## 4 Discussion
Indeed, this study showed that individuals in the highest HGS fertile had a lower risk (95% CI 0.64-0.77) of severe NAFLD than those in the lowest HGS tertile [41]. In addition, in a recent meta-analysis, [PERSON] et al. also demonstrated that individuals with low HGS had a higher risk of NAFLD compared to those with normal HGS (OR = 3.32, 95% CI: 1.91-5.75). Furthermore, the authors reported that the risk among patients with low HGS affected by NAFLD was higher than that in normal people (OR = 3.31, 95% CI: 2.45-4.47) [57]. We observed, in our study, a higher prevalence of NAFLD among subjects of both genders and age \(\geq\)50 years than that found in a similar Asian population (53% vs. 22%, respectively) [35]. The observed dissimilarity may, in part, be attributed to the higher average BMI in our study population and the distinctive methodology employed for NAFLD diagnosis [35]. Notably, the CAP score might prove to be more precise in the detection of hepatic steatosis compared to the hepatic steatosis index [58]. We also found that low HGS had a greater and independent effect in the presence of obesity and, particularly, android obesity, which is already associated with a higher risk of developing NAFLD [59]. In light of the above, our results could have important implications because they confirm, in line with studies on adults in Asia and Caucasians in the USA and UK, that fatty liver disease could be directly associated with muscle strength during aging. Studies focusing on muscle mass [60; 61] have highlighted the link between muscle tissue and the liver; however, they may not be enough to fully explain this cross-talk. Studies have demonstrated that preserving or increasing muscle mass in isolation may not be sufficient to halt the decline in muscle function related to aging [62] and that muscle strength holds greater significance than muscle quantity when assessing mortality risk among the elderly [63]. Several studies have underscored the significance of evaluating muscle strength in individuals with liver disorders. These studies have revealed associations between hand-grip strength (HGS) and health-related quality of life [64], as well as the occurrence of hepatic decompensation and HCC in adults with chronic liver conditions [65]. Furthermore, it has been established that a low HGS value serves as a negative prognostic factor for survival in individuals with liver cirrhosis [66] and HCC [67]. Notably, a study [67] involving HCC patients demonstrated that the low HGS group exhibited significantly shorter survival compared to the high HGS group, with low HGS emerging as an independent predictor for overall survival in multivariate analysis, while skeletal muscle depletion did not exhibit the same impact. Additionally, patients with low HGS tended to discontinue therapy more frequently than those with high HGS [67]. HGS is additionally linked to various unfavorable clinical consequences in cirrhosis, such as reduced physical activity and the development of hepatic encephalopathy [68]. Moreover, a study found that reduced handgrip strength (HGS) is linked to a twofold increase in the risk of all-cause and liver-related mortality [66]. Another investigation demonstrated that grip strength is associated with an elevated risk of mortality among patients on liver transplantation waiting lists [69]. Additionally, impaired preoperative HGS is correlated with increased postoperative complications, mortality, and extended hospitalization after surgery [70]. The HGS test stands out as an affordable, widespread screening tool with notable sensitivity and specificity for identifying morbidity and mortality across various healthcare settings. It can be easily administered by nurses, physicians, and other healthcare professionals. When considering the cost and expertise required by alternative tests and their influence on long-term survival, HGS assessment emerges as a superior option. HGS serves as a simple, non-invasive, cost-effective, and real-time predictor of long-term all-cause mortality [69].