Non-alcoholic fatty liver disease is serious but preventable. Learn if you’re at risk.
Editor’s note: This article was updated from an earlier version posted in December 2019.
Karl Burrows was diagnosed with non-alcoholic fatty liver disease years ago, but no one seemed to make a big deal about it. His mother had it, but there were no symptoms to interrupt his normal routines. Over the past year, however, he started noticing a fatigue he couldn’t shake. An MRI revealed that he had progressed to stage four fatty liver disease, where the liver has already started to scar and lose function.
The good news: he can still hold the disease at bay, with a few changes in diet and lifestyles. The bad news is that his risk of liver cancer or need for a transplant are much higher than they were 15 years ago.
He’s not unique, many people either don’t know they have fatty liver disease, or they don’t know that it’s a disease that can seriously impact their lives. At least 30% of Americans today have non-alcoholic fatty liver disease (NAFLD). There may be as many as 4.5 million Americans with advanced stage fatty liver disease, and many don’t know it. It’s on course to become the leading reason for liver transplant in the coming years. And the only cure, liver transplant, can mean long waits on liver registries.
But patients like Mr. Burrows can prevent permanent damage. We talked to gastroenterologist Dr. Dina Halegoua-DeMarzio to understand the risks and best course of action for people worried about the disease.
Do I have fatty liver disease? What are the symptoms, and why does it happen?
“Fatty liver disease is stealthy,” says Dr. Dina Halegoua-DeMarzio, a gastroenterologist and director of the Jefferson Fatty Liver Disease Center. Many people are symptom-free for years as it develops into a more serious illness. Once the liver becomes scarred or crisscrossed with cirrhosis, it stops functioning as well, and that’s when people may begin to notice symptoms. You might notice your skin or the whites of your eyes yellowing – a sign of jaundice. Or you may experience fatigue, confusion, or swelling of the legs or abdomen.
The disease develops when there’s too much fat — in the form of fatty acids — in the bloodstream, which is common with diabetic insulin resistance. Liver cells store the excess fat, as a way to remove these toxins from circulation. Because the liver isn’t a good long-term storage place for fat, ongoing excess of lipids can irritate the cells, cause inflammation and eventually, cell death. When liver cells die, they are replaced by scar tissue, which is stiff and can get in the way of normal liver function. It also increases the risk of cancer and the need for a liver transplant. Patients can live for many years with NAFLD, but many – about 30% – eventually end up with an inflamed liver or NASH (non-alcoholic steatohepatitis), and scarring. Of these, about 20% will develop end-stage cirrhosis, which can lead to liver failure and cancer.
The best news is that the life-style changes don’t have to be huge to make a huge impact.
— Dr. Dina Hilegoua-DeMarzio
Who should get tested?
If you have diabetes you should get tested for NAFLD regularly. The risk of fatty liver disease is almost 70% in patients with diabetes, and it’s not necessarily tied to how well you control your blood sugar, says Dr. Halegoua-DeMarzio. While there are no official screening recommendations yet, doctors are beginning to recognize a growing need to diagnose patients early and prevent severe disease later.
We also know that there’s a higher risk of fatty liver disease in Latin American patients, intermediate risk for whites and lower relative risk for blacks, according to a review of over 350,000 patients records. The disease is also more common in women than men.
This demographic data suggest there may be a hereditary or genetic component to the disease. If you have a family history of the disease, it’s also a good idea to get tested. Although research on genetics/genomics of fatty liver disease is still early, a few genetic connections have been made. In a recent discovery, Jouni Uitto, MD, PhD, who studies rare skin diseases found that mutations in a gene called ABHD5 also led to fatty liver disease in families who also suffered from skin disease Chanarin-Dorfman syndrome. Further research will help determine whether this gene is involved in NAFLD in the general population.
What tests should I ask for?
Not all physicians know about the disease, so it can be important to advocate for the tests you need. A great first step is blood work from an annual physical exam, says Dr. Halegoua-DeMarzio. That work-up usually includes checking liver enzymes. However, researchers have found that liver enzyme values can be misleading – up to 80% of patients with normal liver enzymes can have the disease. She recommends using other tests, such as an abdominal ultrasound. Although blood tests and basic imaging are a good first step they’re not definitive. If the results suggest disease, further follow up is needed with additional liver imaging, like transient elastography, to determine if scarring is present and sometimes biopsy.
Transient elastography is an emerging non-invasive diagnostic technique that checks for liver scarring. Researcher Flavius Guglielmo and others are working to refine the technique so that it can one day replace the more invasive liver biopsy and pathology testing.
Is it really a big deal to have a fatty liver if my symptoms aren’t bad? How can I prevent disease progression?
“Many people, and even some doctors, think fatty liver is just something you have to live with.” says Dr. Halegoua-DeMarzio, “But it’s not. If ignored, it can lead to serious complications including cancer or liver transplant.”
“The best news is that the life-style changes don’t have to be huge to make a huge impact,” she says. Dietary changes can be the best medicine. Cutting out processed foods sometimes makes all the difference. Doctors also recommend losing about 10% of body weight, and cutting out alcohol. “Although, non-alcoholic fatty liver disease is an entirely different disease from fatty-liver caused by alcohol, NAFLD is still exacerbated by alcohol.”
“Many patients try to cut fat out of their diet,” says Dr. Halegoua-DeMarzio, “but that’s wrong. It’s the carbohydrates and sugars that are usually responsible for the excess fat in the liver. Good fats are great.”
Are there any treatment options if lifestyle changes aren’t helping?
There are several therapies that seem to help limit fatty liver disease, says Dr. Halegoua-DeMarzio, including certain diabetes drugs. But there are no FDA-approved therapies to date.
A large number of companies are working on different approaches to treat fatty liver disease or prevent progression. The therapies are offered via clinical trial participation. Although, as with all clinical trials, it’s important to know that the treatment is experimental and may not work, it could have side effects, and you may be randomly placed in a group that does not receive the test treatment at all.