## 4 Discussion  
To our knowledge, this is the first report involving Italian adults that highlights a potential association between hepatic steatosis, as evaluated through TE, and a decline in muscle function, as indicated by reduced muscle strength. The aging of societies and the increase in life expectancy in Italy are unfortunately also associated with a demographic and epidemiological transition towards a frail population. Although at an international level, this increase is seen as a public health success story, in approximately the same period of time, there has been an increase in several non-communicable diseases (NCDs), which include liver disease and sarcopenia [51]. In Italy, the estimated prevalence of NAFLD in the general population is approximately 25%, with higher prevalence rates in the southern regions compared to the northern regions (Campania region: 12.1% vs. Trentino Alto Adige region: 3.1%) [52]. In at-risk populations, such as obese and/or diabetic individuals, the prevalence increases to levels exceeding 50%. The prevalence of NAFLD found in our study is in line with that reported in other similar studies [53; 54; 55]. Approximately 30% of the Italian population will develop NAFLD by 2030 [56] with likely associated comorbidities, with an increase in the economic and healthcare burden associated with this disease. This treatable clinical condition has huge costs, precedes the appearance of diabetes, and predicts mortality. Therefore, our work suggests how to set up measures for the early identification of those individuals affected by NAFLD and how to treat them. In particular, our retrospective study reveals that adults, especially females in apparently good health belonging to the first rHGS tertile (lowest rHGS value), had a very high CAP score and a higher prevalence of NAFLD than those in the third tertile of rHGS (Figure 2a and Tables 1 and S1), even after adjusting for confounding factors. Furthermore, individuals in tertile I also had a higher prevalence of severe hepatic steatosis than those in rHGS tertile III (Figure 2b). A key finding was that adults with lower rHGS had a greater risk of having NAFLD than those with higher rHGS values, and that this risk is independent of age (Table 2). These results are in line with those demonstrated for Asian adults \begin{table}
\begin{tabular}{c c c} \hline \hline  & **OR (95\% CI)** & \(\mathbf{p}\) \\ \hline \multicolumn{3}{c}{**Model 1**} \\ \hline High rHGS & 1 (ref) & \\ Mild rHGS & 2.48 (1.26–4.87) & 0.008 \\ Low rHGS & 4.85 (2.30–10.20) & \textless{}0.001 \\ Gender & 2.70 (1.40–5.21) & 0.003 \\ \hline \multicolumn{3}{c}{**Model 2**} \\ \hline High rHGS & 1 (ref) & \\ Mild rHGS & 2.02 (0.91–4.48) & 0.08 \\ Low rHGS & 3.63 (1.49–8.82) & 0.004 \\ General Obesity & 2.44 (1.41–4.28) & 0.002 \\ \hline \multicolumn{3}{c}{**Model 3**} \\ \hline High rHGS & 1 (ref) & \\ Mild rHGS & 2.56 (1.17–5.59) & 0.018 \\ Low rHGS & 5.30 (2.24–12.57) & \textless{}0.001 \\ Android Obesity & 239 (1.36–4.18) & 0.002 \\ \hline \hline \end{tabular} Model 1 was adjusted for age and gender. Model 2 was adjusted for age, gender, smoking habit, physical activity, hyperlipidemia, HDL-C, TG, creatinine, and AST. Model 3 was adjusted for age, gender, smoking habit, physical activity, hyperlipidemia, android obesity, HDL-C, TG, creatinine, and AST. NAFLD, non-alcoholic fatty liver disease; rHGS, relative handgrip strength; OR, odds ratio; CI, confidence interval.  
\end{table} 
Table 2: Odds ratio for NAFLD risk by relative handgrip strength tertiles and other factors. regarding the high risk of fatty liver disease in individuals with low muscle function [33; 34; 35; 36; 37]. Therefore, our findings suggest that differences in muscle strength values between different ethnicities do not affect this strong relationship [9]. This evidence is strengthened by the prospective study conducted on a European cohort [41].