{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,18]],"date-time":"2026-09-18T00:22:40Z","timestamp":1789690960059,"version":"4.0.1"},"reference-count":117,"publisher":"MDPI AG","issue":"12","license":[{"start":{"date-parts":[[2023,6,12]],"date-time":"2023-06-12T00:00:00Z","timestamp":1686528000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Pfizer Inc."}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Despite its increasing prevalence, nonalcoholic fatty liver disease (NAFLD) remains under-diagnosed in primary care. Timely diagnosis is critical, as NAFLD can progress to nonalcoholic steatohepatitis, fibrosis, cirrhosis, hepatocellular carcinoma, and death; furthermore, NAFLD is also a risk factor linked to cardiometabolic outcomes. Identifying patients with NAFLD, and particularly those at risk of advanced fibrosis, is important so that healthcare practitioners can optimize care delivery in an effort to prevent disease progression. This review debates the practical issues that primary care physicians encounter when managing NAFLD, using a patient case study to illustrate the challenges and decisions that physicians face. It explores the pros and cons of different diagnostic strategies and tools that physicians can adopt in primary care settings, depending on how NAFLD presents and progresses. We discuss the importance of prescribing lifestyle changes to achieve weight loss and mitigate disease progression. A diagnostic and management flow chart is provided, showing the key points of assessment for primary care physicians. The advantages and disadvantages of advanced fibrosis risk assessments in primary care settings and the factors that influence patient referral to a hepatologist are also reviewed.<\/jats:p>","DOI":"10.3390\/jcm12124001","type":"journal-article","created":{"date-parts":[[2023,6,13]],"date-time":"2023-06-13T02:00:45Z","timestamp":1686621645000},"page":"4001","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":6,"title":["Identifying Patients with Nonalcoholic Fatty Liver Disease in Primary Care: How and for What Benefit?"],"prefix":"10.3390","volume":"12","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0914-3182","authenticated-orcid":false,"given":"Andrew D.","family":"Schreiner","sequence":"first","affiliation":[{"name":"Department of Medicine, Medical University of South Carolina, 171 Ashley Ave, Charleston, SC 29425, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Naveed","family":"Sattar","sequence":"additional","affiliation":[{"name":"Institute of Cardiovascular & Medical Sciences, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,6,12]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"73","DOI":"10.1002\/hep.28431","article-title":"Global epidemiology of nonalcoholic fatty liver disease\u2014Meta-analytic assessment of prevalence, incidence, and outcomes","volume":"64","author":"Younossi","year":"2016","journal-title":"Hepatology"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"851","DOI":"10.1016\/S2468-1253(22)00165-0","article-title":"The prevalence and incidence of NAFLD worldwide: A systematic review and meta-analysis","volume":"7","author":"Riazi","year":"2022","journal-title":"Lancet Gastroenterol. Hepatol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"3194","DOI":"10.1007\/s10620-015-3728-3","article-title":"Prevalence of nonalcoholic fatty liver disease and economy","volume":"60","author":"Zhu","year":"2015","journal-title":"Dig. Dis. Sci."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"2809","DOI":"10.1016\/j.cgh.2021.12.002","article-title":"2019 global NAFLD prevalence: A systematic review and meta-analysis","volume":"20","author":"Le","year":"2022","journal-title":"Clin. Gastroenterol. Hepatol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1605","DOI":"10.1002\/hep.31173","article-title":"Changes in the global burden of chronic liver diseases from 2012 to 2017: The growing impact of NAFLD","volume":"72","author":"Paik","year":"2020","journal-title":"Hepatology"},{"key":"ref_6","unstructured":"Global Burden of Disease Causes of Death Collaborators (2018). Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980\u20132017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet, 392, 1736\u20131788."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1649","DOI":"10.1038\/s41395-018-0088-6","article-title":"NASH leading cause of liver transplant in women: Updated analysis of indications for liver transplant and ethnic and gender variances","volume":"113","author":"Noureddin","year":"2018","journal-title":"Am. J. Gastroenterol."},{"key":"ref_8","unstructured":"Global Burden of Disease Cirrhosis Collaborators (2020). The global, regional, and national burden of cirrhosis by cause in 195 countries and territories, 1990\u20132017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet Gastroenterol. Hepatol., 5, 245\u2013266."