TYPE Original Research PUBLISHED 21 November 2022 DOI 10.3389/fendo.2022.971864 Dysglycemia in young women OPEN ACCESS attenuates the protective effect EDITED BY Andreea Ciudin, Vall d’Hebron University Hospital, against fatty liver disease Spain REVIEWED BY Alejandra Pérez-Montes de Oca 1,2†, Marı́a Teresa Julián 1,2†, Joana Nicolau, Son Llàtzer Hospital, Spain Guillem Pera 3,4, Llorenç Caballerı́a 3,4, Rosa Morillas 4,5, Alexandru Ciudin, Hospital Clinic of Barcelona, Spain Pere Torán 3,4, Carmen Expósito 3,4, Josep Franch-Nadal 6,7, *CORRESPONDENCE Didac Mauricio 2,6,8* and Nuria Alonso 1,2,6* Didac Mauricio 1 Department of Endocrinology and Nutrition, Hospital Germans Trias I Pujol, Barcelona, Spain, didacmauricio@gmail.com 2 Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain, 3 Unitat de Suport Nuria Alonso a la Recerca Metropolitana Nord, Fundació Institut Universitari per a la Recerca a l’Atenció Primària nurialonsopedrol@gmail.com de Salut Jordi Gol i Gurina (IDIAPJGol), Mataró, Spain, 4 Centro d’Investigaciones Biomédicas en † Red, Enfermedades Hepatologia y Digestivas, Barcelona, Spain, 5 Hepatology Department, Hospital These authors have contributed equally to this work and share Germans Trias I Pujol, Barcelona, Spain, 6 Center for Biomedical Research on Diabetes and first authorship Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III, Madrid, Spain, 7 Primary Health Care Center Raval Sud, Gerència d’Atenció Primaria, Institut Català de la Salut, Barcelona, SPECIALTY SECTION Spain, 8 Hospital de la Santa Creu i Sant Pau, Institut d’Investigació Biomèdica Sant Pau (IIB Sant Pau), This article was submitted to Barcelona, Spain Translational Endocrinology, a section of the journal Frontiers in Endocrinology RECEIVED 01 July 2022 ACCEPTED 07 November 2022 Introduction: Sexual dimorphism has been reported in non-alcoholic fatty liver PUBLISHED 21 November 2022 disease (NAFLD), similar to the sex differences evident with cardiovascular CITATION disease. Type 2 diabetes mellitus (T2D) significantly increases the risk and Pérez-Montes de Oca A, Julián MT, severity of NAFLD, but there is scarce information on whether T2D or altered Pera G, Caballerı´a L, Morillas R, glucose metabolism can modify the prevalence of NAFLD in men and women Torán P, Expósito C, Franch-Nadal J, Mauricio D and Alonso N (2022) of reproductive age. Dysglycemia in young women attenuates the protective effect against Purpose: To investigate the relationship between age, sex and NAFLD in fatty liver disease. Front. Endocrinol. 13:971864. subjects with and without dysglycemia. doi: 10.3389/fendo.2022.971864 COPYRIGHT Materials and methods: We analyzed 2,790 patients. NAFLD was characterized © 2022 Pérez-Montes de Oca, Julián, using established diagnostic criteria: one or more positive results on the fatty Pera, Caballerı´a, Morillas, Torán, Expósito, Franch-Nadal, Mauricio and liver index and hepatic ultrasound. Liver fibrosis (liver stiffness measurement ® Alonso. This is an open-access article [LSM] ≥8.0 kPa) was assessed by Fibroscan . For analysis purposes, we included distributed under the terms of the both T2D and prediabetes under the predefined condition of dysglycemia. Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is Results: The global prevalence of NAFLD was higher in men than in women (50% permitted, provided the original and 34%; P<0.001), and the prevalence increased with age in both sexes. Older author(s) and the copyright owner(s) are credited and that the original women (≥ 50 years) had a higher prevalence than younger women (<50 years), publication in this journal is cited, in both in the overall cohort and in non-dysglycemic subjects. In dysglycemic accordance with accepted academic subjects, the prevalence of NAFLD was slightly higher in men (68% vs 61%, practice. No use, distribution or reproduction is permitted which does p=0.021); in younger subjects, there were no differences in the prevalence of not comply with these terms. NAFLD between men and women (68% vs 64%, respectively; p=0.635). We found an interaction between dysglycemia and female sex (odds ratio [OR] 1.6 95% confidence interval [CI] 1.0-2.4, p=0.030), and between and age ≥50 years (OR 0.6, 95% CI 0.3-1.0, p=0.046). The global prevalence of LSM ≥8.0 kPa was higher in men compared with women (8% vs 4%; p< 0.001). This prevalence increased Frontiers in Endocrinology 01 frontiersin.org Pérez-Montes de Oca et al. 