFLD remains inconclusive.

Methods

Using a large database of genome-wide association studies, genetic loci that are independent of each other and strongly associated with body circumference and testosterone levels were selected as instrumental variables, the causal relationship between body circumference and testosterone and risk of MAFLD was investigated by two-sample Mendelian randomization methods such as inverse variance weighted (IVW), MR-Egger regression, and weighted median estimator (WME), using the odds ratios (ORs) as evaluation indicators.

Results

A total of 344 SNPs were included as instrumental variables in this study, including 180 for waist circumference, 29 for waist-to-hip ratio, and 135 for testosterone levels. Using the above two-sample Mendelian Randomization method to derive the causal association between exposure and outcome. The results of this study showed that three exposure factors were causally associated with the risk of MAFLD. Waist circumference obtained three statistically significant results for IVW, WME and Weighted mode (IVW: OR = 3.53, 95%CI: 2.23–5.57, P < 0.001; WME: OR = 3.88, 95%CI: 1.81–8.29, P < 0.001; Weighted mode: OR = 3.58, 95%CI: 1.05–12.16, P = 0.043). Waist-to-hip ratio obtained one statistically significant result for IVW (OR = 2.29, 95%CI: 1.12–4.66, P = 0.022). Testosterone levels obtained one statistically significant result for IVW (OR = 1.93, 95%CI: 1.30–2.87, P = 0.001). Waist circumference, waist-to-hip ratio and testosterone level were considered as risk factors for MAFLD. The Cochran Q test for IVW and MR-Egger method indicated that there was no intergenic heterogeneity in SNPs. The test for pleiotropy indicated that the possibility of pleiotropy in the causal analysis was weak.

Conclusion

The results of the two-sample Mendelian randomization analysis showed that waist circumference was the exact risk factor for MAFLD, waist-to-hip ratio and testosterone levels were potential risk factors for MAFLD, the risk of developing MAFLD increases with these three exposure factors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-023-15467-4.

Gender difference in association between low muscle mass and risk of non-alcoholic fatty liver disease among Chinese adults with visceral obesity

Background and aims

Although the association between low muscle mass and the risk of non-alcoholic fatty liver disease is well-known, it has not been explored in viscerally obese populations by gender. Besides, whether low muscle mass still increases the NAFLD risk in subjects with visceral obesity, independent of obesity, is still unknown. The aim of this study was to explore the gender-specific association between low muscle mass and the risk of non-alcoholic fatty liver disease (NAFLD) in subjects with visceral obesity.

Methods

Overall, 1,114 participants aged 19-89 years were recruited in this retrospective study. Liver disease was diagnosed by hepatic ultrasound. Skeletal muscle mass was estimated by bioimpedance analysis and defined by the appendicular skeletal muscle index (ASMI). Gender-specific differences in the ASMI value were compared between NAFLD and control groups. Restricted cubic spline and multivariate logistic regression were performed to analyze the association (stratified by gender and age) between the ASMI and the risk of NAFLD, respectively.

Results

Middle-aged females (40-60 years) and males (of any age) with NAFLD had a significantly lower ASMI compared with controls (P-value < 0.05). An inverse linear association was found between the ASMI and risk of NAFLD (all P _{fornon-linearity} > 0.05). Lower quartiles of the ASMI conferred independent risk of NAFLD compared to higher quartiles (all P for trend < 0.001). Low muscle mass conferred a higher risk of NAFLD in middle-aged females (adjusted odds ratio = 2.43, 95% confidence interval: 1.19-4.95) and males [18-39 years: 3.76 (1.79-7.91); 40-60 years: 4.50 (2.16-9.39); and >60 years: 4.10 (1.13-14.84)]. Besides, Low muscle mass and low muscle mass with obesity increase the risk of developing NAFLD, independent of obesity.

Conclusion

Among those with visceral obesity, low muscle mass increased the risk of NAFLD in males of any age, and middle-aged females, this may be explained by the postmenopausal decline in estrogen.

The associations of total testosterone with probable nonalcoholic steatohepatitis and nonalcoholic fatty liver disease fibrotic progression in men with type 2 diabetes: a cross-sectional study

BACKGROUND

Testosterone has an impact on metabolic disorders and men with type 2 diabetes mellitus (T2DM) are predisposed to hypogonadism; meanwhile, patients with T2DM have higher risk of NAFLD. Therefore, we speculate that testosterone may affect the progression of NAFLD in T2DM patients and we aim to investigate whether total testosterone is associated with NAFLD progression in men with T2DM.

METHODS

A cross-sectional study. A total of 1782 male participants with T2DM were enrolled from seven communities in Shanghai. Probable nonalcoholic steatohepatitis (NASH) was defined by the concurrence of NAFLD and metabolic syndrome (MetS). NAFLD fibrosis score was used to identify patients with probable advanced fibrosis. Multinomial logistic regression and ordinal logistic regression was used to measure the association of total testosterone (independent variable) and the progression category of NAFLD (dependent variable).

RESULTS

In male, TT quartiles were negatively associated with probable NASH (Q1 vs. Q4 OR 2.07 95% CI 1.31-3.28, P for trend = 0.001) and inflammatory progression of NAFLD with OR of 1 SD increment of ln (TT) 0.81 (95% CI 0.72-0.92, P for trend < 0.001), but positively with fibrotic progression (Q1 vs. Q4 OR 0.45, 95% CI 0.29-0.72, P for trend = 0.001) with OR of 1 SD increment of ln (TT) 1.24 (95% CI 1.07-1.45). According to stratified analyses, for inflammatory progression, the interactions of age strata, duration of diabetes strata, and dyslipidemia status with 1 SD increment of ln (TT) were significant (P for interaction 0.007, 0.003, and 0.012, respectively); as for fibrotic progression, we found no interactions (all P for interaction ≥ 0.05).

CONCLUSIONS

Different associations between TT and inflammatory and fibrotic progression of NAFLD in male were observed, suggesting different roles of TT in inflammatory and fibrotic stages of NAFLD.

Non-alcoholic fatty liver disease across endocrinopathies: Interaction with sex hormones

Nonalcoholic fatty liver disease (NAFLD) has emerged as the most frequent chronic liver disease globally. NAFLD is strongly associated with metabolic syndrome and it has been recently suggested that to rename NAFLD as metabolic dysfunction-associated fatty liver disease (MAFLD). NAFLD has been studied in different endocrine axes and accumulating body of clinical and experimental studies have suggested that NAFLD is associated with polycystic ovarian syndrome (PCOS), hypopituitarism, growth hormone deficiency (GHD), hypogonadism and other endocrine disorders. In fact, endocrine dysfunction may be considered as the major contributor for the development, progression, and severity of NAFLD. In the present comprehensive review, we discussed the epidemiological and clinical evidence on the epidemiology, pathophysiology, and management of NAFLD in endocrine disorders, with an emphasis on the effects of sex-specific hormones/conditions as well as molecular basis of NAFLD development in these endocrine diseases.

