Ojong EW, Ngemenya MN, Tafili MM, Tanue EA, Achidi EA. Association of non-alcoholic fatty liver disease with glycemic control among patients with type 2 diabetes mellitus at Limbe Regional Hospital, Southwest, Cameroon. World J Hepatol 2025; 17(2): 101936 [DOI: 10.4254/wjh.v17.i2.101936]
Corresponding Author of This Article
Ebot Walter Ojong, MSc, PhD Chemical Pathology, Senior Lecturer, Medical Laboratory Science, Faculty of Health Sciences, University of Buea, Buea PO Box 63, Southwest, Cameroon. ebot.ojong@ubuea.cm
Research Domain of This Article
Endocrinology & Metabolism
Article-Type of This Article
Retrospective Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Hepatol. Feb 27, 2025; 17(2): 101936 Published online Feb 27, 2025. doi: 10.4254/wjh.v17.i2.101936
Association of non-alcoholic fatty liver disease with glycemic control among patients with type 2 diabetes mellitus at Limbe Regional Hospital, Southwest, Cameroon
Ebot Walter Ojong, Moses Njutain Ngemenya, Melvis Mwantem Tafili, Elvis Asangbeng Tanue, Eric Akum Achidi, Medical Laboratory Science, Faculty of Health Sciences, University of Buea, Buea PO Box 63, Southwest, Cameroon
Eric Akum Achidi, Department of Biochemistry and Molecular Biology, University of Buea, Buea PO Box 63, Southwest, Cameroon
Author contributions: Ngemenya MN, Ojong EW, and Tafili MM conceived and designed the study; Tafili MM, Ojong EW, and Tanue EA participated in the data collection and data entry; Ojong EW, Achidi EA, and Tanue EA analyzed the data and performed the background literature review for the manuscript; Ojong EW, Ngemenya MN, and Tafili MM drafted the manuscript. All authors reviewed, edited, and approved the final version of the manuscript.
Institutional review board statement: The approval for this study was obtained from the Institutional Review Board, Faculty of Health Sciences, University of Buea, Cameroon (approval ID: 2024/2312-01/UB/SG/IRB/FHS). Authorization to collect research data was obtained from the Ministry of Public Health, Cameroon (40/MPH/SWR/RHL/DO/04/2024).
Informed consent statement: Written informed consent was obtained from all participants before recruitment into the study.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
Data sharing statement: The data that support the findings of this study are available on request from the corresponding author.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Ebot Walter Ojong, MSc, PhD Chemical Pathology, Senior Lecturer, Medical Laboratory Science, Faculty of Health Sciences, University of Buea, Buea PO Box 63, Southwest, Cameroon. ebot.ojong@ubuea.cm
Received: October 1, 2024 Revised: December 5, 2024 Accepted: January 2, 2025 Published online: February 27, 2025 Processing time: 141 Days and 12.4 Hours
Abstract
BACKGROUND
Type 2 diabetes mellitus (T2DM) is a chronic metabolic disease characterized by combinations of insulin resistance and insulin deficiency. Non-alcoholic fatty liver disease (NAFLD) is emerging as a public health problem worldwide and affects up to 70% of patients with T2DM. Although patients with T2DM have an increased risk of developing advanced liver disease compared to healthy individuals, varying prevalence rates of NAFLD among patients with T2DM, ranging from 34% to 94%, have been reported.
AIM
To determine prevalence and identify associated factors of NAFLD among Limbe patients with T2DM and evaluate correlation with glycemic control.
METHODS
A cross-sectional study was carried out from February to June 2024 among patients with T2DM. Gamma-glutamyl transferase (GGT) activity and serum triglycerides (TGs) were measured by spectrophotometry. NAFLD was diagnosed using the fatty liver index score. Data were analyzed using SPSS version 26.0 for Windows. Student’s t-test was used to compare the means of two groups. The χ2 test was applied to determine the association of NAFLD and T2DM. Logistic regression analysis was performed to identify predictors of NAFLD. P < 0.05 was considered statistically significant.