10.3389/fendo.2022.971864 with age, mainly in men. We did not find any association between liver fibrosis and age and gender. Conclusions: While the global prevalence of NAFLD is higher in men than in women across all ages, younger women with dysglycemia have a similar risk of developing NAFLD as men of a similar age. Therefore, the presence of dysglycemia may erase the protective effect of female sex against fatty liver disease. KEYWORDS NAFLD, female sex, hyperglycemia, premenopausal woman, dysglycemia, fibrosis Introduction without T2D were significantly negatively associated with having liver fibrosis (9). There is evidence that suggests that gender and reproductive Several epidemiological studies have shown that status modulate the risk and severity of developing non- premenopausal women experience a higher degree of alcoholic fatty liver disease (NAFLD), similar to the sex cardioprotection than men of similar age (1, 2). Moreover, differences that is evident with cardiovascular disease (1, 2). evidence suggests that cardioprotection in women is lost under Data from several longitudinal studies reveal that the prevalence metabolic conditions, such as T2D (7, 8). To our knowledge, of NAFLD is higher in men than in women and that gender- there is scarce information on whether T2D or impaired glucose specific differences exist in relation to age (3, 4). In women, metabolism can level or turn the prevalence of NAFLD in men menopausal status and older age are strong risk factors for and women of reproductive age. The aim of the present study NAFLD. Overall, the prevalence of NAFLD is higher in was to investigate the relationship between age, reproductive postmenopausal women when compared with premenopausal status, and NAFLD in subjects with an alteration in glucose women, suggesting a protective anti-steatogenic effect of metabolism (dysglycemia: T2D or prediabetes) and in subjects estrogens (5). without dysglycemia. Regarding liver fibrosis, when it comes to sex differences, the results are mixed. In a previous cross-sectional population-based study, we described that male gender was a risk factor Materials and methods independently associated with increased liver stiffness measurement (LSM) assessed by transient elastography (TE) Study design (6). In relation to the reproductive status, however, there is strong evidence that menopause increases the risk of liver This was a cross-sectional study in an urban area of Catalonia, fibrosis in the general population due to estrogen deficiency in southwestern Europe. We included two well-characterized and dysmetabolic features that can occur in this reproductive cohorts, both based on previous cross-sectional descriptive studies period (2, 7). (9, 13). The two cohorts differed in their eligibility criteria and On the other hand, it is well known that the presence of type 2 design; the first cohort was reflective of the general population in diabetes mellitus (T2D) significantly increases the risk and severity general practice in Catalonia and included subjects regardless of the of NAFLD (8). Evidence from community-based studies reveals presence of dysglycemia, while the second cohort included subjects that the prevalence of increased LSM is also significantly higher in with T2D. In the first cohort, the recruitment was conducted in subjects with T2D compared with those without (9–11). Also, T2D several municipalities in the northern part of the Barcelona and insulin resistance have been linked to increase the risk of metropolitan area between April 2012 and January 2016. advanced fibrosis in patients with nonalcoholic steatohepatitis (12). Participants in the study were randomly selected from a total of Data from a previous population study performed by our group 162,950 subjects aged 18 to 75 years from the registries of the revealed that the female sex was negatively associated with NAFLD primary health care centers of the municipalities included in the in subjects with and without diabetes. However, only women study. Patients with a current history of liver disease, including Frontiers in Endocrinology 02 frontiersin.org Pérez-Montes de Oca et al. 10.3389/fendo.2022.971864 cholestasis, hepatitis C or B virus infection, and high-risk alcohol Statistical analysis consumption were excluded from the study. Other exclusion criteria were active malignancy, other severe diseases (congestive Continuous variables are expressed as mean ± standard