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  • 1. Aims and Scope

    Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE

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    Yong Chan Lee Professor of Medicine
    Director, Gastrointestinal Research Laboratory
    Veterans Affairs Medical Center, Univ. California San Francisco
    San Francisco, USA

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    Deputy Editor
    Jong Pil Im Seoul National University College of Medicine, Seoul, Korea
    Robert S. Bresalier University of Texas M. D. Anderson Cancer Center, Houston, USA
    Steven H. Itzkowitz Mount Sinai Medical Center, NY, USA
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    All papers submitted to Gut and Liver are reviewed by the editorial team before being sent out for an external peer review to rule out papers that have low priority, insufficient originality, scientific flaws, or the absence of a message of importance to the readers of the Journal. A decision about these papers will usually be made within two or three weeks.
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Letter to the Editor

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Comments on Relationship between the High Fatty Liver Index and Risk of Fracture: Reply

Min-Ji Kim1 , Jae-Hyung Roh2 , Jae-Han Jeon1

1Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, and 2Department of Internal Medicine, Chungnam National University Sejong Hospital, Chungnam National University College of Medicine, Daejeon, Korea

Correspondence to: Jae-Han Jeon
ORCID https://orcid.org/0000-0002-9217-968X
E-mail jeonjh@knu.ac.kr

Received: January 31, 2023; Revised: February 13, 2023; Accepted: February 15, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gut Liver 2023;17(4):663-664. https://doi.org/10.5009/gnl230035

Published online April 6, 2023, Published date July 15, 2023

Copyright © Gut and Liver.

Reply:

We appreciate Dr. Lai and his colleagues’ interest and comments1 on our article entitled “Relationship between the High Fatty Liver Index and Risk of Fracture,” which was published in the journal Gut and Liver.2 They pointed out the importance of ruling out alcohol consumption as a factor influencing the relationship between nonalcoholic fatty liver disease (NAFLD) and risk of fracture in our study. Additionally, they remarked that the study was limited because fractures were not grouped according to whether they were “osteoporotic” or “traumatic.”

We agree with Dr. Lai and colleagues that studies into the relationship between NAFLD and risk of fracture should only include study subjects with little or no alcohol consumption. At the same time, we would like to emphasize that the definition of NAFLD is a weekly alcohol consumption of less than 210 g in men and 140 g in women, according to the guideline of the European Association for the Study of the Liver3,4 and the Korean Association for the Study of Liver NAFLD guidelines.5 In our study, the alcohol consumptions in the fatty liver index (FLI) quartile groups were Q1: 36.7±83.9, Q2: 60.0±112.9, Q3: 87.1±142.0, and Q4: 139.9±189.6 g/wk,2 indicating that most, if not all, of the subjects drank less alcohol than that stipulated in the NAFLD guidelines. Additionally, we excluded 190,883 patients with known liver disease. Although alcohol consumption is an important factor in the progression of fatty liver disease, the highest mean amount of alcohol consumption in Q4 was less than 140 g/wk. In subgroup analysis of the original article,2 we analyzed the data after dividing the subjects into three groups according to their weekly alcohol consumption (0, 1–139, and ≥140 g). The data showed no significant difference in the hazard ratio between the three groups (alcohol consumption=0 g/wk group: hazard ratio [HR], 1.10; 95% confidence interval [CI], 1.04 to 1.17; alcohol consumption=1–139 g/wk group: HR, 1.13; 95% CI, 1.00 to 1.26; alcohol consumption ≥140 g/wk group: HR, 1.14; 95% CI, 0.99 to 1.31). In other words, the FLI was a significant determinant of fracture incidence independent of alcohol consumption. However, the remarks of Dr. Lai and colleagues are still relevant because even a small amount of alcohol can lead to fatty liver disease,6 and we agree that it will be important to conduct a new analysis focusing on people who drink little or no alcohol. Further analysis of the data is needed to extract those individuals with negligible alcohol consumption.

