Rivera Esteban JM, Augustin S. Metabolic comorbidity, the new enemy. Metabolic syndrome and steatohepatitis. Editorial Metabolic comorbidity, the new enemy. Metabolic syndrome and steatohepatitis Rivera Esteban JM, Augustin S Liver Unit, Department of Internal Medicine. Hospital Universitario Vall D’Hebron. Vall d’Hebron Research Institute (VHIR). Universidad Autónoma de Barcelona. Barcelona. In recent decades we have observed a progres- (defined as a body mass index of over 30 kg/m2)5,6 sive increase in the prevalence of non-communicable Such numbers contradict the stereotypical percep- chronic diseases worldwide. This trend is more nota- tions held in experts circles outside prison, since they ble in developed countries and has been attributed to are not very different from those observed amongst (amongst other factors) a gradual ageing of the popu- the general population. lation, unhealthy lifestyles and to healthcare advances One factor that could help to explain the increase that have increased life expectancy. The prison popu- of metabolic pathology amongst inmates is that the lation is also afectted by these global socio-demogra- prison population is ageing, as we commented above. phic changes. Another probable explanation is that particular fac- The prison population in Spain has been ageing tors of this population are contributing towards the progressively in recent years, mainly due to an increa- increase in prevalence. sed imprisonment of older people and longer senten- On the one hand, we know that the prevalence ces. At present, the average age of inmates in Spain is of metabolic syndrome increases by up to 70% in 39 years and almost 30% of inmates are over 45 years patients with mental illnesses in the general popu- of age1,2. lation. These patients often take second-generation One non-communicable chronic disease that has antipsychotic drugs, which are linked to weight gain recently come under the spotlight is metabolic syn- and the risk of dyslipidemia or diabetes mellitus. This drome. The incidence of this condition has increased factor takes on even greater importance in prison, exponentially in recent years to become one of the where the prevalence of severe mental illness is four main public health concerns of this century and is times that of the general population, and almost half now a high priority health objective at international of the patients that go to psychiatric consultations in level. prison receive treatment with neuroleptic medica- Metabolic syndrome is made up of a spectrum of tion7. diseases (obesity, higharterial hypertension, diabetes It has also been documented that the prison popu- mellitus and dyslipidemia), and their importance rests lation is more likely to fall ill than the general public, on their role as risk factors for high morbimortality when compared by age and sex, probably because diseases, such as cardiovascular, respiratory and hepa- of their origins (many are from the Third or Fourth tic diseases, etc3,4. World), their high risk behaviours and lifestyles. National studies in general population shows a Likewise, higher levels of prison morbidity and mor- prevalence of metabolic syndrome in Spain around tality have been recorded in recent years that are rela- 22-32%, but unfortunately there are very few stu- ted to non-communicable diseases and in particular dies evaluating the presence and impact of metabolic to metabolic issues, (mainly cardiovascular events), at syndrome in prison population. The prevalence of the expense of deaths attributed to infectious diseases. arterial hypertensión in Spanish prisons is estimated One of the chronic pathologies associated with to be 25%; while levels of dyslipidemia are estimated metabolic syndrome that merits special attention is at 18% and diabetes mellitus at 10% in persons over the metabolic (dysfunction) associated fatty liver 45 years of age, while 20% of such patients are obese disease “MAFLD”, previusly named non alcoholic Rev Esp Sanid Penit. 2020;22(2):55-57 55 doi: 10.18176/resp.00010 Rivera Esteban JM, Augustin S. Metabolic comorbidity, the new enemy. Metabolic syndrome and steatohepatitis. fatty liver disease “NAFLD”, which represents one Accesibility problems to this technology has led of the greatest hidden heatlhcare threats for general to the development of serum biomarkers to stratify and prison population. The incidence of MAFLD is the risk of advanced fibrosis and monitor the disease increasingly rapidly worldwide, in parallel with the progression. These include FIB-4 (fibrosis-4 score) epidemics of obesity, diabetes mellitus and metabolic and ELF (enhanced liver fibrosis score) biomarkers syndrome. for fibrosis and FLI (fatty liver index) for steatosis The current prevalence of MAFLD worldwide is diagnosis. estimated around 25% with major geographical varia- The main strategy to treat MAFLF is based on tions, being in the case of Europe about 25-35%. This modifying lifestyle habits to weight loss, which has prevalence increases up to 60-80% in obese and dia- been shown to be the most effective strategy for a his- betic patients, and can reach 80-100% if both are pre- tological improvement of MAFLD10. However, only sent. On the other hand, it is estimated that 20-30% of 10% of patients are able to lose the amount of weight patients with MAFLD shall progress to severe condi- necessary to bring about such an improvement, and tions, presenting inflammation with different levels of so a large percentage of patients with MAFLD are fibrosis, and that 10% of them can develop cirrhosis expected to require farmalogical treatment to prevent and its associated complications, which include liver the progression to cirrhosis. Currently we dont hace cancer8. any drug approved for use in MAFLD but there is When we extrapolate the data obtained from intensive research on this disease and the therapeutic prevalence studies in general population and natu- arsenal is very likely to increase exponentially in the ral history, we found that 3-4% of the general adult next years. population may have MAFLD with advanced fibro- In resume, metabolic syndrome and MAFLD sis and 0.5% of these individuals may be in a phase are increasingly prevalent pathologies in the general of asymptomatic cirrhosis (also called compensated population and may well be so amongst prison inma- or silent cirrhosis). Furthermore, it is estimated that tes, with an associated morbidity and mortality that approximately 50% of these patients remains undiag- is likewise on the increase. Such diseases are preven- nosed and therefore are not currently benefiting from table, easy to diagnose and potentially treatable, and screening and intervention programs necessary in the therefore their treatment and management should be advanced pre-symptomatic phases of the disease9. made a high priority healthcare objective for the gene- Recent studies have also revealed the pre-existence ral public and for inmates. of polymorphisms in specific genes, including notable ones such as PNPLA3 (patatin like phospholipase domain containing 3) and TM6SF2 (transmembrane 6 CORRESPONDENCE superfamily member 2), which have a role in the onset and progression of MAFLD. This genetic predisposi- Jesús M. Rivera Esteban tion may explain, at least partially the major inter-eth- E-mail: jesusriveraest@gmail.com nic predisposition variability to present MAFLD (it Salvador Augustin has been commented that Latin-American and Asian E-mail: salva.augustin@gmail.com individuals run a higher risk of this disease than those of European and African descent). This point may be of special importance in the Spanish prison context, REFERENCES where up to 45% of inmates are foreigners, with a high proportion of Latin-American inmates. 1. Fazel S, Baillargeon J. The health of prisoners. The dramatic increase in the prevalence and Lancet. 2011;377:956-65. impact of MAFLD has attached a development of 2. Bretschneider W, Elger B, Wangmo T. Ageing Pri- new diagnostic and therapeutic methods. Transient soners’ Health Care: Analysing the Legal Settings elastography (which most well-known device used in Europe and the United States. 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