Relationship between growth hormone deficiency and nonalcoholic fatty liver disease in patients with pituitary stalk interruption syndrome

BACKGROUND

Pituitary stalk interruption syndrome (PSIS), characterized by thinning or disappearance of the pituitary stalk, hypoplasia of the anterior pituitary, and an ectopic posterior pituitary, can lead to congenital combined pituitary hormone deficiency. There is a high prevalence of various metabolic disorders, including nonalcoholic fatty liver disease (NAFLD), in this population.

OBJECTIVE

To investigate the characteristics of NAFLD in Chinese adult patients with PSIS and its association with growth hormone deficiency.

DESIGN

Retrospective cross-sectional study in a tertiary referral center of China.

PATIENTS

Adult patients with PSIS diagnosed, followed up between September 2019 and August 2021, were consecutively enrolled.

MEASUREMENTS

Abdominal ultrasonography images were evaluated and noninvasive fibrosis scores were determined to assess the severity of NAFLD. Anthropometric, clinical, and biochemical parameters were compared between patients with and without NAFLD. Logistic regression was performed to assess the independent effects of insulin-like growth factor-1 (IGF-1) on NAFLD.

RESULTS

A total of 93 patients (77 men, 16 women, mean age: 29.6 ± 7.1 years) were included. The prevalence of NAFLD and advanced fibrosis/cirrhosis was 50.5% and 4.3%, respectively. Insufficient hormone therapy and prominent metabolic disorders, including central obesity, dyslipidemia, insulin resistance, and metabolic syndrome, were more common in the NAFLD (+) group. After adjusting for multiple variables, IGF-1 &lt;-2 standard deviation score (SDS) was found to be associated with an increased prevalence of NAFLD (odds ratio [OR]: 4.92, 95% confidence interval [CI]: 1.21-24.55, p = .035). Per 1 SDS increase in IGF-1 was associated with a 27% lower risk of NAFLD (OR: 0.73, 95% CI: 0.52-0.97, p = .042).

CONCLUSION

NAFLD is a frequent comorbidity among Chinese adult patients with PSIS and is strongly associated with lower IGF-1 levels. Timely and appropriate hormone replacement, particularly growth hormone may contribute to decreasing the risk of NAFLD in these patients.

Associations between sex hormones and metabolic-associated fatty liver disease in a middle-aged and elderly community

Metabolic-associated fatty liver disease (MAFLD) was proposed by an international expert consensus to replace non-alcoholic fatty liver disease (NAFLD) in 2020. Previous studies have shown that sex hormones are strongly linked to NAFLD development. This study aims to explore whether sex hormones are associated with MAFLD and liver fat content (LFC) in a middle-aged and elderly community. The study included 732 subjects aged 50-80 years enrolled from communities. MAFLD was diagnosed using the 2020 International Expert Consensus. LFC was calculated using parameters from abdominal ultrasound images. Serum estradiol (E2), total testosterone (TT), sex hormone-binding globulin (SHBG), FSH, and LH were measured by chemiluminescent microparticle immunoassay. MAFLD was diagnosed in 107/304 (35.2%) men and 154/428 (35.2%) women. After adjustments for confounding factors, logistic regression analysis showed that SHBG was negatively correlated with MAFLD in men (OR, 0.95 [0.93-0.97], p < 0.001). In women, SHBG and FSH were negatively correlated with MAFLD (OR, 0.95 [0.94-0.97], p < 0.001; OR, 0.97 [0.96-0.98], p < 0.001). Multivariate linear regression analysis showed that SHBG was a negative factor for LFC in both men (standardized β = -0.188, p < 0.001) and women (standardized β = -0.184, p < 0.001). FSH was a negative factor for LFC in women (standardized β = -0.082, p = 0.046). SHBG was negatively correlated with MAFLD in middle-aged and elderly men and women. Moreover, FSH was negatively correlated, and bioactive testosterone was positively correlated with MAFLD in women. These findings suggest a relationship between sex hormones and MAFLD.

Low Serum Total Testosterone Is Associated with Non-Alcoholic Fatty Liver Disease in Men but Not in Women with Type 2 Diabetes Mellitus

Materials and Methods

There were 1155 patients with T2DM included in the analysis. Serum levels of total testosterone and the precursors of androgens, including androstenedione, DHEA, and DHEAS, were quantified using liquid chromatography-tandem mass spectrometry assays.

Results

The risk of NAFLD decreased as total testosterone concentration increased in men with T2DM. After adjusting for age, current smoking, current drinking, body mass index, duration of T2DM, diastolic blood pressure, total cholesterol, triglycerides, low-density lipoprotein/high-density lipoprotein cholesterol ratio, uric acid, C-reactive protein, and sex hormones in model 4, the adjusted odds ratio (OR) and 95% confidence interval (CI) of NAFLD for tertile3 vs tertile1 was 0.37 (0.17-0.77; P = 0.024 for trend). When taken as a continuous variable, this association was still robust in model 4 (OR, 0.58; 95% CI, 0.42-0.80; P < 0.05). No significant associations were found between increasing levels of the precursors of androgens and the odds of NAFLD in men with T2DM (all P > 0.05). Moreover, women showed no significant associations of total testosterone, androstenedione, DHEA, and DHEAS, with the odds of NAFLD (all P > 0.05).

Conclusions

Serum total testosterone was independently associated with the risk of NAFLD among men with T2DM. This study highlights the potential role of testosterone as a risk factor for NAFLD in patients with T2DM.

Digestive Health in Sexual and Gender Minority Populations

It has been over 50 years since the Stonewall Inn Riots in June 1969, a seminal event for the lesbian, gay, bisexual, transgender, queer, intersex, and other sexual and gender-diverse minorities (LGBTQI+, or lesbian, gay, bisexual, transgender, queer, intersex, and everyone else) rights movement. However, sexual and gender minority (SGM) individuals still face discrimination and harassment due to their sexual orientation or gender identity. As such, the National Institute on Minority Health and Health Disparities has identified SGM communities as a "health disparity population." Broadly, there are higher rates of sexually transmitted infections, substance use and abuse, mental health conditions, obesity and eating disorders, certain cancers (breast, cervical, and anorectal), and cardiovascular disease in SGM communities. Transgender patients, especially those of color, are more likely to be uninsured, experience discrimination, and be denied health care than cisgender patients. In addition, SGM individuals have twice the risk of lifetime exposure to emotional, physical, and sexual trauma compared with heterosexuals. It is expected all these factors would negatively affect digestive health as well. This review summarizes the effects of social determinants of health and discrimination on health care access, highlights important digestive diseases to consider in the SGM population, and offers solutions to improve and prioritize the health of these communities. We aim to draw attention to SGM-specific issues that affect gastrointestinal health and spur research that is desperately lacking.

