Regular physical activity substantially reduces mortality risk in adults with hypertension regardless of underlying fatty liver severity, with higher fatty liver burden independently associated with increased all-cause and cardiovascular mortality.
Key Findings
Results
Higher fatty liver burden (FLI ≥ 60) was associated with significantly increased all-cause mortality in adults with hypertension.
HR 1.35 (95% CI 1.26–1.44) for all-cause mortality in individuals with FLI ≥ 60 compared to lower FLI categories
Study population included 139,015 individuals aged ≥ 20 years from the Korean National Health Insurance Service health screening program
Participants were enrolled between 2009 and 2012 and followed through 2021 with a median follow-up of 9.1 years
12,281 total deaths occurred over the follow-up period
Results
Higher fatty liver burden (FLI ≥ 60) was associated with significantly increased cardiovascular mortality in adults with hypertension.
HR 1.32 (95% CI 1.12–1.56) for cardiovascular mortality in individuals with FLI ≥ 60
2,013 cardiovascular deaths occurred among the 12,281 total deaths
Fatty liver burden was assessed using the Fatty Liver Index (FLI) and categorized as <30, 30–59, or ≥60
Results
Higher physical activity levels (≥ 1000 MET-min/week) were consistently associated with lower all-cause and cardiovascular mortality across all fatty liver burden categories.
PA levels were self-reported and classified as <500, 500–999, and ≥1000 MET-min/week
The strongest benefit was observed among those with FLI < 30, with HR 0.51 for all-cause mortality and HR 0.49 for cardiovascular mortality at ≥1000 MET-min/week
High PA levels remained protective even in individuals with severe fatty liver burden (FLI ≥ 60)
The protective association of PA was consistent across all three FLI categories
Results
The protective effect of high physical activity on mortality was most pronounced in individuals with the lowest fatty liver burden (FLI < 30).
HR 0.51 for all-cause mortality and HR 0.49 for cardiovascular mortality in the FLI < 30 group with ≥1000 MET-min/week of PA
Despite attenuated magnitude, the protective association persisted in those with FLI ≥ 60
This pattern suggests a possible interaction between fatty liver burden and the mortality-reducing benefit of physical activity
Methods
This nationwide cohort study examined independent and joint associations of physical activity and fatty liver burden with mortality specifically in adults with hypertension.
139,015 hypertensive individuals aged ≥ 20 years were analyzed
Data were drawn from the Korean National Health Insurance Service health screening program (2009–2012), followed through 2021
Median follow-up was 9.1 years
Both hypertension and NAFLD were noted to 'frequently coexist and share metabolic pathways that elevate cardiovascular and all-cause mortality risk'
What This Means
This research examined how fatty liver disease and physical activity levels each affect the risk of dying — from any cause or specifically from heart disease — in people who have high blood pressure. Using health records from over 139,000 Korean adults followed for nearly a decade, the researchers found that people with a higher degree of fatty liver (measured by a score called the Fatty Liver Index) had a 32–35% higher risk of dying compared to those with lower fatty liver scores. This was true even after accounting for other health factors.
On the other hand, people who exercised more — at least 1,000 MET-minutes per week, roughly equivalent to about 150 minutes of moderate activity — had substantially lower risks of death. This benefit was seen across all levels of fatty liver disease, meaning even people with severe fatty liver who exercised regularly had meaningfully lower mortality risk. The greatest protective effect was seen in people with both high physical activity and low fatty liver burden, where the risk of dying from cardiovascular causes was roughly cut in half.
This research suggests that encouraging regular physical activity could be an important strategy for reducing death risk in people with high blood pressure, and that this benefit exists even when fatty liver disease is present. The findings highlight that fatty liver disease and physical inactivity are independently harmful in hypertensive individuals, and that addressing both factors together may offer the greatest benefit to long-term health.
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Han Y, Choi Y, Kim Y. (2026). Independent and joint associations of fatty liver index and physical activity with mortality in adults with hypertension: a nationwide cohort study.. Hypertension research : official journal of the Japanese Society of Hypertension. https://doi.org/10.1038/s41440-026-02600-0