heart failure New York Heart Association >2, chronic obstructive deviation (SD) and categorical variables as frequency and pulmonary disease Global Initiative for Chronic Obstructive Lung percentage. Comparison of proportions and prevalences were Disease >2, chronic kidney disease requiring dialysis, previous tested using chi-squared tests. Univariate logistic regression organ transplantation, and severe neurologic diseases), or models were performed to assess the relationship between admission to long-term nursing homes. The second cohort was NAFLD or fibrosis (outcomes) and gender, age over 50 and recruited from an outpatient clinic in Lleida, also in Catalonia, dysglycemia. Additionally, the same model was applied using a Spain. This was also a population-based cohort recruited to evaluate computed variable integrating the combination of gender, age the prevalence of prediabetes in the general population (13). The and dysglycemia to better show how each profile is more or less inclusion criteria were age range 40–75 years; T2D diagnosis; associated with NAFLD. Finally, logistic regression models absence of established impaired renal function (calculated including gender, diabetes, age over 50, abdominal obesity and glomerular filtration rate (eGFR) <60 ml/min) and absence of the interaction terms between the first 3 variables were known cardiovascular disease. performed. All the analyses were performed using Stata v17. Definitions Ethics Aspartate transaminase (AST) and/or alanine transaminase All participants gave their written informed consent. The (ALT) values >40 IU/L were considered as high serum protocol followed the current and relevant standards and transaminases. To determine high-risk alcohol consumption, regulations, and it was authorized by the Fundació Gol I Gorina’s standard drinking units/week were used: 21 for men and 14 for Ethics Committee (P11/58) (Barcelona, Spain) and the Ethics women. In the absence of secondary causes of steatosis, NAFLD Committee of Hospital Arnau de Vilanova (Lleida, Spain). was characterized using established diagnostic criteria: one or more positive results on the fatty liver index (FLI) and abdominal echography. The FLI uses body mass index (BMI), waist circumference, serum gamma-glutamyltransferase (GGT), Results and triglycerides to calculate the amount of fat in the liver. A FLI score of 60 or higher was used to define NAFLD (6, 14, 15). Characteristics of the study population Liver fibrosis was measured by TE, performed by three specially trained liver nurses. TE was conducted using the Fibroscan® system We analyzed a total of 2,790 subjects, 2,507 from the first cohort (402, Echosens®, Paris, France) using only the M probe (the XL and 283 from the second cohort (Figure 1). The median age was 55 probe was unavailable). Moderate-to-advanced liver fibrosis was ± 12 years old, 60% were female with a mean BMI of 29 ± 5 kg/m2. defined as an increased LSM ≥8.0 kPa. In a recent large population- A third of the patients were dysglycemic and 41% had NAFLD. The based investigation, this cut-off demonstrated the prediction of main characteristics of the subjects are represented in Table 1. substantial liver fibrosis, particularly in people with NAFLD (10). The LSM by TE was only available in the first cohort. T2D and prediabetes diagnosis were based on a registered Prevalence of NAFLD according to age diagnosis in the clinical records or having an HbA1c ≥6.5% or and sex fasting glucose ≥126 mg/dL and Hb1Ac 5.7-6.4% or fasting glucose 100-125 mg/dL, respectively (16). Abdominal obesity The global prevalence of NAFLD was 50% for men and 34% was defined as waist circumference ≥102 cm in men or ≥88 cm for women (p< 0.001). According to age, this prevalence was in women. For the purpose of this analysis we included both lower in younger subjects (38% in men and 19% in women), and T2D and prediabetes subjects under the predefined category of higher in older subjects (56% in men and 41% in women). In all dysglycemia. Age ≥50 years old was considered to define older age groups, the prevalence was higher in men than in women subjects and age < 50 years old was used to define younger (p<0.001). The overall prevalence of NAFLD according to age subjects according to a previous review (2). and sex is shown in Table 2. Frontiers in Endocrinology 03 frontiersin.org Pérez-Montes de Oca et al. 10.3389/fendo.2022.971864 FIGURE 1 Flowchart of study selection. HBV, Hepatitis