Nutrition, Metabolism & Cardiovascular Diseases (2014) 24, 256e262
Available online at www.sciencedirect.com
Nutrition, Metabolism & Cardiovascular Diseases journal homepage: www.elsevier.com/locate/nmcd
Metabolically healthy obese subjects are at risk of fatty liver but not of pre-clinical atherosclerosis Ki-Chul Sung a,*,1, Sung-Chul Cha a,1, Joo-Wook Sung a, Min-Suk So a, Christopher D. Byrne b a Division of Cardiology, Department of Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, #108, Pyung Dong, Jongro-Ku, Seoul 110-746, Republic of Korea b Nutrition and Metabolism Unit, IDS Building, Southampton General Hospital, University of Southampton, and Southampton National Institute for Health Research Biomedical Research Centre, MP 887 Southampton, UK
Received 20 May 2013; received in revised form 18 July 2013; accepted 21 July 2013 Available online 9 October 2013
KEYWORDS Metabolically healthy obese; Coronary artery calcium (CAC) score; Non alcoholic fatty liver disease (NAFLD); Fatty liver; Atherosclerosis; Cardio-metabolic risk factors; Metabolic syndrome (MetS)
Abstract Backgrounds and aims: Whether obesity increases risk of cardiovascular disease (CVD) and fatty liver because of the co-existence of other risk factors is uncertain. We investigated odds ratios (ORs) for: a) a measure of pre-clinical atherosclerosis and b) fatty liver, in metabolically healthy obese (MHO) subjects, metabolically abnormal obese (MAO) subjects and metabolically abnormal non obese subjects (MANO), using a metabolically healthy non obese (MHNO) group as the reference. Methods and results: 14,384 South Koreans from an occupational cohort underwent cardiac computed tomography (CT) estimation of CAC score, liver ultrasound determination of fatty liver, and measurement of cardiovascular risk factors. Pre-clinical atherosclerosis was defined by a CAC score >0. We used logistic regression to determine ORs for CAC >0, and fatty liver in MHO, MAO and MANO subjects (reference group MHNO). There was no increase in OR for CAC score >0 (OR Z 0.93, [95% CIs 0.67,1.31], p Z 0.68), in the MHO group, whereas there was an increase in the ORs for CAC score >0 in the MAO, and MANO groups (OR Z 1.64 [95% CI 1.36,1.98], p < 0.001) and (OR Z 1.38 [95% CI 1.17,1.64], p < 0.001), respectively. In contrast, for fatty liver, there was an increase in OR in each group (OR Z 3.63 [95% CI 3.06, 4.31] p < 0.001); (OR Z 5.89 [5.18,6.70] p < 0.001); and (OR Z 1.83 [95% CI 1.69,2.08]) in the MHO, MAO group and MANO groups respectively. Conclusion: MHO subjects are at risk of fatty liver but attenuated risk of pre-clinical atherosclerosis. Both MAO and MANO subjects are at risk of fatty liver and pre-clinical atherosclerosis. ª 2013 Elsevier B.V. All rights reserved.
Introduction Obesity is a risk factor that is common to type 2 diabetes and cardiovascular disease (CVD) [1,2]. However, obesity is
a stronger risk factor for type 2 diabetes than for CVD, suggesting that there is a differential impact of fat mass or fat function on either disease. Increasing evidence suggests that body mass index (BMI) is an imprecise measure of
Abbreviations: BP, blood pressure; TC, total cholesterol; TG, triglyceride; CVD, cardiovascular disease; NAFLD, non alcoholic fatty liver disease; IR, insulin resistance; ORs, odds ratios; CAC, coronary artery calcium; MHO, metabolically healthy obese; MAO, metabolically abnormal obese; MANO, metabolically abnormal non obese; MHNO, metabolically healthy non obese. * Corresponding author. E-mail address: [email protected] (K.-C. Sung). 1 Equal contributors (co-first author). 0939-4753/$ - see front matter ª 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.numecd.2013.07.005
Dietary patterns and lipoprotein subclasses
cardio-metabolic risk amongst individuals with similar BMIs, and there may be marked differences in cardiometabolic risk factors in people with similar BMIs that contribute differentially to diseases such as type 2 diabetes, CVD and NAFLD [3]. Metabolically Abnormal Obese (MAO) subjects are obese people who also have other features of the metabolic syndrome (MetS); whereas Metabolically Healthy Obese (MHO) subjects are people who are obese, but who are metabolically healthy. To date, whether MHO subjects are at increased risk of CVD is uncertain. A recent paper reported that MHO individuals had lower risk of all-cause mortality, non-fatal and fatal cardiovascular disease, and cancer mortality, than their metabolically unhealthy obese peers [4]. It has been suggested that 30% of obese patients are metabolically healthy, and that this