Case Control Study
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. May 7, 2016; 22(17): 4362-4372
Published online May 7, 2016. doi: 10.3748/wjg.v22.i17.4362
Non-alcoholic fatty liver disease is not associated with a lower health perception
Liat Mlynarsky, Dalit Schlesinger, Roni Lotan, Muriel Webb, Zamir Halpern, Erwin Santo, Oren Shibolet, Shira Zelber-Sagi
Liat Mlynarsky, Roni Lotan, Muriel Webb, Zamir Halpern, Erwin Santo, Oren Shibolet, Shira Zelber-Sagi, Department of Gastroenterology, Tel Aviv Medical Center, Tel-Aviv 6423906, Israel
Liat Mlynarsky, Roni Lotan, Muriel Webb, Zamir Halpern, Erwin Santo, Oren Shibolet, The Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv 6997801, Israel
Dalit Schlesinger, Shira Zelber-Sagi, School of Public Health, University of Haifa, Haifa 3498838, Israel
Author contributions: Zelber-Sagi S conceived and designed the study; Schlesinger D and Zelber-Sagi S analyzed the data; Lotan R, Webb M and Zelber-Sagi S performed the data collection; Halpern Z, Santo E and Shibolet O conducted on data collection; Mlynarsky L, Shibolet O and Zelber-Sagi S wrote the manuscript; all authors critically reviewed the manuscript and approved it.
Institutional review board statement: The study was approved by the institutional review board of Tel Aviv medical center.
Informed consent statement: All participants signed an informed consent.
Conflict-of-interest statement: The authors declare no conflicts of interest.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at
Open-Access: 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:
Correspondence to: Shira Zelber-Sagi, RD, PhD, Head of Nutrition and Behavior Program, School of Public Health, the University of Haifa and the Tel-Aviv Medical Center, 6 Weizman Street, Tel-Aviv 64239, Israel.
Telephone: +972-3-6973984 Fax: +972-3-6966286
Received: December 18, 2016
Peer-review started: December 20, 2016
First decision: January 13, 2016
Revised: February 9, 2016
Accepted: March 2, 2016
Article in press: March 2, 2016
Published online: May 7, 2016

AIM: To examine the association between non-alcoholic fatty liver disease (NAFLD) and general health perception.

METHODS: This cross sectional and prospective follow-up study was performed on a cohort of a sub-sample of the first Israeli national health and nutrition examination survey, with no secondary liver disease or history of alcohol abuse. On the first survey, in 2003-2004, 349 participants were included. In 2009-2010 participants from the baseline survey were invited to participate in a follow-up survey. On both baseline and follow-up surveys the data collected included: self-reported general health perception, physical activity habits, frequency of physician's visits, fatigue impact scale and abdominal ultrasound. Fatty liver was diagnosed by abdominal ultrasonography using standardized criteria and the ratio between the median brightness level of the liver and the right kidney was calculated to determine the Hepato-Renal Index.

RESULTS: Out of 349 eligible participants in the first survey, 213 volunteers participated in the follow-up cohort and were included in the current analysis, NAFLD was diagnosed in 70/213 (32.9%). The prevalence of "very good" self-reported health perception was lower among participants diagnosed with NAFLD compared to those without NAFLD. However, adjustment for BMI attenuated the association (OR = 0.73, 95%CI: 0.36-1.50, P = 0.392). Similar results were observed for the hepato-renal index; it was inversely associated with "very good" health perception but adjustment for BMI attenuated the association. In a full model of multivariate analysis, that included all potential predictors for health perception, NAFLD was not associated with the self-reported general health perception (OR = 0.86, 95%CI: 0.40-1.86, P = 0.704). The odds for "very good" self-reported general health perception (compared to "else") increased among men (OR = 2.42, 95%CI: 1.26-4.66, P = 0.008) and those with higher performance of leisure time physical activity (OR = 1.01, 95%CI: 1.00-1.01, P < 0.001, per every minute/week) and decreased with increasing level of BMI (OR = 0.91, 95%CI: 0.84-0.99, P = 0.028, per every kg/m2) and older age (OR = 0.96, 95%CI: 0.93-0.99, P = 0.033, per one year). Current smoking was not associated with health perception (OR = 1.31, 95%CI: 0.54-3.16, P = 0.552). Newly diagnosed (naive) and previously diagnosed (at the first survey, not naive) NAFLD patients did not differ in their self-health perception. The presence of NAFLD at the first survey as compared to normal liver did not predict health perception deterioration at the 7 years follow-up. In terms of health-services utilization, subjects diagnosed with NAFLD had a similar number of physician’s visits (general physicians and specialty consultants) as in the normal liver group. Parameters in the fatigue impact scale were equivalent between the NAFLD and the normal liver groups.

CONCLUSION: Fatty liver without clinically significant liver disease does not have independent impact on self-health perception.

Keywords: Non-alcoholic fatty liver disease, Health perception, Quality of life, Fatigue, Health-care services utilization

Core tip: In recent years there is overwhelming evidence that non-alcoholic fatty liver disease (NAFLD) is a major public health concern; the most common chronic liver disorder globally and associated with hepatic and extrahepatic morbidity and mortality. However, this study demonstrates that NAFLD diagnosis among a general population is not independently associated with lower general health perception nor is it associated with higher health care utilization. Moreover, NAFLD does not seem to predict health perception deterioration over the years. These findings imply that in the general population, NAFLD is not considered a disease in the eyes of the NAFLD beholder, probably until an advanced stage.