Diabetes Metab J > Volume 47(2); 2023 > Article
Kim, Kim, and Jung: Association of Myosteatosis with Nonalcoholic Fatty Liver Disease, Severity, and Liver Fibrosis Using Visual Muscular Quality Map in Computed Tomography (Diabetes Metab J 2023;47:104-17)
We appreciate Dr. Roh’s comments on our recent article, “Association of myosteatosis with nonalcoholic fatty liver disease, severity, and liver fibrosis using visual muscular quality map in computed tomography” [1]. We are also grateful for the additional opportunity to discuss different views on this topic.
We agree with Dr. Roh’s remarks on the findings of our study, as they clearly reflect and emphasize the background of our study. Regarding the relationship between nonalcoholic fatty liver disease (NAFLD) and sarcopenia, previous studies primarily focused on low skeletal muscle mass as a possible risk factor for NAFLD [2-4]. As Dr. Roh mentioned, the reverse relationship was demonstrated for the first time in her recently published article, in which elderly people with high hepatic steatosis index and fatty liver index showed increased risk of low muscle mass and low muscle strength (measured as handgrip strength) [5]. The complexity of liver-muscle crosstalk is noted, as sarcopenia and NAFLD share common pathophysiologic mechanisms, which may explain the mutual associations between the two. These mechanisms include insulin resistance, chronic inflammation, and changes in regulation of myokines and hepatokines [6].
Additionally, Dr. Roh discussed the emphasis on low muscle strength in the updated definition of sarcopenia. Dr. Roh’s recent study (mentioned above) measured handgrip strength to evaluate muscle strength [5]. We measured muscle quality by measuring skeletal muscle attenuation on computed tomography (CT). Muscle with low attenuation represented lipid-rich and poor quality muscle. As more studies start to evaluate muscle strength and quality, we look forward to more consistent results being obtained through well-controlled longitudinal studies on muscle and liver health in near future.
With respect to myosteatosis, we have looked into its association with various cardiometabolic diseases, all of which have shown consistent results. Other than NAFLD, poor quality muscle was associated with an increased prevalence of hypertension [7], dyslipidemia (not yet published), type 2 diabetes mellitus [8], and subclinical coronary atherosclerosis [9]. Dr. Roh recommended that future studies seek to identify optimal cutoffs for muscle fat; however, our study group recently presented sex-specific diagnostic cutoff points for myosteatosis based on T-scores measured by CT and suggested normal attenuation muscle area (NAMA) divided by total abdominal muscle area (TAMA), the so-called NAMA/TAMA index, as a new index for good quality muscle and myosteatosis [10]. This could provide useful information about myosteatosis, muscle quality, and associated cardiometabolic risk in people with previous abdominal CT scans in future studies.
Once more, we thank Dr. Roh for her comprehensive review and valuable comments.



No potential conflict of interest relevant to this article was reported.


1. Kim HS, Lee J, Kim EH, Lee MJ, Bae IY, Lee WJ, et al. Association of myosteatosis with nonalcoholic fatty liver disease, severity, and liver fibrosis using visual muscular quality map in computed tomography. Diabetes Metab J 2023;47:104-17.
Article  PubMed  PMC  PDF 
2. Koo BK, Kim D, Joo SK, Kim JH, Chang MS, Kim BG, et al. Sarcopenia is an independent risk factor for non-alcoholic steatohepatitis and significant fibrosis. J Hepatol 2017;66:123-31.
Article  PubMed 
3. Hong HC, Hwang SY, Choi HY, Yoo HJ, Seo JA, Kim SG, et al. Relationship between sarcopenia and nonalcoholic fatty liver disease: the Korean Sarcopenic Obesity Study. Hepatology 2014;59:1772-8.
Article  PubMed 
4. Wijarnpreecha K, Kim D, Raymond P, Scribani M, Ahmed A. Associations between sarcopenia and nonalcoholic fatty liver disease and advanced fibrosis in the USA. Eur J Gastroenterol Hepatol 2019;31:1121-8.
Article  PubMed 
5. Roh E, Hwang SY, Yoo HJ, Baik SH, Lee JH, Son SJ, et al. Impact of non-alcoholic fatty liver disease on the risk of sarcopenia: a nationwide multicenter prospective study. Hepatol Int 2022;16:545-54.
Article  PubMed  PDF 
6. Kuchay MS, Martinez-Montoro JI, Kaur P, Fernandez-Garcia JC, Ramos-Molina B. Non-alcoholic fatty liver disease-related fibrosis and sarcopenia: an altered liver-muscle crosstalk leading to increased mortality risk. Ageing Res Rev 2022;80:101696.
Article  PubMed 
7. Jung HN, Cho YK, Kim HS, Kim EH, Lee MJ, Lee WJ, et al. Association between hypertension and myosteatosis evaluated by abdominal computed tomography. Hypertens Res 2023;46:845-55.
Article  PDF 
8. Kim EH, Kim HK, Lee MJ, Bae SJ, Kim KW, Choe J. Association between type 2 diabetes and skeletal muscle quality assessed by abdominal computed tomography scan. Diabetes Metab Res Rev 2022;38:e3513.
Article  PubMed  PDF 
9. Lee MJ, Kim HK, Kim EH, Bae SJ, Kim KW, Kim MJ, et al. Association between muscle quality measured by abdominal computed tomography and subclinical coronary atherosclerosis. Arterioscler Thromb Vasc Biol 2021;41:e128-40.
Article  PubMed 
10. Kim HK, Kim KW, Kim EH, Lee MJ, Bae SJ, Ko Y, et al. Age-related changes in muscle quality and development of diagnostic cutoff points for myosteatosis in lumbar skeletal muscles measured by CT scan. Clin Nutr 2021;40:4022-8.
Article  PubMed 

Editorial Office
101-2104, Lotte Castle President, 109 Mapo-daero, Mapo-gu, Seoul 04146, Korea​
Tel: +82-2-714-9064    Fax: +82-2-714-9084    E-mail: diabetes@kams.or.kr                

Copyright © 2023 by Korean Diabetes Association.

Developed in M2PI

Close layer