Observational Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Apr 27, 2020; 12(4): 149-159
Published online Apr 27, 2020. doi: 10.4254/wjh.v12.i4.149
Comparison of four non-alcoholic fatty liver disease detection scores in a Caucasian population
Lars Lind, Lars Johansson, Håkan Ahlström, Jan W Eriksson, Anders Larsson, Ulf Risérus, Joel Kullberg, Jan Oscarsson
Lars Lind, Jan W Eriksson, Anders Larsson, Department of Medical Sciences, Uppsala University, Uppsala 75185, Sweden
Lars Johansson, Håkan Ahlström, Joel Kullberg, Antaros Medical AB, BioVenture Hub, Mölndal 43153, Sweden
Håkan Ahlström, Joel Kullberg, Department of Surgical Sciences, Uppsala University, Uppsala 75185, Sweden
Ulf Risérus, Department of Public Health and Caring Sciences Clinical Nutrition and Metabolism, Uppsala University, Uppsala 75122, Sweden
Jan Oscarsson, Global Medicines Development, AstraZeneca, MöIndal 43150, Sweden
Author contributions: Lind L, Johansson L, Ahlström H, Eriksson JW, Larsson A, Risérus U, Kullberg J, and Oscarsson J contributed to the concept, design, and conduct of the study; All authors have read and approved the final manuscript.
Institutional review board statement: The study was approved by the Ethics Committee of Uppsala University (D5881C00007/EFFECT I and D5883C00004/EFFECT II).
Informed consent statement: All the participants gave their written informed consent.
Conflict-of-interest statement: Dr. Lind, Dr. Larsson, and Dr. Risérus declare no conflicts. Dr. Johansson, Dr. Kullberg and Dr. Ahlström are cofounders, co-owners, and part-time employees of Antaros Medical AB, BioVenture Hub, Mölndal, Sweden; Dr. Eriksson has received consultancy fees for planning of this study and received research grants or honoraria from AstraZeneca, Bristol-Myers Squibb, Merck Sharp and Dohme, Novo Nordisk, and Sanofi; Dr. Oscarsson is an employee of AstraZeneca.
Data sharing statement: Data underlying the findings described in this manuscript may be obtained in accordance with AstraZeneca’s data sharing policy described at https://astrazenecagrouptrials.pharmacm.com/ST/Submission/Disclosure.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
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: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Lars Lind, MD, PhD, Professor, Department of Medical Sciences, Uppsala University, Akademiska Sjukhuset, Entrance 40, 5th Floor, Uppsala 75185, Sweden. lars.lind@medsci.uu.se
Received: December 20, 2019
Peer-review started: December 20, 2019
First decision: January 6, 2020
Revised: March 16, 2020
Accepted: March 22, 2020
Article in press: March 22, 2020
Published online: April 27, 2020

Non-alcoholic fatty liver disease (NAFLD) is a common disorder, with an estimated prevalence ranging from 20% to 35% in the general population. Several scores based on easily measurable biochemical and clinical parameters, including the fatty liver index (FLI), hepatic steatosis index (HSI), lipid accumulation product (LAP), and NAFLD liver fat score (LFS), have been developed for the detection of NAFLD. However, comparative information regarding the efficacy of these scores for predicting NAFLD in population-based samples comprising normal and high-risk individuals is lacking.


To evaluate four NAFLD detection scores in two samples with different NAFLD risks.


NAFLD screening was performed in a population-based sample of 50-year-old individuals in Uppsala, Sweden [n = 310; Prospective investigation of obesity, energy and metabolism (POEM) study] and a high-risk population comprising patients with a body mass index > 25 kg/m2 and either high plasma triglycerides (≥ 1.7 mmol/L) or type 2 diabetes (n = 310; EFFECT studies). NAFLD was defined as liver fat > 5.5% using magnetic resonance imaging-proton density fat fraction. FLI, HSI, LAP, and NAFLD LFS were assessed. A logistic regression model was used to evaluate the effectiveness of the different scores.


The prevalence of NAFLD was 23% in POEM. FLI showed the highest receiver operating characteristic area under the curve (ROC AUC; 0.82) and was significantly better than the LAP score (P = 0.005 vs LAP, P = 0.08 vs LFS, P = 0.12 vs HSI) for detection of NAFLD. The other three indices performed equally in POEM (0.77-0.78). The prevalence of NAFLD was 74% in EFFECT; LFS performed best (ROC AUC 0.80) in this sample. The ROC AUC for LFS (0.80) was significantly higher than that for FLI (P = 0.0019) and LAP (P = 0.0022), but not HSI (P = 0.11). We performed a sensitivity analysis with stratification for the two high-risk subgroups (patients with diabetes or hypertriglyceridemia) from the EFFECT studies. LAP performed best in patients with hypertriglyceridemia. No major differences were observed between the other scores.


The four investigated NAFLD scores performed differently in the populationbased vs high-risk setting. FLI was preferable in the population-based setting, while LFS performed best in the high-risk setting.

Keywords: Comparison, EFFECT studies, Fatty liver, Non-alcoholic fatty liver disease, Non-invasive indices, Screening

Core tip: Several non-invasive indices based on routinely available biochemical and physical parameters have been developed for the detection of non-alcoholic fatty liver (NAFLD) disease. However, data comparing the efficacy of these indices within a population-based sample are lacking. Here we compared four non-invasive indices, namely, fatty liver index, lipid accumulation product, hepatic steatosis index, and liver fat score, in a population-based (Prospective investigation of obesity, energy and metabolism study) sample and a high-risk (EFFECT studies) sample. Our study demonstrated differences in NAFLD detection between the scores in the two samples. Of the four evaluated scores, fatty liver index was preferable in the population-based sample (NAFLD prevalence, 23%), whereas liver fat score performed best in the high-risk sample (NAFLD prevalence, 73%).