RESULTS
Of the 150 patients with T2DM recruited for this study, 63 (58%) were females and the majority (84.7%) had good glycemic control (glycated hemoglobin < 7%). Prevalence of NAFLD among patients with T2DM was 19%. Patients with NAFLD had significantly elevated levels of TGs, GGT, and increased body mass index and waist circumference compared to those without NAFLD. There was a significant association between NAFLD and glycemic control. Predictive factors of NAFLD among patients with T2DM were vegetable intake of less than three times per week [adjusted odds ratio (aOR): 0.131, 95%CI: 0.020-0.839; P = 0.032], central obesity (aOR: 0.167, 95%CI: 0.037-0.748; P = 0.019), and metformin treatment for T2DM (aOR: 0.167, 95%CI: 0.037-0.718; P < 0.001).
CONCLUSION
The prevalence of NAFLD in patients with T2DM in Limbe Regional Hospital was 19%. Age, central obesity, metformin use, and infrequent consumption of vegetables were important predictors of NAFLD.
Core Tip: Few studies have evaluated the association between non-alcoholic fatty liver disease (NAFLD) and glycemic control in Africa. This study was the first to be conducted in Cameroon and the Central African Region. NAFLD was evaluated using the fatty liver index algorithm recommended for resource limited settings. One of five patients with type 2 diabetes mellitus in Limbe, Cameroon suffer from NAFLD, which is significantly associated with glycemic control. Findings from this study support clinical practice guidelines recommending screening individuals with diabetes for NAFLD and contribute to the scarce data on the topic in Africa. Future longitudinal studies are needed.
Citation: Ojong EW, Ngemenya MN, Tafili MM, Tanue EA, Achidi EA. Association of non-alcoholic fatty liver disease with glycemic control among patients with type 2 diabetes mellitus at Limbe Regional Hospital, Southwest, Cameroon. World J Hepatol 2025; 17(2): 101936
Type 2 diabetes mellitus (T2DM) is a chronic metabolic disease characterized by hyperglycemia, insulin resistance, and relative impairment in insulin secretion[1]. In 2021, the International Diabetes Federation estimated that the global prevalence of DM was 10.5% with T2DM representing approximately 98% of global diabetes diagnoses[2]. In 2045, more than 693 million individuals are expected to be affected by T2DM[3]. In Cameroon, the prevalence of DM is estimated to be 5.7% in urban areas, with an estimated 1 million people living with the disease, 70% of whom remain undiagnosed[4]. In many countries in sub-Saharan Africa, there are large unmet needs for T2DM care, and national programs need to be adequately funded and coordinated to manage non-communicable diseases (NCDs)[5].
Non-alcoholic fatty liver disease (NAFLD) has become an epidemic, much like other NCDs such as cancer, obesity, diabetes, and cardiovascular disease[6]. A systematic review reported that NAFLD was present in 50%-75% of patients with T2DM[7]. Among the multiple hits in the pathogenesis of NAFLD, obesity, insulin resistance, and T2DM are the major drivers of its progression[8]. NAFLD and T2DM have a close bidirectional relationship; NAFLD increases the risk of T2DM and its complications, whereas T2DM increases the severity of NAFLD and its complications[9]. Both conditions also share risk factors such as genetic predisposition, diet rich in fat, sedentary lifestyle, metabolic syndrome, and obesity[10].
Individuals with NAFLD with concurrent T2DM face a two-fold risk of developing advanced liver disease including cirrhosis and advanced fibrosis[11]. Studies have also demonstrated that among individuals with NAFLD, those with T2DM are at higher risk of liver-related mortality compared to those without T2DM[12]. Although clinical practice guidelines recommend screening individuals with diabetes for NAFLD to slow progression to liver fibrosis, cirrhosis, and hepatocellular carcinoma, evidence supporting this recommendation in Africa is currently limited[12].