group have similar insulin sensitivity to lean individuals, lower liver fat and lower intima media thickness of the carotid artery, compared with the majority of metabolically unhealthy obese patients [5,6]. Some studies have also shown that CVD risk is similar in this group to subjects who are Metabolically Healthy and Not Obese (MHNO) [7,8]. However, this is not a consensus view, and in contrast, recent longitudinal studies have suggested that MHO subjects are at increased risk for CVD (compared with MHNO subjects) [9,10]. Resolving this controversy is important because strategies and treatments for the primary prevention of CVD in the MHO group could be relaxed if people in this group were at similar CVD risk to people in a MHNO group. Similarly, identification of a high risk obese phenotype would help identify those obese people who are most likely to benefit most from pharmacological treatments of risk factors, lifestyle changes and even bariatric surgery. The coronary artery calcium (CAC) score is a useful marker of pre-clinical atherosclerosis and may predict risk of CVD events better than traditional risk factors [11,12]. To date, whether there are differences in the prevalence of CAC in MHO subjects versus MHNO subjects is uncertain. Our aim was to investigate the odds ratios (ORs) for: a) a measure of pre-clinical atherosclerosis and b) fatty liver, in metabolically healthy obese (MHO) subjects, metabolically abnormal obese (MAO) subjects and metabolically abnormal non obese (MANO) subjects, using a metabolically healthy non obese (MHNO) subjects as the reference group. Subjects and methods Study subjects The study population consisted of subjects in an occupational cohort who participated in a comprehensive health examination in 2010 at Kangbuk Samsung Hospital, College of Medicine, Sungkyunkwan University. Figure 1 shows the flow chart for inclusion and exclusion of subjects in analyses that: (A) included people with hypertension and diabetes; and (B) that excluded people with either hypertension or diabetes. Data were analysed from
257
Potential participants identified (n = 14912)
Excluded prior cerebrovascular accident (n =35 ) Excluded prior coronary artery disease (n =107 ) (N.B. some people had both PRIOR CVA and CAD)
Potential participants identified (n =14843 )
Participants identified for analyses (A) (n = 14384)
Participants identified for analyses (B) (n = 12421)
Excluded missing smoking data (n =143 ) Excluded missing alcohol data (n =111 ) Excluded missing physical activity data (n = 116) Excluded HCV antibody +ve (n=28); or missing HCV antibody status (n=26) (N.B. some people were excluded for more than one reason) Excluded history of diabetes or hypertension (n=1947) (1751 hypertension and 559 diabetes) (N.B. some people had both diabetes and hypertension)
Figure 1 Flow diagram for study design showing inclusion of participants in analyses. [(A) including people with diabetes and hypertension, and (B) excluding participants with diabetes and hypertension].
either 14,384 subjects (A), or 12,421 subjects (B). The cohort was stratified into four groups (MHO, MAO, MHNO and MANO). MHO subjects had no metabolic syndrome (MetS) components, except obesity, MAO subjects had obesity and a feature of MetS, and MHNO subjects had neither obesity nor MetS features for 12,421 subjects (B). Subjects with diabetes and hypertension were included for the analyses of 14,384 subjects (A), to investigate the effects of diabetes and hypertension in each of the groups. Questionnaires were used to ascertain information regarding alcohol consumption (glass/week), smoking (never or ex-/current), and frequency of exercise (Exercise (moderate activity 3 times/week or less)). Exercise/ moderate activity was defined as more than 30 min activity per day that induced slight breathlessness. The study was approved by the institutional review board at Kangbuk Samsung Hospital. Informed consent requirement was waived because personal identifying information was not accessed. Definitions A BMI (25 kg/m2) based on the World Health Organization Asia Pacific guidelines and a WC (90 cms in men, 80 cms in women) was used to define obesity. MHO was defined as those who were only obese and have no metabolic abnormalities which belonging to MetS criteria
258