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"328","DOI":"10.1002\/hep.29367","article-title":"The diagnosis and management of nonalcoholic fatty liver disease: Practice guidance from the American Association for the Study of Liver Diseases","volume":"67","author":"Chalasani","year":"2018","journal-title":"Hepatology"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"711","DOI":"10.1053\/j.gastro.2012.02.003","article-title":"Role of obesity and lipotoxicity in the development of nonalcoholic steatohepatitis: Pathophysiology and clinical implications","volume":"142","author":"Cusi","year":"2012","journal-title":"Gastroenterology"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"793","DOI":"10.1016\/j.jhep.2019.06.021","article-title":"The global epidemiology of NAFLD and NASH in patients with type 2 diabetes: A systematic review and meta-analysis","volume":"71","author":"Younossi","year":"2019","journal-title":"J. Hepatol."},{"key":"ref_12","first-page":"643","article-title":"Fibrosis progression in nonalcoholic fatty liver vs nonalcoholic steatohepatitis: A systematic review and meta-analysis of paired-biopsy studies","volume":"13","author":"Singh","year":"2015","journal-title":"Clin. Gastroenterol. Hepatol. Off. Clin. Pract. J. Am. Gastroenterol. Assoc."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"e2159","DOI":"10.1097\/MD.0000000000002159","article-title":"Visceral obesity predicts significant fibrosis in patients with nonalcoholic fatty liver disease","volume":"94","author":"Yu","year":"2015","journal-title":"Medicine"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"3017","DOI":"10.1007\/s10620-013-2743-5","article-title":"Predictors of all-cause mortality and liver-related mortality in patients with non-alcoholic fatty liver disease (NAFLD)","volume":"58","author":"Stepanova","year":"2013","journal-title":"Dig. Dis. Sci."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1410","DOI":"10.1136\/gut.2010.213553","article-title":"Components of metabolic syndrome are independent predictors of mortality in patients with chronic liver disease: A population-based study","volume":"59","author":"Stepanova","year":"2010","journal-title":"Gut"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"56","DOI":"10.12688\/f1000research.21918.1","article-title":"Dyslipidemia as a risk factor for liver fibrosis progression in a multicentric population with non-alcoholic steatohepatitis","volume":"9","year":"2020","journal-title":"F1000Res"},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Jarvis, H., Craig, D., Barker, R., Spiers, G., Stow, D., Anstee, Q.M., and Hanratty, B. (2020). Metabolic risk factors and incident advanced liver disease in non-alcoholic fatty liver disease (NAFLD): A systematic review and meta-analysis of population-based observational studies. PLoS Med., 17.","DOI":"10.1371\/journal.pmed.1003100"},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Alexander, M., Loomis, A.K., Fairburn-Beech, J., van der Lei, J., Duarte-Salles, T., Prieto-Alhambra, D., Ansell, D., Pasqua, A., Lapi, F., and Rijnbeek, P. (2018). Real-world data reveal a diagnostic gap in non-alcoholic fatty liver disease. BMC Med., 16.","DOI":"10.1186\/s12916-018-1103-x"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1149","DOI":"10.1111\/apt.15679","article-title":"Nonalcoholic fatty liver disease progression rates to cirrhosis and progression of cirrhosis to decompensation and mortality: A real world analysis of Medicare data","volume":"51","author":"Loomba","year":"2020","journal-title":"Aliment. Pharm."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"2587","DOI":"10.1007\/s11606-021-07197-3","article-title":"Nonalcoholic fatty liver disease underdiagnosis in primary care: What are we missing?","volume":"37","author":"Nielsen","year":"2022","journal-title":"J. Gen. Intern. Med."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"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) (2016). EASL-EASD-EASO clinical practice guidelines for the management of non-alcoholic fatty liver disease. J. Hepatol., 64, 1388\u20131402.","DOI":"10.1016\/j.jhep.2015.11.004"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"70","DOI":"10.1111\/jgh.13857","article-title":"Asia-Pacific Working Party on non-alcoholic fatty liver disease guidelines 2017-part 1: Definition, risk factors and assessment","volume":"33","author":"Wong","year":"2018","journal-title":"J. Gastroenterol. Hepatol."},{"key":"ref_23","first-page":"500","article-title":"Therapy for nonalcoholic fatty liver disease: Current options and future directions","volume":"43","author":"Campbell","year":"2021","journal-title":"Clin."