Prevalence of Elevated Alanine Aminotransferase Among US Adolescents and Associated Factors: NHANES 1999–2004

doi:10.1053/j.gastro.2007.08.077

Gastroenterology

Volume 133, Issue 6, December 2007, Pages 1814-1820

https://doi.org/10.1053/j.gastro.2007.08.077 Get rights and content

Background & Aims: Nonalcoholic fatty liver disease (NAFLD) is a common cause of liver disease in children and adolescents. The majority of studies of NAFLD in children have been in select populations of the clinically obese. Study aims were to estimate the prevalence of elevated alanine aminotransferase (ALT, as a marker of NAFLD) in a general contemporary adolescent population and to identify leading risk factors for ALT elevation (>30 U/L). Methods: We analyzed data of adolescent participants (aged 12–19 years; N = 5586) in the National Health and Nutrition Examination Survey 1999–2004, a representative sample of the civilian noninstitutionalized US population. Results: The prevalence of elevated ALT levels (>30 U/L) was 7.4% among white adolescents, 11.5% among Mexican American adolescents, and 6.0% among black adolescents. Elevated ALT levels were prevalent in 12.4% of male subjects compared with 3.5% of female subjects. Multivariable associations with elevated ALT levels were found for sex (odds ratio [OR] male vs female, 7.7; 95% confidence interval [CI], 3.9–15.1), ethnicity (OR black vs white, 0.6; 95% CI, 0.3–1.3; OR Mexican American vs white, 1.6; 95% CI, 1.0–2.6), waist circumference (OR per 1 SD, 1.4; 95% CI, 1.0–2.0), and fasting insulin level (OR per 1 SD, 1.6; 95% CI, 1.2–2.1). Age, C-reactive protein levels, and triglyceride levels were also positively and socioeconomic position inversely associated with elevated ALT levels. The magnitude of associations were similar across ethnic groups. Conclusions: ALT level is associated with waist circumference and insulin resistance even in a young population. These characteristics could be utilized to identify adolescents who may benefit from screening for NAFLD, offering an opportunity to prevent disease progression at an early age.

Section snippets

Materials and Methods

NHANES is a complex, multistage probability sample of the civilian noninstitutionalized population of the United States.²⁵ Since 1999, NHANES has become a continuous survey. Data from 3 cross-sectional surveys, 1999–2000, 2001–2002, and 2003–2004, are included here. For our main analyses, we included all participants aged 12–19 years. Blood samples were available for participants aged 12 years and older, and information on birth weight and maternal smoking during pregnancy was available for

Results

Elevated ALT level (defined as ALT level >30 U/L) was present in 8.0% of the study population. Mean ALT level was 19.3 U/L (SD, 15.6; interquartile range, 5–196; range, 5–526). Characteristics of the study population by ALT elevation are presented in Table 1. Among white adolescents the prevalence was 7.4%, among Mexican Americans it was 11.5%, among black adolescents it was 6.0%, and among adolescents classified as “other” (other race, including multiracial, other Hispanic subjects) it was

Discussion

Our study aims were to estimate the prevalence of elevated ALT level in a general contemporary adolescent population, to examine associations between a range of early life factors with ALT levels, and to identify leading risk factors for ALT elevation. We found that the prevalence of elevated ALT level, a surrogate marker of NAFLD in the absence of other causes of liver disease, was 8.0% among US adolescents 12–19 years of age. To the best of our knowledge, there are only 2 other published