The reported prevalence rates of NAFLD in T2DM in Africa range from 10.4% in Nigeria to 73.3% in Egypt, with a pooled prevalence of 48.1%[13]. No study has been conducted in the Central African Region in general and in Cameroon in particular to evaluate NAFLD prevalence among patients with T2DM and its association with glycemic control. Since the prevalence of NAFLD among patients with T2DM is high, putting them at a significantly higher risk of developing end-stage liver disease, hepatocellular carcinoma, and cardiovascular disease, early identification through non-invasive biomarkers is important[14].
The main objective of this study was to evaluate the relationship between NAFLD and glycemic control among patients with T2DM in Limbe Regional Hospital, Limbe, Cameroon.
MATERIALS AND METHODS
Ethical considerations
This study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the institutional review board of the Faculty of Health Sciences, University of Buea, Cameroon (2024/2296-01/UB/SG/IRB/FHS) on March 27, 2024. Authorization to collect research data was obtained from the Ministry of Public Health, Cameroon (40/MPH/SWR/RHL/DO/04/2024). All patients provided written informed consent.
Study design and setting
This study was a single-center cross-sectional study conducted in the diabetic clinic of Limbe Regional Hospital, Southwest Cameroon. Limbe Regional Hospital is one of the two main referral secondary care centers found in the Southwest Region of Cameroon. The diabetic center in this hospital caters to the needs of registered diabetics.
Study population
The study inclusion criteria were patients with T2DM, aged 21 years and above, who consented to take part in the study (Figure 1). The patients with T2DM undergoing treatment at the diabetic unit of Limbe Regional Hospital were recruited by systematic sampling. Patients were excluded from the study if they had a history of acute hepatitis, chronic liver disease, liver malignancy, consumed alcohol regularly, were pregnant or breastfeeding, or had a history of traditional medicine use.
Figure 1
Prevalence of non-alcoholic fatty liver disease among patients with type 2 diabetes mellitus.
Data collection
Participants’ sociodemographic, anthropometric [height, weight, waist circumference (WC), hip circumference, waist-to-hip ratio, and blood pressure (BP)], lifestyle (smoking, alcohol consumption, calorie intake, physical activity), and clinical information were recorded using a structured and pretested questionnaire. Weekly vegetable intake was evaluated using a food frequency questionnaire. This was self-reported by participants and may be subject to recall bias. Physical activity was evaluated using World Health Organization (WHO) guidelines for adults and graded as sufficient or insufficient[15]. Participants’ height were measured with them barefoot using a portable stadiometer and recorded to the nearest 0.1 cm. Participants’ body weight was measured with them wearing light clothing, using a calibrated scale and recorded to the nearest 0.1 kg. Body mass index (BMI) was calculated using the formula: weight (kg) divided by the square of height (m2). Overweight was defined as BMI of 25-29 kg/m2 and obesity was defined as BMI ≥ 30 kg/m2 according to WHO guidelines[16]. Systolic and diastolic BPs were measured three times using a mercury sphygmomanometer following a 10-minute rest, and the average of the readings was recorded. American Heart Association guidelines were used to define hypertension as BP ≥ 140/90 mmHg[17]. WC was measured using a measuring tape and recorded to the nearest 0.1 cm. Central obesity was considered in males with a WC > 102 cm and females with a WC > 88 cm according to the National Heart, Lung, and Blood Institute recommendations[18]. T2DM was defined based on WHO criteria [fasting plasma glucose values ≥ 7.0 mmol/L (126 mg/dL)], 2-hour post-load plasma glucose ≥ 11.1 mmol/L (200 mg/dL)[12], glycated hemoglobin (HbA1c) ≥ 6.5% (48 mmol/mol); or random blood glucose ≥ 11.1 mmol/L (200 mg/dL) in the presence of signs and symptoms considered related to diabetes[19]. Good glycemic control was considered when HbA1c < 7 and poor glycemic control when HbA1c > 7 according to WHO recommendations[20].