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1657","DOI":"10.1053\/j.gastro.2021.07.049","article-title":"Clinical care pathway for the risk stratification and management of patients with nonalcoholic fatty liver disease","volume":"161","author":"Kanwal","year":"2021","journal-title":"Gastroenterology"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"771","DOI":"10.1016\/j.jhep.2021.10.025","article-title":"The global NAFLD policy review and preparedness index: Are countries ready to address this silent public health challenge?","volume":"76","author":"Lazarus","year":"2021","journal-title":"J. Hepatol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"e14799","DOI":"10.1111\/dme.14799","article-title":"An exploration of barriers and facilitators to implementing a nonalcoholic fatty liver disease pathway for people with type 2 diabetes in primary care","volume":"39","author":"Gracen","year":"2022","journal-title":"Diabet. Med."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"758","DOI":"10.1016\/S1665-2681(19)31317-1","article-title":"Primary care practitioners survey of non-alcoholic fatty liver disease","volume":"12","author":"Said","year":"2013","journal-title":"Ann. Hepatol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"2982","DOI":"10.1016\/j.jacc.2020.11.010","article-title":"Global burden of cardiovascular diseases and risk factors, 1990\u20132019: Update from the GBD 2019 study","volume":"76","author":"Roth","year":"2020","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"896","DOI":"10.1016\/j.jhep.2018.05.036","article-title":"Modeling NAFLD disease burden in China, France, Germany, Italy, Japan, Spain, United Kingdom, and United States for the period 2016\u20132030","volume":"69","author":"Estes","year":"2018","journal-title":"J. Hepatol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"293","DOI":"10.1016\/j.cld.2015.10.011","article-title":"Histology of nonalcoholic fatty liver disease and nonalcoholic steatohepatitis in adults and children","volume":"20","author":"Kleiner","year":"2016","journal-title":"Clin. Liver Dis."},{"key":"ref_31","first-page":"25","article-title":"Systematic review of existing guidelines for NAFLD assessment","volume":"7","author":"Monelli","year":"2021","journal-title":"Hepatoma Res."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"808","DOI":"10.1002\/hep.31014","article-title":"Effect of metabolic traits on the risk of cirrhosis and hepatocellular cancer in nonalcoholic fatty liver disease","volume":"71","author":"Kanwal","year":"2020","journal-title":"Hepatology"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1161\/CIRCULATIONAHA.122.060411","article-title":"High circulating triglycerides are most commonly a marker of ectopic fat accumulation: Connecting the clues to advance lifestyle interventions","volume":"146","author":"Sattar","year":"2022","journal-title":"Circulation"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"389","DOI":"10.1053\/j.gastro.2015.04.043","article-title":"Liver fibrosis, but no other histologic features, is associated with long-term outcomes of patients with nonalcoholic fatty liver disease","volume":"149","author":"Angulo","year":"2015","journal-title":"Gastroenterology"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1219","DOI":"10.3748\/wjg.v19.i8.1219","article-title":"NAFLD fibrosis score: A prognostic predictor for mortality and liver complications among NAFLD patients","volume":"19","author":"Treeprasertsuk","year":"2013","journal-title":"World J. Gastroenterol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1265","DOI":"10.1016\/j.jhep.2017.07.027","article-title":"Fibrosis stage but not NASH predicts mortality and time to development of severe liver disease in biopsy-proven NAFLD","volume":"67","author":"Nasr","year":"2017","journal-title":"J. Hepatol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"1557","DOI":"10.1002\/hep.29085","article-title":"Increased risk of mortality by fibrosis stage in nonalcoholic fatty liver disease: Systematic review and meta-analysis","volume":"65","author":"Dulai","year":"2017","journal-title":"Hepatology"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1999","DOI":"10.1053\/j.gastro.2019.11.312","article-title":"MAFLD: A consensus-driven proposed nomenclature for metabolic associated fatty liver disease","volume":"158","author":"Eslam","year":"2020","journal-title":"Gastroenterology"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"509","DOI":"10.1016\/S2468-1253(18)30077-3","article-title":"Non-alcoholic fatty liver disease and the interface between primary and secondary care","volume":"3","author":"Tsochatzis","year":"2018","journal-title":"Lancet Gastroenterol. Hepatol."