Although liver disease is typically associated with people who drink excessive amounts of alcohol, it can also occur independent of alcohol consumption. That’s the case with those who have a condition known as nonalcoholic fatty liver disease (NAFLD). It’s an ailment that’s becoming increasingly frequent and is, in fact, the most common type of liver disease in the United States, where it afflicts one out of four people. Also, studies in recent years have shown people with type 2 diabetes are at high risk for NAFLD and this risk is related to blood sugar control. The most common cause of death in people with NAFLD is cardiovascular disease, while a variety of NAFLD called NASH (nonalcoholic steatohepatitis) causes fibrosis and cirrhosis and can lead to cancer.
A new report published in the Journal of the Endocrine Society now indicates that although we realized that there’s a connection between NAFLD and type 2 diabetes, the condition has been widely underrecognized in diabetes patients, who, the study says, are not being screened for NAFLD nearly enough.
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Low screening rates for NAFLD
The research team, which was led by Anastasia-Stefania Alexopoulos, MBBS, MHS, of the Department of Medicine at Duke University, retrieved records on 228 patients with poorly controlled diabetes. Their average age was 58 and nearly seven out of ten (68.5%) self-identified as Black or African American. Of this group, only 15 had been diagnosed with NAFLD. Among the other 213 patients, however, one-third of them had tested positive for abnormal liver enzymes. But despite the positive tests, very few (less than 10%) had been referred to specialists or been given further medical scrutiny.
Screening tests do exist for NAFLD. One of the most used is the FIB-4 test, which is used to estimate the amount of scarring in the liver. A noninvasive and inexpensive procedure, it’s considered safe and reliable. However, the researchers reported that FIB-4 scores were hardly ever reported among the patients in their survey — a total of two individuals — and this even though some 85% of the patients qualified for the FIB-4 test based on their medical evaluations. Another method of liver evaluation — liver ultrasound — was also found to be seldom used. Even though about one out of three patients had indications of abnormal liver enzymes, only 7% of them had been given a liver ultrasound examination and just 4.7% were referred to a liver clinic.
In an interview with the medical news website MedPage Today, lead author Alexopoulos speculated on the possible reasons that NAFLD appears to be underrecognized in people with type 2 diabetes. One possibility, she said, is “low awareness among providers and patients of NAFLD.” Also, uncertainty about what can be done following a diagnosis is likely a factor, as well as the “lack of FDA-approved treatments.” In general, she commented, “There is also the inaccurate perception that there isn’t anything we can do about it.” Finally, she said, “I also suspect that providers have so many other things they need to focus on during clinical visits that NAFLD often falls by the wayside.”
At the end of the new paper, the authors wrote, “In conclusion, NAFLD is underrecognized in poorly controlled [type 2 diabetes] even though risk of progressive liver disease in this population is high. As such, there is a great need for primary care physicians and endocrinologists alike to incorporate detection and risk stratification of NAFLD into their diabetes practice, and to join in multidisciplinary efforts to tackle this rising public health threat.”