[13]. Metabolically abnormal obese (MAO) subjects were defined as those who were obese and had at least one other factor according to the MetS criteria. The metabolically healthy non obese (MHNO) group was defined by inclusion of subjects who were not obese and who had no metabolic abnormalities belonging to the MetS criteria. And hypertension was defined by systolic blood pressure 140 mm Hg or diastolic blood pressure 90 mm Hg, or medication for hypertension, and diabetes was defined by fasting glucose 126 mg/dl, or medication for diabetes. Measurements and calculations The measurements collected in this study included body weight, height, body mass index (BMI), waist circumference (WC), and systolic and diastolic blood pressures. Body mass index (BMI) was calculated as weight in kilograms divided by height in meters squared (kg/m2). The waist circumference (WC) was measured using a non stretchable fiber measuring tape. The subjects were asked to stand in a relaxed position with both feet together on a flat at the levels of the umbilicus and greater trochanter of the femur, respectively. The subject’s blood pressure was measured twice by a skilled nurse following at least 10 min of rest, and the mean value was calculated. Blood samples were collected from the antecubital vein following a minimum 12-h overnight fast. We analyzed the samples for aspartate aminotransferase, alanine aminotransferase, blood lipid profile, fasting blood glucose level, serum insulin level and HbA1c. Biochemical markers were measured using Bayer Reagent Packs on an automated chemistry analyzer (ADVIA 1650 Autoanalyzer; Bayer HealthCare, Tarrytown, NY). (Advia 1650 Autoanalyzer; Bayer Diagnostics, Leverkusen, Germany). Lipid profiles, including values for total cholesterol (TC), triglycerides (TG), low density lipoprotein (LDL) cholesterol, and high density lipoprotein (HDL) cholesterol, were measured via enzymatic colorimetric assay. High sensitivity C-reactive protein (hs-CRP) was determined by immunonephelometry (Behring Nephelometer II, Dade Behring Marburg GmbH, Germany). Serum insulin concentration was measured with an immunoradiometric assay (Biosource, Nivelle, Belgium) with an intra- and interassay coefficient of variation of 2.1e4.5% and 4.7e12.2%, respectively. As a marker of insulin resistance, the homeostatic model assessment (HOMA-IR) was calculated [14]. Since, there are no population-specific thresholds to indicate IR in a Korean population we stratified the populations using the 75th centile to establish an insulin-resistant group (HOMA-IR >75th centile), which was compared with a more insulin-sensitive group (HOMA-IR, 75th centile). Abdominal ultrasonography (ASPEN; Acuson, PA, USA) using a 3.5-MHz probe was performed in all subjects by experienced clinical radiologists, blinded to clinical presentation and laboratory findings. Fatty liver was diagnosed based on standard criteria, including hepatorenal echo contrast, liver brightness, and vascular blurring [15].
K.-C. Sung et al.
Imaging data for the evaluation of coronary artery calcification was acquired from an ECG-gated 64 channel multidetector CT scanner (Brilliance 40, EBW version 3.02 RRS, Philips Medical Systems, Best, The Netherlands), with a 400 ms gantry rotation time and image reconstruction thickness/interval 2.5 mm/2.5 mm. Agaston method was used for the measurement of CACS [16]. The area of coronary artery calcium was defined as at least four contiguous pixels with a CT density 130 Hounsfield Units. The total CAC score was computed, comprising all calcified lesions in the epicardial coronary system. Proportions of subjects in each group with a CAC score >0 were calculated. Statistical analysis Continuous variables were expressed as mean SD for normally distributed variables or median (interquartile range) if not normally distributed. Continuous variables were compared using independent t tests, non-normally distributed variables were compared using ManneWhitney U tests, and categorical variables were expressed as percentages and compared between groups using the x2 test. We used multiple logistic regression analysis to determine odds ratios (ORs) for CAC score >0, and fatty liver, in MHO, MAO and MANO subject groups, using the MHNO subjects as the reference group. Two regression models were examined (A) including all subjects (A) (Fig. 1); and (B) excluding subjects with diabetes and hypertension (B). Adjustments for potential confounders were as follows. Model 1 Z adjusted for age and sex; Model 2 Z model 1 plus smoking, alcohol intake and exercise (smoking status (current or ex-/non-)), exercise frequency (3 times/ week), alcohol consumption (glass/day); Model 3 Z model 2 plus LDL-C and HOMA IR; Model 4 Z model 3 plus CRP and TSH. All data analysis was performed using SPSS, version 15.0 (SPSS, Chicago, IL). P values 0 (%) HTN (%) DM (%) IFG(%) Triglyceride 150 mg/dL(%) HDL-C