Blood tests included fasting blood glucose, HbA1c, gamma-glutamyl transferase (GGT), and triglycerides (TGs). To assess the presence and severity of metabolic dysfunction-associated FLD, the fatty liver index (FLI) score was used. FLI = [e0.953 × ln (TG) + 0.139 × BMI + 0.718 × ln (GGT) + 0.053 × WC – 15.745 / (1 + e0.953 × ln (TG) + 0.139 × BMI + 0.718 × ln (GGT) + 0.053 × WC – 15.745] × 100. NAFLD was diagnosed when the FLI value reached or exceeded 60, whereas a value below 30 excluded the diagnosis[21].
Study outcomes
The primary outcome of the study was the prevalence of NAFLD by FLI score using anthropometric and biochemical measurements[21]. Factors associated with NAFLD among patients with T2DM in Limbe, Cameroon were identified. The secondary objective was to determine if there was any association between NAFLD and glycemic control in patients with T2DM.
Statistical analyses
Data obtained via questionnaire were input into Microsoft Excel, and statistical analyses were conducted using the Statistical Package for Social Sciences 26 (IBM Corp., Armonk, NY, United States). Descriptive statistics were presented for the collected variables and stratified according to the presence or absence of NAFLD. For continuous variables that were normally distributed, the mean and standard deviations are reported. For those that were not normally distributed, the median and interquartile range are reported. For categorical variables, the number of patients and the percentages are reported. To test for statistical differences in characteristics between the groups with and without NAFLD, the t-test (for normally distributed continuous data) and χ2 test were used (for categorical variables). Stepwise multiple logistic regressions were used to identify independent factors associated with NAFLD. For statistical significance, P < 0.05 was considered statistically significant at the 95%CI for all analyses.
RESULTS
A total of 150 patients with T2DM were enrolled in this study, including 63 (42%) males and 87 (58%) females. The median age was 56 years with most participants aged between 41 years and 65 years (57%). Most of the study participants were employed [58 (44%)], and 54% were married. Most of the participants [92 (61%)] were living in urban areas. Only 24 (16%) participants had attained tertiary education, with about 79 (53%) having attained a secondary school level of education (Table 1). Most of the participants [100 (67%)] consumed fruit and vegetables less than 3 days per week. Regarding the level of physical activity, 86 (57%) study participants performed sufficient physical activity. The duration of living with T2DM ranged from 1 year to more than 21 years. Of the total enrolled study participants, 10 (7%), 55 (37%), and 83 (55%) patients were currently being treated with insulin, metformin, and combined drugs (insulin and metformin), respectively. There were significant differences in the frequency of different sociodemographic parameters between patients with T2DM with and without NAFLD (P < 0.05), as shown in Table 1.
Table 1 Sociodemographic, anthropometric, and clinical characteristics of patients with type 2 diabetes mellitus at Limbe Regional Hospital, n (%).
