Non-Alcoholic Fatty Liver Disease (NAFLD) has become one of the most prevalent chronic liver diseases globally and is a significant public health issue. It is defined as a massive fat deposition in the liver cells without the presence of significant amounts of alcohol or any other cause of hepatic steatosis. The liver changes seen in NAFLD are a spectrum that ranges from simple steatosis to non-alcoholic steatohepatitis, fibrosis, cirrhosis, and hepatocellular carcinoma. The increasing prevalence of NAFLD is due to the increase in obesity, a sedentary lifestyle, metabolic syndrome, and diabetes mellitus worldwide [1.2]. Type 2 Diabetes Mellitus (T2DM) is a metabolic disorder in which the body becomes more resistant to the effects of insulin and has glucose intolerance. Insulin resistance is a key factor in the pathogenesis of both T2DM and NAFLD, making patients with T2DM especially vulnerable to developing NAFLD. Insulin resistance increases lipolysis and the accumulation of fat in the liver, which is implicated in liver inflammation and fibrosis. Diabetes is one of the most important risk factors for NAFLD, and the prevalence of NAFLD in diabetic patients has been reported from 40% to 70% [3,4]. It is important to note that NAFLD and T2DM often coexist, with significant clinical implications. Patients with both diabetes and liver disease have a higher risk of having advanced liver disease, cardiovascular complications, chronic kidney disease, and mortality than patients without diabetes. Additionally, NAFLD can negatively affect glycemic control and lead to greater insulin resistance, which may exacerbate the disease process. Hence, the early detection and treatment of NAFLD in diabetic patients is crucial to avoid the subsequent complications [5.6]. Patients with T2DM have several risk factors for developing NAFLD. Risk factors that are present in most cases of obesity include central obesity, dyslipidemia, hypertension, poor glycemic control, and a longer duration of diabetes. Hepatic steatosis is strongly correlated with higher BMI and serum triglyceride levels. Moreover, poor dietary habits and lack of physical activity are major contributors to the NAFLD morbidity burden within people with diabetes [7]. Ultrasonography is a valuable and readily available non-invasive method for diagnosing fatty liver disease. It is a cost-effective, readily available, and moderately sensitive method for diagnosing moderate-to-severe hepatic steatosis. In high-risk groups like people with diabetes, routine screening by ultrasonography can help early identify NAFLD [8]. The rapid urbanization, decrease in physical activity, and changes in diet are contributing to the growing incidence of T2DM and obesity in Pakistan. Thus, NAFLD is also becoming commonplace in Pakistan. But very little local information is available about the prevalence of NAFLD in people with T2DM. Estimating the prevalence of NAFLD in diabetic patients will enable healthcare providers to formulate appropriate prevention and management strategies [9]. Hence, this study was conducted to find out the prevalence of NAFLD among Type 2 Diabetic patients and its relationship with obesity, dyslipidemia, and control of diabetes. Early identification of patients at high risk can help to optimize clinical outcomes and liver-related morbidity and mortality [10].

Study Design & Setting

This was a cross-sectional study conducted in the Department of Gastroenterology at Ayub Teaching Hospital, Abbottabad, from January 2024 to June 2024.

Participants

The total number of patients with Type 2 Diabetes Mellitus (T2DM) aged 30 to 70 years was 100, selected through non-probability sampling. Patients attending the outpatient department or admitted to the medical wards were included, both male and female. Patients who used alcohol or had chronic liver disease, viral hepatitis, pregnancy, or hepatotoxic drugs were excluded.

Sample Size Calculation

The sample size of 100 patients was calculated using the WHO sample size calculator with an anticipated prevalence of Non-Alcoholic Fatty Liver Disease among Type 2 diabetic patients of 58%, 95% confidence level, and a margin of error of 10%. The calculated sample size was deemed adequate for achieving statistical reliability in the study.

Inclusion Criteria

• Patients aged 30–70 years
• Patients diagnosed with Type 2 Diabetes Mellitus.
• Both male and female patients
• Patients who are willing to participate in the study.

Exclusion Criteria

• Information on how alcohol has affected their lives.Background of drinking history.
• Viral hepatitis B or C positive patients
• Chronic liver disease patients:
• Pregnant women
• Individuals taking drugs known to damage the liver. People who are taking a drug that can hurt the liver.

Diagnostic and Management Strategy.

Details of clinical history, physical examination, BMI, HbA1c, liver function tests, and lipid profile were obtained. Abdominal ultrasonography was used to diagnose NAFLD. Patients with fatty liver disease were counseled on lifestyle changes (diet, exercise, and glycemic control).

