Ruth Chan

Prevalence of non-alcoholic fatty liver disease and advanced fibrosis in Hong Kong Chinese: a population study using proton-magnetic resonance spectroscopy and transient elastography

Objective Knowledge of the epidemiology of non-alcoholic fatty liver disease (NAFLD) is incomplete because liver biopsy cannot be performed on the general population to assess disease severity. New non-invasive tests allow accurate and safe assessment in healthy individuals. The aim of this study was to examine the prevalence of NAFLD and advanced fibrosis in the general Hong Kong Chinese population. Methods Subjects were recruited from the community by random selection from the government census database. Liver fat and fibrosis were assessed by proton-magnetic resonance spectroscopy and transient elastography, respectively. Results Overall, 264 of 922 (28.6%) subjects had intrahepatic triglyceride content ≥5%. Excluding 12 subjects with significant alcohol consumption, the population prevalence of NAFLD was 27.3% (95% CI 24.5% to 30.2%). Each component of the metabolic syndrome increased the risk of fatty liver in a dose-dependent manner (prevalence of 4.5% in subjects without any component and 80.0% in those with all five components). 8 (3.7%) patients with fatty liver had liver stiffness ≥9.6 kPa, a level suggestive of advanced fibrosis. Body mass index and alanine aminotransferase level were independent factors associated with liver stiffness. Together with other clinical prediction scores, the estimated prevalence of advanced fibrosis in patients with fatty liver in the community was <10%. Compared with non-drinkers, modest drinkers (<10 g per day) did not have higher risk of fatty liver after adjustment for demographic and metabolic factors. The liver stiffness was 4.7±1.9 kPa in modest drinkers and 4.6±1.7 kPa in non-drinkers (p=0.54). Conclusion NAFLD is found in over a quarter of the general adult Chinese population, but the proportion of patients with advanced fibrosis is low. Modest alcohol consumption does not increase the risk of fatty liver or liver fibrosis.

Prevention of Overweight and Obesity: How Effective is the Current Public Health Approach

Obesity is a public health problem that has become epidemic worldwide. Substantial literature has emerged to show that overweight and obesity are major causes of co-morbidities, including type II diabetes, cardiovascular diseases, various cancers and other health problems, which can lead to further morbidity and mortality. The related health care costs are also substantial. Therefore, a public health approach to develop population-based strategies for the prevention of excess weight gain is of great importance. However, public health intervention programs have had limited success in tackling the rising prevalence of obesity. This paper reviews the definition of overweight and obesity and the variations with age and ethnicity; health consequences and factors contributing to the development of obesity; and critically reviews the effectiveness of current public health strategies for risk factor reduction and obesity prevention.

Community-based lifestyle modification programme for non-alcoholic fatty liver disease: A randomized controlled trial

BACKGROUND & AIMS Healthy lifestyle is the most important management of non-alcoholic fatty liver disease (NAFLD). This study aimed at assessing the efficacy of a community-based lifestyle modification programme in the remission of NAFLD. METHODS This was a parallel group, superiority, randomized controlled trial. 154 adults with NAFLD identified during population screening were randomized to participate in a dietitian-led lifestyle modification programme at 2 community centres or receive usual care for 12 months. The primary outcome was remission of NAFLD at month 12 as evidenced by intrahepatic triglyceride content (IHTG) of less than 5% by proton-magnetic resonance spectroscopy. RESULTS 74 patients in the intervention group and 71 patients in the control group completed all study assessments. In an intention-to-treat analysis of all 154 patients, 64% of the patients in the intervention group and 20% in the control group achieved remission of NAFLD (difference between groups 44%; 95% CI 30-58%; p<0.001). The mean (SD) changes in IHTG from baseline to month 12 were -6.7% (6.1%) in the intervention group and -2.1% (6.4%) in the control group (p<0.001). Body weight decreased by 5.6 (4.4) kg and 0.6 (2.5) kg in the two groups, respectively (p<0.001). While 97% of patients with weight loss of more than 10% had remission of NAFLD, 41% of those with weight loss of 3.0-4.9% could also achieve the primary outcome. CONCLUSIONS The community-based lifestyle modification programme is effective in reducing and normalizing liver fat in NAFLD patients.

Incidence of non-alcoholic fatty liver disease in Hong Kong: a population study with paired proton-magnetic resonance spectroscopy.