Available online at www.sciencedirect.com
Nutrition, Metabolism & Cardiovascular Diseases journal homepage: www.elsevier.com/locate/nmcd
Metabolically healthy obese subjects are at risk of fatty liver but not of pre-clinical atherosclerosis Ki-Chul Sung a,*,1, Sung-Chul Cha a,1, Joo-Wook Sung a, Min-Suk So a, Christopher D. Byrne b a Division of Cardiology, Department of Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, #108, Pyung Dong, Jongro-Ku, Seoul 110-746, Republic of Korea b Nutrition and Metabolism Unit, IDS Building, Southampton General Hospital, University of Southampton, and Southampton National Institute for Health Research Biomedical Research Centre, MP 887 Southampton, UK
Received 20 May 2013; received in revised form 18 July 2013; accepted 21 July 2013 Available online 9 October 2013
KEYWORDS Metabolically healthy obese; Coronary artery calcium (CAC) score; Non alcoholic fatty liver disease (NAFLD); Fatty liver; Atherosclerosis; Cardio-metabolic risk factors; Metabolic syndrome (MetS)
Abstract Backgrounds and aims: Whether obesity increases risk of cardiovascular disease (CVD) and fatty liver because of the co-existence of other risk factors is uncertain. We investigated odds ratios (ORs) for: a) a measure of pre-clinical atherosclerosis and b) fatty liver, in metabolically healthy obese (MHO) subjects, metabolically abnormal obese (MAO) subjects and metabolically abnormal non obese subjects (MANO), using a metabolically healthy non obese (MHNO) group as the reference. Methods and results: 14,384 South Koreans from an occupational cohort underwent cardiac computed tomography (CT) estimation of CAC score, liver ultrasound determination of fatty liver, and measurement of cardiovascular risk factors. Pre-clinical atherosclerosis was defined by a CAC score >0. We used logistic regression to determine ORs for CAC >0, and fatty liver in MHO, MAO and MANO subjects (reference group MHNO). There was no increase in OR for CAC score >0 (OR Z 0.93, [95% CIs 0.67,1.31], p Z 0.68), in the MHO group, whereas there was an increase in the ORs for CAC score >0 in the MAO, and MANO groups (OR Z 1.64 [95% CI 1.36,1.98], p < 0.001) and (OR Z 1.38 [95% CI 1.17,1.64], p < 0.001), respectively. In contrast, for fatty liver, there was an increase in OR in each group (OR Z 3.63 [95% CI 3.06, 4.31] p < 0.001); (OR Z 5.89 [5.18,6.70] p < 0.001); and (OR Z 1.83 [95% CI 1.69,2.08]) in the MHO, MAO group and MANO groups respectively. Conclusion: MHO subjects are at risk of fatty liver but attenuated risk of pre-clinical atherosclerosis. Both MAO and MANO subjects are at risk of fatty liver and pre-clinical atherosclerosis. ª 2013 Elsevier B.V. All rights reserved.
Introduction Obesity is a risk factor that is common to type 2 diabetes and cardiovascular disease (CVD) [1,2]. However, obesity is
a stronger risk factor for type 2 diabetes than for CVD, suggesting that there is a differential impact of fat mass or fat function on either disease. Increasing evidence suggests that body mass index (BMI) is an imprecise measure of
Abbreviations: BP, blood pressure; TC, total cholesterol; TG, triglyceride; CVD, cardiovascular disease; NAFLD, non alcoholic fatty liver disease; IR, insulin resistance; ORs, odds ratios; CAC, coronary artery calcium; MHO, metabolically healthy obese; MAO, metabolically abnormal obese; MANO, metabolically abnormal non obese; MHNO, metabolically healthy non obese. * Corresponding author. E-mail address: [email protected] (K.-C. Sung). 1 Equal contributors (co-first author). 0939-4753/$ - see front matter ª 2013 Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.numecd.2013.07.005
Dietary patterns and lipoprotein subclasses
cardio-metabolic risk amongst individuals with similar BMIs, and there may be marked differences in cardiometabolic risk factors in people with similar BMIs that contribute differentially to diseases such as type 2 diabetes, CVD and NAFLD [3]. Metabolically Abnormal Obese (MAO) subjects are obese people who also have other features of the metabolic syndrome (MetS); whereas Metabolically Healthy Obese (MHO) subjects are people who are obese, but who are metabolically healthy. To date, whether MHO subjects are at increased risk of CVD is uncertain. A recent paper reported that MHO individuals had lower risk of all-cause mortality, non-fatal and fatal cardiovascular disease, and cancer mortality, than their metabolically unhealthy obese peers [4]. It has been suggested that 30% of obese patients are metabolically healthy, and that this group have similar insulin