Associations of Sex Steroids and Sex Hormone-Binding Globulin with Non-Alcoholic Fatty Liver Disease: A Population-Based Study and Meta-Analysis

Background: Prior studies have reported inconsistent results or less well-explored associations between sex hormones and non-alcoholic fatty liver disease (NAFLD). Here, we aimed to investigate the associations of NAFLD with sex steroids and sex hormone-binding globulin (SHBG) in the population-based study and conduct a comprehensive systematic review and meta-analysis of all published observational studies. Methods: Analyses included 755 men and 1109 women with available data on sex steroids, SHBG, and ultrasound-based NAFLD from the Rotterdam Study. Multivariable regression models were used to examine the associations. Additionally, we searched five databases from inception to 1 April 2022 and performed a systematic review and meta-analysis. Random-effects (DerSimonian-Laird) method was used for meta-analysis, odds ratios (ORs) were calculated for the effect estimate, subgroup and leave-one-out sensitivity analyses were conducted, and meta-regression was performed to explore the pooled statistics with high heterogeneity. Results: In the Rotterdam Study, lower levels of SHBG were associated with NAFLD in both sexes, while lower testosterone was associated with NAFLD only among women. Similarly, the meta-analysis of 16 studies indicated no sex-specific association between SHBG and NAFLD (men: OR = 0.37, 95%CI 0.21–0.53; women: OR = 0.40, 95%CI 0.21–0.60), yet there was a sex-specific association between testosterone and NAFLD (men: OR = 0.59, 95%CI 0.42–0.76; women: OR = 1.06, 95%CI 0.68–1.44). Moreover, men with NAFLD had lower estradiol levels than those without NAFLD. Conclusions: Lower SHBG levels were associated with NAFLD in both sexes, but testosterone levels were associated in a sex-specific manner. In addition, our results showed estradiol with the potential as a protective factor for NAFLD in healthy men.

Testosterone therapy reduces hepatic steatosis in men with type 2 diabetes and low serum testosterone concentrations

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is highly prevalent in people with diabetes with no available treatment.

AIM

To explore the effect of testosterone treatment on liver. Testosterone therapy improves insulin resistance and reduces total body fat, but its impact on the liver remains poorly studied.

METHODS

This secondary analysis of a 40 wk, randomised, double-blinded, placebo-controlled trial of intramuscular testosterone undecanoate in men with type 2 diabetes and lowered serum testosterone concentrations evaluated the change in hepatic steatosis as measured by liver fat fraction on magnetic resonance imaging (MRI).

RESULTS

Of 88 patients enrolled in the index study, 39 had liver MRIs of whom 20 received testosterone therapy and 19 received placebo. All patients had > 5% hepatic steatosis at baseline and 38 of 39 patients met diagnostic criteria for NAFLD. Median liver fat at baseline was 15.0% (IQR 11.5%-21.1%) in the testosterone and 18.4% (15.0%-28.9%) in the placebo group. Median ALT was 34units/L (26-38) in the testosterone and 32units/L (25-52) in the placebo group. At week 40, patients receiving testosterone had a median reduction in absolute liver fat of 3.5% (IQR 2.9%-6.4%) compared with an increase of 1.2% in the placebo arm (between-group difference 4.7% P < 0.001). After controlling for baseline liver fat, testosterone therapy was associated with a relative reduction in liver fat of 38.3% (95% confidence interval 25.4%-49.0%, P < 0.001).

CONCLUSION

Testosterone therapy was associated with a reduction in hepatic steatosis in men with diabetes and low serum testosterone. Future randomised studies of testosterone therapy in men with NAFLD focusing on liver-related endpoints are therefore justified.

Relationship between total testosterone, sex hormone-binding globulin levels and the severity of non-alcoholic fatty liver disease in males: a meta-analysis

BACKGROUND

In recent years, many studies have reported the relationship between non-alcoholic fatty liver disease (NAFLD) and sex hormones, especially total testosterone (TT) and sex hormone-binding globulin (SHBG). However, the relationship between sex hormones and the severity of NAFLD is still unclear.

METHODS

PubMed, Embase, Cochrane Library, Web of Science, WanFang, China National Knowledge Infrastructure and VIP databases were searched for relevant studies from inception to 31 August 2021. Values of weighted mean differences (WMDs) and odds ratios (ORs) with their 95% confidence intervals (CIs) were combined by Stata 12.0 software to evaluate the relationship between TT, SHBG and the severity of NAFLD in males.

RESULTS

A total of 2995 patients with NAFLD from 10 published cross-sectional studies were included for further analysis. The meta-analysis indicated that the moderate-severe group had a lower TT than the mild group in males with NAFLD (WMD: -0.35 ng/ml, 95% CI = -0.50 to -0.20). TT and SHBG were important risk factors of moderate-severe NAFLD in males (OR_TT = 0.79, 95% CI = 0.73 to 0.86; OR_SHBG = 0.22, 95% CI = 0.12 to 0.39; p < 0.001). Moreover, when the analysis was limited to men older than age 50, SHBG levels were lower in those with moderate-severe disease (WMD: -11.32 nmol/l, 95% CI = -14.23 to -8.40); while for men with body mass index (BMI) >27 kg/m², moderate-severe NAFLD had higher SHBG levels than those with mild disease (WMD: 1.20 nmol/l, 95% CI = -2.01 to 4.42).

CONCLUSION

The present meta-analysis shows that lower TT is associated with the severity of NAFLD in males, while the relationship between SHBG and severity of NAFLD is still to be further verified.

A low follicle-stimulating hormone level is a protective factor for non-alcoholic fatty liver disease in older men aged over 80

PURPOSE

Recent studies have suggested the significant relationship between follicle-stimulating hormone (FSH) and non-alcoholic fatty liver disease (NAFLD) in postmenopausal women. However, it is unknown whether FSH impacts the risk of NAFLD in men. This study aimed to investigate the association between serum FSH levels and NAFLD in elderly Chinese men aged 80-98, a particular group with worse outcomes of NAFLD.

PATIENTS AND METHODS

A cross-sectional analysis was performed in 444 subjects in a geriatric health center. The highest quartile of serum FSH was used as reference. Hepatic steatosis was defined according to the results of liver ultrasound. Fibrosis-4 (FIB-4) Index > 2.67 was defined as advanced fibrosis.

