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J Hepatol. 2018 Oct;69(4):896-904. doi: 10.1016/j.jhep.2018.05.036. Epub 2018 Jun 8.

Modeling NAFLD disease burden in China, France, Germany, Italy, Japan, Spain, United Kingdom, and United States for the period 2016-2030.

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Center for Disease Analysis (CDA), Lafayette, CO, USA.
Liver Research Group, Institute of Cellular Medicine, The Medical School, Newcastle University, Framlington Place, Newcastle-upon-Tyne, United Kingdom.
Gastroenterology and Hepatology Department, Marqués de Valdecilla University Hospital, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Santander, Spain; Infection, Immunity and Digestive Pathology Group, Research Institute Marqués de Valdecilla (IDIVAL), Santander, Spain.
Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.
Gastroenterology and Hepatology Service, Clinica Santa Chiara, Locarno, Switzerland.
Hepatology Unit, Hospital Clinic, Institute of Biomedical Research August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red: Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain.
Center for Translational Research in Hepatology, Clinical and Research Center Humanitas, Rozzano, Italy.
Department of Gastroenterology, University of Palermo, Palermo, Italy.
Gastroenterology and Hepatology Department, Infection, Immunity and Digestive Pathology Group, IDIVAL, Instituto de Investigación Valdecilla, Hospital Universitario Marqués de Valdecilla, Santander, Spain.
Liver Center, Saga University Hospital, Saga University, Saga, Japan.
Division of Hepatology, Department of Medicine II, University of Würzburg, Würzburg, Germany.
Center for Global Health, Istituto Superiore di Sanita, Rome, Italy.
Department of Medicine III, RWTH University Hospital Aachen, Aachen, Germany.
ISGlobal, Hospital Clinic, University of Barcelona, Barcelona, Spain.
NAFLD Research Center, Department of Medicine, University of California San Diego, La Jolla, CA, USA; Division of Gastroenterology, Department of Medicine, University of California at San Diego, La Jolla, CA, USA.
Unit of Metabolic Diseases and Clinical Dietetics, DIMEC, "Alma Mater" University, Bologna, Italy.
Division of Gastroenterology, Yokohama City University Graduate School of Medicine, Yokohama, Japan.
Divisions of Gastroenterology and Hepatology and of Clinical Pathology, University Hospital, rue Gabrielle-Perret-Gentil 4, 1211 Genève 14, Switzerland.
Section of Gastroenterology and Hepatology, Di.Bi.M.I.S., University of Palermo, Italy.
Department of Hepatology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique Hopitaux de Paris, Paris, France; University Pierre et Marie Curie, Institut National de la Santé et de la Recherche Médicale UMR 938, Paris, France.
Unit for the Clinical Management of Digestive Diseases & CIBERehd, Virgen del Rocio University Hospital, Seville, Spain.
Virginia Commonwealth University Medical Center, Richmond, VA, USA.
Department of Medicine I, University Medical Centre, Johannes Gutenberg University Mainz, Mainz, Germany.
Department of Epidemiology, Infectious Disease Control and Prevention, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan.
Peking University People's Hospital, Peking University Hepatology Institute, Beijing, China; Key Laboratory of Hepatitis C and Immunotherapy for Liver Diseases, Beijing, China.
JW Goethe University Hospital, Frankfurt, Germany.
Center for Disease Analysis (CDA), Lafayette, CO, USA. Electronic address:



Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are increasingly a cause of cirrhosis and hepatocellular carcinoma globally. This burden is expected to increase as epidemics of obesity, diabetes and metabolic syndrome continue to grow. The goal of this analysis was to use a Markov model to forecast NAFLD disease burden using currently available data.


A model was used to estimate NAFLD and NASH disease progression in eight countries based on data for adult prevalence of obesity and type 2 diabetes mellitus (DM). Published estimates and expert consensus were used to build and validate the model projections.


If obesity and DM level off in the future, we project a modest growth in total NAFLD cases (0-30%), between 2016-2030, with the highest growth in China as a result of urbanization and the lowest growth in Japan as a result of a shrinking population. However, at the same time, NASH prevalence will increase 15-56%, while liver mortality and advanced liver disease will more than double as a result of an aging/increasing population.


NAFLD and NASH represent a large and growing public health problem and efforts to understand this epidemic and to mitigate the disease burden are needed. If obesity and DM continue to increase at current and historical rates, both NAFLD and NASH prevalence are expected to increase. Since both are reversible, public health campaigns to increase awareness and diagnosis, and to promote diet and exercise can help manage the growth in future disease burden.


Non-alcoholic fatty liver disease and non-alcoholic steatohepatitis can lead to advanced liver disease. Both conditions are becoming increasingly prevalent as the epidemics of obesity and diabetes continue to increase. A mathematical model was built to understand how the disease burden associated with non-alcoholic fatty liver disease and non-alcoholic steatohepatitis will change over time. Results suggest increasing cases of advanced liver disease and liver-related mortality in the coming years.


Burden of disease; Cardiovascular disease; Cirrhosis; Diabetes mellitus; HCC; Health care resource utilization; Metabolic syndrome; NAFLD; NASH; Obesity

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