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"g4596","DOI":"10.1136\/bmj.g4596","article-title":"Non-alcoholic fatty liver disease","volume":"349","author":"Sattar","year":"2014","journal-title":"BMJ"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"234","DOI":"10.1016\/j.jhep.2011.03.020","article-title":"Presence and severity of non-alcoholic fatty liver disease in a large prospective primary care cohort","volume":"56","author":"Armstrong","year":"2012","journal-title":"J. Hepatol."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"195","DOI":"10.1016\/S0168-8278(01)00094-0","article-title":"Findings on liver biopsy to investigate abnormal liver function tests in the absence of diagnostic serology","volume":"35","author":"Skelly","year":"2001","journal-title":"J. Hepatol."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"6","DOI":"10.1136\/gutjnl-2017-314924","article-title":"Guidelines on the management of abnormal liver blood tests","volume":"67","author":"Newsome","year":"2018","journal-title":"Gut"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"18","DOI":"10.1038\/ajg.2016.517","article-title":"ACG clinical guideline: Evaluation of abnormal liver chemistries","volume":"112","author":"Kwo","year":"2017","journal-title":"Am. J. Gastroenterol."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"115.e17","DOI":"10.1016\/j.amjmed.2015.07.019","article-title":"Understanding and reducing ceruloplasmin overuse with a decision support intervention for liver disaese evaluation","volume":"129","author":"Tapper","year":"2016","journal-title":"Am. J. Med."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"313","DOI":"10.1016\/j.jhep.2016.09.017","article-title":"Extensive testing or focused testing of patients with elevated liver enzymes","volume":"66","author":"Tapper","year":"2017","journal-title":"J. Hepatol."},{"key":"ref_47","doi-asserted-by":"crossref","unstructured":"Ma, X., Liu, S., Zhang, J., Dong, M., Wang, Y., Wang, M., and Xin, Y. (2020). Proportion of NAFLD patients with normal ALT value in overall NAFLD patients: A systematic review and meta-analysis. BMC Gastroenterol., 20.","DOI":"10.1186\/s12876-020-1165-z"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"333","DOI":"10.1007\/s10620-014-3346-5","article-title":"Gaps in recognition and evaluation of incidentally identified hepatic steatosis","volume":"60","author":"Wright","year":"2015","journal-title":"Dig. Dis. Sci."},{"key":"ref_49","unstructured":"National Institute for Health and Care Excellence (2023, April 03). Non-Alcoholic Fatty Liver Disease (NAFLD): Assessment and Management. Available online: https:\/\/www.nice.org.uk\/guidance\/ng49\/chapter\/Recommendations."},{"key":"ref_50","doi-asserted-by":"crossref","unstructured":"American Diabetes Association Professional Practice Committee (2022). 4. Comprehensive medical evaluation and assessment of comorbidities: Standards of medical care in diabetes\u20142022. Diabetes Care, 45, S46\u2013S59.","DOI":"10.2337\/dc22-S004"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"1417","DOI":"10.4254\/wjh.v13.i10.1417","article-title":"Machine learning models for predicting non-alcoholic fatty liver disease in the general United States population: NHANES database","volume":"13","author":"Atsawarungruangkit","year":"2021","journal-title":"World J. Hepatol."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"1537","DOI":"10.1002\/hep4.1935","article-title":"Predicting NAFLD prevalence in the United States using National Health and Nutrition Examination Survey 2017\u20132018 transient elastography data and application of machine learning","volume":"6","author":"Noureddin","year":"2022","journal-title":"Hepatol. Commun."},{"key":"ref_53","doi-asserted-by":"crossref","unstructured":"European Association for the Study of the Liver (2021). EASL clinical practice guidelines on non-invasive tests for evaluation of liver disease severity and prognosis\u20142021 update. J. Hepatol., 75, 659\u2013689.","DOI":"10.1016\/j.jhep.2021.05.025"},{"key":"ref_54","unstructured":"National Institute for Health and Care Excellence (2023, April 03). Non-Alcoholic Fatty Liver Disease: Assessment and Management. Available online: https:\/\/www.nice.org.uk\/guidance\/ng49\/evidence\/full-guideline-pdf-2548213310."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"1082","DOI":"10.1002\/hep.24452","article-title":"Diagnostic accuracy and reliability of ultrasonography for the detection of fatty liver: A meta-analysis","volume":"54","author":"Hernaez","year":"2011","journal-title":"Hepatology"},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"2139","DOI":"10.1111\/liv.12840","article-title":"Clinical value of liver ultrasound for the diagnosis of nonalcoholic fatty liver disease in overweight and obese patients","volume":"35","author":"Bril","year":"2015","journal-title":"Liver Int."