As outlined in one of the limitations of the retrospective analysis in the discussion section of our paper, there was no information on whether the fractures were “osteoporotic” or “traumatic,” although we recorded the 10th revision of the International Classification of Disease codes for fractures. Further prospective trials are needed to examine whether a low FLI is associated with a low incidence of “osteoporotic” fracture. As noted in another comment, tailored strategies to reduce effectively fracture risk in patients with NAFLD remain a clinical unmet need.7 The development of such strategies merits further research. Nevertheless, our study clearly demonstrates that Korean adults with a high FLI are predisposed toward fractures, and therefore patients with a high FLI score warrant more attention for the primary prevention of fracture in clinical practice.

No potential conflict of interest relevant to this article was reported.

  1. 1. Lai SW, Liao KF. Comments on relationship between the high fatty liver index and risk of fracture. Gut Liver 2023;17:661-662.
    Pubmed CrossRef
  2. Kim MJ, Kim MS, Lee HB, Roh JH, Jeon JH. Relationship between the High Fatty Liver Index and Risk of Fracture. Gut Liver 2023;17:119-129.
    Pubmed KoreaMed CrossRef
  3. Puri P, Sanyal AJ. Nonalcoholic fatty liver disease: definitions, risk factors, and workup. Clin Liver Dis (Hoboken) 2012;1:99-103.
    Pubmed KoreaMed CrossRef
  4. Sberna AL, Bouillet B, Rouland A, et al. European Association for the Study of the Liver (EASL), European Association for the Study of Diabetes (EASD) and European Association for the Study of Obesity (EASO) clinical practice recommendations for the management of non-alcoholic fatty liver disease: evaluation of their application in people with type 2 diabetes. Diabet Med 2018;35:368-375.
    Pubmed CrossRef
  5. Kang SH, Lee HW, Yoo JJ, et al. KASL clinical practice guidelines: Management of nonalcoholic fatty liver disease. Clin Mol Hepatol 2021;27:363-401.
    Pubmed KoreaMed CrossRef
  6. Choi JH, Sohn W, Cho YK. The effect of moderate alcohol drinking in nonalcoholic fatty liver disease. Clin Mol Hepatol 2020;26:662-669.
    Pubmed KoreaMed CrossRef
  7. Hong N. High fatty liver index and fracture risk: clinical implications. Gut Liver 2023;17:6-7.
    Pubmed KoreaMed CrossRef

Article

Letter to the Editor

Gut and Liver 2023; 17(4): 663-664

Published online July 15, 2023 https://doi.org/10.5009/gnl230035

Copyright © Gut and Liver.

Comments on Relationship between the High Fatty Liver Index and Risk of Fracture: Reply

Min-Ji Kim1 , Jae-Hyung Roh2 , Jae-Han Jeon1

1Department of Internal Medicine, Kyungpook National University Chilgok Hospital, School of Medicine, Kyungpook National University, Daegu, and 2Department of Internal Medicine, Chungnam National University Sejong Hospital, Chungnam National University College of Medicine, Daejeon, Korea

Correspondence to:Jae-Han Jeon
ORCID https://orcid.org/0000-0002-9217-968X
E-mail jeonjh@knu.ac.kr

Received: January 31, 2023; Revised: February 13, 2023; Accepted: February 15, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Body

Reply:

We appreciate Dr. Lai and his colleagues’ interest and comments1 on our article entitled “Relationship between the High Fatty Liver Index and Risk of Fracture,” which was published in the journal Gut and Liver.2 They pointed out the importance of ruling out alcohol consumption as a factor influencing the relationship between nonalcoholic fatty liver disease (NAFLD) and risk of fracture in our study. Additionally, they remarked that the study was limited because fractures were not grouped according to whether they were “osteoporotic” or “traumatic.”