BACKGROUND & AIMS Because abdominal ultrasonography cannot reliably quantify hepatic steatosis, accurate data on the incidence of non-alcoholic fatty liver disease (NAFLD) are lacking. We aimed to study the population incidence of NAFLD with state-of-the-art non-invasive tests. METHODS This was a prospective cohort study. The intrahepatic triglyceride (IHTG) content was measured serially with proton-magnetic resonance spectroscopy in community subjects. Transient elastography was performed to assess liver fibrosis. RESULTS 565 subjects (mean age 48 years, 62.7% women) without NAFLD at baseline underwent follow-up assessment after a median interval of 47 months (range 34-60 months). 78 (13.8%) subjects developed incident fatty liver with a mean IHTG content of 8.9% (SD 5.3%). 16 (20.5%) subjects had an IHTG content ⩾ 11.0% suggestive of moderate to severe steatosis. After excluding 2 men with significant alcohol consumption, the population incidence of NAFLD at 3-5 years was 13.5% (95% CI 10.6-16.3%; 3.4% per year). Only 1 subject with incident NAFLD had high liver stiffness (11.1 kPa) suggestive of advanced fibrosis. Metabolic syndrome at baseline was the strongest predictor of incident fatty liver. Incident central obesity developed in 31.0% of subjects with incident fatty liver and 5.6% of those without (p<0.001). No subject with incident fatty liver had regression of impaired fasting glucose, which occurred in 51.1% of those without incident fatty liver (p=0.001). CONCLUSIONS 13.5% of the Hong Kong Chinese adult population develop NAFLD in 3-5 years, but few have severe steatosis or advanced fibrosis. Metabolic syndrome is the most important risk factor of incident NAFLD.

Prostate cancer and vegetable consumption

Epidemiological studies have shown marked variations in prostate cancer incidence and mortality across different geographic regions, leading to the rising interest in the role of nutrition in prostate cancer risk. There is also a large body of evidence that a diverse diet, rich in vegetables, can reduce the risk of prostate cancer. In this review, the role of various kinds of vegetables and their bioactive compounds associated with prostate cancer risk, and the underlying mechanisms of these associations are summarized. There is accumulating evidence to support the consumption of lycopene, in particular tomato and tomato-based products, as protective factors against prostate cancer. Evidence on the protective role of beta-carotene was inconsistent from cohort and case-control studies. Evidence on the effect of pulses or soy consumption on prostate cancer risk was limited but suggestive of decreased risk with increased pulses or soy consumption. However, the role of vitamin C, vitamin E, allium vegetables, and cruciferous vegetables on prostate cancer risk remains to be determined due to limited evidence. Although the impact on prostate cancer risk differs among various vegetables and their constituent nutrients, the overall benefits of plant based diet on cancer prevention and other diet-related diseases should be promoted.

Association between serum 25-hydroxyvitamin D and psychological health in older Chinese men in a cohort study

BACKGROUND Few studies evaluated the association between vitamin D and psychological health in Chinese. This study examined these associations in Chinese older men in Hong Kong. METHODS Baseline serum 25-hydroxyvitamin D (25OHD), depression and cognitive function were assessed in 939 community-dwelling Chinese men aged >65. Data on depression status at 4-year follow up was available in 629 men. Data were collected for confounding factors: demographics, number of diseases, smoking, alcohol use, body mass index, physical activity, mobility limitations, dietary intake, season of blood measurement, and serum parathyroid hormone level. Multivariate logistic regression analyses were performed with adjustments for confounding factors. RESULTS An inverse association between serum 25OHD and baseline depression was observed. Men in the highest (>=92 nmol/L) compared with lowest (<=63 nmol/L) quartile of serum 25OHD had an adjusted odds ratio for depression of 0.46 (95% CI: 0.22-0.98, P(trend)=0.004). The association was more pronounced in low vitamin D season than in high vitamin D season. No association was observed between serum 25OHD and incident depression at 4 years. Baseline cognitive impairment was not associated with serum 25OHD in all models. LIMITATIONS Self-reported measure of depression and cognitive performance, the small number of incident depression at 4-year follow up and selection bias may affect the study validity. CONCLUSIONS Serum 25OHD was inversely associated with depression at baseline and was not linked to baseline cognitive impairment and 4-year incident depression in Chinese older men. Future studies are warranted to evaluate these associations in populations with higher prevalence of vitamin D deficiency.

Fatty pancreas, insulin resistance, and β-cell function: a population study using fat-water magnetic resonance imaging.

OBJECTIVES:Nonalcoholic fatty liver disease is the most common chronic liver disease. Fatty pancreas has also been described but is difficult to assess. It is now possible to measure pancreatic and liver fat accurately with magnetic resonance imaging (MRI). We aimed to define the normal range of pancreatic fat and identify factors associated with fatty pancreas. In addition, the effect of fatty liver and fatty pancreas on insulin resistance (IR) and pancreatic β-cell function was studied.METHODS:Fat-water MRI and proton-magnetic resonance spectroscopy were performed on 685 healthy volunteers from the general population to measure pancreatic and liver fat, respectively. On the basis of fasting plasma glucose and insulin levels, the IR and β-cell function were assessed using the homeostasis model assessment (HOMA).RESULTS:Among subjects without significant alcohol consumption or any component of metabolic syndrome, 90% had pancreatic fat between 1.8 and 10.4%. Using the upper limit of normal of 10.4%, 110 (16.1%; 95% confidence interval 13.3–18.8%) subjects had fatty pancreas. On multivariable analysis, high serum ferritin, central obesity, and hypertriglyceridemia were independent factors associated with fatty pancreas. Subjects with both fatty pancreas and fatty liver had higher HOMA-IR than did those with either condition alone. Fatty pancreas was not associated with HOMA-β after adjusting for liver fat and body mass index.CONCLUSIONS:In all, 16.1% of this community cohort of adult Hong Kong Chinese volunteers had a fatty pancreas by our definition. Central obesity, hypertriglyceridemia, and hyperferritinemia are associated with fatty pancreas. Individuals with fatty pancreas have increased IR.

