What is Fatty Liver?
By Dr. Andrew Oswari
Non-Alcoholic Fatty Liver Disease (NAFLD) is a condition where the liver has greater than 5-10% fat accumulation by weight. It is estimated that 30% of NAFLD can progress to Non-Alcoholic Steato-Hepatitis (NASH) which includes inflammation and scarring of the liver. Approximately 20% of NASH will progress to cirrhosis which may lead to Hepato-Cellular Carcinoma and failure requiring liver transplants. These non-alcohol related conditions have now surpassed alcohol related disease as the leading cause of liver related diseases. (1), (2)
In addition to the above risks, having fat in the liver doubles the risk of cardiovascular disease (CVD) including heart attacks, strokes, and atherosclerosis. CVD is the leading cause of death from NAFLD and its other forms.
It is estimated that 30-40% of the general global population has some form of fatty liver disease. Latin American countries are closer to 44% and the United States is a little over 30%. Most of these patients are undiagnosed, asymptomatic and have liver laboratory values within the normal reference range. (1)
The American Diabetic Association, American Academy of Clinical Endocrinology, American Association for the Study of Liver Diseases, and the American Gastroenterological Association recommends screening for NAFLD on individuals that fall into these categories:
- Type 2 Diabetes
- Pre-diabetics
- Or have two or more of the following:
| Central Abdominal obesity (measured by waist circumference) | Men: greater than 40 inches Women: greater than 35 inches |
| Elevated Triglycerides | > 150 mg/dL |
| Low High Density Lipoprotein (HDL) | Men: < 40 mg/dL Women: < 50 mg/dL |
| High Blood Pressure | > 130/85 mmHg or if on medication |
| High Fasting Glucose | > 100 mg/dL |
| Family History of Cirrhosis | Due to NAFLD / NASH |
| Medically Complicated Obesity | Ie. Sleep apnea, etc.. |
| Significant Alcohol use | > 1 drink per day |
If the criteria above is met, screening would include a Fibrosis-4 (FIB-4) index blood test and other non-invasive testing. Standard ultrasounds have a poor sensitivity in screening and should not be used. Almost 70% of patient referrals for NAFLD evaluation are due to elevated liver enzymes on their laboratory blood work results (reference). If much of the NAFLD population is undiagnosed, asymptomatic and within normal reference range of liver enzymes, there is a significant population that is being overlooked. Magnetic Resonance Elastography (MRE) is considered the gold standard for non-invasive testing, but due to costs and access, Vibration Controlled Transient Elastography (VCTE) via a Fibroscan device is recommended. (3),(4)
After finding out that close to 40% of the general world population has NAFLD, better methods of screening are mandatory. We are pleased to announce that VCTE in the form of a Fibroscan is now available at the Chung Institute. This is the perfect addition to our philosophy of preventing disease and restoring health. Insurance will cover the procedure as long as the above conditions are met. Screening is also available for those who do not meet the criteria but want to pay for it out of pocket.
It is interesting to note that the conditions discussed have recently been renamed to reflect the real cause of fatty liver which is metabolic dysfunction. NAFLD is now MAFLD (Metabolic Dysfunction Associated Liver Disease) and NASH is now MASH (Metabolic Dysfunction Associated Steatohepatitis). That being said, the condition can be improved or even reversed by a change in diet and lifestyle.
One study has already shown an improvement in MASH with just 6 days of a change in diet (ref). The Chung Institute will help you along in your journey to get metabolically healthy and prevent disease allowing you to achieve not just a numerical age but ensure your wellness as your age.
Take this quiz to see if you are at risk: thinkliverthinklife.org/quiz
For additional information, please see these articles:
Fatty Liver Disease (Steatotic Liver Disease) – American Liver Foundation
- Younossi ZM, Golabi P, Paik JM, Henry A, Van Dongen C, Henry L. The global epidemiology of nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH): a systematic review. Hepatology. 2023 Apr 1;77(4):1335-1347. doi: 10.1097/HEP.0000000000000004. Epub 2023 Jan 3. PMID: 36626630; PMCID: PMC10026948.
- Harrison SA, Gawrieh S, Roberts K, Lisanti CJ, Schwope RB, Cebe KM, Paradis V, Bedossa P, Aldridge Whitehead JM, Labourdette A, Miette V, Neubauer S, Fournier C, Paredes AH, Alkhouri N. Prospective evaluation of the prevalence of non-alcoholic fatty liver disease and steatohepatitis in a large middle-aged US cohort. J Hepatol. 2021 Aug;75(2):284-291. doi: 10.1016/j.jhep.2021.02.034. Epub 2021 Mar 18. PMID: 33746083.
- Kwo, Paul Y MD, FACG, FAASLD1; Cohen, Stanley M MD, FACG, FAASLD2; Lim, Joseph K MD, FACG, FAASLD3. ACG Clinical Guideline: Evaluation of Abnormal Liver Chemistries. American Journal of Gastroenterology 112(1):p 18-35, January 2017. | DOI: 10.1038/ajg.2016.517
- Rinella, Mary E.1; Neuschwander-Tetri, Brent A.2; Siddiqui, Mohammad Shadab3; Abdelmalek, Manal F.4; Caldwell, Stephen5; Barb, Diana6; Kleiner, David E.7; Loomba, Rohit8. AASLD Practice Guidance on the clinical assessment and management of nonalcoholic fatty liver disease. Hepatology 77(5):p 1797-1835, May 2023. | DOI: 10.1097/HEP.0000000000000323