Fatty liver disease is now considered as one of the leading liver diseases, and has been associated with the worldwide obesity and metabolic risk factor epidemic. It is defined by excessive accumulation of fat in the hepatocytes and can lead to simple steatosis, steatohepatitis, hepatic fibrosis, cirrhosis and hepatocellular carcinoma [1,2]. Most cases of metabolic dysfunction are now referred to as metabolic dysfunction-associated steatotic liver disease (MASLD) due to the well-established link between hepatic steatosis and cardiometabolic risk factors [3].

The prevalence of fatty liver disease is around 33% in adults worldwide, and ultrasound-based prevalence also has significantly increased in recent decades [4]. The growing burden is similar to the global problem of overweight and obesity, unhealthy food intake and sedentary lifestyle which are important risk factors for hepatic fat deposition [1].

The following lifestyle behaviours affect hepatic fat deposition: excess energy intake, poor diet, physical inactivity and prolonged sedentary behaviour. Increased consumption of refined carbohydrates, added sugars, saturated fats and energy dense foods have been linked to higher rates of metabolic dysfunction and hepatic steatosis [5,6].

On the other hand, small amounts of weight loss can be achieved through steady exercise that enhances insulin sensitivity, energy expenditure and visceral adiposity, without the need for major weight loss [7]. Sedentary behaviour and low levels of physical activity are often accompanied by unhealthy food habits, leading to a behaviour pattern that is linked to higher risk for fatty liver disease [6,8]. Therefore, lifestyle factors should be analyzed as "whole package" as opposed to individual exposures when assessing the development of hepatic steatosis.

Body mass index (BMI) is a commonly used index of adiposity and easily measureable indicator of overweight and obesity for clinical and population-based research. There is a consistent association of higher BMI with higher risk of fatty liver disease, and a dose-dependent association with NAFLD risk has been shown in the meta-analysis of data [9]. Insulin resistance and free fatty acid delivery to the liver are also thought to be additional mechanisms by which central adiposity contributes to hepatic steatosis [10,11]. Ultrasound is a simple and non-invasive means of diagnosis of hepatic steatosis, and is still widely used for the diagnosis of fatty liver in clinical practice [12,13]. Thus, the investigation of lifestyle risk factors and BMI in the context of ultrasound-detected fatty liver disease gives the clinical context to understanding the factors associated with hepatic steatosis.

Research Objective

To determine the relationship between lifestyle risk factors, body mass index, and ultrasound-detected fatty liver disease.

Study Design and Setting An analytical cross sectional study was conducted at the hospital to evaluate the association between lifestyle risk factors, BMI and fatty liver disease detected by ultrasound in adult participants. The study was carried out in Pakistan Tertiary Care Hospital which renders all diagnostic and clinical services to a cross-section of patient population. The study lasted for 1 year, from March 2025 to February 2026. Study Population All adult participants (aged 18 years or older) who attended the study period and completed clinical evaluation, anthropometric measurements, lifestyle assessment and abdominal ultrasonography were included in the study population. Sample Size and Sampling Technique The total sample that was used for the study consisted of 240 participants. The number of samples was deemed sufficient to test the association between lifestyle risk factors, BMI, and fatty liver disease in the ultrasound imaging. The data collection was consecutive non-probability sampling. All the eligible participants who appeared during the study period were consecutively recruited till the 240 sample size was obtained. Inclusion and Exclusion Criteria Those who had written informed consent and were 18 years or older at the time of the examination and had an abdominal ultrasonography performed were included. Those who had full information on the relevant demographic, anthropometric, lifestyle and ultrasonographic data were included. Those who had evidence of previous diagnosis of chronic liver disease of a non-metabolic etiology, high intake of alcohol, pregnancy or incomplete clinical, anthropometric, lifestyle and ultrasonographic data were excluded. Those who had conditions that could also be associated with hepatic steatosis independently were excluded (when clinically identified). Data Collection Procedure Structured data collection proforma was used to collect the data. Information on demography, lifestyle was collected from the participants through face-to-face interviews. Dietary intake, physical activity, sedentary behaviour, smoking status and other factors related to lifestyle were collected. Standardized procedures were followed for measuring height and weight, and then calculating the BMI. Abdominal ultrasound was performed for all participants, to assess hepatic steatosis. Systematic recording of clinical and ultrasonographic findings was carried out. Study Variables The principal dependent variable was the ultrasound diagnosis of fatty liver disease (FLD). Lifestyle risk factors and BMI were considered as the main independent variables. Age, sex and other demographics and clinical parameters were analyzed as possible covariates and confounding variables. Statistical Analysis The data collected were analyzed using SPSS version 26.0. Continuous variables were expressed as mean ± SD or median (interquartile range) as per the distribution of the data and categorical variables were explained as frequencies and percentages. The normality of the continuous variables was tested by the Shapiro–Wilk test. Categorical variables were tested for association with other categorical variables by the chi-square test or Fisher's exact test as appropriate and continuous variables were tested for association with other continuous variables by the independent-samples t-test or Mann–Whitney U test as appropriate based on distribution. Lifestyle risk factors, BMI and ultrasound-detected fatty liver disease were independently associated by multivariable logistic regression analysis after controlling for potential confounding factors. Odds ratios adjusted for 95% confidence intervals are reported. A p value < 0.05 was deemed to be statistically significant.

