Management of nonalcoholic fatty liver disease in the Middle East

Table 1 Prevalence and Estimation Studies of Risk Factors of nonalcoholic fatty liver disease in United Arab Emirates, Kingdom of Saudi Arabia, and Kuwait

Place of study	Study	Main findings	Ref.
Dubai, UAE	Cross-sectional study to access prevalence of MetS and its associated risk factors among children and adolescents (596 students)	Prevalence of MetS was 3.7%; was more common among boys than girls (12 boys versus 10 girls); 18.6% were overweight; 21.2% were obese; MetS was more commonly found in obese (16%) compared to overweight students (2%)	Haroun et al[81], 2018
Abu Dhabi, UAE	Multicenter cohort study to determine cardiovascular risk factor prevalence rates (50138 participants)	35% were obese, 32% were overweight, 55% had central obesity, 18% were diabetic, 27% were prediabetic; Age-standardized diabetes and prediabetes rates were 25% and 30%, respectively; Age-standardized obesity and overweight rates were 41% and 34%, respectively	Hajat et al[12], 2012
UAE	Systematic review and qualitative synthesis of prevalence, incidence rates, trends, and Economic Burden of Obesity and cardiometabolic disorder (36 studies)	All studies reported high prevalence rates for obesity, diabetes, hypertension, and MetS; Obesity and related cardiometabolic disorders seem highly prevalent in the UAE but estimating an accurate occurrence is challenging due to methodological heterogeneity of the epidemiological studies addressing them; Frequency of overweight and obesity was reported to increase by 2-3-fold between 1989 and 2017	Radwan et al[13], 2018
Saudi Arabia	Survey to determine obesity prevalence and associated factors (n = 10293)	28.7% of the population evaluated were obese; Obesity prevalence was higher among women (33.5%) than men (24.1%)	Memish et al[14], 2014
Saudi Arabia	Secondary analysis to estimate the trends in the prevalence of adult obesity over the period 1992–2022 (5 studies)	Obesity trend from 1992-2005: In men, the prevalence increased from (1) 10.1% to 27.1% in age-group 25-34 yr; and (2) 12.9% to 31.0% in age group 55-64 yr. In women, obesity prevalence was higher; increased from (1) 16.1% to 39.5% in age group 25-34 yr; and (2) 22.8% to 53.2% in age group 55-64 yr. Obesity projection from 1992-2022: The future obesity prevalence was estimated to increase from (1) 12% to 41% in men; and (2) 21% to 78% in women	Al-Quwaidhi et al[15], 2014
Saudi Arabia	Cross sectional study to evaluate the prevalence of MetS	The prevalence of MetS in Saudi Arabia was found to be 39.8% (34.4% in men and 29.2% in women) as per the NCEP ATP III and 31.6% (45.0% in men and 35.4% in women) as per IDF criteria	Al-Rubeaan et al[26], 2018
Kuwait	Observational study (multicenter) to examine the prevalence of MetS and its components (992 adults ≥ 20 yr)	Obesity percentage was significantly greater in females (54.7%) compared to males (32.3%); Abdominal obesity was the most predominant MetS abnormality; Prevalence of MetS increased with age and was higher in females than males	Al Zenki et al[82], 2012
Kuwait	Cross-sectional survey to estimate prevalence of overweight, obesity, and various types of adiposity (3589 adults, 18-69 yr)	Overall obesity prevalence was 40.3% (men, 36.5%; women, 44.0%); The prevalence of Class I, Class II, and Class III obesity was 24.9%, 9.9%, and 5.5%, respectively	Weiderpass et al[83], 2019
Kuwait	Descriptive, cross-sectional survey (multicenter) to understand the prevalence of MetS, and estimation of the 10-year risk for developing T2DM and CHD (n = 1610)	4% subjects were found to have screen detected T2DM. A history of high blood glucose levels was reported by 18.0% subjects; 35.5% of the participants were obese; MetS was present in about 32% of the participants; Almost 30% of participants were found to be at moderate/high/very high risk of developing T2DM within the next 10 yr; 8.45% were found to be at moderate/high/very high risk of developing both T2DM/CHD within the next 10 yr	Awad et al[84], 2014

IDF: International Diabetes Federation; MetS: Metabolic syndrome; NCEP ATP III: National Cholesterol Education Program and Adult Treatment Panel III; T2DM: Type 2 diabetes mellitus; UAE: United Arab Emirates.

Table 2 Key diagnostic modalities for nonalcoholic fatty liver disease and nonalcoholic steatohepatitis[11,35,85,86]

Diagnostic Tests	Advantages	Limitations
Liver enzymes and other blood tests for fibrosis
Platelet count; APRI; AST; ALT; AST/ALT ratio; Hyaluronic acid; ELF; Hepascore; FibroSpect; FibroTest/FibroSure	Simple and easy; AST/ALT of > 1 is predictive of fibrosis; ELF can predict stage of fibrosis and outcomes	AST and ALT can be normal in some patients with NAFLD; ELF is not widely available; Some tests initially developed for HCV; Limited published data on external validation
Radiology
Ultrasonography	Easily available; Safe; Overall scanning of abdominal organs	Cannot detect mild degree of steatosis (< 30% of hepatocytes); Does not distinguish between steatosis and NASH; Operator dependent
MRI	More sensitive than ultrasonography	Cost and availability; Does not distinguish between steatosis and NASH
Transient; Elastography	Can detect fibrosis	Cost and availability
MRE	Can detect fibrosis and MRI-PDFF can quantify steatosis	Cost and availability
Fibrosis scoring systems
NAFLD fibrosis score (NFS), Fibro Meter Fibrosis-4 (FIB-4)	Allow a more targeted use of liver biopsy by reliably excluding advanced fibrosis in a high proportion of NAFLD patients; Potentially predict liver-related and cardiovascular complications and death	Significant number with indeterminate scores; Limited external validation in NASH
Liver biopsy	Gold standard for diagnosis of NAFLD and NASH; Allows staging of the disease	Invasive; Associated with complications – pain, intraperitoneal bleeding; Cost

ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; APRI: AST-to-platelet ratio index; CT: Computerized tomographic; ELF: Enhanced liver fibrosis; MRE: Magnetic resonance elastography; MRI: Magnetic resonance imaging; MRI-PDFF: MRI-based proton density fat fraction; NAFLD: Nonalcoholic fatty liver disease; NASH: Nonalcoholic steatohepatitis.