RESULTS

Based on liver ultrasound, 108 (24.3%) subjects had NAFLD. FSH level were negatively correlated with total testosterone, estradiol, nutritional risk, and the prevalence of high education level (all P < 0.01), and positively correlated with age, luteinizing hormone, alanine aminotransferase and aspartate aminotransferase (all P < 0.05). The correlation between FSH and body mass index or antihypertensive drug usage was marginally significant (P = 0.057; P = 0.066, respectively). The percentage of subjects with NAFLD had a trend to increase following the quartiles of serum FSH (20.0% in quartile 1, 18.2% in quartile 2, 27.3% in quartile 3, and 31.6% in quartile 4). After adjustment for common pathogenic risk factors, nutritional risk, and other sex hormones, serum FSH were progressively associated with odds ratios for NAFLD. The adjusted odds ratios and 95% CIs for quartile 1, quartile 2, and quartile 3, compared with quartile 4 were 0.132 (0.034-0.516), 0.190 (0.052-0.702), and 0.404 (0.139-1.173), respectively. Obesity was not involved in the potential negative role of circulating FSH on the risk of NAFLD in our population. Furthermore, our results revealed no significant association between FSH and advance fibrosis, the OR (95% CI) for advanced fibrosis was 1.018 (0.983-1.054) (P = 0.316) after adjusting for the potential covariates, although a positive correlation of FSH and FIB-4 score was observed (r = 0.325, P = 0.001).

CONCLUSION

Low FSH level may decrease the risk of NAFLD in elderly Chinese men. These findings warrant replication in more extensive studies.

Correlation Between Sex Hormones and Non-alcoholic Fatty Liver Disease Before and After Laparoscopic Sleeve Gastrectomy

OBJECTIVES

To investigate the cross-sectional and longitudinal correlation between sex hormones and non-alcoholic fatty liver disease (NAFLD) in patients with obesity before and after laparoscopic sleeve gastrectomy (LSG).

METHODS

A total of 360 patients with obesity aged 16-48 years (170 men and 190 women) were enrolled between May 2017 and March 2021. Among them, 132 patients (55 men and 77 women) who underwent LSG had follow-up data. Anthropometric parameters, metabolic variables, and sex hormones were measured. NAFLD was assessed by FibroScan with controlled attenuation parameter (CAP) and liver stiffness measurement (LSM).

RESULTS

In the preoperative cohort, levels of CAP and LSM were significantly higher in men than women. Lower total testosterone (TT) was associated with higher CAP and LSM in men, whereas higher TT was associated with higher CAP in women. In the postoperative cohort, TT levels and NAFLD were significantly modified after LSG in both genders. Changes in TT levels at 3 months after surgery were negatively correlated with changes in CAP levels in men, and changes in TT levels at 6 months after surgery were positively correlated with changes in CAP levels in women. After adjusting possible confounders, the changes in TT levels were independently correlated with CAP variation in both genders.

CONCLUSIONS

LSG significantly modified TT levels and NAFLD in both genders. The correlation between TT levels and NAFLD at baseline as well as the changes after surgery suggested TT levels play an important role in the development and regression of NAFLD in both genders.

Severity of non-alcoholic steatohepatitis is not linked to testosterone concentration in patients with type 2 diabetes

BACKGROUND

Hypogonadism is reported to occur in non-alcoholic fatty liver disease (NAFLD), but earlier studies used low-sensitivity diagnostic techniques (CT, ultrasound), for NAFLD diagnosis. We hypothesized that if hypogonadism was due to NAFLD, and not solely attributable to underlying obesity/diabetes, it would be more severe in the presence of steatohepatitis (NASH). To examine the influence of liver disease on testosterone in males with type 2 diabetes mellitus (T2DM), we used gold-standard liver imaging with MR-spectroscopy (1H-MRS), and performed liver biopsies to grade/stage the NAFLD.

METHODS

In this cross-sectional study, we measured in 175 males with T2DM total and free testosterone, markers of insulin resistance, and intrahepatic triglyceride content (IHTG) by 1H-MRS. Those with NAFLD on imaging underwent a liver biopsy.

RESULTS

Total testosterone was higher in the group without NAFLD ("No-NAFLD"; n = 48) compared to isolated steatosis (IS; n = 62) or NASH (n = 65) (385 ± 116 vs. 339 ± 143 vs. 335 ± 127 ng/ml, ptrend 0.03). Testosterone was also lower in obese vs. non-obese subjects in both the No-NAFLD and IS groups (p = 0.06 and p = 0.11, respectively), but not in obese vs. non-obese patients with NASH (p = 0.81). IHTG was independently associated with total testosterone (ß = -4.8, p = 0.004). None of the liver histology characteristics were associated with lower testosterone.

CONCLUSIONS

NAFLD is linked to lower total testosterone in patients with T2DM, but likely given a common soil of insulin resistance/obesity and not from the severity of liver necroinflammation or fibrosis. Nevertheless, clinicians should consider screening patients with T2DM and NAFLD for hypogonadism.

Diagnosis and management of secondary causes of steatohepatitis

The term non-alcoholic fatty liver disease (NAFLD) was originally coined to describe hepatic fat deposition as part of the metabolic syndrome. However, a variety of rare hereditary liver and metabolic diseases, intestinal diseases, endocrine disorders and drugs may underlie, mimic, or aggravate NAFLD. In contrast to primary NAFLD, therapeutic interventions are available for many secondary causes of NAFLD. Accordingly, secondary causes of fatty liver disease should be considered during the diagnostic workup of patients with fatty liver disease, and treatment of the underlying disease should be started to halt disease progression. Common genetic variants in several genes involved in lipid handling and metabolism modulate the risk of progression from steatosis to fibrosis, cirrhosis and hepatocellular carcinoma development in NAFLD, alcohol-related liver disease and viral hepatitis. Hence, we speculate that genotyping of common risk variants for liver disease progression may be equally useful to gauge the likelihood of developing advanced liver disease in patients with secondary fatty liver disease.

Physical Activity, Measured Objectively, Is Associated With Lower Mortality in Patients With Nonalcoholic Fatty Liver Disease

BACKGROUND & AIMS

The association between physical activity (PA) and all-cause and cause-specific mortality from nonalcoholic fatty liver disease (NAFLD) requires investigation. We studied whether PA, measured by accelerometer, is associated with all-cause and cause-specific mortality among individuals with NAFLD.

METHODS

We performed a longitudinal analysis using the 2003 to 2006 US National Health and Nutrition Examination Survey data of adults (age, ≥20 y) and collecting mortality data through December 2015. NAFLD was defined based on the hepatic steatosis index or US fatty liver index scores, in the absence of other causes of chronic liver disease. PA was measured from participants who wore accelerometers 10 h/d for a minimum of 4 days over a 7-day period and were classified as total PA, moderate to vigorous PA (MVPA), and sedentary behavior.

RESULTS

Over an average follow-up period of 10.6 years, increasing the duration of total PA was associated with a reduced risk of death, from any cause, in an age- and sex-adjusted model (hazard ratio [HR], 0.52; 95% CI, 0.32-0.86 for highest quartile vs lowest quartile; P for trend = .001) and multivariable model (HR, 0.46; 95% CI, 0.28-0.75; P for trend < .001) among individuals with NAFLD. Increasing the duration of MVPA was associated with a lower risk of death from any cause in individuals with NAFLD. Furthermore, longer total PA was associated with a lower risk for cardiovascular disease-related death in individuals with NAFLD (HR, 0.28; 95% CI, 0.08-0.98 for highest quartile vs lowest quartile; P for trend = .007). We did not find this association for cancer-related mortality in individuals with NAFLD. Increasing the duration of sedentary behavior did not affect all-cause or cause-specific mortality in individuals with NAFLD.

