Evaluation of sleep quality and obstructive sleep apnea in non-alcoholic fatty liver disease: a cross-sectional study

Abstract

Sleep is essential for metabolic homeostasis and overall health. NAFLD, recently reclassified as MASLD, is the most prevalent chronic liver disease globally (~ 25% prevalence) and is strongly linked to metabolic comorbidities. Growing evidence associates adverse sleep conditions including short sleep duration, OSA, and circadian misalignment with NAFLD onset and progression. However, data from Iranian and Middle Eastern populations remain scarce, and no study has simultaneously evaluated sleep quality and OSA risk in a large Iranian NAFLD cohort. This study aimed to address this gap using the PSQI and STOP-BANG questionnaire. This cross-sectional study utilized registry data from the PERSIAN Organizational Cohort Study (POCS) at Mashhad University of Medical Sciences. A total of 958 NAFLD patients diagnosed by abdominal ultrasonography were included. Among 958 participants (69.6% male; mean age 46.7 ± 9.1 years), 35.4% had sleep disturbance (31.6% mild; 3.8% moderate). Over half (53.4%) were at intermediate OSA risk. Sleep disturbance was significantly associated with female sex (p = 0.022), single marital status (p = 0.019), higher BMI (p = 0.026), and hypertension (p = 0.007). BMI correlated weakly but significantly with PSQI scores (r = 0.072, p = 0.036). Hepatic steatosis grade was not associated with sleep disturbance (p = 0.193) but correlated positively with STOP-BANG scores (r = 0.232, p < 0.001). Sleep disturbance and elevated OSA risk are common among patients with NAFLD and were associated, in unadjusted analyses, with female sex, elevated BMI, hypertension and single marital status. These findings support consideration of sleep assessment in this population on case-finding grounds; whether identifying or treating these conditions improves hepatic or metabolic outcomes cannot be determined from a cross-sectional study.