We agree with Dr. Lai and colleagues that studies into the relationship between NAFLD and risk of fracture should only include study subjects with little or no alcohol consumption. At the same time, we would like to emphasize that the definition of NAFLD is a weekly alcohol consumption of less than 210 g in men and 140 g in women, according to the guideline of the European Association for the Study of the Liver3,4 and the Korean Association for the Study of Liver NAFLD guidelines.5 In our study, the alcohol consumptions in the fatty liver index (FLI) quartile groups were Q1: 36.7±83.9, Q2: 60.0±112.9, Q3: 87.1±142.0, and Q4: 139.9±189.6 g/wk,2 indicating that most, if not all, of the subjects drank less alcohol than that stipulated in the NAFLD guidelines. Additionally, we excluded 190,883 patients with known liver disease. Although alcohol consumption is an important factor in the progression of fatty liver disease, the highest mean amount of alcohol consumption in Q4 was less than 140 g/wk. In subgroup analysis of the original article,2 we analyzed the data after dividing the subjects into three groups according to their weekly alcohol consumption (0, 1–139, and ≥140 g). The data showed no significant difference in the hazard ratio between the three groups (alcohol consumption=0 g/wk group: hazard ratio [HR], 1.10; 95% confidence interval [CI], 1.04 to 1.17; alcohol consumption=1–139 g/wk group: HR, 1.13; 95% CI, 1.00 to 1.26; alcohol consumption ≥140 g/wk group: HR, 1.14; 95% CI, 0.99 to 1.31). In other words, the FLI was a significant determinant of fracture incidence independent of alcohol consumption. However, the remarks of Dr. Lai and colleagues are still relevant because even a small amount of alcohol can lead to fatty liver disease,6 and we agree that it will be important to conduct a new analysis focusing on people who drink little or no alcohol. Further analysis of the data is needed to extract those individuals with negligible alcohol consumption.

As outlined in one of the limitations of the retrospective analysis in the discussion section of our paper, there was no information on whether the fractures were “osteoporotic” or “traumatic,” although we recorded the 10th revision of the International Classification of Disease codes for fractures. Further prospective trials are needed to examine whether a low FLI is associated with a low incidence of “osteoporotic” fracture. As noted in another comment, tailored strategies to reduce effectively fracture risk in patients with NAFLD remain a clinical unmet need.7 The development of such strategies merits further research. Nevertheless, our study clearly demonstrates that Korean adults with a high FLI are predisposed toward fractures, and therefore patients with a high FLI score warrant more attention for the primary prevention of fracture in clinical practice.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

References

  1. 1. Lai SW, Liao KF. Comments on relationship between the high fatty liver index and risk of fracture. Gut Liver 2023;17:661-662.
    Pubmed CrossRef
  2. Kim MJ, Kim MS, Lee HB, Roh JH, Jeon JH. Relationship between the High Fatty Liver Index and Risk of Fracture. Gut Liver 2023;17:119-129.
    Pubmed KoreaMed CrossRef
  3. Puri P, Sanyal AJ. Nonalcoholic fatty liver disease: definitions, risk factors, and workup. Clin Liver Dis (Hoboken) 2012;1:99-103.
    Pubmed KoreaMed CrossRef
  4. Sberna AL, Bouillet B, Rouland A, et al. European Association for the Study of the Liver (EASL), European Association for the Study of Diabetes (EASD) and European Association for the Study of Obesity (EASO) clinical practice recommendations for the management of non-alcoholic fatty liver disease: evaluation of their application in people with type 2 diabetes. Diabet Med 2018;35:368-375.
    Pubmed CrossRef
  5. Kang SH, Lee HW, Yoo JJ, et al. KASL clinical practice guidelines: Management of nonalcoholic fatty liver disease. Clin Mol Hepatol 2021;27:363-401.
    Pubmed KoreaMed CrossRef
  6. Choi JH, Sohn W, Cho YK. The effect of moderate alcohol drinking in nonalcoholic fatty liver disease. Clin Mol Hepatol 2020;26:662-669.
    Pubmed KoreaMed CrossRef
  7. Hong N. High fatty liver index and fracture risk: clinical implications. Gut Liver 2023;17:6-7.
    Pubmed KoreaMed CrossRef
Gut and Liver

Vol.18 No.3
May, 2024

pISSN 1976-2283
eISSN 2005-1212

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