Gastroenterology

Gastroenterology

Volume 138, Issue 4, April 2010, Pages 1346-1356.e3
Gastroenterology

Clinical Advances in Liver, Pancreas, and Biliary Tract
Trunk Fat Is Associated With Increased Serum Levels of Alanine Aminotransferase in the United States

https://doi.org/10.1053/j.gastro.2009.12.053Get rights and content

Background & Aims

Liver injury is associated with obesity and related measures, such as body mass index (BMI) and waist circumference. The relationship between liver injury and body composition has not been evaluated in a population-based study.

Methods

Using data from a US population-based survey, we examined the contributions of body composition, measured by dual-energy x-ray absorptiometry (DXA), to increased serum alanine aminotransferase (ALT) activity among 11,821 adults without viral hepatitis. Trunk fat, extremity fat, trunk lean, and extremity lean mass were divided by height squared and used to categorize subjects into quintiles; logistic regression odds ratios (OR) were calculated for increased ALT.

Results

Increased ALT was associated with higher measures of fat and lean mass (P < .001) after adjustment for alcohol consumption and other liver injury risk factors in separate models for each DXA measure. Trunk fat was associated with increased ALT (P ≤ .001) in models also including any 1 of the other 3 measures. Extremity fat was independently inversely associated among women (P < .001). Trunk and extremity lean mass were not independently related to increased ALT. In models that contained all 4 DXA measures, the OR (95% confidence interval [CI]) for increased ALT for the highest, relative to lowest, quintile of trunk fat/height squared was 13.8 (95% CI: 5.4−35.3) for men and 7.8 (95% CI: 3.9−15.8) for women. When BMI, waist circumference, and trunk fat were considered together, only trunk fat remained independently associated with increased ALT.

Conclusions

Trunk fat is a major body composition determinant of increased ALT, supporting the hypothesis that liver injury can be induced by metabolically active intraabdominal fat.

Section snippets

Materials and Methods

The National Health and Nutrition Examination Survey (NHANES) is conducted in the United States by the National Center for Health Statistics of the Centers for Disease Control and Prevention and since 1999 has been a continuous annual survey.4 It consists of a cross-sectional interview, examination, and laboratory data collected from a complex multistage, stratified, clustered probability sample representative of the civilian, noninstitutionalized population with oversampling of persons aged 60

Results

Mean (standard deviation) body composition indices for the 5903 men and 5918 women included in the analyses are shown in Table 1 (first row for men and women); ranges and quintile cut points are shown in Table 3, Table 4 (footnote). Fat mass tended to increase in middle age, while lean mass tended to decrease in older age (Table 1). Among men, non-Hispanic blacks had lower fat and lean trunk mass and higher extremity lean mass than either non-Hispanic whites or Mexican Americans (Table 1).

Discussion

The main finding of this large, national, population-based study was a strong association of higher trunk fat mass index (trunk fat mass/height squared) with abnormal ALT activity. This relationship was found among both men and women and was independent of extremity fat, trunk lean, and extremity lean mass, BMI, waist circumference, and of other liver injury risk factors. A measure of insulin resistance attenuated but did not eliminate the relationship among women. In an analysis of an earlier

Acknowledgments

The authors thank Zhongyu Fang for programming support and assistance with creation of tables and Danita Byrd-Holt for consultation on SUDAAN programming using multiply imputed data and the residual method.

Author contributions: CER: study concept and design, statistical analysis and interpretation of data, drafting of manuscript; JEE: study concept and design, statistical analysis and interpretation of data, critical revision of manuscript for important intellectual content.

References (58)

  • C.E. Ruhl et al.

    Coffee and caffeine consumption reduce the risk of elevated serum alanine aminotransferase activity in the United States

    Gastroenterology

    (2005)
  • M.A. Banerji et al.

    Liver fat, serum triglycerides and visceral adipose tissue in insulin-sensitive and insulin-resistant black men with NIDDM

    Int J Obes Relat Metab Disord

    (1995)
  • National Health and Nutrition Examination Survey (NHANES)

  • NHANES 1999-2000 laboratory procedure manual—lab 18 biochemistry profile

  • NHANES 2001-2002 laboratory procedure manual—lab 18 biochemistry profile

  • NHANES 2001-2002 laboratory procedure manual - lab 40 ALT

  • NHANES 2003-2004 laboratory procedure manual—lab 40 ALT

  • NHANES 2001-2002 public release data file laboratory 40 - standard biochemistry profile, follicle stimulating hormone, and luteinizing hormone

  • National Center for Health Statistics. National Health and Nutrition Examination Survey: body composition procedures...
  • T.L. Kelly et al.

    Dual energy x-ray absorptiometry body composition reference values from NHANES

    PLoS One

    (2009)
  • National Health and Nutrition Examination Survey: technical documentation for the 1999-2004 dual energy X-ray absorptiometry (DXA) multiple imputation data files

  • National Health and Nutrition Examination Survey anthropometry procedures manual

  • J. Wang et al.

    Independent associations of body-size adjusted fat mass and fat-free mass with the metabolic syndrome in Chinese

    Ann Hum Biol

    (2009)
  • J.C. Wells

    A critique of the expression of paediatric body composition data

    Arch Dis Child

    (2001)
  • W. Willett et al.

    Implications of total energy intake for epidemiologic analyses

  • N.E. Breslow et al.

    Statistical methods in cancer research: the design and analysis of cohort studies

  • NHANES analytic guidelines: June 2004 version

  • A.S. Levey et al.

    National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification

    Ann Intern Med

    (2003)
  • M.U. Jakobsen et al.

    Abdominal obesity and fatty liver

    Epidemiol Rev

    (2007)
  • Cited by (64)

    • The feasibility of two anthropometric indices to identify metabolic syndrome, insulin resistance and inflammatory factors in obese and overweight adults

      2019, Nutrition
      Citation Excerpt :

      Although body mass index (BMI) is the most commonly used anthropometric measure for defining obesity, as recommended by the World Health Organization, the BMI has potential weaknesses. Specifically, the BMI does not distinguish between weight due to fat accumulation and muscle weight [4,5], nor does the BMI distinguish peripheral fat from abdominal fat [6], the latter being more strongly associated with CVD risk. To overcome these shortcomings, the waist circumference (WC) and waist-to-hip ratio (WHR) have been suggested as indicators of central adiposity due to their relevance with fat distribution [7,8].

    • A comparison of the sensitivity and specificity of anthropometric measurements to predict unhealthy metabolic phenotype in overweight and obese women

      2018, Diabetes and Metabolic Syndrome: Clinical Research and Reviews
      Citation Excerpt :

      BMI does not have the ability to detect fat mass (FM) from muscle mass, while increased FM is associated with increased risk of premature death [17]. Also, BMI cannot detect the location of fat distribution if the accumulation of central or abdominal fat is a serious health hazard [18–20]. In fact, BMI is strengthened along with other scales, such as WC and other scales that are derived from waist is a marker for identifying abdominal obesity [21–24].

    View all citing articles on Scopus

    This article has an accompanying continuing medical education activity on page e12. Learning Objective: Upon completion of reading this article, successful learners will be able to explain the relationships of body composition measures with elevated ALT activity in the US population.

    Conflicts of interest The authors disclose no conflicts.

    Funding This work was supported by a contract from the National Institute of Diabetes and Digestive and Kidney Diseases (HHSN267200700001G).

    View full text