CONCLUSIONS

Longer total PA and MVPA, measured by accelerometers over a 7-day period, are associated with lower all-cause and cardiovascular mortality in individuals with NAFLD.

Therapeutic pipeline in nonalcoholic steatohepatitis

Our understanding of nonalcoholic fatty liver disease pathophysiology continues to advance rapidly. Accordingly, the field has moved from describing the clinical phenotype through the presence of nonalcoholic steatohepatitis (NASH) and degree of fibrosis to deep phenotyping with a description of associated comorbidities, genetic polymorphisms and environmental influences that could be associated with disease progression. These insights have fuelled a robust therapeutic pipeline across a variety of new targets to resolve steatohepatitis or reverse fibrosis, or both. Additionally, some of these therapies have beneficial effects that extend beyond the liver, such as effects on glycaemic control, lipid profile and weight loss. In addition, emerging therapies for NASH cirrhosis would have to demonstrate either reversal of fibrosis with associated reduction in portal hypertension or at least delay the progression with eventual decrease in liver-related outcomes. For non-cirrhotic NASH, it is the expectation that reversal of fibrosis by one stage or resolution of NASH with no worsening in fibrosis will need to be accompanied by overall survival benefits. In this Review, we summarize NASH therapies that have progressed to phase II and beyond. We also discuss some of the potential clinical challenges with the use of these new therapies when approved.

Nonalcoholic fatty liver disease and risk of prostatic diseases: Roles of insulin resistance

Nonalcoholic fatty liver disease (NAFLD), the liver component of metabolic syndrome, is considered to be associated with high risk of prostatic diseases but a systematic review has not been conducted. Under a comprehensive review of the eligible clinical studies, a potential positive association between NAFLD and benign prostatic hyperplasia/prostate cancer (BPH/PCa) has been postulated. Insulin resistance and metabolic aberrations are considered to be the potential mechanism for such association. However, the relationship between NAFLD and other prostatic diseases, that is, prostatic inflammation and lower urinary tract symptoms, seems vague due to limited relevant studies in the literatures. The present review highlights that clinicians should be conscious of the detrimental effect of NAFLD on the development of BPH and PCa.

Influence of sex and menopausal status on the relationship between metabolic syndrome and coronary artery calcification: a Chinese community-based cross-sectional study

OBJECTIVE

To evaluate the association between metabolic syndrome and coronary artery calcification according to different sex and menopausal status.

METHODS

This cross-sectional study included 2,704 adults from the Jidong community (Tangshan, China) recruited from July 2013 to August 2014. Adults aged ≥40 years with no cardiovascular disease and with coronary artery calcification score data were included. Metabolic syndrome was defined according to the 2005 International Diabetes Federation standard. Coronary artery calcification score was determined using the Agatston method. The associations between metabolic syndrome and coronary artery calcification prevalence were evaluated using logistic regression.

RESULTS

In the multivariable regression analysis, metabolic syndrome was associated with coronary artery calcification (odds ratio: 1.34, 95% confidence interval: 1.04-1.71, P = 0.021). When stratified by sex, metabolic syndrome was positively associated with coronary artery calcification prevalence in female participants (odds ratio: 2.79, 95% confidence interval: 1.96-3.96, P < 0.001), whereas no association was observed in male participants. Furthermore, metabolic syndrome was associated with a higher prevalence of coronary artery calcification (P < 0.001) independent of adjustment for covariates in postmenopausal women than in premenopausal women, and coronary artery calcification prevalence increased with an increase in conditions related to metabolic syndrome.

CONCLUSIONS

Our findings indicate that metabolic syndrome in postmenopausal women is associated with a higher prevalence of coronary artery disease than in premenopausal women and men.

Fatty liver index is associated with the risk of testosterone deficiency in aging men without metabolic syndrome

OBJECTIVES

Non-alcoholic fatty liver disease (NAFLD) is suggested to be a precursor of metabolic syndrome (MetS) and could influence the risk of testosterone deficiency (TD). Fatty liver index (FLI) is a simple and useful screening tool for NAFLD. We determined the association between the risk of NAFLD assessed by FLI and TD in aging Taiwanese men, especially those without MetS.

MATERIALS AND METHODS

A free health screening program was conducted for men (age: >40 years) in a medical center in Kaohsiung, Taiwan. All participants underwent a physical examination; answered a questionnaire assessing demographics, medical history, and clinical symptoms of TD; and provided 20-mL whole blood samples for biochemical, adipocytokine, and hormonal evaluations. The risk of NAFLD was evaluated using FLI. The presence of NAFLD was ruled out if FLI value was <25 and ruled in if FLI value was ≥35.

RESULTS

A total of 552 men (mean age: 54.7 ± 7.7 years) were enrolled. The prevalence rates of TD and MetS were significantly higher among men with NAFLD than those without NAFLD (both p < 0.001). FLI was significantly correlated with total testosterone (TT) and adipocytokines associated with insulin resistance, such as adiponectin, leptin, and retinol-binding protein-4 (RBP-4) levels, respectively (all p < 0.001). Among men without MetS, those at risk of and with NAFLD had a 3.82 and 8.50 times higher risk of TD, respectively, than those without NAFLD after adjusting for potential covariates.

CONCLUSION

The FLI is associated with the risk of TD in aging Taiwanese men, especially in those without MetS. Our findings also suggest that insulin resistance may be an important link among the inter-relationships of NAFLD, MetS, and TD. Further population-based studies with larger sample sizes of different ethnicities are warranted to confirm these preliminary results.

Sarcopenia is associated with the presence of nonalcoholic fatty liver disease in Zhejiang Province, China: a cross-sectional observational study

Background

Currently, both non-alcoholic fatty liver disease (NAFLD) and sarcopenia have attracted extensive attention in public health. However, the relationship between NAFLD and sarcopenia remains unclear. This study aimed to clarify the sex-specific association between sarcopenia and NAFLD according to the Asian Working Group for Sarcopenia (AWGS).

Methods

Dual-energy X-ray absorptiometry (DXA) and hepatic ultrasonography were measured in 578 participants (92 men and 486 women) during their annual health examinations. Multivariate logistic regression models were used to explore the association between NAFLD and sarcopenia with its two components.

Results

A total of 154 participants (30 men and 124 women) had NAFLD. The prevalence of sarcopenia was higher among the participants with NAFLD than among those without NAFLD (men: 20.0% vs. 9.7%, P = 0.295, women: 15.3% vs. 8.0%, P = 0.019). Low muscle mass (LMM) was independently associated with NAFLD in both men and women (men: odds ratio [OR], 2.88; 95% confidence interval [CI] 1.52–5.46; women: OR, 2.08; 95% CI 1.63–2.67). However, low muscle strength (LMS) was independently associated with NAFLD only in male participants, with an OR of 1.15 (95% CI 1.02–1.28).