Table 1 presents the sociodemographic characteristics of the 240 study participants. The largest age group was 40–49 years, comprising 61 (25.42%) participants, followed by 30–39 years with 57 (23.75%). Males constituted 132 (55.00%) participants, while females accounted for 108 (45.00%). Most participants were from urban areas, representing 151 (62.92%) of the total sample.

Table 1. Sociodemographic Characteristics of Study Participants (n=240)

Table 2 summarizes the anthropometric characteristics of the study participants according to BMI categories. Overweight participants represented the largest proportion, with 83 (34.58%) participants, followed by those with normal weight at 79 (32.92%). Obesity was observed in 60 (25.00%) participants, whereas 18 (7.50%) were underweight. Overall, 59.58% of participants were either overweight or obese.

Table 2. Anthropometric Characteristics of Study Participants (n=240)

Table 3 describes the distribution of lifestyle risk factors among the study participants. Inadequate physical activity was reported by 144 (60.00%) participants, while 149 (62.08%) reported sedentary behaviour of ≥4 hours per day. An unhealthy dietary pattern was observed in 137 (57.08%) participants. Frequent fast-food intake, sugar-sweetened beverage consumption, and smoking were reported by 47.50%, 40.42%, and 27.50% of participants, respectively.

Table 3. Distribution of Lifestyle Risk Factors Among Study Participants (n=240)

Figure 1 presents the prevalence of ultrasound-detected fatty liver disease among the 240 participants. Fatty liver was detected in 103 (42.92%) participants, whereas 137 (57.08%) participants had no evidence of fatty liver on ultrasonography.Thus, approximately two-fifths of the study population had ultrasound-detected fatty liver disease. The findings demonstrate a substantial burden of fatty liver within the study population.

Figure 1:  Ultrasound-Detected Fatty Liver Disease Among Study Participants (n=240)

Figure 2 shows the distribution of fatty liver grades among the 103 participants diagnosed with fatty liver. Grade I fatty liver was the most frequently observed category, affecting 61 (59.22%) participants. Grade II disease was identified in 32 (31.07%) participants, while Grade III was observed in 10 (9.71%). Therefore, most participants with fatty liver had mild sonographic disease, whereas severe-grade disease was less frequent.

Figure 2. Grade of Ultrasound-Detected Fatty Liver Disease (n=103)

Table 4 demonstrates a statistically significant association between BMI category and ultrasound-detected fatty liver disease (χ²=43.72, p<0.001). The prevalence of fatty liver increased progressively across BMI categories, from 11.11% among underweight participants to 22.78% among those with normal weight. Fatty liver was present in 46.99% of overweight participants and 73.33% of obese participants. These findings indicate a strong positive association between increasing BMI and the presence of ultrasound-detected fatty liver.

Table 4. Association Between BMI and Ultrasound-Detected Fatty Liver Disease (n=240)

Note: Statistical test: Pearson chi-square (χ²), df=3.

Table 5 presents the associations between lifestyle risk factors and ultrasound-detected fatty liver disease. Fatty liver was significantly more common among participants with inadequate physical activity (52.78%), sedentary behaviour ≥4 hours/day (51.01%), and an unhealthy dietary pattern (52.55%), with all associations reaching statistical significance. Frequent fast-food intake and sugar-sweetened beverage consumption were also significantly associated with fatty liver (p=0.002 and p=0.003, respectively). In contrast, smoking was not significantly associated with fatty liver in this analysis (χ²=3.80, p=0.051).

Table 5. Association Between Lifestyle Risk Factors and Ultrasound-Detected Fatty Liver Disease

Note: Statistical test: Pearson chi-square (χ²), df=1 for each lifestyle factor.

Table 6 presents the multivariable logistic regression analysis of factors independently associated with ultrasound-detected fatty liver disease. Age ≥40 years, overweight, obesity, inadequate physical activity, high sedentary behaviour, unhealthy dietary pattern, and frequent sugar-sweetened beverage consumption remained significant predictors after adjustment for other variables. Obesity showed the strongest association with fatty liver, with an adjusted OR of 4.67 (95% CI: 2.38–9.17; p<0.001). Male sex, frequent fast-food intake, and smoking were not statistically significant independent predictors in the multivariable model.

