Nonalcoholic Fatty Liver Disease: A Multidisciplinary Team Approach Is Essential for This Disease on the Rise

Jamilé Wakim-Fleming, MD, Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio and Director, Fatty Liver Disease Program, Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, Ohio, is an expert in nonalcoholic fatty liver disease (NAFLD)—a serious and initially silent disease, which, she stated, clinicians should be able to recognize. Unchecked and unaddressed, NAFLD can lead to cirrhosis, the need for liver transplantation and even death. Here, Dr. Wakim-Fleming discusses the essential need for prevention and a multidisciplinary team approach for this condition.

Q: How common is nonalcoholic fatty liver disease (NAFLD) today and is the incidence increasing? If so why?

Jamile Wakim-Fleming, MD: NAFLD is on the rise, and currently affects about 25% of the general population in adults and children in the United States. Worldwide, the incidence is between 10% and 40%, depending on the geographic locations. The condition is more common in Westernized countries, and it is definitely on the rise as the condition increases in parallel with the epidemic rates of obesity. So these two conditions—obesity and NAFLD—often occur together. In fact, about 75% of those people who are diagnosed with NAFLD have obesity and 25% do not. This is where genetics play an important role.

NAFLD is becoming one of the leading reasons for liver transplantation today. If NAFLD is not diagnosed and addressed early on, it may lead to cirrhosis and its consequences, which are liver cancer, liver failure, and death. But this is not the entire story. NAFLD is associated with metabolic disorders. These are diabetes and insulin resistance, hyperlipidemia, and high blood pressure that can be present in people who have obesity and in those who do not have obesity. Therefore, in addition to consequences on the liver, people with NAFLD have cardiovascular and kidney disease due to these metabolic disorders. Hence, it is recently addressed as metabolic- non-alcoholic- fatty liver disease which separates it from alcoholic liver disease in people who drink excessive alcohol.

NAFLD is for the most part a silent disease. Persons may not know they have the condition unless blood work reveals abnormal results, or they present with a complication from the disorder. About 40% of my patients had no idea they had this condition until they have advanced cirrhosis or liver cancer. Usually the primary care doctor is the first to make the diagnosis during a regular check-up. Liver blood tests may be abnormal and the liver ultrasound shows fatty liver or they may have signs and symptoms of advanced liver disease. This triggers a referral to the liver clinic. So it is not unusual for a person to show up in the medical system with features of cirrhosis such as jaundice, enlarging belly filled up with fluid/ascites, confusion, bleeding, and/or cancer.

Q: Who is the typical person who presents with NAFLD in your office? What types of medical problems and conditions are they typically dealing with?

Dr. Wakim-Fleming: In the liver clinic, I receive many referrals for patients who have either an abnormal blood liver panel or a fatty liver on imaging studies. This is where my role begins. I start specific testing to look for risk factors for NAFLD and to assess the degree of damage to the liver. Based on these results, I begin treatment.

A typical person with NAFLD usually has diabetes, is overweight, and has hyperlipidemia, all of which require therapy. Sometimes a patient presents with cirrhosis and this requires screening for liver cancer and for esophageal varices. If they have obesity, I start discussing their dietary habits and refer them for nutrition counseling to help lose weight or back to their medical doctor to do so. A patient with NAFLD may also have heart disease or a kidney problem, which need to be treated.

Individuals at high risk for developing cirrhosis from NAFLD are older than 50 years of age, and they have features of the metabolic syndrome (obesity, large abdominal obesity/waist, abnormal lipid blood panel, diabetes, and high blood pressure). These people are at a high and immediate risk for serious complications, and I would like to target them for treatment immediately. The others who are not in this category are usually at lower risk, and I would like to target them for prevention to advanced disease. As a hepatologist, I also want to make sure patients do not have an underlying liver disorder that will make their NAFLD worse. A few examples of that would be autoimmune hepatitis, primary biliary cholangitis, and excessive iron in the liver or viral hepatitis. I treat these conditions when present to alleviate the dual damage on the liver.

