Nonalcoholic Fatty Liver Disease

A Feature of the Metabolic Syndrome

  1. Giulio Marchesini1,
  2. Mara Brizi1,
  3. Giampaolo Bianchi2,
  4. Sara Tomassetti1,
  5. Elisabetta Bugianesi3,
  6. Marco Lenzi2,
  7. Arthur J. McCullough4,
  8. Stefania Natale1,
  9. Gabriele Forlani1 and
  10. Nazario Melchionda1
  1. 1Unit of Metabolic Diseases, Department of Internal Medicine and Gastroenterology, and
  2. 2Department of Internal Medicine, Cardioangiology, and Hepatology, University of Bologna, Italy
  3. 3Gastroenterology Unit, Hospital San Giovanni Battista, University of Turin, Italy
  4. 4Gastroenterology Division, MetroHealth Medical Center, Cleveland, Ohio


    Insulin sensitivity (euglycemic clamp, insulin infusion rate: 40 mU · m−2 · min−1) was studied in 30 subjects with biopsy-proven nonalcoholic fatty liver disease (NAFLD), normal glucose tolerance, and a BMI <30 kg/m2. Of those 30 subjects, 9 had pure fatty liver and 21 had evidence of steatohepatitis. In addition, 10 patients with type 2 diabetes under good metabolic control and 10 healthy subjects were studied. Most NAFLD patients had central fat accumulation, increased triglycerides and uric acid, and low HDL cholesterol, irrespective of BMI. Glucose disposal during the clamp was reduced by nearly 50% in NAFLD patients, as well as in patients with normal body weight, to an extent similar to that of the type 2 diabetic patients. Basal free fatty acids were increased, whereas insulin-mediated suppression of lipolysis was less effective (−69% in NAFLD vs. −84% in control subjects; P = 0.003). Postabsorptive hepatic glucose production (HGP), measured by [6,6-2H2]glucose, was normal. In response to insulin infusion, HGP decreased by only 63% of basal in NAFLD vs. 84% in control subjects (P = 0.002). Compared with type 2 diabetic patients, NAFLD patients were characterized by lower basal HGP, but with similarly reduced insulin-mediated suppression of HGP. There was laboratory evidence of iron overload in many NAFLD patients, but clinical, histological, and biochemical data (including insulin sensitivity) were not correlated with iron status. Four subjects were heterozygous for mutation His63Asp of the HFE gene of familiar hemochromatosis. We concluded that NAFLD, in the presence of normoglycemia and normal or moderately increased body weight, is characterized by clinical and laboratory data similar to those found in diabetes and obesity. NAFLD may be considered an additional feature of the metabolic syndrome, with specific hepatic insulin resistance.


    • Address correspondence and reprint requests to Giulio Marchesini, MD, Servizio di Malattie del Metabolismo, Università di Bologna, Azienda Ospedaliera S.Orsola-Malpighi, Via Massarenti 9, I-40138 Bologna, Italy. E-mail: marchreg{at}

      Received for publication 3 August 2000 and accepted in revised form 25 April 2001.

      ALT, alanine transaminase; ANOVA, analysis of variance; AST, aspartate transaminase; FFA, free fatty acid; HGP, hepatic glucose production; HOMA, homeostasis model assessment; LBM, lean body mass; NAFLD, nonalcoholic fatty liver disease; NASH, nonalcoholic steatohepatitis; OGTT, oral glucose tolerance test.

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