Advanced fibrosis in nonalcoholic fatty liver disease (NAFLD) is associated with an increased risk of mortality; however, an independent association of liver fibrosis with mortality is not well defined. We aimed to investigate the association between advanced liver fibrosis and all-cause and cardiovascular mortality and the mediation effect of diet quality. We analyzed 35,531 participants with suspected NAFLD, excluding competing etiologies of chronic liver disease, from the Korea National Health and Nutrition Examination Survey 2007–2015, and followed up until 31 December 2019. The severity of liver fibrosis was assessed using the NAFLD fibrosis score (NFS) and the fibrosis-4 index (FIB-4). The Cox proportional hazards model was used to examine the association of advanced liver fibrosis with mortality. During a mean 8.1 years of follow-up, 3426 deaths occurred. Advanced liver fibrosis determined by NFS and FIB-4 was associated with increased risks of all-cause and cardiovascular mortality after adjusting for confounders. When NFS and FIB-4 were combined, the high NFS + high FIB-4 group was significantly associated with higher risks of all-cause mortality (hazard ratio [HR] 1.85, 95% CI 1.42–2.43) and cardiovascular mortality (HR 2.04, 95% CI 1.23–3.39), respectively, compared with the low NFS + low FIB-4 group. However, these associations were attenuated in people with high diet quality. Advanced liver fibrosis is an independent risk factor for all-cause and cardiovascular mortality in people with NAFLD, and the association between advanced liver fibrosis and mortality is modified by a high-quality diet.

This study investigated possible associations between dietary patterns and blood heavy metal levels in Korean adults, using data from the Korea National Health and Nutrition Examination Survey (2012–2016). To explore these associations, demographic, physical activity, anthropometric, biochemical, and dietary data, including a food frequency questionnaire, were analyzed. Foods were categorized into 19 groups, and principal component factor analysis identified three dietary patterns: Meat and processed food-enriched diet (MPD), vegetables and milk-enriched diet (VMD), and fermented and fish-enriched diet (FFD). Multivariate logistic regression was used to evaluate the association between dietary patterns and high levels of heavy metals in the blood. The results showed that a high MPD score had a positive association with high levels of blood Pb (OR = 1.470, 95% CI = 1.173–1.842) and Hg (OR = 1.559, 95% CI = 1.259–1.932); a high FFD score also showed a positive association with high levels of blood Pb (OR = 1.492, 95% CI = 1.227–1.814) and Cd (OR = 1.276, 95% CI = 1.045–1.559). In contrast, VMD score was negatively associated with high levels of blood Pb (OR = 0.760, 95% CI = 0.628–0.920) and Cd (OR = 0.948, 95% CI = 0.781–1.151). Moreover, the effect of each dietary pattern on blood heavy metal levels showed differences by sex. Some dietary patterns, such as a high intake of meat, processed foods, fermented foods, and fish, can increase blood heavy metal levels, whereas other dietary patterns, such as vegetables and milk, have a protective effect against heavy metal concentrations.