By Joseph Webster, MD, MBA, FACP
“The ills that have plagued civilized man are as much a part of civilization as are their prevention and cure”…. Frederick F. Cartwright, “Disease and History” 1972
The “developed nations” of the world have been blessed with “way too much food” per capita and the obesity pandemic is but one reflection of the unintended consequences of this blessing. However, a more devastating trade off has been the concomitant rise of liver disease in adults and children. Today, the leading cause of liver failure in the developed world is Fatty Liver Disease. There are two broad categories of Fatty Liver: Nonalcoholic fatty liver disease (NAFLD) and Alcoholic fatty liver disease or (Alcoholic Steatosis).
NAFLD (Nonalcoholic fatty liver disease) is the type that is not associated with excessive alcohol use and there are two kinds: Simple fatty liver - excessive fat in the liver but no inflammation or liver cell damage. The other type is Nonalcoholic steatohepatitis (NASH) – excessive fat, plus inflammation and cellular damage. The cell damage leads to fibrosis and scarring of the liver, destroying the functional capacity of the liver and causing life threatening cirrhosis of the liver.
What is the cause of fatty liver disease?
The cause(s) of NAFLD is unknown. Research indicates that is more common in certain circumstances:
Type 2 diabetes; obesity; middle age; Hispanic or White; (less common in African Americans); high fat in the blood (triglycerides and or cholesterol); high blood pressure; certain medications (steroids; NSAIDS; methotrexate; etc.); metabolic syndrome; Hepatitis C; and rapid weight loss.
Gut-derived Lipopolysaccharides and Oxidative Stress may contribute to the development of fatty liver disease. The suggestion is the gut biome and a ‘leaky gut’ and subsequent increase in oxidative stress leads to liver inflammation under the appropriate conditions.
It is estimated that nearly 25 percent of the world’s seven billion people may have NAFLD and it is the most common chronic liver disorder in the United States of America. On the other hand, Alcoholic Fatty Liver disease only happens in people who drink heavily for long periods of time. Obesity and postmenopausal women are more susceptible. Recent research suggests that there is some protective effect from estrogen levels, but the data requires further substantiation.
What are the Symptoms?
Unfortunately, there are no symptoms until the liver is severely damaged with irreversible cirrhosis and end stage liver failure.
How is Fatty liver diagnosed?
The “standard” history, physical examination and routine labs will not render a diagnosis of Fatty Liver with any degree of sensitivity over 95 percent of the time. The clinician must treat each patient as a possible candidate for fatty liver disease if the patient has any of the “high risk profile” variables listed previously.
In the case of advanced liver disease with cirrhosis, the bedside exam may reveal either a very large liver or a shrunken liver with or without excessive fluid called ascites. Such cases are beyond medical intervention and may need liver transplantation for treatment or cure.
A leading liver transplant surgeon highlights the “cycle of doom” that the NAFLD and ALCOHOLIC STEATOHEPATITIS creates because the pool of available “healthy livers” is shrinking as the pandemic spreads unmitigated. There are not enough healthy livers to keep up with the demand.
An abdominal ultrasound is an inexpensive exam that does not expose the patient to radiation, and it has a degree of sensitivity that renders it cost effective as a screening test in the appropriate circumstances. Elastography is a more sensitive and specific test for liver stiffness, and it is a surrogate marker for liver fibrosis – the precursor to cirrhosis. Unfortunately, elevation of the liver chemistries is not specific for fatty liver, and they may remain normal for an extended period even though there is significant liver damage ongoing.
Can fatty liver be treated?
There are no approved medications for treatment. For NAFLD aggressive weight loss (at least 7 percent of body weight) has been associated with reversal of fatty deposition and inflammation as well as fibrosis. Any contributing factors such as medications should be discontinued, working in conjunction with the PCP (primary care physician).
For Alcoholic Steatosis the first line of treatment is complete abstinence from alcohol.
Both ALD and Alcoholic Steatosis can lead to cirrhosis. There is no treatment for ‘reversal of cirrhosis’ but the medical management of liver failure has been established by consensus of multiple professional associations nationally and internationally.
Do children get NAFLD?
NAFLD is the most common cause of liver transplants in young adults (< 50 years old) and between 5 percent and 10 percent of children globally have NAFLD according to the Study of Child and Adolescent Liver Epidemiology (SCALE). Over 50 percent of children with NAFLD have inflammation and fibrosis, or NASH at the time of diagnosis. The risk factors for children include prediabetes and obesity. In children the microbiome appears to be a definite risk factor and the lack of “diversity” or gut dysbiosis, increased the risk of severe NASH.
However, the strongest risk factor in children is obesity. Additional risk factors include male gender, Hispanic, and older age. It is less common in girls and African Americans.
Can NAFLD in children be treated?
There is no specific treatment. The best treatment is a high index of suspicion and early diagnosis in the high-risk group. OBESITY PREVENTION should be the target for all children and their families. NAFLD often is a ‘family affair’!
The medical community cannot cure NAFLD, but collaborating with the broader community - we can PREVENT IT.
We often spend too much time hoping for something in the future – instead of taking charge of that which is clearly at hand!
Together, we can Prevent and Cure Obesity! Our civilization is hanging in the balance!
Joseph Webster, MD, MBA, FACP is a gastroenterologist at the Digestive and Liver Center of Florida. He received his medical training at the Miller School of Medicine at University of Miami and U.C.L.A Medical Center in Los Angeles, California. His research interests are obesity and diabetes in children and adolescents while making sure he provides value-based care for families. His innovations in gastroenterology led to professional and community honors, invited to seminars and medical research.