B Virus, HCV, Hepatitis C Virus; HRAC, high-risk alcohol consumption. TABLE 1 Baseline characteristics of study population. Cohort 1 Cohort 2 Total Age (n,SD) 55 ± 12 59 ± 10 55 ± 12 ≥ 50 years old n(%) 1693 (68) 224 (79) 1917 (69) Women (n,%) 1530 (61) 145 (51) 1675 (60) 2 BMI (Kg/m ) (n,SD) 28 ± 5 32 ± 6 29 ± 5 Abdominal obesity (n,%) 1262 (50) 226 (80) 1488 (53) Non-smokers (n,%) 1249 (50) 138 (49) 1387 (50) Ex-smokers (n,%) 706 (28) 84 (30) 790 (28) Smokers (n,%) 540 (22) 59 (21) 599 (22) NAFLD (n,%) 942 (38) 190 (67) 1132 (41) T2D (n,%) 297 (12) 283 (100) 580 (21) T2D /pre-diabetic (n,%) 606 (24) 283 (100) 889 (32) Fasting glucose (mg/dL,SD) 100 ± 26 159 ± 56 106 ± 35 HbA1c (%,SD) 5.7 ± 0.7 7.8 ± 1.4 5.9 ± 1.0 Total cholesterol (mg/dL,SD) 212 ± 39 189 ± 36 210 ± 39 LDL-cholesterol (mg/dL,SD) 134 ± 34 111 ± 31 132 ± 35 HDL-cholesterol (mg/dL,SD) 55 ± 13 51 ± 14 55 ± 13 Cholesterol remanents 24 ± 13 27 ± 16 24 ± 14 Non HDL-cholesterol (mg/dL,SD) 157 ± 37 138 ± 35 155 ± 37 Triglycerides (mg/dL,SD) 121 ± 73 141 ± 98 123 ± 76 Atherogenic dyslipidemia (n, %) 255 ± 10 53 ± 19 308 ± 11 AST and/or ALT >40 (n, %) 207 (8) 46 (16) 253 (9) Fibroscan (kPs, SD) 4.9 ± 2.1 Fibroscan ≥8 (n,%) 139 (6) SD, standard deviation; NAFLD, non-alcoholic fatty liver disease; T2D, Type 2 diabetes; HbA1c, glycated hemoglobin; AST,aspartate aminotransferase; ALT,alanine aminotransferase Frontiers in Endocrinology 04 frontiersin.org Pérez-Montes de Oca et al. 10.3389/fendo.2022.971864 TABLE 2 Prevalence of NAFLD according to age and sex. Global <50 years old ≥50 years old Prevalence (%) p Prevalence (%) P Prevalence (%) p Global Men (n=1115) 50 <0.001 Men (n=364) 38 <0.001 Men (n=751) 56 <0.001 Women (n=1675) 34 Women (n=509) 19 Women (n=1166) 41 Dysglycemia Men (n=432) 68 0.021 Men (n=75) 68 0.635 Men (n=357) 68 0.024 Women (n=457) 61 Women (n=47) 64 Women (n=410) 60 Non-dysglycemia Men (n=683) 39 <0.001 Men (n=289) 30 <0.001 Men (n=394) 46 <0.001 Women (n=1218) 24 Women (n=462) 14 Women (n=756) 30 NAFLD, Non-alcoholic fatty liver disease. In subjects with normoglycemia, the prevalence of NAFLD Regression model for NAFLD, age was significantly higher in men than in women, in line with the and sex finding in the general cohort (39% and 24%; p<0.001). Overall, men had more risk than women despite their age, and older We applied a logistic model to investigate the association of women had twice the prevalence than the younger ones (30% vs. age, sex and dysglycemia with NAFLD. The univariate model 14%, p<0.001). Focusing on subjects with dysglycemia, however, found that female sex was a protective factor (odds ratio [OR] the global prevalence of NAFLD was more similar between 0.5; p<0.001), whereas age ≥50 years (OR 2.4; p<0.001) and sexes, being only slightly higher in men than in women (68% dysglycemia (OR 4.3; p<0.001) were associated with NAFLD. vs 61%, p=0.021). Similar results were found in older subjects Taking as reference normoglycemic young women, a young (68% men vs 60% women; p=0.024). When we analyzed the sex dysglyemic woman had ten times higher risk of NAFLD differences in younger subjects, there were no significant (p<0.001), a slightly higher risk when compared to older differences in the prevalence of NAFLD between men and hyperglycemic women, and an almost similar risk when women (68% vs 64%; p=0.635). Also, younger dysglycemic compared to all men with dysglicemia in the cohort. The women had a similar prevalence than older women with complete univariate model is shown in Table 3. dysglycemia, as well as to males regardless of age. Among After adjusting for abdominal obesity and including women, in young dysglycemic women, the prevalence of interactions, the presence of dysglycemia (OR 3.1; p<0.001), NAFLD was 64% vs 14% (p<0.001) in normoglycemic ones, abdominal obesity (OR 28, p<0.001), and age over 50 years (OR while in older women this tendency remained but was more 1.6; p<0.001) were factors positively associated with NAFLD, attenuated (60% vs. 30%, respectively, p<0.001). whereas female sex was negatively associated with this condition TABLE 3 Univariate model for NAFLD in our general cohort. OR 95% Cl P n Woman 0.5 0.4-0.6 <0.001 554 ≥50 years 2.4 2-2.9 <0.001 234 Dysglycemia 4.3 3.6-5.1 <0.001 318 Non-dysglycemic young men 2.6 1.8-3.7 <0.001 87 Dysglycemic young men 12.8 7.4-22.1 <0.001 24 Non-dysglycemic old men 5 3.6-7 <0.001 180 Dysglycemic old men 12.8 9.1-18 <0.001 114 Non-dysglycemic