Statistical Analysis

SPSS version 25 was used for data analysis. The quantitative variables, such as age, BMI, and HbA1c, were presented as mean ± SD. Qualitative data were expressed as frequencies and percentages. Where appropriate, the following tests were used: the Chi-square test and the independent t-test. P values ≤0.05 were regarded as statistically significant.

Ethical Approval Statement

Ethical approval for this study was obtained from the Institutional Review Board/Ethical Committee of the respective hospital and medical college before data collection. Written informed consent was obtained from all participants. Confidentiality and anonymity of patient information were strictly maintained throughout the study in accordance with ethical research guidelines and the Declaration of Helsinki.

A total of 100 patients with Type 2 Diabetes Mellitus were included in the study. Among them, 54% were males and 46% were females. The overall mean age of participants was 52.4 ± 9.1 years. Non-Alcoholic Fatty Liver Disease was diagnosed in 58 patients, showing a frequency of 58%. Patients with NAFLD had a significantly higher body mass index than those without NAFLD (30.2 ± 4.3 kg/m² versus 26.1 ± 3.5 kg/m², p=0.002). Mean HbA1c levels were also significantly elevated among NAFLD patients (8.9 ± 1.4%) compared to non-NAFLD individuals (7.5 ± 1.1%, p=0.001). The average duration of diabetes in NAFLD patients was 8.3 ± 3.7 years, whereas patients without fatty liver disease had a mean duration of 5.9 ± 2.8 years (p=0.014). Elevated triglyceride levels were observed in 64% of NAFLD patients, compared with 38% in non-NAFLD patients, indicating a statistically significant association (p=0.011). Obesity, dyslipidemia, and poor glycemic control were strongly associated with the presence of fatty liver disease. The study demonstrated a high prevalence of NAFLD among diabetic patients, particularly among overweight individuals with uncontrolled diabetes mellitus. Table 1: Demographic Characteristics of Study Participants (n=100) Variable Frequency (%) / Mean ± SD Total Patients 100 Male 54 (54%) Female 46 (46%) Mean Age (years) 52.4 ± 9.1 Mean BMI (kg/m²) 28.5 ± 4.2 Mean Duration of Diabetes (years) 7.2 ± 3.4 Mean HbA1c (%) 8.3 ± 1.3 Table 1 shows the demographic and baseline clinical characteristics of patients with Type 2 Diabetes Mellitus included in the study. Table 2: Frequency of Non-Alcoholic Fatty Liver Disease Among Diabetic Patients NAFLD Status Frequency (n) Percentage (%) Present 58 58% Absent 42 42% Total 100 100% Table 2 demonstrates the frequency distribution of Non-Alcoholic Fatty Liver Disease among patients with Type 2 Diabetes Mellitus. Table 3: Comparison of Clinical Parameters Between NAFLD and Non-NAFLD Patients Variable NAFLD Present (n=58) Mean ± SD NAFLD Absent (n=42) Mean ± SD p-value Age (years) 53.6 ± 8.7 50.8 ± 9.4 0.118 BMI (kg/m²) 30.2 ± 4.3 26.1 ± 3.5 0.002 HbA1c (%) 8.9 ± 1.4 7.5 ± 1.1 0.001 Duration of Diabetes (years) 8.3 ± 3.7 5.9 ± 2.8 0.014 Table 3 compares important clinical and metabolic parameters between patients with and without Non-Alcoholic Fatty Liver Disease. Table 4: Association of Risk Factors with Non-Alcoholic Fatty Liver Disease Risk Factor NAFLD Present n (%) NAFLD Absent n (%) p-value Obesity 39 (67.2%) 14 (33.3%) 0.003 Elevated Triglycerides 37 (64%) 16 (38%) 0.011 Poor Glycemic Control (HbA1c >8%) 41 (70.6%) 13 (31%) 0.001 Diabetes Duration >5 years 35 (60.3%) 12 (28.5%) 0.018 Table 4 illustrates The association between major metabolic risk factors and the presence of Non-Alcoholic Fatty Liver Disease among patients with Type 2 Diabetes Mellitus.