Variable
Total (n = 150)
NAFLD (n = 28)
No NAFLD (n = 122)
P value
Sex
0.03
Male
63 (42.0)
10 (36.0)
53 (43.0)
Female
87 (58.0)
18 (64.0)
69 (57.0)
Age group (years)
0.001
25-40
22 (15.0)
6 (21.0)
16 (13.0)
41-65
86 (57.0)
16 (58.0)
70 (57.0)
≥ 66
42 (28.0)
6 (21.0)
36 (30.0)
Marital status
< 0.001
Married
81 (54.0)
19 (68.0)
62 (51.0)
Divorced
38 (25.0)
4 (14.0)
34 (28.0)
Single
11 (7.0)
2 (7.0)
9 (7.0)
Widowed
20 (13.0)
3 (11.0)
17 (14.0)
Level of education
< 0.001
Primary
47 (31.0)
11 (39.0)
36 (29.0)
Secondary
79 (53.0)
16 (57.0)
63 (57.0)
Tertiary
24 (16.0)
1 (4.0)
23 (19.0)
Employment status
< 0.001
Employed
76 (50.7)
13 (46.0)
63 (52.0)
Unemployed
74 (49.3)
15 (54.0)
59 (48.0)
Area of residence
0.04
Rural
58 (39)
10 (36)
48 (39)
Urban
92 (61)
18 (64)
74 (61)
Waist circumference
< 0.001
Centrally obese
51 (34)
20 (57)
31 (25)
Non-obese
99 (66)
8 (29)
91 (75)
Body mass index
< 0.001
Underweight
7 (5)
0 (0)
7 (6)
Normal weight
88 (59)
9 (32)
79 (65)
Overweight
55 (35)
19 (68)
36 (30)
Obese
0 (0.0)
0 (0.0)
0 (0.00)
Consumption of vegetables
0.02
< 3 times/week
100 (67)
12 (43)
88 (72)
> 3 times/week
50 (33)
16 (57)
34 (28)
Physical activity
0.001
Insufficient
64 (43)
15 (57)
49 (40)
Sufficient
86 (57)
13 (46)
73 (60)
Family history
< 0.001
No
59 (39)
12 (43)
49 (40)
Yes
91 (61)
16 (57)
73 (60)
Type of treatment
< 0.001
Insulin
10 (7)
4 (14)
6 (5)
Metformin
55 (37)
10 (36)
45 (37)
Insulin + Metformin
83 (55)
12 (42)
71 (58)
Others
0 (0.0)
2 (7)
0 (0)
Prevalence of NAFLD among patients with T2DM attending Limbe Regional Hospital
The prevalence of NAFLD in this study diagnosed by Bedogni’s FLI category (FLI ≥ 60) was 19.0% (Figure 1).
Factors associated with NAFLD among patients with T2DM attending Limbe Regional Hospital
Bivariate logistic regression analyses revealed that all of the risk factors were associated with NAFLD among the study respondents (Table 2). Table 3 shows the adjustment of the predicting factors of NAFLD among patients with T2DM. Vegetable intake less than three times per week [adjusted odds ratio (aOR): 0.131, 95%CI: 0.020-0.839; P = 0.032], central obesity (aOR: 0.167, 95%CI: 0.037-0.748; P = 0.019), insulin use (aOR: 3.370 × 108, 95%CI: 4.204 × 109-2.702 × 107; P < 0.001), or metformin use (aOR: 7.182 × 109, 95%CI: 1.755 × 109-2.938 × 108; P < 0.001) to treat T2DM were significantly associated with NAFLD (Table 3).
Table 2 Comparison of biochemical and clinical characteristics between patients with type 2 diabetes mellitus with and without non-alcoholic fatty liver disease, mean ± SD.
Variable
Total (n = 150)
No NAFLD (n = 122)
NAFLD (n = 28)
t-test
P value
TG (mg/dL)
102.23 ± 75.33
86.19 ± 62.59
173.68 ± 84.34
5.172
< 0.001
GGT (U/L)
42.71 ± 24.66
37.36 ± 22.31
65.27 ± 22.01
6.033
< 0.001
HbA1c (%)
5.15 ± 1.49
4.66 ± 0.98
7.82 ± 0.85
1.780
0.085
WC (cm)
75.96 ± 26.25
71.94 ± 22.65
92.29 ± 34.89
2.946
0.006
BMI (kg/m2)
24.49 ± 6.22
24.81 ± 18.32
30.08 ± 7.98
2.349
0.021
Table 3 Factors associated with non-alcoholic fatty liver disease among patients with type 2 diabetes mellitus attending Limbe Regional Hospital.