young women Ref 66 Dysglycemic young women 10.6 5.5-20.3 <0.001 17 Non-dysglycemic old women 2.6 1.9-3.5 <0.001 228 Dysglycemic old women 9.1 6.6-12.6 <0.001 163 NAFLD, non-alcoholic fatty liver disease; young, <50 years old; old, ≥50 years old. Frontiers in Endocrinology 05 frontiersin.org Pérez-Montes de Oca et al. 10.3389/fendo.2022.971864 (OR 0.1; p<0.001). We found two interactions: between p<0.001). Female sex was a protective factor (OR 0.3; p<0001). dysglycemia and female sex (OR 1.6 95% confidence interval No interactions were found to be significant. [CI] 1.0-2.4, p=0.030) and between dysglycemia and age over 50 years (OR 0.6, 95% CI 0.3-1.0, p=0.046). No interaction between gender and age was found. Discussion There is little information on the impact of glucose Prevalence of moderate-to-advanced metabolism on NAFLD according to sex and age. Most of the liver fibrosis according to age and sex studies evaluated either diabetes or reproductive status but not both concomitantly. To our knowledge, the present study Subsequently, we analyzed the prevalence of liver fibrosis describes for the first time the influence of dysglycemia on the assessed by TE. Data from TE was only available for the first prevalence of NAFLD and liver fibrosis assessed by TE and its cohort (n= 2507). The prevalence of moderate-to-advanced liver relationship with age and sex. fibrosis in the general cohort defined by LSM ≥8.0 kPa, was The present study found that the prevalence of NAFLD was higher in men compared to women (8% vs 4%; p< 0.001). This higher in men compared to women in the whole cohort (50% vs prevalence increased with age, mainly in men (4% in young men 34%), independent of age. It is known that NAFLD has a higher vs 11% in older men). Among young subjects, no differences prevalence among men than women (3, 4, 17). A study reported were observed in the prevalence of LSM ≥8.0 kPa regarding sex. by Wong et al. found that NAFLD, assessed by proton magnetic Similar findings were found in normoglycemic subjects. The resonance spectroscopy, was more prevalent in men than in prevalence of liver fibrosis according to age and sex is presented women (37% vs. 23%). The prevalence of fatty liver (FL) was in Table 4. especially low in women below age 50 years (12-16%), but it The prevalence of moderate-to-advanced liver fibrosis was increased steadily after menopause, while in men it remained higher in subjects in the dysglycemic group than in subjects constant across ages (17). According to this study, we found that without dysglycemia regardless of their age and sex. In general, older women had double the prevalence of NAFLD than men with dysglycemia had a higher prevalence of liver fibrosis younger women but not more than older men. This result is than dysglycemic women (18% vs 11%; p=0.012), mainly in consistent with other studies (18, 19). Moreover, in the older subjects. However, this sex difference disappeared when Framingham Heart Study that was designed to evaluate the younger subjects were analyzed (11% vs 4%; p= 0.348). incidence of hepatic steatosis in a community based-cohort The logistic regression model revealed that older and study of 685 patients, the frequency of FL measured by younger men with dysglycemia had a 8.7-fold and 4.4-fold risk computed tomography was similar in postmenopausal women of having moderate-to-advanced hepatic fibrosis compared to and men (19% vs. 22%), while it was lower in premenopausal young normoglycemic women. The difference in the risk of women (9%) (20). All these findings suggest that men and having liver fibrosis in younger hyperglycemic women compared postmenopausal women are more likely to have NAFLD. The to younger normoglycemic ones did not reach statistical exact reason is unknown, but dysregulated sex hormones, significance. In the multivariate analysis adjusted for especially estrogens, appear to have an important role due to abdominal obesity (OR 5.9; p<0.001), having dysglucemia was their various effects on the liver (17). Given that estradiol has an associated with moderate-to-advanced liver fibrosis (OR 3.8; inhibitory effect on inflammatory markers such as TGF-b1, TABLE 4 Prevalence of moderate-to-advanced liver fibrosis according to age and sex. Global <50 years old ≥50 years old Prevalence (%) p Prevalence P Prevalence (%) P Global Men (n=977) 8 <0.001 Men (n=327) 4 0.417 Men (n=650) 11 <0.001 Women (n=1530) 4 Women (n=487) 3 Women (n=1043) 4 Dysglycemia Men (n=294) 18 0.012 Men (n=38) 11 0.348 Men (n=256) 19 0.013 Women (n=312) 11 Women (n=25) 4 Women (n=287) 11 Non-dysglycemia Men (n=683) 5 0.001 Men (n=289) 3 0.888 Men (n=394) 6 <0.001 Women (n=1218) 2 Women (n=462) 12 Women (n=756) 1 Moderate-to-advanced liver fibrosis was defined by transient elastography ≥8 Kpa. Frontiers in Endocrinology 06 frontiersin.org Pérez-Montes de Oca et al. 10.3389/fendo.2022.971864 TNF-a, IL-6, and IL-1B, it is hypothesized that the fertility status In relation to liver fibrosis, there are inconclusive data on the may have a protective influence on the development of NAFLD presence of age-specific sex differences (19). In a prospective (5). Regarding NAFLD biomarkers, there is evidence on the cohort study of 40,700 adults with NAFLD, obesity and weight limitation and necessity to confirm the value of transaminases in gain, but not sex, were related to the risk of fibrosis progression the clinical diagnosis of NAFLD. A meta-analysis found that measured by the AST to Platelet Ratio Index (APRI) (26). In a normal ALT values are present even in 25% of the patients with previous cross-sectional population-based study, we described NAFLD and 19% with nonalcoholic steatohepatitis (NASH). In that one of the factors independently associated with increased our study, only 9% of the patients had elevated ALT and/or LSM was male gender (6). Female sex was negatively associated AST (21). with moderate-to-severe liver fibrosis but this did not reach a It is well known that diabetes plays an important role in the statistical difference in subjects with diabetes (9). Finally, in incidence and progression of NAFLD. The prevalence of another study, the occurrence of advanced fibrosis was advanced fibrosis in patients with NAFLD and T2D was substantially higher in postmenopausal women (27.6%) estimated to be 17% in a previous meta-analysis study (22). In a compared to premenopausal women (14.4%) and men (22.2%) recent study published by our group in a general population, the in 541 persons with biopsy-proven NAFLD. After adjusting for prevalence of NAFLD was higher in subjects with T2D compared several metabolic factors, postmenopausal women had a 1.5-fold to those without (9). Moreover, not only T2D but insulin increased risk of having more severe liver fibrosis than resistance have shown to play an important role in the premenopausal women (7). In the present study, we found progression of NAFLD, specifically an increased risk of that the prevalence of liver fibrosis increased with age and was advanced fibrosis in patients with NASH (12). This occurred two-fold higher in men than in women, as also described in even when subjects are not obese (23). According to recent other studies (6). However, sex differences were attenuated in research, the distribution of adipose tissue may be more younger subjects regardless of the presence or absence of important for the development of metabolic diseases than the hyperglycemia. As expected, when dysglycemic subjects were actual amount of body fat. There may be a connection between the evaluated, the prevalence of moderate-to-advanced liver fibrosis amount of abdominal adipose tissue and obesity-related NAFLD was higher than in non-hyperglycemic subjects. In a population (24). In the present study, the presence of abdominal adiposity based-study reported by our group, the prevalence of liver was the strongest risk for NAFLD and hyperglycemia was a risk fibrosis assessed by TE was higher in the diabetic population factor for NAFLD and for moderate-to-advanced liver fibrosis in compared to those without (21% vs 3%). In general, we found multivariate analysis. On the other hand, there is evidence that the that hyperglycemic men had a higher prevalence of liver fibrosis development of T2D causes a disproportionately increased risk of compared to women, mainly in older subjects. In contrast to CVD in women, approaching that of men (19). In addition, the what occurs in NAFLD, we did not find an association between presence of gender and age dimorphism has been reported in liver fibrosis and reproductive status (i.e between pre- NAFLD. However, if this phenomenon occurs in the presence of menopausal and post-menopausal women). However, these diabetes is not understood. results must be interpreted with caution due to the small size As expected, among hyperglycemic subjects, the prevalence of the sample. of NAFLD was