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Background With its increasing incidence, nonalcoholic fatty liver disease ( NAFLD) is of particular concern in the Veterans Health Administration ( VHA). Aims To evaluate risk factors for advanced fibrosis in biopsy-proven NAFLD in the VHA, to identify patients at risk for adverse outcomes. Methods In randomly selected cases from VHA databases (2005-2015), we performed a retrospective case-control study in adults with biopsy-defined NAFLD or normal liver. Results Of 2091 patients reviewed, 399 met inclusion criteria. Normal controls (n = 65) had normal liver function. The four NAFLD cohorts included: NAFL steatosis (n = 76), nonalcoholic steatohepatitis ( NASH) without fibrosis (n = 68), NAFLD/ NASH stage 1-3 fibrosis (n = 82), and NAFLD/ NASH cirrhosis (n = 70). NAFLD with hepatocellular carcinoma ( HCC) was separately identified (n = 38). Most patients were older White men. NAFLD patients with any fibrosis were on average severely obese ( BMI>35 kg/m2). Diabetes (54.4%-79.6%) and hypertension (85.8%-100%) were more common in NAFLD with fibrosis or HCC. Across NAFLD, 12.3%-19.5% were enrolled in diet/exercise programs and 0%-2.6% had bariatric surgery. Hispanics exhibited higher rates of NASH (20.6%), while Blacks had low NAFLD rates (1.4%-11.8%), particularly NAFLD cirrhosis and HCC (1.4%-2.6%). Diabetes ( OR 11.8, P < .001) and BMI ( OR 1.4, P < .001) were the most significant predictors of advanced fibrosis. Conclusions In the VHA, diabetes and severe obesity increased risk for advanced fibrosis in NAFLD. Of these patients, only a small proportion (~20%) had enrolled in diet/exercise programs or had bariatric surgery (~2%). These results suggest that providers should focus/tailor interventions to improve outcomes, particularly in those with diabetes and severe obesity. [ABSTRACT FROM AUTHOR]