Conclusion

The occurrence of sarcopenia was associated with a higher risk of NAFLD, especially in men, as demonstrated by lower muscle mass and lower muscle strength.

Associations between serum total, free and bioavailable testosterone and non-alcoholic fatty liver disease in community-dwelling middle-aged and elderly women

BACKGROUND AND AIMS

Non-alcoholic fatty liver disease (NAFLD) is considered both a cause and consequence of the metabolic syndrome (MetS). While emerging evidence has indicated that testosterone is associated with MetS, the relationship between testosterone and NAFLD in women remains unclear. Therefore, this study investigated the associations between serum testosterone levels and NAFLD prevalence risk in a community-based cross-sectional study.

METHODS

A total of 2117 adult women were included in the analysis. Serum total testosterone (TT) was measured by chemiluminescence immunoassay, and other testosterone-related indices, such as concentrations and percentages of calculated free testosterone (cFT) and bioavailable testosterone (BioT), and free androgen index (FAI), were also calculated. NAFLD was diagnosed by clinical criteria. Logistic regression was used to explore these associations.

RESULTS

There were significant differences in TT, FAI, cFT and BioT between women with and without NAFLD (all P<0.001). Multivariate logistic-regression analyses demonstrated that both absolute concentrations and percentages of cFT and BioT were positively associated with NAFLD risk prevalence in all models. Adjusted ORs (95% CI) for quartile 4 vs quartile 1 of % cFT and % BioT were 5.94 (4.29-8.22) and 5.21 (3.79-7.17) in model 2, and 4.35 (3.07-6.18) and 3.58 (2.55-5.03) in model 3 (all P<0.001 for trend). In addition, quartiles of TT, FAI, cFT and BioT were significantly correlated with degree of hepatic steatosis. ROC analysis also showed that % cFT and % BioT were more accurate for predicting NAFLD prevalence than was TT.

CONCLUSION

Serum cFT and BioT were positively associated with NAFLD risk, and elevated levels of cFT and BioT could be independent risk factors of NAFLD prevalence in middle-aged and elderly women.

NAFLD and NASH in Postmenopausal Women: Implications for Diagnosis and Treatment

Nonalcoholic fatty liver disease (NAFLD) prevalence in women is increasing worldwide. Women of reproductive age have lower rates of NAFLD compared with men; however, this protection is lost following the menopausal transition when NAFLD prevalence in postmenopausal women becomes similar to or surpasses that in age-matched male counterparts. Ongoing epidemiological, clinical, and experimental studies indicate greater NAFLD risk and higher rates of severe hepatic fibrosis in postmenopausal women relative to premenopausal women, and that older women with NAFLD experience greater mortality than men. Investigations involving ovariectomized animal models demonstrate a causal relationship between estrogen deficiency and heightened susceptibility to the development of fatty liver and steatohepatitis, although dietary factors may exacerbate this complex relationship. The accumulated findings suggest that a better understanding of the interplay among menopausal status, metabolic comorbidities, and sex steroids in NAFLD pathogenesis is needed. Further, the mechanisms underlying the difference in NAFLD risk between postmenopausal and premenopausal women remain incompletely understood. The goals of this review are to summarize studies of NAFLD risk in postmenopausal women, discuss results from animal models of estrogen deficiency, and explore the development of NAFD within the context of altered sex hormone profiles resulting from the menopausal transition. Potential implications for the prevention, diagnosis, and treatment of NAFLD in this relatively understudied cohort are also addressed.

Nonalcoholic fatty liver disease in males with low testosterone concentrations

AIMS

There are limited clinical data on the association between serum testosterone concentrations and nonalcoholic fatty liver disease (NAFLD) in men. The main aim of this study was to evaluate the association between testosterone concentrations and NAFLD in adult men, in terms of noninvasive indices of NAFLD and hepatic fibrosis.

METHODS

In this cross-sectional study, 98 men were recruited on an outpatient basis and were divided into low-testosterone (<12 nmol/l or <346 ng/dl, n = 37) or high-testosterone groups (≥12 nmol/l or ≥346 ng/dl, n = 61). Serum testosterone concentrations were measured by immuno-chemiluminescence. Hepatic steatosis index (HSI) and Triglyceride-to-HDL-C ratio (THR), as non-invasive indices of NAFLD, as well as AST-to-Platelet Ratio Index (APRI), fibrosis-4 index (FIB-4) and NAFLD fibrosis score (NFS), as non-invasive indices of hepatic fibrosis, were calculated based on standard formulas.

RESULTS

Both the non-invasive indices of NAFLD (HSI and THR) were higher in low-testosterone compared with high-testosterone group (HSI: 47.5 ± 2.9 vs. 38.4 ± 1.0, p = 0.005; THR: 1.70 ± 0.16 vs. 0.98 ± 0.07, p < 0.001). On the contrary, none of the non-invasive indices of hepatic fibrosis was different between groups. HSI (p = 0.038), but not THR, remained inversely independently associated with serum testosterone, after adjustment for potential confounders, including sex hormone-binding globulin.

CONCLUSIONS

Men with low testosterone concentrations have higher non-invasive indices of NAFLD (HSI and THR), but not of hepatic fibrosis (APRI, FIB-4, NFS), compared with counterparts of high testosterone concentrations. HSI was inversely and independently associated with testosterone concentrations.

Sex-specific genetic effects across biomarkers

Sex differences have been shown in laboratory biomarkers; however, the extent to which this is due to genetics is unknown. In this study, we infer sex-specific genetic parameters (heritability and genetic correlation) across 33 quantitative biomarker traits in 181,064 females and 156,135 males from the UK Biobank study. We apply a Bayesian Mixture Model, Sex Effects Mixture Model (SEMM), to Genome-wide Association Study summary statistics in order to (1) estimate the contributions of sex to the genetic variance of these biomarkers and (2) identify variants whose statistical association with these traits is sex-specific. We find that the genetics of most biomarker traits are shared between males and females, with the notable exception of testosterone, where we identify 119 female and 445 male-specific variants. These include protein-altering variants in steroid hormone production genes (POR, UGT2B7). Using the sex-specific variants as genetic instruments for Mendelian randomization, we find evidence for causal links between testosterone levels and height, body mass index, waist and hip circumference, and type 2 diabetes. We also show that sex-specific polygenic risk score models for testosterone outperform a combined model. Overall, these results demonstrate that while sex has a limited role in the genetics of most biomarker traits, sex plays an important role in testosterone genetics.

Nonalcoholic Fatty Liver Disease Is Associated with Benign Prostate Hyperplasia

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is associated with a wide spectrum of metabolic abnormalities. This study aimed to evaluate whether NAFLD is associated with benign prostatic hyperplasia (BPH) independent of other risk factors.