higher compared to non-hyperglycemic subjects, Our study had some limitations that deserve mentioning: (i) and it was slightly higher in men. If we focus on sex differences Fibroscan was only performed on one of the two cohorts, so the according to age, we did not find significant differences in the number of subjects with dysglycemia who had LSM was prevalence of NAFLD between younger men and younger relatively small. This fact may have affected the statistical women with dysglycemia. Hereby, we report for the first time power, and consequently the liver fibrosis results; (ii) the exact that younger women lose the protective effect against liver age of onset of menopause is unknown in these cohorts. Age ≥50 steatosis in the presence of dysglycemia. In fact, a younger years old was considered to define older subjects and age <50 dysglycemic woman had ten times the risk of harboring years old was used to define younger subjects according to a NAFLD compared to a young non-hyperglycemic woman, a previous review (2); (iii) The XL probe was not available in this risk that was similar to all men in the global cohort. A recent study; the percentage of unreliable measurements of liver study from the UK examined sex differences in intra-organ fat stiffness was only 1.5% as the study subjects were not overtly and hepatic VLDL1-triacylglycerol export before and after major obese, with few patients having class 2 and 3 obesity. The use of dietary weight loss and found that in T2D, women have liver and an XL probe could reduce this failure rate, although we do not pancreas fat levels as high as those of men, associated with raised believe it would have impacted the main results of the study”.; hepatic VLDL1-TG production rates. They concluded that these (iv) we don’t have available the data of the specific antidiabetic changes may contribute to women with diabetes having a treatment received by each individual that could influence the disproportionately higher cardiovascular risk (25). progression of NAFLD. Frontiers in Endocrinology 07 frontiersin.org Pérez-Montes de Oca et al. 10.3389/fendo.2022.971864 Conclusions Funding We hereby report for the first time that, similar to what The project received a research grant from the Carlos III occurs in cardiovascular disease; dysglycemia may eliminate the Institute of Health, Ministry of Economy and Competitiveness protective effect of female sex on NAFLD. In a hyperglycemic (Spain), awarded on the 2011 call under the Health Strategy scenario, being a woman at a younger age had a negative impact Action 2013–2016, within the National Research Program on the prevalence of NAFLD. An active search for hepatic oriented to Societal Challenges, within the Technical, Scientific steatosis would be recommended in younger women with any and Innovation Research National Plan 2013–2016, with degree of dysglycemia. reference PI11/0267, PI14/00407, co-funded by European Union European Regional Development Fund funds. Also supported by grants from Fondo de Investigación Sanitaria Data availability statement Instituto de Salud Carlos III-Subdirección General de Evaluación and the European Regional Development Fund The original contributions presented in the study are Fondo Europeo de Desarrollo Regional (PI16/00043), Carlos included in the article/Supplementary Materials. Further III Institute of Health (PI21/00817), the Agencia de Gestió inquiries can be directed to the corresponding authors. d’Ajuts Universitaris i de Recerca, the European Horizon 20/ 20 program, H20/20-SC1-2016- RTD, Institució Catalana de Ethics statement Recerca I Estudis Avançats Academy Award (P G). The studies involving human participants were reviewed and approved by Fundació Gol I Gorina’s Ethics Committee (P11/ Conflict of interest 58) (Barcelona, Spain) and the Ethics Committee of Hospital Arnau de Vilanova (Lleida, Spain). The patients/participants The authors declare that the research was conducted in the provided their written informed consent to participate in absence of any commercial or financial relationships that could this study. be construed as a potential conflict of interest. Author contributions Publisher’s note All authors had full access to all of the data in this study and take complete responsibility for the integrity of the data and All claims expressed in this article are solely those of the accuracy of the data analysis. 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