In the present study, NAFLD was found to be highly prevalent in Type 2 Diabetes Mellitus (T2DM), with a prevalence of 58%. The study is in line with more recent international research that found an increased prevalence of NAFLD in persons with diabetes. Recent studies have shown that around 55-70% of T2DM patients might suffer from NAFLD, mostly because of insulin resistance, obesity, and metabolic abnormalities [11]. The study showed that the mean age of the subjects was 52.4 years (9.1 years SD) and that middle-aged people were more likely to have NAFLD. The study by Sinha et al. (2023) also reported a significant age-related increase in the prevalence of NAFLD among diabetic patients. The prevalence in their study was 57% among T2DM patients, a value very close to that observed in the current study. Shared metabolic risk factors such as sedentary lifestyle,

obesity, and duration of diabetes could account for the similarity of this finding [12,13]. This study also revealed a male predominance (54% males and 46% females). Recent studies on the diabetic population have reported similar gender distribution; males had a slightly higher prevalence of fatty liver disease. This difference may be related to greater visceral fat accumulation and metabolic abnormalities in male patients [14]. The BMI was significantly higher in NAFLD patients (30.2 ± 4.3 kg/m²) than in patients without NAFLD (26.1 ± 3.5 kg/m²) in the present study (p=0.002). The study of these findings reinforces the strong evidence that obesity plays a significant role as a risk factor for fatty liver disease. Another study found that obesity and dyslipidemia are also two important factors associated with NAFLD in diabetic patients. Similarly, obesity and insulin resistance were identified as the primary pathways underlying hepatic fat accumulation in patients with T2DM [15,16]. Another important finding of the present study was the poor glycemic control. Mean HbA1c levels were considerably higher in NAFLD patients (8.9 ± 1.4%) than in non-NAFLD patients (7.5 ± 1.1%, p=0.001). The findings are similar to those reported over the last five years, in which high HbA1c was independently associated with hepatic steatosis and liver fibrosis. Ongoing hyperglycemia leads to increased hepatic lipogenesis, oxidative stress, and inflammatory responses, thereby accelerating NAFLD progression [17]. This study also revealed diabetes duration as a statistically significant factor associated with NAFLD. The prevalence of fatty liver disease was higher in patients with a longer duration of diabetes, consistent with recent epidemiological studies that showed an increased risk of liver fibrosis and cirrhosis with increasing duration of diabetes. In the present study, elevated triglyceride levels were observed in patients with NAFLD, which further reinforces the link between dyslipidemia and hepatic steatosis [18]. The interaction between NAFLD and T2DM has gained increasing attention in recent years in the literature. NAFLD can also complicate diabetes and may exacerbate insulin resistance and glycemic control, leading to a vicious cycle of increasing insulin resistance and worsening glycemic control. In addition, the prevalence of obesity and diabetes has grown throughout the world in recent years. It is expected to have significant consequences for the burden of metabolic-associated fatty liver disease in the coming decades [19]. This study underscores the importance of early screening for NAFLD in diabetic patients using non-invasive techniques such as abdominal ultrasonography. Applying lifestyle changes (such as weight loss, exercise, and glycemic control) early on may slow disease progression and decrease liver-related complications. Therefore, it is important to have routine metabolic evaluation and awareness programs to improve outcomes for patients with Type 2 Diabetes Mellitus in the long term [20].

Limitations

The study had several shortcomings, such as a small sample size and a single-center design, which may limit its generalizability. Due to the invasive nature of liver biopsy, this was not performed, which is the gold standard for diagnosing NAFLD. Moreover, long-term follow-up was not performed to analyze disease progression and therapeutic outcomes.

NAFLD was highly prevalent in Type 2 Diabetes Mellitus patients and was significantly associated with obesity, poor glycemic control, dyslipidemia, and longer duration of Type 2 Diabetes Mellitus. In diabetic patients, early diagnosis through ultrasonography and appropriate lifestyle changes could help reduce liver-related complications and improve metabolic health.

Disclaimer: Nil

Conflict of Interest: Nil

Funding Disclosure: Nil

Authors' Contributions

1. Concept & Design of Study: Hafizullah Khan, Syeda Anam Noor Kazmi, Prof. Adil Naseer Khan
2. Data Acquisition: Hafizullah Khan, Zabihullah
3. Data Analysis & Interpretation: Hafizullah Khan, Syeda Anam Noor Kazmi
4. Drafting of Manuscript: Hafizullah Khan,Muhammad Sarwar Khan
5. Critical Review & Intellectual Content: Syeda Anam Noor Kazmi, Zabihullah, Prof. Adil Naseer Khan

Final Approval of the Version to be Published: All authors reviewed and approved the final version of the manuscript and agree to be accountable for all aspects of the work in accordance with the ICMJE authorship criteria.