METHODS

A total of 3,508 subjects who underwent prostate and hepatic ultrasonography were enrolled. NAFLD was diagnosed and graded by ultrasonographic findings. BPH was defined by total prostate volume.

RESULTS

The prevalence of BPH was significantly increased according to NAFLD severity (P < 0.001). The multivariate analysis showed that NAFLD was associated with a 22% increase in the risk of BPH (odds ratio [OR], 1.22; 95% confidence interval [CI], 1.02-1.45). In non-obese subjects, NAFLD was associated with a 41% increase in the risk of BPH (OR, 1.41; 95% CI, 1.14-1.73), and an incremental increase in the risk of BPH according to NAFLD severity was pronounced (adjusted OR [95% CI], 1.32 [1.05-1.68] for mild NAFLD, 1.55 [1.15-2.10] for moderate to severe NAFLD vs. no NAFLD, P for trend = 0.004). However, in the obese population, the association of NAFLD in the risk of BPH was insignificant (P = 0.208).

CONCLUSION

NAFLD is associated with an increased risk of BPH regardless of metabolic syndrome, especially in non-obese subjects. An incrementally increased risk of BPH according to NAFLD severity is prominent in non-obese subjects with NAFLD. Thus, physicians caring for non-obese patients with NAFLD may consider assessing the risk of BPH and associated urologic conditions.

Impact of Androgen Deprivation Therapy on Non-Alcoholic Fatty Liver Disease in Patients with Prostate Cancer: A CT Evaluation

PURPOSE

The aim of this study was to investigate the influence of androgen deprivation therapy (ADT) on the progression of non-alcoholic fatty liver disease (NAFLD) in patients with prostate cancer (PCa) by evaluation of hepatic steatosis on computed tomography (CT).

METHODS

The study included 77 PCa patients who underwent abdominal CT at baseline and after 6 months of ADT. The degree of hepatic steatosis was evaluated according to the attenuation value for liver parenchyma (CTLP), the attenuation ratio for liver and spleen (LSratio), and the difference in attenuation between LS (LSdif). The associations between these 3 indices and various metabolic syndrome-related factors were analyzed.

RESULTS

The number of NAFLD patients increased from 9 (11.6%) at baseline to 16 (20.7%) after ADT. The CTLP, LSratio, and LSdif values were significantly lower after ADT than before (p < 0.05). There were significant correlations between the percent change in CTLP and the percent change in HbA1c, between the percent change in LSratio and the percent change in abdominal circumference, and between the percent change in LSdif and the percent change in BMI.

CONCLUSIONS

Six months of ADT was associated with significant progression of NAFLD in PCa patients. This progression was strongly correlated with changes in HbA1c, abdominal circumference, and BMI.

Sex differences in non-alcoholic fatty liver disease: hints for future management of the disease

Non-alcoholic fatty liver disease (NAFLD) remains a major cause of chronic liver disease worldwide. Despite extensive studies, the heterogeneity of the risk factors as well as different disease mechanisms complicate the goals toward effective diagnosis and management. Recently, it has been shown that sex differences play a role in the prevalence and progression of NAFLD. In vitro, in vivo, and clinical studies revealed that the lower prevalence of NAFLD in premenopausal as compared to postmenopausal women and men is mainly due to the protective effects of estrogen and body fat distribution. It has been also described that males and females present differential pathogenic features in terms of biochemical profiles and histological characteristics. However, the exact molecular mechanisms for the gender differences that exist in the pathogenesis of NAFLD are still elusive. Lipogenesis, oxidative stress, and inflammation play a key role in the progression of NAFLD. For NAFLD, only a few studies characterized these mechanisms at the molecular level. Therefore, we aim to review the reported differential molecular mechanisms that trigger such different pathogenesis in both sexes. Differences in lipid metabolism, glucose homeostasis, oxidative stress, inflammation, and fibrosis were discussed based on the evidence reported in recent publications. In conclusion, with this review, we hope to provide a new perspective for the development of future practice guidelines as well as a new avenue for the management of the disease.

Food Insecurity May Be an Independent Risk Factor Associated with Nonalcoholic Fatty Liver Disease among Low-Income Adults in the United States

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD), considered a "barometer" of metabolic health, is the leading cause of liver disease in the United States. Despite established associations between food insecurity and obesity, hypertension, and diabetes, little is known about the relation between food insecurity and NAFLD.

OBJECTIVE

We sought to evaluate the association of food insecurity with NAFLD among low-income adults in the United States.

METHODS

We conducted a cross-sectional analysis of a nationally representative sample of adults from the NHANES (2005-2014 waves). Participants included adults in low-income households (≤200% of the federal poverty level) without chronic viral hepatitis or self-reported heavy alcohol use. Food insecurity was measured using the Household Food Security Survey. Our primary outcome was NAFLD, as estimated by the US Fatty Liver Index, and our secondary outcome was advanced fibrosis, as estimated by the NAFLD fibrosis score. The association between food insecurity (defined as low and very low food security) and hepatic outcomes was assessed using multivariable logistic regression, adjusting for sociodemographic factors.

RESULTS

Among 2627 adults included in the analysis, 29% (95% CI: 26%, 32%) were food insecure. The median age was 43 y, 58% were female, and 54% were white. The weighted estimated prevalence of NAFLD did not differ significantly by food security status (food secure 31% compared with food insecure 34%, P = 0.21). In the multivariable model, food-insecure adults were more likely to have NAFLD (adjusted OR: 1.38; 95% CI: 1.08, 1.77) and advanced fibrosis (adjusted OR: 2.20; 95% CI: 1.27, 3.82) compared with food-secure adults.

CONCLUSIONS

Food insecurity may be independently associated with NAFLD and advanced fibrosis among low-income adults in the United States. Future strategies should assess whether improved food access, quality, and healthy eating habits will decrease the growing burden of NAFLD-associated morbidity and mortality among at-risk adults.

Association between Serum Uric Acid and Non-Alcoholic Fatty Liver Disease according to Different Menstrual Status Groups

OBJECTIVE

The present study aimed to explore the association between SUA and NAFLD in women with different menstrual statuses.

METHODS

A total of 6043 women were selected from the Jidong and Kailuan communities for inclusion in the present study. The SUA levels of participants were divided into quartiles. NAFLD was determined by abdominal ultrasonography. Data from laboratory tests and clinical examination were collected, and basic information was obtained from standardized questionnaires. The menstrual status was stratified into menstrual period, menopause transition period, and postmenopause. Multivariate logistic regression models were used to determine the relationship between menstrual status, SUA, and NAFLD.

