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Non‐alcoholic fatty liver disease and the risk of dementia—Authors' reply

We thank Dr. Zhou et al. for their thorough review of our article.1 We agree that the different baseline characteristics in nonalcoholic fatty liver disease (NAFLD) and nonNAFLD groups in investigating the risk of dementia deserve some attention. Yet, we are afraid that the baseline characteristics of these two groups can hardly be comparable in the realworld set. To counter such a limitation, multiple strategies were used to rigorously adjust for differences in baseline characteristics, including multivariable adjustment, propensity score matching, and competing risk analyses. Despite that we cannot completely rule out the potential of unmeasured confounders, the present approach involving a fairly large study population with a long followup duration can be considered reasonable given that the incidence of dementia in NAFLD was relatively low. We also agree that a certain lifestyle can affect the development of dementia.2,3 Since the study population was recruited from the national base which was void of the information on lifestyles, the study was not able to take that into account. Future studies involving such information in their analysis will guide us to a better understanding of the relationship between NAFLD and dementia. Although the metaanalysis stated in the letter suggested that NAFLD does not increase the risk of dementia, several studies have reported the opposite as well.4– 6 Our study clearly showed that NAFLD, defined by the hepatic steatosis index, was associated with an increased risk of dementia. A recent study involving 608 994 adults has also reported that NAFLD, defined by the fatty liver index, was associated with the risk of dementia, particularly Alzheimer's disease.4 Evidence supporting the association of NAFLD with dementia can be found in yet another study that showed moderatetosevere NAFLD, defined by ultrasound, was associated with dementia.5 With the rising prevalence of both NAFLD and dementia resulting in substantial clinical and economic burden worldwide, we are in great need of welldesigned future studies and more solid evidence in regard to their relationship. In the meantime, it would be advisable to keep in mind the potential of dementia when treating patients with NAFLD.