Table 6. Multivariable Logistic Regression Analysis of Factors Associated with Ultrasound-Detected Fatty Liver Disease

The present study showed that 42.92% of all participants (103 cases) had fatty liver disease detected by ultrasound, which included Grade I, 59.22%; Grade II, 31.07%; and Grade III, 9.71%. This prevalence was also higher than that of the general population of Pakistan which was 29.82% in a recent systematic review and meta-analysis. The difference could be attributed to the hospital setting of the present study and the focus on lifestyle and metabolic risk factor population. However, the high prevalence reported makes opportunistic detection of fatty liver in Pakistani adults a clinical priority [14]. Results of the demography section revealed that the age group 40-49 years old was the most dominant age group with 25.42% of the participants, followed by 55.00% male and 45.00% female participants. In the present study, age ≥40 years remained independently associated with fatty liver (adjusted OR=1.84, 95% CI: 1.08–3.14; p=0.025), whereas male sex was not significant (adjusted OR=1.32, 95% CI: 0.79–2.20; p=0.288). These results are largely comparable to the previous evidence from Pakistan which showed more prevalence of NAFLD among older age and male gender, but the present multivariable analysis indicated age as a more independent risk factor than gender [15]. There was a positive association between BMI and fatty liver. The prevalence of fatty liver was 46.99% in overweight and significantly higher to 73.33% in obese participants compared to 22.78% in normal and 11.11% in underweight participants (χ²=43.72, p<0.001). This gradient was still observed after adjustment was made with overweight participants having an adjusted OR of 2.18 (95% CI: 1.18–4.03; p=0.013) and obese participants an adjusted OR of 4.67 (95% CI: 2.38–9.17; p<0.001). These results are in line with 21 cohort studies that have shown a dose-response association between elevated BMI and elevated risk of NAFLD [16]. Important association were also observed for lifestyle characteristics and fatty liver. 60.00% of the participants reported inadequate levels of physical activity, and this was found to be related to having fatty liver (χ²=14.29, p=0.001), compared with 28.13% of participants who reported adequate levels of physical activity. In addition, this lack of physical activity was independently associated with fatty liver (aOR=1.76; 95% CI: 1.03–3.01; p=0.039). This is in line with a meta-analysis that indicated that increased physical activity was associated with decreased risk of NAFLD, particularly as intensity of physical activity increased [17]. Similarly, high levels of sedentary activity were independently related to fatty liver (aOR=1.69, p=0.046). A similar trend was observed for dietary behaviour. Fifty-two.55% of the participants had an unhealthy dietary pattern and 52.55 % had fatty liver, while 30.10 % had a relatively healthy diet (χ²=12.10, p<0.001). However, its significance persisted after adjustment with an adjusted OR of 1.91 (95% CI: 1.12–3.25; p=0.018). These results are consistent with a systematic review and meta-analysis that revealed that Western dietary patterns with processed food and refined dietary components were linked to higher risk of NAFLD while healthier dietary patterns were linked to lower risk [18]. The 40.42% who reported consuming sugar-sweetened drinks were more likely to have fatty liver than the 34.97% who did not (χ²=9.13, p=0.003). Importantly, this association remained when adjusting for the other variables (adjusted OR=1.72, 95% CI: 1.01–2.93; p=0.045), while frequent fast-food intake (p=0.138) and smoking (p=0.419) were not independent risk factors. That sugar-sweetened beverages were associated with significantly increased risk of NAFLD is in line with a dose-response meta-analysis that found increased risk of NAFLD in consumers of sugar-sweetened drinks [19], suggesting that decreasing consumption of such beverages would be part of a lifestyle-based approach to prevention. The overall results of the present study suggest that combined effect of excess adiposity and modifiable lifestyle behaviours are associated with ultrasound detected fatty liver disease. Strengths and Limitations The analytical cross-sectional design of this study was one of its strengths as it enabled simultaneous evaluation of BMI, lifestyle risk factors and fatty liver disease assessed by ultrasound in a well-defined sample of 240 adults. Abdominal ultrasonography was a useful, non-invasive tool for identification and grading of fatty liver, and multivariable logistic regression enabled assessment of independent associations, with adjustment for potential confounding factors. But the results may not be representative of the broader population of Pakistan because of the hospital-based study conducted and non-probability consecutive sampling. The cross-sectional design also does not allow for the determination of temporal and causal relationships between lifestyle factors, BMI and fatty liver. Also, the information on lifestyle was self-reported by the participants and may be subject to recall or reporting bias, and ultrasonography may not be as sensitive as detecting mild hepatic steatosis.

The study findings indicate that fatty liver disease that is detected by ultrasound is a significant health issue among adults and appears to be closely related to excess body weight and lifestyle modification. Being overweight, sedentary lifestyle, sedentary time, unhealthy eating and regular intake of sugary drinks seem to increase the risk for fatty liver disease. The results highlight the need to identify individuals at risk early, and to encourage healthy nutrition, physical activity and decreased sedentary time, along with appropriate weight management as prevention and risk reduction strategies.

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