Fatty liver disease is an “underappreciated problem that seems to be getting worse,” according to Mitch Lazar, MD, PhD, chief of the division of endocrinology, diabetes and metabolism at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia.
For many years physicians believed that fatty liver was a benign condition but in 1980 non-alcoholic fatty liver disease (NAFLD) was designated a real condition.
“Fortunately with increasing knowledge and research on the disease, there is a growing awareness,” says Dina Halegoua-Demarzio, MD, director of the Fatty Liver Center at Thomas Jefferson University Hospital, also located in Philadelphia. “More awareness of the problem in doctors and patients will enable early intervention that can prevent cirrhosis, liver failure and liver cancer.”
It’s a particular issue for people with type 2 diabetes. Up to 70 percent of obese type 2 diabetes patients have fatty livers, meaning at least five percent of liver cells show evidence of fat. Although fatty livers are benign and estimates vary considerably, about five to 10 percent of people with the condition will go on to develop the more serious non-alcoholic steatohepatitis (NASH) that causes inflammation, scarring and damage to the liver cells. 1
Fatty livers can also start a cascade of serious damage to the liver and attempts by the organ to regenerate itself that culminate in an abundance of scar tissue and impaired liver function. It has also been linked to increased risk of heart attack and stroke.2
Studies show that anywhere from three to 26 percent of people with NASH will progress to cirrhosis, which can lead to cancer of the liver and eventual liver failure.3
“By 2020, non-alcoholic cirrhosis is predicted to be the number one reason for liver transplants,” says Dr. Halegoua-Demarzio. “Even with a transplant, there is no guarantee that fatty liver won’t return.”
The liver is the body’s second largest organ and helps process food and drink into energy and nutrients. It’s also responsible for removing harmful substances from the body. While it’s normal for liver cells to contain some fat, too much can cause inflammation and interfere with normal functioning.
Diabetes affects the body’s ability to regulate insulin and sugar but it can also affect fat metabolism in different ways. In type 1, where the body doesn’t make any insulin, the liver can burn through fat, resulting in diabetic ketoacidosis , a life-threatening condition.4 However, in people with type 2 diabetes, where the body can’t employ the insulin it produces, insulin resistance can cause fatty acid molecules in the blood to increase. Fat that can’t be taken up by the muscles or organs of the body can get stored in the liver, a condition that can lead to NAFLD. This may explain why it’s more of a health issue for people with type 2 diabetes.
“The hardest part of fatty liver disease,” says Dr. Halegoua-Demarzio, “is that there are no clear symptoms, only vague ones like fatigue, or a dull pain in the upper right quadrant from an enlarged liver. It’s often not discovered until it’s reached cirrhosis and patients are quite shocked.” Cirrhosis is dangerous because it can cause internal bleeding, mental changes, and accumulation of fluids.5
Those who will progress from fatty liver to NASH or cirrhosis are also tough to predict.
“We don’t know who will get cirrhosis or fibrosis, and we don’t yet know if treating fatty liver will prevent either condition,” says Dr. Lazar admitting there’s still a lot of uncertainty surrounding the problem.
Although it was once believed that only patients with uncontrolled blood sugars developed fatty liver, doctors are discovering that diabetic patients with well-controlled sugars can be afflicted as well as people with prediabetes, too.
“Early in the development of insulin resistance, when the pancreas can make enough insulin and blood sugar is normal, the pancreas keeps pumping out insulin,” explains Dr. Lazar. “Eventually the pancreas is not going to be able to keep up with insulin resistance and will pump out less insulin. But people with prediabetes are pumping out more insulin than average, which can lead to fatty livers.”
Dietary changes, exercise and weight loss are the first line of defense against NAFLD. There are no medications to treat the condition but doctors sometimes recommend Vitamin E to their patients.6
“Oxidative stress plays a central role in the transition from simple fatty liver to non-alcoholic steatohepatitis (NASH),” says Dr. Halegoua-Demarzio.7 “An effective therapeutic strategy is to target reduction in oxidative stress in NASH patients. Vitamin E is a potent antioxidant. Unfortunately, many concerns about vitamin E have been raised such as increasing risk of death, stroke and prostate cancer.
There is, however, some good news: Fatty liver is one of the few liver diseases that may be reversed.8
According to Dr. Halegoua-Demarzio the best way to prevent this problem is through lifestyle modification. “Avoiding processed carbohydrates, getting regular exercise, and if a patient is obese, losing weight.”
About 10 drugs are currently in development for NASH, Dr. Halegoua-Demarzio says. “The medications are focused on reducing the fibrosis or scarring, to detoxify the effects of the fat and to prevent NASH from progressing to cirrhosis,” she says.
At present, there are no FDA recommendations to screen patients for fatty liver disease, in part because there are no drugs to cure it and it is still a fairly new condition. If a blood test reveals high levels of liver enzymes, your doctor may suspect NAFLD. An ultrasound can confirm a diagnosis but may not be recommended.
Dr. Lazar notes that the expense of performing an MRI or ultrasound on every person who is obese or has type 2 diabetes to measure their amount of liver fat may not be worth it since doctors currently lack therapies to make the condition better. “It’s a little bit of a chicken and an egg situation,” he says.
“Up until now, the main causes of liver disease have been Hepatitis C and Hepatitis B, as well as alcohol. But with the development of vaccinations for Hepatitis B and medications for Hepatitis C, the number of people with cirrhosis from hepatitis is going to go way down,” says Dr. Lazar. “Once that happens, the percentage of transplants due to non-alcoholic cirrhosis is going to increase as more and more fatty livers progress to cirrhosis.”