Q: Do people in the low-risk category have a chance of improving their condition? Or is it definitely a noncurable and progressive disease?

Dr. Wakim-Fleming: The condition can be curable, and yet, it is also progressive. So when we talk about NAFLD, we usually refer to a disease on a spectrum of disorders. The spectrum goes from simple steatosis or the presence of harmless fat in the liver identified on microscopic liver biopsy to more inflammation as in nonalcoholic steatohepatitis, and finally scarring. People without these findings are at low risk, but they should be followed at regular intervals. Once cirrhosis is established, it is very unlikely to reverse and more likely to cause cancer, liver failure, and death.

Q: Why is a preventive and integrative approach so important for this condition?

Dr. Wakim-Fleming: A preventive approach is very important, because we want to stop the progression along the fatty liver disease spectrum. It takes a coordinated effort among all treating parties to achieve the goal we want. In the integrative approach, we target other metabolic risk factors that not only cause liver damage, but also cause cardiovascular and kidney disease. Patients with NAFLD might end up with a heart attack and ischemic heart injuries or a stroke in addition to liver damage. We want to identify and prevent these conditions because they are as much contributing to the morbidity and mortality of the patient as the fatty liver disease itself.

I often take a multidisciplinary approach. I involve the primary care doctor and the different resources we have at Cleveland Clinic depending on the treatment that is needed.

Q: What are some of the results of exercise and losing weight? What kind of diet do you recommend and what is the impact that it can have?

Dr. Wakim-Fleming: The literature states that if a person loses 3% to 5% of their body weight, a person could reverse the steatosis and the inflammation of the liver. If a person loses up to 10% of their body weight, they could experience regression of the fibrosis. We always aim for a healthy weight, and recommend weight loss in people who have obesity. There are many diets out there, and not one fits all. People can get confused. I have heard patients say, “I used this diet” or “that diet,” “but it didn't work.” That is why taking a multidisciplinary approach can be very helpful.

I recommend removing sugars and saturated fats as a first step. A daily exercise program must be included for each individual that includes at least 150 minutes of aerobic and intense activity a week. I also recommend coffee. Studies have shown that adding four to five cups of coffee a day without milk or sugar is beneficial for those who can handle it. It is also important to always ask patients what they want to do and what treatment plan they would like to try. Patients with fatty liver disease should be involved in their own care and need to understand their disease. For that reason, I take the time to clarify and discuss their concerns. I emphasize the need to get their input so the plan can be successful. As a member of the multidisciplinary team, I encourage my patients and celebrate their own efforts because I want them to feel confident to continue a working plan.

Q: How does stress impact NAFLD, and what do you recommend in that regard?

Dr. Wakim-Fleming: One of the management aspects of treating NAFLD is to assess a person's level of stress. Some of us manage stress by overeating or drinking alcohol, a phenomenon that I saw during the 2020 pandemic. Some of my patients who had lost weight in 2019 and 2018 gained it back in 2020. Management of stress is very integral to the management of fatty liver disease and is one of the first topics I cover with my patients.

In terms of what clinicians should recommend for stress, it depends on what the needs are. For instance, stress can be addressed with mindfulness-based stress reduction, meditation, yoga, and walking every day, according to a person's abilities. Sometimes people need assistance from a psychologist. Maybe patients are depressed and need treatment for their depression or they have an eating disorder. It is important for patients to receive the resources that they need to help manage stress and to feel good about themselves. This kind of confidence and encouragement will keep them on track to continue to pursue the road to healing their body and mind.

Q: What further advice do you have for clinicians who are seeing patients, and when should they be thinking about this condition?

Dr. Wakim-Fleming: Primary care doctors are essential in first recognizing this disease. As silent as it can be, if they think about it, they will find it early. There is hope for people who have this condition especially when it is caught early. Educating patients about their health and getting them involved in the treatment plan are also important. I encourage them to follow up with a primary care doctor. A few patients I see in my clinic have not seen a primary care doctor in years. Being a silent disease in the most part, they will miss out on many opportunities for recognizing and reversing the disease.▪