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"1114","DOI":"10.1053\/jlts.2002.36740","article-title":"One hundred consecutive hepatic biopsies in the workup of living donors for right lobe liver transplantation","volume":"8","author":"Ryan","year":"2002","journal-title":"Liver Transpl."},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"745","DOI":"10.1053\/gast.2002.35354","article-title":"The utility of radiological imaging in nonalcoholic fatty liver disease","volume":"123","author":"Saadeh","year":"2002","journal-title":"Gastroenterology"},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"W320","DOI":"10.2214\/AJR.07.2123","article-title":"Interobserver and intraobserver variability in the sonographic assessment of fatty liver","volume":"189","author":"Strauss","year":"2007","journal-title":"AJR Am. J. Roentgenol."},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"635","DOI":"10.1381\/096089204323093408","article-title":"The role of ultrasound in the diagnosis of hepatic steatosis in morbidly obese patients","volume":"14","author":"Mottin","year":"2004","journal-title":"Obes. Surg."},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"2392","DOI":"10.1111\/liv.12809","article-title":"Impact of skin capsular distance on the performance of controlled attenuation parameter in patients with chronic liver disease","volume":"35","author":"Shen","year":"2015","journal-title":"Liver Int."},{"key":"ref_62","doi-asserted-by":"crossref","unstructured":"Ratchatasettakul, K., Rattanasiri, S., Promson, K., Sringam, P., and Sobhonslidsuk, A. (2017). The inverse effect of meal intake on controlled attenuation parameter and liver stiffness as assessed by transient elastography. BMC Gastroenterol., 17.","DOI":"10.1186\/s12876-017-0609-6"},{"key":"ref_63","doi-asserted-by":"crossref","first-page":"e462","DOI":"10.1152\/ajpendo.00064.2004","article-title":"Magnetic resonance spectroscopy to measure hepatic triglyceride content: Prevalence of hepatic steatosis in the general population","volume":"288","author":"Szczepaniak","year":"2005","journal-title":"Am. J. Physiol. Endocrinol. Metab."},{"key":"ref_64","doi-asserted-by":"crossref","first-page":"1930","DOI":"10.1002\/hep.26455","article-title":"Utility of magnetic resonance imaging versus histology for quantifying changes in liver fat in nonalcoholic fatty liver disease trials","volume":"58","author":"Noureddin","year":"2013","journal-title":"Hepatology"},{"key":"ref_65","doi-asserted-by":"crossref","first-page":"5180","DOI":"10.1007\/s00330-019-06071-5","article-title":"Diagnostic accuracy of hepatic proton density fat fraction measured by magnetic resonance imaging for the evaluation of liver steatosis with histology as reference standard: A meta-analysis","volume":"29","author":"Qu","year":"2019","journal-title":"Eur. Radiol."},{"key":"ref_66","doi-asserted-by":"crossref","first-page":"70","DOI":"10.1007\/s12072-016-9772-z","article-title":"Non-invasive diagnosis of hepatic steatosis","volume":"11","author":"Stern","year":"2017","journal-title":"Hepatol. Int."},{"key":"ref_67","doi-asserted-by":"crossref","first-page":"142","DOI":"10.1016\/j.jhep.2016.08.023","article-title":"Aerobic vs. resistance exercise in non-alcoholic fatty liver disease: A systematic review","volume":"66","author":"Hashida","year":"2017","journal-title":"J. Hepatol."},{"key":"ref_68","doi-asserted-by":"crossref","first-page":"862","DOI":"10.1210\/clinem\/dgab795","article-title":"The effect of high-intensity interval training versus moderate-intensity continuous training on liver fat: A systematic review and meta-analysis","volume":"107","author":"Sabag","year":"2022","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_69","first-page":"1398","article-title":"Exercise-based interventions for nonalcoholic fatty liver disease: A meta-analysis and meta-regression","volume":"14","author":"Orci","year":"2016","journal-title":"Clin. Gastroenterol. Hepatol. Off. Clin. Pract. J. Am. Gastroenterol. Assoc."},{"key":"ref_70","doi-asserted-by":"crossref","first-page":"6318","DOI":"10.3748\/wjg.v22.i27.6318","article-title":"Effectiveness of exercise in hepatic fat mobilization in non-alcoholic fatty liver disease: Systematic review","volume":"22","author":"Golabi","year":"2016","journal-title":"World J. Gastroenterol."},{"key":"ref_71","doi-asserted-by":"crossref","unstructured":"Babu, A.F., Csader, S., Lok, J., G\u00f3mez-Gallego, C., Hanhineva, K., El-Nezami, H., and Schwab, U. (2021). Positive effects of exercise intervention without weight loss and dietary changes in NAFLD-related clinical parameters: A systematic review and meta-analysis. Nutrients, 13.","DOI":"10.3390\/nu13093135"},{"key":"ref_72","doi-asserted-by":"crossref","first-page":"157","DOI":"10.1016\/j.jhep.2012.02.023","article-title":"Exercise and non-alcoholic fatty liver disease: A systematic review and meta-analysis","volume":"57","author":"Keating","year":"2012","journal-title":"J. Hepatol."