Explanatory variable
Crude odds ratio (95%CI)
P value
Adjusted odds ratio (95%CI)
P value
Sex
Male
4.357 (-)
< 0.001
1.824 (0.441-7.541)
0.406
Female
1 (-)
-
1 (-)
-
Age group (years)
25-40
4.357 (-)
< 0.001
15.701 (0.956-257.852)
0.054
41-65
4.357 (-)
< 0.001
1.278 (0.134-12.212)
0.831
≥ 66
1 (-)
-
1 (-)
-
Marital status
Married
4.357 (-)
< 0.001
1.340 (0.128-14.043)
0.807
Single
4.357 (-)
< 0.001
0.321 (0.018-5.621)
0.437
Divorced
4.357 (-)
< 0.001
0.455 (0.023-8.842)
0.603
Widow
1 (-)
-
1 (-)
-
Residence
Rural
4.357 (-)
< 0.001
0.972 (0.260-3.634)
0.967
Urban
1 (-)
-
1 (-)
-
Level of education
Primary
4.357 (-)
< 0.001
14.374 (0.869-237.818)
0.063
Secondary
4.357 (-)
< 0.001
4.616 (0.343-62.090)
0.249
Tertiary
1 (-)
-
1 (-)
-
Occupation
Trader
4.357 (-)
< 0.001
3.762 (0.671-21.092)
0.132
Teacher
4.357 (-)
< 0.001
0.397 (0.052-3.023)
0.372
Driver
4.357 (-)
< 0.001
8.166 × 10^8
0.988
Farmer
4.357 (-)
< 0.001
0.138 (0.005-3.635)
0.235
Housewife
4.357 (-)
< 0.001
3.565 (0.335-37.939)
0.292
Others
1 (-)
-
1 (-)
-
Physical exercise
No
4.357 (-)
< 0.001
0.529 (0.116-2.418)
0.411
Yes
1 (-)
-
1 (-)
-
Vegetable intake
< 3 times/week
4.357 (-)
< 0.001
0.131 (0.020-0.839)
0.032
> 3 times/week
1(-)
-
1 (-)
-
Physical exercise
Insufficient
4.357 (-)
< 0.001
0.529 (0.116-2.418)
0.411
Sufficient
1 (-)
-
1 (-)
-
Vegetable intake
< 3 times/week
4.357 (-)
< 0.001
0.131 (0.020-0.839)
0.032
> 3 times/week
1(-)
-
1 (-)
-
Central obesity (cm)
Present
4.357 (-)
< 0.001
0.167 (0.037-0.748)
0.019
Absent
1 (-)
-
1 (-)
-
Body mass index (kg/m2)
Underweight
4.357 (-)
< 0.001
6.511 × 10^7 (0.000-NA)
0.992
Overweight and obese
4.357 (-)
< 0.001
0.917 (0.152-5.512)
0.924
Normal weight
1 (-)
-
1 (-)
-
Family history of diabetes
Yes
4.357 (-)
< 0.001
2.269 (0.557-9.252)
0.253
No
1 (-)
-
1 (-)
-
Type of treatment for type 2 diabetes mellitus
Insulin
4.357 (-)
< 0.001
3.370 × 108 (4.204 × 109-2.702 × 107)
< 0.001
Metformin
4.357 (-)
< 0.001
0.167 (0.037-0.718)
< 0.001
Insulin + Metformin
4.357 (-)
< 0.001
5.856 × 109 (5.856 ×109-5.856 ×109)
NA
Others
1 (-)
-
1 (-)
-
Duration of type 2 diabetes mellitus (years)
1-10
4.357 (-)
< 0.001
0.898 (0.046-17.404)
0.943
11-20
4.357 (-)
< 0.001
2.541 × 107 (0.000-NA)
0.99
≥ 21
1 (-)
-
1 (-)
-
Comparison of biochemical and clinical characteristics between patients with T2DM with and without NAFLD
Mean TG (173.68 ± 84.34 vs 86.19 ± 62.59, P < 0.001), WC (92.29 ± 34.89 vs 71.94 ± 22.65, P = 0.006, GGT (65.27 ± 22.01 vs 37.36 ± 22.31, P < 0.00), and BMI (30.08 ± 7.98 vs 24.81 ± 18.32, P = 0.021) of patients with T2DM with NAFLD were greater than those without NAFLD (Table 2).
