Key findings
Here, we shed light on the influence of migration on the prevalence of MAFLD by studying the FLI in a homogenous Ghanaian population living in rural Ghana, urban Ghana and Europe. The homogenous Ghanaian population living in three distinct environments is used as a proxy for migration. This study has three important findings. First, the prevalence of an elevated FLI (FLI ≥60) as an indicator of hepatic steatosis increased from rural participants, through urban participants, to European migrants, irrespective of sex. Second, T2DM was positively associated with higher odds for FLI in both Ghanaian men and women. Third, an elevated FLI (FLI ≥60) was associated with an higher odds for 10-year risk of ASCVD (≥7.5%) in both men and women, with a more pronounced effect in men.
Discussion of the key findings
Studies of human migration and features of cardiometabolic disease are scarce. Several studies have reported differences in the prevalence of MAFLD among different ethnicities; however, these were performed in participants residing in a single country.16,19 For instance, multiple studies report a lower prevalence of MAFLD in African Americans compared to Hispanic Americans.19–21 The prevalence of MAFLD in migrants of African descent is often lower than the prevalence of MAFLD in the general population of the host country.20,21 Interestingly, this contrasts with the prevalence of morbidities with a close relation to MAFLD, i.e. obesity, T2DM, and hypertension, which are found to be more prevalent among ethnic minorities in Europe, including African groups.20
Factors driving variation in cardiometabolic health across geographical locations are thought to include changes in nutritional patterns, physical inactivity, and stress, in combination with genetic susceptibility and gene-environment interactions.20,22 As MAFLD is driven by insulin resistance and obesity, one would expect the aforementioned factors to play a similar role in the effects of migration on the prevalence of MAFLD.23 Interestingly, in our models, the effect sizes only slightly changed upon adjustment for lifestyle factors, such as physical activity, alcohol consumption, and T2DM. This may fit with the ‘multiple hit’ hypothesis which postulates that multiple factors act together in inducing MAFLD, and adjustment for a few of these factors would not have a major effect.24 In addition to physical inactivity and genetic susceptibility, gut microbiota have been suggested to play a role. Several studies report the interaction between liver and gut as a critical player in the onset of MAFLD.25–27 Dietary factors may alter the composition of the gut microbiota, which in turn may contribute to the development of MAFLD.28 Evidence for these changed dietary factors in an urban population compared to a rural population was found in a prospective cohort study that was conducted in South Africa. The nutrition intakes of urban-residing men and women were consistently higher than those of their rural counterparts.29 This is often accompanied by a nutrition transition to a Westernized diet, frequently high in fat and sugar.30 This reported change in dietary factors could also play a role in our study population. Taken together, the sizeable disparity in FLI in our study between similar populations living in different environments suggests a more significant role for environmental factors such as dietary changes and alterations in the gut microbiome, in driving the prevalence of MAFLD than for genetic susceptibility.
Of note, we found a strong relation of the FLI with the presence of T2DM. The interplay between T2DM and MAFLD is complex. T2DM is an important risk factor for developing MAFLD, and vice versa, MAFLD may contribute to insulin resistance. Insulin resistance is a central mechanism that leads to lipolysis in peripheral adipose tissue and an increased hepatopetal flux of free fatty acids, driving lipotoxicity in the liver, with subsequent inflammation and hepatocyte injury.4,31 A higher prevalence of MAFLD in patients with T2DM has been found.23,32 In turn, ectopic fat accumulation in MAFLD is thought to affect T2DM. This ectopic fat accumulation is associated with increased gluconeogenesis, decreased glycogen synthesis and inhibition of insulin signalling.32
We observed a significant association of FLI with 10-year risk of ASCVD, bolstering the notion that patients with MAFLD may have increased ASCVD. The relation between MAFLD and ASCVD is supported by studies of subclinical atherosclerosis, such as carotid intima-media thickness (commonly known as carotid IMT) and coronary calcification.33,34 Lee et al.35 conducted a cross-sectional study to investigate the influence of MAFLD on subclinical coronary atherosclerosis as detected by coronary computed tomography angiography (commonly referred to as CCTA). Fatty liver was assessed by ultrasound. In patients with MAFLD, ORs after adjustment for cardiovascular risk factors were higher for atherosclerotic plaques (OR: 1.18). In addition, there was a significant association of FLI ≥30 with non-calcified plaque (OR: 1.37). In addition, meta-analyses of studies with cardiovascular events also support the relation of MAFLD and ASCVD.36 The underlying pathways are likely complex and difficult to decipher since many comorbid factors may co-exist in these patients, such as hypertension, T2DM and obesity. Low grade inflammation38 and hypercoagulable state39 have also been implicated to mediate the relation between NAFLD and asCVD. Yet, evidence from Mendelian randomization studies most strongly supports that the MAFLD may drive ASCVD by mixed hyperlipidemia, through very low-density lipoprotein (i.e. VLDL) hypersecretion.6,37
Strengths and limitations
The FLI is a surrogate marker validated against ultrasonography by Bedogni et al.14 in a Caucasian population and replicated by others.13,40 Potential anthropometric and laboratory data were used in a logistic regression model to obtain a simple and accurate algorithm for the prediction of increased liver fat content, after exclusion of participants with hepatitis B and C. Due to this anthropometric and laboratory data, FLI is not directly based on liver fat content; yet, Bedogni et al.14 reported an area under the receiver operating characteristic curve of 0.85. In the RODAM study, no imaging modalities of hepatic steatosis, such as abdominal ultrasound or MRI-PDFF,41 or liver biopsies, were available to validate our findings with the FLI. When using the applied cut-off value of 60, in order to validate the FLI in a population-based study, the likelihood ratio was 5.10 for the presence of MAFLD. Additionally, a cut-off of ≥60 showed a specificity of 91%.42 Unfortunately, blood platelets were not included in the RODAM study; hence, liver fibrosis proxies, such as Fibrosis-4 and aspartate to aminotransferase (i.e. AST) to platelet ratio (APRI) could not be included in our current analysis. We excluded other liver conditions in our calculations, as much as possible. We were able to exclude participants that used an excessive amount of alcohol and participants that used medication for hepatitis B and retroviral therapy. However, no data on untreated participants was available in the RODAM study. A great strength of the study is the homogeneity of the studied population, which provides a unique opportunity to investigate the metabolic effects of migration.