sensitivity to lean individuals, lower liver fat and lower intima media thickness of the carotid artery, compared with the majority of metabolically unhealthy obese patients [5,6]. Some studies have also shown that CVD risk is similar in this group to subjects who are Metabolically Healthy and Not Obese (MHNO) [7,8]. However, this is not a consensus view, and in contrast, recent longitudinal studies have suggested that MHO subjects are at increased risk for CVD (compared with MHNO subjects) [9,10]. Resolving this controversy is important because strategies and treatments for the primary prevention of CVD in the MHO group could be relaxed if people in this group were at similar CVD risk to people in a MHNO group. Similarly, identification of a high risk obese phenotype would help identify those obese people who are most likely to benefit most from pharmacological treatments of risk factors, lifestyle changes and even bariatric surgery. The coronary artery calcium (CAC) score is a useful marker of pre-clinical atherosclerosis and may predict risk of CVD events better than traditional risk factors [11,12]. To date, whether there are differences in the prevalence of CAC in MHO subjects versus MHNO subjects is uncertain. Our aim was to investigate the odds ratios (ORs) for: a) a measure of pre-clinical atherosclerosis and b) fatty liver, in metabolically healthy obese (MHO) subjects, metabolically abnormal obese (MAO) subjects and metabolically abnormal non obese (MANO) subjects, using a metabolically healthy non obese (MHNO) subjects as the reference group. Subjects and methods Study subjects The study population consisted of subjects in an occupational cohort who participated in a comprehensive health examination in 2010 at Kangbuk Samsung Hospital, College of Medicine, Sungkyunkwan University. Figure 1 shows the flow chart for inclusion and exclusion of subjects in analyses that: (A) included people with hypertension and diabetes; and (B) that excluded people with either hypertension or diabetes. Data were analysed from
257
Potential participants identified (n = 14912)
Excluded prior cerebrovascular accident (n =35 ) Excluded prior coronary artery disease (n =107 ) (N.B. some people had both PRIOR CVA and CAD)
Potential participants identified (n =14843 )
Participants identified for analyses (A) (n = 14384)
Participants identified for analyses (B) (n = 12421)
Excluded missing smoking data (n =143 ) Excluded missing alcohol data (n =111 ) Excluded missing physical activity data (n = 116) Excluded HCV antibody +ve (n=28); or missing HCV antibody status (n=26) (N.B. some people were excluded for more than one reason) Excluded history of diabetes or hypertension (n=1947) (1751 hypertension and 559 diabetes) (N.B. some people had both diabetes and hypertension)
Figure 1 Flow diagram for study design showing inclusion of participants in analyses. [(A) including people with diabetes and hypertension, and (B) excluding participants with diabetes and hypertension].
either 14,384 subjects (A), or 12,421 subjects (B). The cohort was stratified into four groups (MHO, MAO, MHNO and MANO). MHO subjects had no metabolic syndrome (MetS) components, except obesity, MAO subjects had obesity and a feature of MetS, and MHNO subjects had neither obesity nor MetS features for 12,421 subjects (B). Subjects with diabetes and hypertension were included for the analyses of 14,384 subjects (A), to investigate the effects of diabetes and hypertension in each of the groups. Questionnaires were used to ascertain information regarding alcohol consumption (glass/week), smoking (never or ex-/current), and frequency of exercise (Exercise (moderate activity 3 times/week or less)). Exercise/ moderate activity was defined as more than 30 min activity per day that induced slight breathlessness. The study was approved by the institutional review board at Kangbuk Samsung Hospital. Informed consent requirement was waived because personal identifying information was not accessed. Definitions A BMI (25 kg/m2) based on the World Health Organization Asia Pacific guidelines and a WC (90 cms in men, 80 cms in women) was used to define obesity. MHO was defined as those who were only obese and have no metabolic abnormalities which belonging to MetS criteria
258