Glycemic control in patients with T2DM attending Limbe Regional Hospital
Figure 2 shows that the majority [127 (84.7%)] of patients with T2DM in Limbe had good glycemic control with mean and standard deviation HbA1c levels of 5.513% and 2.333%, respectively.
Figure 2
Glycemic control of patients with type 2 diabetes mellitus attending Limbe Regional Hospital.
Comparison of biochemical and clinical characteristics between patients with good and poor glycemic control
Mean GGT (53.48 ± 25.08 mg/dL vs 40.60 ± 24.23 mg/dL, P = 0.030) and HbA1c (7.82 ± 0.85 vs 4.66 ± 0.98, P < 0.001) were greater in patients with poor glycemic control (Table 4).
Table 4 Comparison of biochemical and clinical characteristics between patients with good and poor glycemic control, mean ± SD.
Variable
Total (n = 150)
Good control (n = 127)
Poor control (n = 23)
t-test
P value
TG (mg/dL)
102.23 ± 75.33
97.97 ± 74.56
127.61 ± 74.69
-1.751
0.090
GGT (U/L)
42.71 ± 24.66
40.60 ± 24.23
53.48 ± 25.08
-2.278
0.030
HbA1c (%)
5.15 ± 1.49
4.66 ± 0.98
7.82 ± 0.85
-16.036
< 0.001
WC (cm)
75.96 ± 26.25
74.90 ± 25.79
80.39 ± 30.12
-0.822
0.418
BMI (kg/m2)
24.49 ± 6.22
25.57 ± 18.17
27.06 ± 7.64
-0.659
0.512
Association between NAFLD and glycemic control
Table 5 reveals that NAFLD was greater in patients with poor glycemic control (57.1% vs 42.9%, P < 0.001).
Table 5 Relationship between non-alcoholic fatty liver disease and glycemic control among patients with type 2 diabetes mellitus attending Limbe Regional Hospital, n (%).
Variable
No NAFLD
NAFLD
Total
χ2
P value
Glycemic control status
Poor (HbA1c ≥ 7 %)
11 (9.0)
16 (57.1)
27 (15.3)
20.089
< 0.001
Good (HbA1c < 7 %)
111 (91.0)
12 (42.9)
123 (84.7)
Total
122 (100.0)
28 (100.0)
150 (100.0)
DISCUSSION
This study found that 1 of every 5 patients diagnosed with T2DM had NAFLD. Diet, central obesity, and treatment with insulin and metformin were factors associated with NAFLD among patients with T2DM. Poor glycemic control is associated with an increased prevalence of NAFLD. These findings suggest that patients with T2DM at risk of NAFLD should be screened for early diagnosis and management to reduce progression of or completely reverse NAFLD.
Several studies have evaluated the prevalence of NAFLD among diabetics. The current study of 150 patients with T2DM reported a lower prevalence of NAFLD (19.0%) in Limbe, Cameroon compared to many existing studies. A systematic review and meta-analysis of 156 studies in 2023 provided a global prevalence rate of NAFLD of 65.04% (95%CI: 61.79%-68.15%; I2 = 99.90%) among 1832125 patients with T2DM[22]. A study conducted among 233 patients with T2DM in Sri Lanka found an overall prevalence of NAFLD of 62.6%[23]. A possible explanation for the lower prevalence of NAFLD in the current study is that the majority of patients with T2DM (84.7%) had good glycemic control. The prevalence of NAFLD in diabetic populations is dependent on the prevalence of risk factors such as genetic predisposition, obesity, diet, exercise, and health-related behaviors[24]. However, the prevalence of NAFLD of 19.0% in the current study is higher than that reported among diabetics (16.7%) in a case-control study among 336 participants in Nigeria[25].