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Non-Alcoholic Fatty Liver Disease (NAFLD) is a global public health risk. The occurrence of adolescent NAFLD coincides with high rates of overweight and obesity, with an unhealthy lifestyle also playing a role. Data on prevalence and factors contributing to NAFLD among Asian adolescents is lacking as most studies focus on adults. This systematic review aims to determine the prevalence and factors contributing to NAFLD among adolescents.
A systematic search was conducted using five (Goh et al., 2013) [5] databases: Cochrane, PubMed, Scopus, Science Direct, EBSCO and grey literature. Two reviewers independently screened studies using predefined inclusion and exclusion criteria and performed data extraction. Assessment of methodological quality was completed using the Newcastle–Ottawa checklist.
The quality of most studies were of high quality, with the majority reporting no association between lifestyle factors and NAFLD. A total of 6 studies were included in this systematic review. The prevalence of NAFLD among adolescents varied between 8.0% (Fraser et al., 2007) in a study on 5586 adolescents aged 12–19 and 16.0% (Chen et al., 2009) in another survey of 1724 adolescents aged 12–13 years old. Snacking habits and lack of physical activity had potential associations with adolescent NAFLD. Current evidence shows that lifestyle factor (Western dietary pattern) is associated with a higher risk of developing NAFLD among adolescents.
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Fatty liver disease (FLD) has a wide histopathology spectrum including simple steatosis, steatohepatitis with or without fibrosis, and cirrhosis that may be complicated by hepatocellular carcinoma (HCC). The two main entities that comprise FLD, alcohol-related liver disease (ALD) and nonalcoholic fatty liver disease (NAFLD) associated to metabolic dysfunction, have both similarities and differences. In this chapter, some of the features that are common to both are considered, followed by a review of the pathogenetic and pathological features of each and discussion on how the two can be distinguished clinically and histopathologically. NAFLD concurrent with other liver disease, NAFLD in other clinical settings and treatment options are also discussed.
Relationship Between Handgrip Strength and Laboratory Values in Adolescents With Non-Alcoholic Fatty Liver Disease
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Introduction: The worldwide prevalence of non-alcoholic fatty liver disease in adolescents is increasing. Measuring handgrip strength is a simple and non-invasive method for assessing sarcopenia in adolescents. However, the association between handgrip strength and laboratory values has not yet been evaluated in a clinical setting. This study proposes an association between handgrip strength and laboratory values of adolescents with non-alcoholic fatty liver disease. Methodology: Data were obtained from 100 adolescents (76 males; 24 females; age, 10–18 years) who had been diagnosed with non-alcoholic fatty liver disease. Anthropometric values and handgrip strength were measured, and blood test parameters were evaluated. The association between HGS and each laboratory value was evaluated. Results: The handgrip strength of males and females was different between the low and high alkaline phosphatase level (275 U/L) groups. Regarding the handgrip-to-body weight ratio, there was a difference between the low and high groups based on alanine aminotransferase level < 24.1 U/L in males. Conclusion: Handgrip strength is easy to measure in schools and clinics. This is the first study to determine the usefulness of handgrip strength in Korean adolescents with non-alcoholic fatty liver disease. As more data are gathered, handgrip strength may be used to screen and manage adolescents with non-alcoholic fatty liver disease.
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Hypertransaminasemia is a frequent finding in pediatrics, which could reflect potentially treatable serious disease. The aim of this document is to establish, by reviewing the available evidence, a consensus for an adequate management of hypertransaminasemia, from its detection until the study is complete. To this end, a working group was formed with the participation of members of the Society of Pediatric Gastroenterology, Hepatology and Nutrition (SEGHNP), the Spanish Association of Primary Care Pediatrics (AEPap) and the Spanish Society of Primary Care Pediatrics (SEPEAP). Twenty-one recommendations are established with a marked practical component that will be useful in hospital clinical practice and primary care.
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Citation Excerpt :
In a study in a higher-risk population of Mexican children, the frequencies of NAFL were 24.51% in boys and 11.96% in girls (OR = 2.39; 95% CI, 1.10–5.19; P = 0.025).31 A study of data from the NHANES database reported a prevalence of NAFL (elevated ALT) of 12.4% in male subjects versus 3.5% in female subjects (OR = 7.7; 95% CI, 3.9–15.1).27 Metabolic comorbidities associated with the development of NAFL in children are similar to those in adults.
Nonalcoholic fatty liver (NAFL) is a major contributor to pediatric liver disease. This review evaluated the current literature on prevalence, screening, diagnosis, and management of NAFL in children and explored recent advances in the field of pediatric NAFL.
A PubMed search was performed for manuscripts describing disease burden, diagnosis, and management strategies in pediatric NAFL published within the past 15 years. Systematic reviews, clinical practice guidelines, randomized controlled trials, and cohort and case–control studies were reviewed for the purpose of this article.
The prevalence of NAFL in children is increasing. It is a leading cause of liver-related morbidity and mortality in children. Screening and diagnosis of NAFL in children are a challenge. Lifestyle changes and exercise are the cornerstones of the management of NAFL.
Further research is needed to develop better screening and diagnostic tools for pediatric NAFL, including noninvasive diagnostics. NAFL therapeutics is another area of much-needed, ongoing research.
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: Supported by the University of Bristol Overseas Research Student Award Scheme (A.F.), by a UK Department of Health Career Scientist Award (to D.A.L.), and in part by the Intramural Research Program of the National Institute of Environmental Health Sciences, National Institutes of Health. The partial sponsor of the study had no role in the study design, data collection, data analysis, data interpretation, or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

: The authors report that no conflict of interest exists.

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Clinical–Liver, Pancreas, and Biliary TractPrevalence of Elevated Alanine Aminotransferase Among US Adolescents and Associated Factors: NHANES 1999–2004

Section snippets

Materials and Methods

Results

Discussion

Gastroenterology

Gastroenterol Clin North Am

J Pediatr

J Pediatr

J Pediatr

Am J Clin Nutr

J Hepatol

Am J Gastroenterol

Trends Endocrinol Metab

J Pediatr

Atherosclerosis

Clin Liver Dis

Liver diseaseNon-alcoholic fatty liver disease: current concepts and management strategies

Clin Med

Nonalcoholic fatty liver disease (NAFLD) in children

Curr Opin Pediatr

Steatohepatitis in obese children: a cause of chronic liver dysfunction

Am J Gastroenterol

Obese children with steatohepatitis can develop cirrhosis in childhood

Am J Gastroenterol

American Gastroenterological Association medical position statement: nonalcoholic fatty liver disease

Gastroenterology

Women and men have similar amounts of liver and intra-abdominal fat, despite more subcutaneous fat in women: implications for sex differences in markers of cardiovascular risk

Diabetologia

Alanine aminotransferase levels and fatty liver in childhood obesity: associations with insulin resistance, adiponectin, and visceral fat

J Clin Endocrinol Metab

Influence of gender, race, and ethnicity on suspected fatty liver in obese adolescents

Pediatrics

Clinical–Liver, Pancreas, and Biliary Tract
Prevalence of Elevated Alanine Aminotransferase Among US Adolescents and Associated Factors: NHANES 1999–2004