},{"key":"ref_73","doi-asserted-by":"crossref","first-page":"63","DOI":"10.1111\/1753-0407.13086","article-title":"Effect of exercise on hepatic steatosis: Are benefits seen without dietary intervention? A systematic review and meta-analysis","volume":"13","author":"Baker","year":"2021","journal-title":"J. Diabetes"},{"key":"ref_74","doi-asserted-by":"crossref","first-page":"1013","DOI":"10.1111\/hepr.13688","article-title":"Evidence-based clinical practice guidelines for nonalcoholic fatty liver disease\/nonalcoholic steatohepatitis 2020","volume":"51","author":"Tokushige","year":"2021","journal-title":"Hepatol. Res."},{"key":"ref_75","doi-asserted-by":"crossref","first-page":"330","DOI":"10.1016\/j.jada.2008.11.041","article-title":"Position of the American Dietetic Association: Weight management","volume":"109","author":"Seagle","year":"2009","journal-title":"J. Am. Diet. Assoc."},{"key":"ref_76","doi-asserted-by":"crossref","first-page":"1321","DOI":"10.1093\/nutrit\/nuaa146","article-title":"Effect of dietary carbohydrate and lipid modification on clinical and anthropometric parameters in nonalcoholic fatty liver disease: A systematic review and meta-analysis","volume":"79","author":"Avelar","year":"2021","journal-title":"Nutr. Rev."},{"key":"ref_77","doi-asserted-by":"crossref","first-page":"716783","DOI":"10.3389\/fnut.2021.716783","article-title":"Dietary interventions in patients with non-alcoholic fatty liver disease: A systematic review and meta-analysis","volume":"8","author":"Houttu","year":"2021","journal-title":"Front. Nutr."},{"key":"ref_78","doi-asserted-by":"crossref","first-page":"765","DOI":"10.1093\/nutrit\/nuz029","article-title":"Effect of dietary intervention, with or without co-interventions, on inflammatory markers in patients with nonalcoholic fatty liver disease: A systematic literature review","volume":"77","author":"Reddy","year":"2019","journal-title":"Nutr. Rev."},{"key":"ref_79","doi-asserted-by":"crossref","first-page":"903","DOI":"10.1016\/S2468-1253(21)00308-3","article-title":"Non-alcoholic fatty liver disease and risk of fatal and non-fatal cardiovascular events: An updated systematic review and meta-analysis","volume":"6","author":"Mantovani","year":"2021","journal-title":"Lancet Gastroenterol. Hepatol."},{"key":"ref_80","doi-asserted-by":"crossref","first-page":"938","DOI":"10.1093\/eurjpc\/zwab212","article-title":"Risk of cardiovascular events in patients with non-alcoholic fatty liver disease: A systematic review and meta-analysis","volume":"29","author":"Alon","year":"2022","journal-title":"Eur. J. Prev. Cardiol."},{"key":"ref_81","doi-asserted-by":"crossref","first-page":"33386","DOI":"10.1038\/srep33386","article-title":"Association of non-alcoholic fatty liver disease with major adverse cardiovascular events: A systematic review and meta-analysis","volume":"6","author":"Wu","year":"2016","journal-title":"Sci. Rep."},{"key":"ref_82","doi-asserted-by":"crossref","first-page":"484","DOI":"10.1038\/s41574-021-00507-z","article-title":"Emerging therapeutic approaches for the treatment of NAFLD and type 2 diabetes mellitus","volume":"17","author":"Ferguson","year":"2021","journal-title":"Nat. Rev. Endocrinol."},{"key":"ref_83","doi-asserted-by":"crossref","first-page":"1097","DOI":"10.1042\/CS20150308","article-title":"Modified high-intensity interval training reduces liver fat and improves cardiac function in non-alcoholic fatty liver disease: A randomized controlled trial","volume":"129","author":"Hallsworth","year":"2015","journal-title":"Clin. Sci."},{"key":"ref_84","doi-asserted-by":"crossref","first-page":"379","DOI":"10.1016\/j.jhep.2019.04.013","article-title":"The beneficial effects of Mediterranean diet over low-fat diet may be mediated by decreasing hepatic fat content","volume":"71","author":"Gepner","year":"2019","journal-title":"J. Hepatol."},{"key":"ref_85","unstructured":"GIHep (2023, April 03). Fibrosis 4 Score. Available online: http:\/\/gihep.com\/calculators\/hepatology\/fibrosis-4-score\/."},{"key":"ref_86","doi-asserted-by":"crossref","unstructured":"Halfon, P., Ansaldi, C., Penaranda, G., Chiche, L., Dukan, P., Stavris, C., Plauzolles, A., Retornaz, F., and Bourliere, M. (2021). Prospective screening of liver fibrosis in a primary care cohort using systematic calculation of fib-4 in routine results. PLoS ONE, 16.","DOI":"10.1101\/2021.01.13.21249262"},{"key":"ref_87","doi-asserted-by":"crossref","first-page":"1006","DOI":"10.1136\/gutjnl-2021-324243","article-title":"Diagnostic accuracy of non-invasive tests for advanced fibrosis in patients with NAFLD: An individual patient data meta-analysis","volume":"71","author":"Lee","year":"2022","journal-title":"Gut"},{"key":"ref_88","doi-asserted-by":"crossref","first-page":"1453","DOI":"10.1016\/j.cgh.2017.02.031","article-title":"Diagnostic accuracy of noninvasive fibrosis scores in a population of individuals with a low prevalence of fibrosis","volume":"15","author":"Mahady","year":"2017","journal-title":"Clin. Gastroenterol. Hepatol."