By Scott Howell, D.O., MPH&TM, CPE, Advisor to Echosens
Physician practices providing integrative medicine (IM) understand the value of healing-oriented medicine that treats the whole person, including all aspects of patient lifestyles. The emphasis of the therapeutic relationship between practitioner and patient is informed by evidence and utilizes every appropriate therapy to meet the patient’s health needs.
Today, there is an opportunity for IM practices to help reverse the nation’s liver disease epidemic through early detection and monitoring of non-alcoholic fatty liver disease (NAFLD): a spectrum of the disease characterized by the accumulation of lipids in liver cells not associated with the consumption of alcohol, and its more severe form non-alcoholic steatohepatitis (NASH).
People most at risk for developing NAFLD or NASH have obesity, Type 2 diabetes, hyperlipidemia and/or metabolic syndrome. In some cases, NASH may lead to cirrhosis, liver cancer and liver transplant. Estimates show that 357 million people will have NASH globally by 2030. NASH, which is mostly asymptomatic, often underdiagnosed and underreported, recently became the most common reason for a liver transplant in women and older patients.
More commonly, NAFLD is associated with a 2x increase in all-cause mortality in people with Type 2 diabetes over those diabetics without NAFLD and attributed to a 2x increase in cardiovascular mortality. NASH is associated with a 3x increase in all-cause mortality in this population, attributable to the addition of liver-related mortality.
IM Practices Take Positive Steps for Liver Health
Implementing an IM program that targets liver health can address the broader needs of patients and prevent them from developing NASH. In fact, this is a critical imperative given the costs and complications associated with NASH–a challenging, high-volume and chronic condition that lacks a standardized care delivery model.
Because NAFLD and NASH are so tightly intertwined with obesity, diabetes and lifestyle, a “whole person” approach to patient engagement is needed to support behavioral changes that will result in better outcomes across the co-morbid conditions affecting the individual patient. This is also the most cost-effective approach, with minimal impact on the IM physician’s practice.
IM practices should also consider integrating non-invasive, point-of-care liver examinations as a way to improve outcomes, lower costs and enhance income stream.
Understanding the Impact of NAFLD
NAFLD has become the most common chronic liver disease in the world and affects between 25% to 30% of adults in the United States. Comprised of a spectrum of disease severity, NAFLD ranges from simple steatosis to NASH and steatosis with hepatocyte inflammation, necrosis and fibrosis. About 20% of patients with NAFLD will progress to NASH, with around one-quarter of those developing liver fibrosis. Patients with NASH experience significantly increased mortality due to cirrhosis and hepatocellular carcinoma (HCC) and extrahepatic complications, such as CVD and malignancy.
For IM physicians, it is important to recognize NAFLD so that early intervention can be implemented. Lifestyle modifications and strict control of metabolic risk factors are the most effective treatment. Because disease progression is typically slow, patients can be managed well by primary care physicians. NAFLD patients with advanced liver fibrosis should be referred to specialist care for further assessment. While finding and managing fibrotic NASH is an important component to addressing liver disease, patients with steatosis alone are at a greater risk of cardiovascular mortality and morbidity.
Recent studies have suggested that NAFLD is often present as a comorbidity in patients with Type 2 diabetes. The mutual interrelationship between these conditions shows that Type 2 diabetes can exacerbate NAFLD by promoting progression to nonalcoholic hepatosteatosis or fibrosis, while NAFLD causes the natural course of diabetic complications to worsen in Type 2 diabetes patients.
Addressing the Consequences of NAFLD
The increasing prevalence and incidence of NAFLD with advanced fibrosis is concerning because patients appear to experience higher non-liver-related morbidity and mortality than the general population. Recent clinical evidence suggests that NAFLD is directly associated with an increased risk of cardio-metabolic disorders.
Implementing an IM program that targets liver health can address the broader needs of at-risk patients and prevent them from developing NASH. In fact, this is a critical imperative given the costs and complications associated with NASH. Although the NASH progression rate may be slower than other types of liver disease, the incidence of NASH, and its sequela hyperlipidemia, hypertension, Type 2 diabetes, obesity and metabolic syndrome, is increasing throughout the world. Currently, new NASH/antifibrotic therapies are being evaluated in clinical trials, although these drugs are expected to lead to even higher costs.
Weight loss is the best treatment option for NAFLD and fibrosis progression:
NAFLD is reversible if caught in the early stages and accompanied by lifestyle change. In many patients, a 5-7% decrease in body weight is associated with a reduction in liver fat and inflammation. Screening and early detection can help to prevent more serious conditions, such as end-stage liver disease or liver cancer.
Treatment Options for NAFLD
The liver is the key to insulin resistance, but the good news is that fatty liver can be improved without drugs. In fact, weight loss is the best treatment option for NALFD and the prevention of fibrosis progression.
If a patient loses 3% of weight this can lead to a 35% reversal in steatosis, with greater weight loss leading to lower inflammation, NASH resolution and, at 10% weight loss, fibrosis regression. This makes it clear that weight loss can be more efficient than drug intervention.
IM programs that effectively impact lifestyle changes are critical and have significantly greater cost-savings if effectively implemented and weight loss is maintained. Lifestyle modification for patients also improves comorbid conditions. The challenge is that lifestyle changes are not always sustainable or efficient. This is where a liver examination, combined with IM strategies, can optimize a drug-free and highly effective way to reverse liver damage.
Value of IM and Liver Exams
Given the challenge of low compliance in lifestyle changes, an IM plan to weight management can be effective in treating fatty liver and its underlying conditions. This means engaging the patient to focus on lifestyle management to achieve a long-term impact and prompt rapid and potentially meaningful changes in liver fat as estimated by a liver exam score, which can further validate the lifestyle interventions.
While the most common form of diagnostics includes measuring circulating markers of inflammation, such as alanine aminotransferase (ALT) and aspartate aminotransferase (AST), there are new technologies available for the diagnosis and monitoring of adult patients as part of an overall evaluation of liver health.
FibroScan, for example, is an FDA cleared technology for the diagnosis and monitoring of adult patients as part of an overall evaluation of liver health. And unlike blood tests which offer limited scope, this tool directly and non-invasively measures physical properties of stiffness and liver fat. FibroScan provides reproducible results, allowing for both diagnosis and monitoring of liver stiffness and liver fat. FibroScan has been recognized as a cost-effective tool for screening and also identifying cirrhosis in people with NAFLD. This information can support care management across key components of the metabolic syndrome – diabetes and hyperlipidemia. For more on FibroScan, see below.
Ultimately, an IM approach to care, combined with quantifiable information, can improve individual health outcomes, lower payer costs by avoiding expensive, invasive interventions and enhance the financial performance of IM practices.
FibroScan is a non-invasive technology that quickly provides a quantitative assessment of liver stiffness and liver fat at the point of care. As part of an overall patient assessment, FibroScan-based scores can be used to efficiently rule out the need for further assessment, like a painful liver biopsy, saving time and resources for people who do not require additional assessment for end-stage liver disease. Learn more here.