RESULTS

The levels of SUA in subjects with NAFLD in the menstrual period, menopause transition period, and postmenopause were 268.0 ± 71.1, 265.6 ± 67.8, and 286.7 ± 75.8 (mmol/L), respectively, and were higher than those in subjects without NAFLD. The adjusted odds ratios (ORs) with 95% confidence interval (CI) for NAFLD among participants in the menopause transition period and postmenopausal period were 1.10 (0.89-1.37) and 1.28 (1.04-1.58), respectively, compared with the menstrual period women. Compared to the lowest quartile of SUA, the adjusted ORs with 95% CI of the highest quartile for NAFLD were 2.24 (1.69-2.99) for females in the menstrual period, 1.92 (1.10-3.37) for females in the menopause transition period, and 1.47 (1.06-2.03) for females in postmenopause.

CONCLUSIONS

Menstrual status was significantly correlated with NAFLD. High levels of SUA were associated with NAFLD in females during the three menstrual periods.

Depression is associated with non-alcoholic fatty liver disease among adults in the United States

BACKGROUND

Currently, the relationship between depression and non-alcoholic fatty liver disease (NAFLD) is not clearly defined.

AIM

To determine whether depression is associated with NAFLD and NAFLD-related advanced fibrosis in a large population sample.

METHODS

We performed a cross-sectional analysis using the 2007-2016 National Health and Nutrition Examination Survey database among adults (20 years or older) in the United States (US). Depression and functional impairment due to depression were assessed with the Patient Health Questionnaire (PHQ-9). NAFLD was defined by utilising the US fatty liver index (USFLI), hepatic steatosis index (HSI) and the fatty liver index (FLI) in the absence of other causes of chronic liver disease. The presence and absence of advanced fibrosis in NAFLD were defined by Fibrosis-4 score.

RESULTS

Of the 10 484 subjects (mean age 47.0 years; 48.8% men), the prevalence of depression and functional impairment due to depression was higher in subjects with NAFLD than in those without. Compared to subjects without depression, those with depression were 1.6-2.2-fold more likely to have NAFLD. In our multivariate analyses, depression_med was associated with increased risk of NAFLD using USFLI (odds ratio [OR] 1.48 95% confidence interval [CI] 1.17-1.87), HSI (OR 1.51 95% CI 1.04-2.19) and FLI (OR 2.01 95% CI 1.65-2.48), respectively. The addition of diabetes, obesity and lipid profile to the model reduced the ORs for depression, but the significance persisted. Depression was not associated with NAFLD-related advanced fibrosis.

CONCLUSIONS

In a nationally representative sample of US adults, depression was independently associated with NAFLD.

Nonalcoholic fatty liver disease in the over-60s: Impact of sarcopenia and obesity

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease in children and adults of all ethnicities. NAFLD is commonly seen in individuals with metabolic abnormalities, such as obesity and insulin resistance, which are closely associated with sarcopenia. Sarcopenia, defined as low muscle mass and impaired muscle function, is associated with NAFLD and worse outcomes in patients with NAFLD. As the world's elderly population and the prevalence of obesity continues to grow at an unprecedented rate, NAFLD and sarcopenia are projected to increase. Given that there are no approved pharmacologic treatments for NAFLD, it is imperative to gain a better understanding of the disease pathophysiology, to guide treatment options. Recent studies have given new insight into sarcopenic obesity, but there is no consensus on its definition. In this review, we attempt to address the impact of sarcopenia and obesity on NAFLD, especially in the elderly population.

Cardio-Metabolic Disorders in Non-Alcoholic Fatty Liver Disease

With the progressive epidemics of obesity, non-alcoholic fatty liver disease (NAFLD) has become the most common cause of chronic liver disease in adults and children. The increasing prevalence and incidence of NAFLD with advanced fibrosis is concerning because patients appear to experience higher non-liver-related morbidity and mortality than the general population. Recent clinical evidence suggests that NAFLD is directly associated with an increased risk of cardio-metabolic disorders. This mini review describes briefly the current understanding of the pathogenesis of NAFLD, summarizing the link between NAFLD and cardio-metabolic complications, focusing mainly upon ischemic stroke, type 2 diabetes mellitus (DM), hypertension, chronic kidney disease (CKD) and cardiac arrhythmias. In addition, it describes briefly the current understanding of the pathogenesis of NAFLD.

Reproductive Endocrinology of Nonalcoholic Fatty Liver Disease

The liver and the reproductive system interact in a multifaceted bidirectional fashion. Sex steroid signaling influences hepatic endobiotic and xenobiotic metabolism and contributes to the pathogenesis of functional and structural disorders of the liver. In turn, liver function affects the reproductive axis via modulating sex steroid metabolism and transport to tissues via sex hormone-binding globulin (SHBG). The liver senses the body's metabolic status and adapts its energy homeostasis in a sex-dependent fashion, a dimorphism signaled by the sex steroid milieu and possibly related to the metabolic costs of reproduction. Sex steroids impact the pathogenesis of nonalcoholic fatty liver disease, including development of hepatic steatosis, fibrosis, and carcinogenesis. Preclinical studies in male rodents demonstrate that androgens protect against hepatic steatosis and insulin resistance both via androgen receptor signaling and, following aromatization to estradiol, estrogen receptor signaling, through regulating genes involved in hepatic lipogenesis and glucose metabolism. In female rodents in contrast to males, androgens promote hepatic steatosis and dysglycemia, whereas estradiol is similarly protective against liver disease. In men, hepatic steatosis is associated with modest reductions in circulating testosterone, in part consequent to a reduction in circulating SHBG. Testosterone treatment has not been demonstrated to improve hepatic steatosis in randomized controlled clinical trials. Consistent with sex-dimorphic preclinical findings, androgens promote hepatic steatosis and dysglycemia in women, whereas endogenous estradiol appears protective in both men and women. In both sexes, androgens promote hepatic fibrosis and the development of hepatocellular carcinoma, whereas estradiol is protective.

Obesity, Male Reproductive Function and Bariatric Surgery

Overweight and obesity are associated with several chronic complications, such as type 2 diabetes, arterial hypertension and atherosclerotic cardiovascular diseases, with relevant consequences for patients and public health systems. Reproductive function abnormalities, such as obesity-related secondary hypogonadism, erectile dysfunction and infertility, represent other abnormalities negatively affecting the quality of life of men suffering from obesity but, despite their high prevalence, these are often understated because of a general lack of awareness in clinical practice. Obesity and gonadal function are closely related, with obesity being associated with hypogonadism that is reversed by body weight reduction thus ameliorating reproductive and sexual health. Clinical studies specifically evaluating the impact of non-surgical weight loss on testosterone levels sometimes showed conflicting results, whereas extensive literature has demonstrated that weight loss after bariatric surgery is correlated with an increase in testosterone levels greater than that obtained with only lifestyle interventions, suggesting the role of surgery also for the treatment of hypogonadism in obese male. However, studies concerning the consequences of bariatric surgery on overall reproductive function in the male, including also sexual activity and fertility, are limited and data regarding long-term effects are lacking. Here we present a brief review summarizing the evidence regarding the interplay between obesity and reproductive abnormalities in the obese male, together with the role of bariatric surgery for the treatment of these complications, describing both the positive effects and the limitations of this procedure.