Lean versus Obese Non-Alcoholic Fatty Liver Disease: A Cross-Sectional Comparative Cohort with Liver Stiffness and Fibrosis Risk Profiling

Dr. Richa sharma , Komal Sharma, Prashant Saraswat

Non-Alcoholic Fatty Liver Disease; NAFLD; Lean NAFLD; Metabolic Syndrome; Liver Stiffness; FIB-4; PNPLA3; Insulin Resistance

Non-alcoholic fatty liver disease (NAFLD) was historically considered the hepatic manifestation of obesity, but a substantial fraction of South Asian NAFLD occurs in individuals with body mass index below 25 the lean NAFLD phenotype. We compared 320 patients with biopsy-proven or imaging-confirmed NAFLD across three BMI strata: lean (BMI LESSTHAN 25, n=98), overweight (BMI 25-30, n=122), and obese (BMI ≥30, n=100). Despite lower BMI, lean NAFLD patients showed substantial metabolic dysfunction: insulin resistance in 42.5%, type 2 diabetes in 28.4%, and metabolic syndrome in 24.6%. Median liver stiffness on FibroScan was 6.4 kPa in lean patients, 7.8 kPa in overweight patients, and 9.6 kPa in obese patients. Advanced fibrosis (F3-F4) prevalence was 16.3% in lean, 19.7% in overweight, and 26.0% in obese patients a smaller gradient than BMI alone would predict. Independent predictors of advanced fibrosis were type 2 diabetes, age above 55 years, metabolic syndrome, insulin resistance, AST/ALT ratio above 1, and PNPLA3 GG genotype where assessed. Lean NAFLD is a metabolically meaningful phenotype warranting structured screening, regular fibrosis surveillance, and integrated cardiometabolic management.

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