[13]. Metabolically abnormal obese (MAO) subjects were defined as those who were obese and had at least one other factor according to the MetS criteria. The metabolically healthy non obese (MHNO) group was defined by inclusion of subjects who were not obese and who had no metabolic abnormalities belonging to the MetS criteria. And hypertension was defined by systolic blood pressure 140 mm Hg or diastolic blood pressure 90 mm Hg, or medication for hypertension, and diabetes was defined by fasting glucose 126 mg/dl, or medication for diabetes. Measurements and calculations The measurements collected in this study included body weight, height, body mass index (BMI), waist circumference (WC), and systolic and diastolic blood pressures. Body mass index (BMI) was calculated as weight in kilograms divided by height in meters squared (kg/m2). The waist circumference (WC) was measured using a non stretchable fiber measuring tape. The subjects were asked to stand in a relaxed position with both feet together on a flat at the levels of the umbilicus and greater trochanter of the femur, respectively. The subject’s blood pressure was measured twice by a skilled nurse following at least 10 min of rest, and the mean value was calculated. Blood samples were collected from the antecubital vein following a minimum 12-h overnight fast. We analyzed the samples for aspartate aminotransferase, alanine aminotransferase, blood lipid profile, fasting blood glucose level, serum insulin level and HbA1c. Biochemical markers were measured using Bayer Reagent Packs on an automated chemistry analyzer (ADVIA 1650 Autoanalyzer; Bayer HealthCare, Tarrytown, NY). (Advia 1650 Autoanalyzer; Bayer Diagnostics, Leverkusen, Germany). Lipid profiles, including values for total cholesterol (TC), triglycerides (TG), low density lipoprotein (LDL) cholesterol, and high density lipoprotein (HDL) cholesterol, were measured via enzymatic colorimetric assay. High sensitivity C-reactive protein (hs-CRP) was determined by immunonephelometry (Behring Nephelometer II, Dade Behring Marburg GmbH, Germany). Serum insulin concentration was measured with an immunoradiometric assay (Biosource, Nivelle, Belgium) with an intra- and interassay coefficient of variation of 2.1e4.5% and 4.7e12.2%, respectively. As a marker of insulin resistance, the homeostatic model assessment (HOMA-IR) was calculated [14]. Since, there are no population-specific thresholds to indicate IR in a Korean population we stratified the populations using the 75th centile to establish an insulin-resistant group (HOMA-IR >75th centile), which was compared with a more insulin-sensitive group (HOMA-IR, 75th centile). Abdominal ultrasonography (ASPEN; Acuson, PA, USA) using a 3.5-MHz probe was performed in all subjects by experienced clinical radiologists, blinded to clinical presentation and laboratory findings. Fatty liver was diagnosed based on standard criteria, including hepatorenal echo contrast, liver brightness, and vascular blurring [15].
K.-C. Sung et al.
Imaging data for the evaluation of coronary artery calcification was acquired from an ECG-gated 64 channel multidetector CT scanner (Brilliance 40, EBW version 3.02 RRS, Philips Medical Systems, Best, The Netherlands), with a 400 ms gantry rotation time and image reconstruction thickness/interval 2.5 mm/2.5 mm. Agaston method was used for the measurement of CACS [16]. The area of coronary artery calcium was defined as at least four contiguous pixels with a CT density 130 Hounsfield Units. The total CAC score was computed, comprising all calcified lesions in the epicardial coronary system. Proportions of subjects in each group with a CAC score >0 were calculated. Statistical analysis Continuous variables were expressed as mean SD for normally distributed variables or median (interquartile range) if not normally distributed. Continuous variables were compared using independent t tests, non-normally distributed variables were compared using ManneWhitney U tests, and categorical variables were expressed as percentages and compared between groups using the x2 test. We used multiple logistic regression analysis to determine odds ratios (ORs) for CAC score >0, and fatty liver, in MHO, MAO and MANO subject groups, using the MHNO subjects as the reference group. Two regression models were examined (A) including all subjects (A) (Fig. 1); and (B) excluding subjects with diabetes and hypertension (B). Adjustments for potential confounders were as follows. Model 1 Z adjusted for age and sex; Model 2 Z model 1 plus smoking, alcohol intake and exercise (smoking status (current or ex-/non-)), exercise frequency (3 times/ week), alcohol consumption (glass/day); Model 3 Z model 2 plus LDL-C and HOMA IR; Model 4 Z model 3 plus CRP and TSH. All data analysis was performed using SPSS, version 15.0 (SPSS, Chicago, IL). P values 0 (%) HTN (%) DM (%) IFG(%) Triglyceride 150 mg/dL(%) HDL-C