In the current study, the majority (84.7%) of the 150 patients with T2DM had good glycemic control. This proportion is higher than that reported by previous studies. A systematic review and meta-analysis of 74 studies reported a pooled prevalence of good glycemic control of 30% (95%CI: 27.6–32.9) among patients with T2DM in sub-Saharan Africa. The glycemic control prevalence ranged from 10% to 60%[26]. One of the main goals of DM management is to achieve glycemic control to delay or prevent the onset of diabetes complications. Worldwide, only approximately 50% of patients achieve glycemic control[27], and in sub-Saharan Africa, glycemic control rates are generally poor and compounded by numerous challenges including inadequate resources, limited access to HbA1c monitoring, coexisting traditional health priorities, ill-preparedness for chronic disease management, and low health insurance coverage[28]. There is a paucity of data on glycemic control among patients with T2DM in Cameroon. A randomized controlled trial reported that community-based peer support, in addition to usual care, significantly improved glycemic control in patients with uncontrolled T2DM in Yaoundé, Cameroon[29].
Our study found a significant association of central obesity, vegetable intake of less than three times per week, and use of insulin and metformin for NAFLD among patients with T2DM in Limbe, Cameroon. Previous studies have reported that diet, greater BMI, and WC are significantly associated with NAFLD[30]. A systematic review and meta-analysis revealed that Western dietary patterns increase the risk of NAFLD by 56%, although Mediterranean dietary patterns reduce the risk of this disease by 22% and 23%, respectively. The present study was carried out in Limbe, an urban setting in Cameroon where the majority of residents adopt Western dietary patterns and consume high levels of processed food, red meat, high-fat dairy, and refined grains. Mediterranean dietary patterns of high intake of fruits, vegetables, whole grains, fish, and olive oil is not a routine practice[31]. The present study reported an association between both central obesity and general obesity with NAFLD. NAFLD is often accompanied by diabetes, dyslipidemia, and hypertension. Central obesity is strongly associated with metabolic factors and induces fatty liver[32]. Central obesity without insulin resistance has been shown to play a limited role in fatty liver, indicating that metabolic factors are significant in the role of central obesity[33]. Similarly, data from a large population-based cohort of patients with T2DM identified therapeutic parameters associated with NAFLD incidence[34].
The current study further revealed that mean TG, WC, BMI, and GGT was significantly higher in patients with T2DM with NAFLD compared to those without NAFLD. Similarly, other studies have reported higher BMI and TGs in patients with T2DM with NAFLD[35].
Based on the association between NAFLD and glycemic control, χ2 analysis showed that glycemic control status is associated with NAFLD among patients with T2DM (χ2: 20.089; P < 0.001) with poorer glycemic control than patients diagnosed with NAFLD (42.9% vs 9.0%). Few studies have evaluated the correlation between glycemic control and NAFLD. A study in Northeast Ethiopia[36] and Nigeria[37] reported a lower prevalence of NAFLD in patients with diabetes with good glycemic control.
CONCLUSION
In conclusion, about 1 of 5 patients with T2DM in Limbe has NAFLD. Diet, central obesity, and treatment with insulin and metformin are associated with NAFLD in the T2DM population. NAFLD is associated with increased biochemical and anthropometric parameters. Poor glycemic control is associated with increased biochemical parameters. NAFLD is significantly associated with glycemic control in T2DM. There is a need for screening and management of NAFLD in patients with T2DM, especially those with central obesity and poor glycemic control. There is also a need for future longitudinal studies in different regions in Africa.
Footnotes
Provenance and peer review: Invited article; Externally peer reviewed.
Peer-review model: Single blind
Corresponding Author's Membership in Professional Societies: African Society for Laboratory Medicine, 00201/13; Society on Liver Disease in Africa; Royal Society of Tropical Medicine and Hygiene.
Specialty type: Gastroenterology and hepatology
Country of origin: Cameroon
Peer-review report’s classification
Scientific Quality: Grade D
Novelty: Grade C
Creativity or Innovation: Grade C
Scientific Significance: Grade C
P-Reviewer: Moriyama K S-Editor: Liu H L-Editor: A P-Editor: Zhao YQ
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