},{"key":"ref_89","doi-asserted-by":"crossref","first-page":"1133","DOI":"10.1016\/j.dld.2017.05.002","article-title":"AST to platelet ratio index and fibrosis 4 calculator scores for non-invasive assessment of hepatic fibrosis in patients with non-alcoholic fatty liver disease","volume":"49","author":"Peleg","year":"2017","journal-title":"Dig. Liver Dis."},{"key":"ref_90","doi-asserted-by":"crossref","first-page":"846","DOI":"10.1002\/hep.21496","article-title":"The NAFLD fibrosis score: A noninvasive system that identifies liver fibrosis in patients with NAFLD","volume":"45","author":"Angulo","year":"2007","journal-title":"Hepatology"},{"key":"ref_91","doi-asserted-by":"crossref","first-page":"1797","DOI":"10.1097\/HEP.0000000000000323","article-title":"AASLD Practice Guidance on the clinical assessment and management of nonalcoholic fatty liver disease","volume":"77","author":"Rinella","year":"2023","journal-title":"Hepatology"},{"key":"ref_92","doi-asserted-by":"crossref","unstructured":"Tincopa, M.A., and Loomba, R. (2023). Non-invasive diagnosis and monitoring of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis. Lancet Gastroenterol. Hepatol.","DOI":"10.1016\/S2468-1253(23)00066-3"},{"key":"ref_93","doi-asserted-by":"crossref","first-page":"1264","DOI":"10.1053\/j.gastro.2018.12.036","article-title":"Noninvasive assessment of liver disease in patients with nonalcoholic fatty liver disease","volume":"156","author":"Loomba","year":"2019","journal-title":"Gastroenterology"},{"key":"ref_94","doi-asserted-by":"crossref","first-page":"275","DOI":"10.3138\/canlivj-2021-0004","article-title":"Comparing the performance of Fibrosis-4 and Non-Alcoholic Fatty Liver Disease Fibrosis Score with transient elastography scores of people with non-alcoholic fatty liver disease","volume":"4","author":"Cox","year":"2021","journal-title":"Can. Liver J."},{"key":"ref_95","doi-asserted-by":"crossref","first-page":"261","DOI":"10.1111\/liv.14669","article-title":"Prognostic accuracy of FIB-4, NAFLD fibrosis score and APRI for NAFLD-related events: A systematic review","volume":"41","author":"Lee","year":"2021","journal-title":"Liver Int."},{"key":"ref_96","doi-asserted-by":"crossref","first-page":"1486","DOI":"10.1002\/hep.29302","article-title":"Comparison of laboratory tests, ultrasound, or magnetic resonance elastography to detect fibrosis in patients with nonalcoholic fatty liver disease: A meta-analysis","volume":"66","author":"Xiao","year":"2017","journal-title":"Hepatology"},{"key":"ref_97","doi-asserted-by":"crossref","first-page":"740","DOI":"10.1038\/ajg.2016.453","article-title":"Age as a confounding factor for the accurate non-invasive diagnosis of advanced NAFLD fibrosis","volume":"112","author":"McPherson","year":"2017","journal-title":"Am. J. Gastroenterol."},{"key":"ref_98","doi-asserted-by":"crossref","first-page":"1793","DOI":"10.1111\/liv.13739","article-title":"Diabetes impacts prediction of cirrhosis and prognosis by non-invasive fibrosis models in non-alcoholic fatty liver disease","volume":"38","author":"Bertot","year":"2018","journal-title":"Liver Int."},{"key":"ref_99","doi-asserted-by":"crossref","first-page":"916","DOI":"10.14309\/ajg.0000000000000153","article-title":"Impact of obesity and alanine aminotransferase levels on the diagnostic accuracy for advanced liver fibrosis of noninvasive tools in patients with nonalcoholic fatty liver disease","volume":"114","author":"Petta","year":"2019","journal-title":"Am. J. Gastroenterol."},{"key":"ref_100","doi-asserted-by":"crossref","first-page":"331","DOI":"10.1111\/liv.13549","article-title":"Steatosis severity affects the diagnostic performances of noninvasive fibrosis tests in nonalcoholic fatty liver disease","volume":"38","author":"Joo","year":"2018","journal-title":"Liver Int."},{"key":"ref_101","unstructured":"Siemens Healthineers (2023, April 03). The Enhanced Liver Fibrosis (ELF) Blood Test: Literature Compendium Volume 1. Available online: https:\/\/www.siemens-healthineers.com\/en-uk\/laboratory-diagnostics\/assays-by-diseases-conditions\/liver-disease\/elf-test."