Prevalence and Severity of Nonalcoholic Fatty Liver Disease in Non-Obese Patients: A Population Study Using Proton-Magnetic Resonance Spectroscopy

OBJECTIVES:Some studies suggest that non-obese patients with nonalcoholic fatty liver disease (NAFLD) may have more severe disease. We aim to study the epidemiology and severity of non-obese NAFLD.METHODS:A total of 911 community subjects were randomly recruited from the census database of the Hong Kong Government. Intrahepatic triglycerides (IHTG) and liver fibrosis were assessed by proton-magnetic resonance spectroscopy and transient elastography, respectively. The Asian body mass index cutoff of 25 kg/m2 was used to define non-obese NAFLD.RESULTS:The prevalence of NAFLD was 19.3% in non-obese subjects and 60.5% in obese subjects (P<0.001). Compared with obese NAFLD patients, non-obese NAFLD patients had similar IHTG content (median 9.8% vs. 9.9%; P=0.100) but lower cytokeratin-18 fragments (149 vs. 182 IU/l; P=0.019) and liver stiffness (4.6 vs. 5.6 kPa; P<0.001). The G allele at the patatin-like phospholipase domain-containing protein 3 gene (PNPLA3 rs738409) was more common in non-obese than obese NAFLD patients (78.4% vs. 59.8%; P=0.001). Obesity, high hemoglobin A1c, insulin resistance, hyperferritinemia, and the PNPLA3 G allele were independent factors associated with NAFLD in non-obese subjects. Even among non-obese subjects with normoglycemia, those with NAFLD were more insulin resistant (mean homeostasis model assessment of insulin resistance: 2.0±1.0 vs. 1.1±1.1; P<0.001).CONCLUSIONS:One-fifth of the general non-obese Chinese population has NAFLD. Non-obese patients with NAFLD do not have a higher risk of steatohepatitis or advanced fibrosis. Patients with risk factors of advanced fibrosis such as metabolic syndrome and PNPLA3 G allele carriage should be assessed for severe NAFLD.

Relative Contributions of Geographic, Socioeconomic, and Lifestyle Factors to Quality of Life, Frailty, and Mortality in Elderly

Background To date, few studies address disparities in older populations specifically using frailty as one of the health outcomes and examining the relative contributions of individual and environmental factors to health outcomes. Methodology/Principal Findings Using a data set from a health survey of 4,000 people aged 65 years and over living in all regions of Hong Kong, we examined regional variations in self-rated health, frailty, and four-year mortality, and analyzed the relative contributions of lifestyle, socioeconomic status, and geographical location of residence to these outcomes using path analysis. We hypothesize that lifestyle, socioeconomic status, and regional characteristics directly and indirectly through interactions contribute to self-rated physical and psychological health, frailty, and four-year mortality. District variations directly affect self-rated physical health, and also exert an effect through socioeconomic position as well as lifestyle factors. Socioeconomic position in turn directly affects self-rated physical health, as well as indirectly through lifestyle factors. A similar pattern of interaction is observed for self-rated mental health, frailty, and mortality, although there are differences in different lifestyle factors and district associations. Lifestyle factors also directly affect physical and mental components of health, frailty, and mortality. The magnitude of direct district effect is comparable to those of lifestyle and socioeconomic position. Conclusions/Significance We conclude that district variations in health outcomes exist in the Hong Kong elderly population, and these variations result directly from district factors, and are also indirectly mediated through socioeconomic position as well as lifestyle. Provision and accessibility to health services are unlikely to play a significant role. Future studies on these district factors would be important in reducing health disparities in the older population.

Outcome of a postnatal depression screening programme using the Edinburgh Postnatal Depression Scale: a randomized controlled trial

BACKGROUND There is a lack of evidence on the effectiveness of postnatal depression (PND) screening programmes in reducing morbidity. The aim of this study was to evaluate the effectiveness of a PND screening programme using Edinburgh Postnatal Depression Scale (EPDS) in improving maternal mental health. METHODS The randomized controlled trial design was used. Participants were 462 Chinese mothers with 2-month-old babies visiting Maternal and Child Health Centres in Hong Kong. Participants in the intervention group were screened for PND using the EPDS, whereas those in the control group were screened by clinical assessment. In both groups, participants identified with PND were offered follow-up management according to protocol. RESULTS Participants in the intervention group had better maternal mental health outcome as assessed by EPDS at 6 months (risk ratio: 0.59; 95% confidence interval: 0.39-0.89). The number needed to screen was 25. CONCLUSIONS A PND screening programme comprising the use of EPDS as the screening tool and the provision of follow-up care had resulted in an improvement in maternal mental health at 6 months.