As part of the growing awareness about chronic disease, it’s important to understand the relationship between nonalcoholic fatty liver disease (NAFLD), an asymptomatic condition characterized by elevated levels of fat in the liver, and diabetes. As a common complication of Type 2 diabetes and obesity, NAFLD can be overlooked comorbidity.
Diabetes is one of the leading causes of disability and death in the United States. One in 10 Americans have diabetes – more than 30 million people – and another 84 million adults are at high risk of developing Type 2 diabetes.
Today, a growing number of primary care providers and liver specialists recognize that NAFLD has become the most common chronic liver disease in developed countries. It is often characterized by insulin resistance and hepatic triglyceride accumulation in the absence of co-existing etiologies, such as excessive alcohol consumption, viral hepatitis, medications, or other etiologies for hepatic steatosis.
Fortunately, NAFLD can be reversible if caught in the early stages, and innovative examination technology makes it possible to quickly and non-invasively combat the spike in NAFLD among patients with Type 2 diabetes.
Treatment and Prevention Options
Current treatments for NAFLD are to control body weight by changing lifestyle and improving insulin resistance. Studies suggest that weight loss can be an effective treatment. Notably, a body-weight reduction of at least 3% to 5% may improve hepatic steatosis, and greater body-weight reduction (≥ 7%) may improve the histologic features of NASH including fibrosis. Also, exercise and diet can reduce fat accumulation in the liver and improve hyperlipidemia, hypertension, and insulin resistance.
Currently, there are no drugs to treat liver disease, but treatments are expected to be approved as early as 2021. Any drug treatment must be balanced with the benefits and risks to mitigate adverse events and pharmacological interactions. A more accurate understanding of the molecular mechanisms of geriatric NAFLD can help in identifying the most appropriate diagnostic and therapeutic approaches for individual elderly patients.
The American Diabetes Association (ADA) guidelines recommend screening patients with T2DM for NAFLD. These patients have a higher all-cause mortality than those without NAFLD.
ADA Standards of Medical Care recommends that patients with T2DM or prediabetes and elevated liver enzymes (alanine aminotransferase) or fatty liver on ultrasound should be evaluated for the presence of NASH and liver fibrosis.
ADA also recommends noninvasive tests, such as elastography or fibrosis biomarkers, to assess risk of fibrosis, but referral to a liver specialist and liver biopsy may be required for definitive diagnosis.
While the American Association for the Study of Liver Diseases (AASLD) does not currently recommend routine screening for NAFLD or NASH, it does recognize FibroScan as part of an overall approach to identifying patients with NAFLD or NASH. It suggests there should be a high index of suspicion for NAFLD and NASH in patients with T2DM. Clinical decision aids include NAFLD fibrosis score (NFS), fibrosis-4 index (FIB-4) or vibration controlled transient elastography (VCTE), a medical non-imaging modality that quantifies the stiffness of liver tissue.
Fast, Painless Assessment
Many clinicians now rely upon a non-invasive, painless technology designed to quantify the stiffness of the liver via VCTE to identify those at low or high risk for advanced fibrosis (bridging fibrosis or cirrhosis).
This innovative technology provides consistent information about the presence or status of the disease, which is important in the diagnosis and monitoring of NAFLD. For example, FibroScan, which simultaneously measures levels of liver stiffness and fat, is designed to be performed by a medical assistant in the physician’s office and is also covered by Medicare, Medicaid, and most insurance plans.
Physicians can get rapid results and test scores and analyze the data and information in real-time to refer patients to a specialist or recommend changes to their overall care plans if needed.
This type of technology represents a vast improvement over the traditional approach of identifying liver disease with a blood test, which reveals liver enzymes that are released after a liver cell dies and may suggest inflammation. As appropriate and needed, this is followed by extracting a liver tissue sample — a percutaneous liver biopsy. This allows doctors to see signs of scar tissue and ballooning under a microscope to determine how far the disease has progressed.
This standard method, however, has been brought into question not only because it is invasive and often painful, but also for its inaccuracy. In fact, scientists estimate that more than 30% of biopsy diagnoses may be wrong. Additionally, it adds another layer of cost to the diagnosis.
The point of non-invasive, painless technology is that these tools can quickly and easily measure the amount of liver stiffness and fat to better target more expensive or more invasive diagnostic procedures – saving time and resources for clinicians by eliminating patients who don’t need additional assessment.
Scott Howell, D.O., MPH&TM, CPE, is an advisor for Echosens, The Liver Company.