},{"key":"ref_102","doi-asserted-by":"crossref","unstructured":"Xie, Q., Zhou, X., Huang, P., Wei, J., Wang, W., and Zheng, S. (2014). The performance of enhanced liver fibrosis (ELF) test for the staging of liver fibrosis: A meta-analysis. PLoS ONE, 9.","DOI":"10.1371\/journal.pone.0092772"},{"key":"ref_103","doi-asserted-by":"crossref","first-page":"1369","DOI":"10.1053\/j.gastro.2018.01.005","article-title":"Accuracy of the enhanced liver fibrosis test vs. FibroTest, elastography, and indirect markers in detection of advanced fibrosis in patients with alcoholic liver disease","volume":"154","author":"Thiele","year":"2018","journal-title":"Gastroenterology"},{"key":"ref_104","doi-asserted-by":"crossref","first-page":"134","DOI":"10.1055\/a-0713-1330","article-title":"Noninvasive liver fibrosis tests in patients with nonalcoholic fatty liver disease: An external validation cohort","volume":"51","author":"Polyzos","year":"2019","journal-title":"Horm. Metab. Res."},{"key":"ref_105","doi-asserted-by":"crossref","first-page":"252","DOI":"10.1016\/j.jhep.2020.03.036","article-title":"Enhanced liver fibrosis test for the non-invasive diagnosis of fibrosis in patients with NAFLD: A systematic review and meta-analysis","volume":"73","author":"Vali","year":"2020","journal-title":"J. Hepatol."},{"key":"ref_106","doi-asserted-by":"crossref","first-page":"134","DOI":"10.1002\/hep.29489","article-title":"Performance characteristics of vibration-controlled transient elastography for evaluation of nonalcoholic fatty liver disease","volume":"67","author":"Vuppalanchi","year":"2018","journal-title":"Hepatology"},{"key":"ref_107","unstructured":"National Institute for Health and Care Excellence (2023, April 03). FibroScan for Assessing Liver Fibrosis and Cirrhosis in Primary Care. Available online: https:\/\/www.nice.org.uk\/advice\/mib216\/chapter\/Expert-comments."},{"key":"ref_108","unstructured":"Echosens (2023, April 03). Fibroscan\u00ae. Available online: https:\/\/www.echosens.com\/fibroscan\/."},{"key":"ref_109","doi-asserted-by":"crossref","first-page":"1717","DOI":"10.1053\/j.gastro.2019.01.042","article-title":"Accuracy of FibroScan controlled attenuation parameter and liver stiffness measurement in assessing steatosis and fibrosis in patients with nonalcoholic fatty liver disease","volume":"156","author":"Eddowes","year":"2019","journal-title":"Gastroenterology"},{"key":"ref_110","first-page":"156","article-title":"Vibration-controlled transient elastography to assess fibrosis and steatosis in patients with nonalcoholic fatty liver disease","volume":"17","author":"Siddiqui","year":"2019","journal-title":"Clin. Gastroenterol. Hepatol. Off. Clin. Pract. J. Am. Gastroenterol. Assoc."},{"key":"ref_111","first-page":"242","article-title":"Assessment of transient elastography (FibroScan) for diagnosis of fibrosis in non-alcoholic fatty liver disease: A systematic review and meta-analysis","volume":"7","author":"Hashemi","year":"2016","journal-title":"Casp. J. Intern. Med."},{"key":"ref_112","first-page":"828","article-title":"Pitfalls of liver stiffness measurement: A 5-year prospective study of 13,369 examinations","volume":"51","author":"Foucher","year":"2010","journal-title":"Hepatology"},{"key":"ref_113","unstructured":"Echosens (2023, April 03). New FibroScan\u00ae GO. Available online: https:\/\/www.flipsnack.com\/98A8B8AA9F7\/fibroscan-go_brochure-uk_web.html."},{"key":"ref_114","doi-asserted-by":"crossref","unstructured":"Congly, S.E., Shaheen, A.A., and Swain, M.G. (2021). Modelling the cost effectiveness of non-alcoholic fatty liver disease risk stratification strategies in the community setting. PLoS ONE, 16.","DOI":"10.1371\/journal.pone.0251741"},{"key":"ref_115","doi-asserted-by":"crossref","unstructured":"Salomone, F., Micek, A., and Godos, J. (2018). Simple scores of fibrosis and mortality in patients with NAFLD: A systematic review with meta-analysis. J. Clin. Med., 7.","DOI":"10.3390\/jcm7080219"},{"key":"ref_116","doi-asserted-by":"crossref","first-page":"862","DOI":"10.1111\/hepr.12647","article-title":"Comparison of FIB-4 index, NAFLD fibrosis score and BARD score for prediction of advanced fibrosis in adult patients with non-alcoholic fatty liver disease: A meta-analysis study","volume":"46","author":"Sun","year":"2016","journal-title":"Hepatol. Res."},{"key":"ref_117","doi-asserted-by":"crossref","first-page":"508","DOI":"10.23736\/S0031-0808.20.04171-3","article-title":"Noninvasive biomarkers in predicting nonalcoholic steatohepatitis and assessing liver fibrosis: Systematic review and meta-analysis","volume":"63","author":"Ismaiel","year":"2021","journal-title":"Panminerva Med."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/12\/12\/4001\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T19:53:14Z","timestamp":1760125994000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/12\/12\/4001"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,6,12]]},"references-count":117,"journal-issue":{"issue":"12","published-online":{"date-parts":[[2023,6]]}},"alternative-id":["jcm12124001"],"URL":"https:\/\/doi.org\/10.3390\/jcm12124001","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,6,12]]}}}