Case Control Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Jan 18, 2017; 9(2): 91-98
Published online Jan 18, 2017. doi: 10.4254/wjh.v9.i2.91
Predictors for advanced fibrosis in morbidly obese non-alcoholic fatty liver patients
Shira Zelber-Sagi, Dafna Shoham, Isabel Zvibel, Subhi Abu-Abeid, Oren Shibolet, Sigal Fishman
Shira Zelber-Sagi, Dafna Shoham, School of Public Health, University of Haifa, Haifa 3498838, Israel
Shira Zelber-Sagi, Isabel Zvibel, Oren Shibolet, Sigal Fishman, Department of Gastroenterology, Tel Aviv Medical Center, Tel-Aviv 6423906, Israel
Isabel Zvibel, Sigal Fishman, Obesity Service, Department of Gastroenterology, Tel Aviv Medical Center, Tel-Aviv 6423906, Israel
Isabel Zvibel, Oren Shibolet, Sigal Fishman, the Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6423906, Israel
Subhi Abu-Abeid, Bariatric Unit, Department of Surgery, Tel Aviv Medical Center, Tel-Aviv 6423906, Israel
Author contributions: 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 regarding this manuscript.
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, PhD, School of Public Health, University of Haifa, 6 Weizmann St., Haifa 3498838, Israel.
Telephone: +972-3-6973984 Fax: +972-3-6966286
Received: August 10, 2016
Peer-review started: August 10, 2016
First decision: September 12, 2016
Revised: September 30, 2016
Accepted: November 16, 2016
Article in press: November 17, 2016
Published online: January 18, 2017

To investigate predictors for fibrosis specifically in a high risk population of morbidly obese patients, including detailed evaluation of lifestyle.


We conducted a cross-sectional study among morbidly obese patients attending the bariatric clinic at the Tel-Aviv Medical Center between the years 2013-2014 with body mass index (BMI) above 40 or above 35 with co-morbidity. Patients with serum hepatitis B surface antigen or anti-hepatitis C virus antibodies, genetic liver diseases, autoimmune disease or high alcohol intake (≥ 30 g/d in men or ≥ 20 g/d in women) were excluded from the study. Liver fibrosis was estimated by transient elastography (FibroScan®), using the ‘‘XL’’ probe. We collected data on age and gender, education, smoking status and amount, medical history, nutrition and lifestyle habits. All these data were collected using structured and validated questionnaires. Fasting blood test were available for a subsample.


Fibroscan was performed on a total of 91 patients, of which 77 had a valid examination according to the accepted criteria. Of those, 21% had significant fibrosis (F2) and 39% had advanced or severe fibrosis (F3 or F4). In multivariate analysis, male gender and BMI had a positive association with advanced fibrosis; the OR for fibrosis F ≥ 2 was 7.93 (95%CI: 2.36-26.64, P = 0.001) for male gender and 1.33 (1.11-1.60 kg/m2, P = 0.002) for BMI. The OR for fibrosis F ≥ 3 was 2.92 (1.08-7.91, P = 0.035) for male gender and 1.17 (1.03-1.33, P = 0.018) for BMI. Subjects were categorized to subgroups based on the combination of male gender and BMI of 40 and above. A significant dose response association with stiffness level was noted across these categories, with the highest stiffness among men with a higher BMI (P = 0.001). In addition, a significant positive correlation between pack-years cigarette smoking and liver stiffness was demonstrated among men (r = 0.54, P = 0.012).


In the morbidly obese population, a higher BMI, male gender and degree of smoking in men bears a greater risk for advanced nonalcoholic fatty liver disease.

Keywords: Non-alcoholic fatty liver disease, Morbid obesity, Fibrosis, Fibroscan, Diet

Core tip: The presented results indicate that male gender and a higher body mass index (BMI) are risk factors for advanced fibrosis in morbidly obese patients. There is also a positive correlation between cigarette smoking and liver stiffness in men. Our study highlights the fact that even in the upper BMI ranges, higher BMI bears greater risk for advanced disease. Therefore, in the morbidly obese population it may seem useful to emphasize the importance of weight reduction, even within the range of obesity.