Re: Should We Screen Children for Fatty Liver Disease?

[Guest guest]

Every single child referred to the Ped's GI clinic for elevated LFTs ('fatty

liver') were overweight/obese.

Treatment = lifestyle changes for the entire family to promote healthy growth

w/o any further weight gain (or sometimes reasonable weight loss): stop the

sugar beverages (including juice), increase vegetables, whole grains (instead of

white processed foods), PORTION control, decreased fried foods, and MOVE (i.e.

get off that couch).

It's like beating my head against a wall, though. Even the 'scare' of liver

disease was not enough motivation for any of these families to follow-through

with recommendations.

 

Screen for pediatric obesity in the pediatrician's office. If they are BMI >85th

%ile, frank talk about all of the above issues. No reason for expensive lab

tests. 

 

[getting on my soap box]

 

But even that is a dead end. Every time I get a phone call from a parent (or a

pediatricians office) " my child needs to lose weight " I will explain what I do

(visit the home and review healthy family lifestyle, etc). When asked about

insurance I have to explain it's not covered by any insurance nor Medicaid. When

asked how much for this home visit, the response they give me is " I'll have to

talk it over with my husband....I'll have to get back with you " and I never hear

from them again. It feels like they want " free " magic wand that I can give them

a pill/potion that makes their child's weight go away without any cost/effort. 

Sigh.

 

 Holly

----------

Holly Lee Brewer, MS RD CDE

Pediatric Dietitian, Diabetes Educator

Medical Nutrition Therapist, Las Vegas, NV

Maj Holly Brewer, USAFR BSC http://hollyinbalad.blogspot.com

301st MDS, NAS JRB Fort Worth (Carswell), TX

Joint Base Balad, Iraq (Jan-Jul 2009)

>To: RD-USA <rd-usa >

>Sent: Tuesday, August 16, 2011 3:02 PM

>Subject: Should We Screen Children for Fatty Liver Disease?

>

>

> 

>Question

>

>With the increasing rates of obesity in children, what are the current

>recommendations for screening for, and management of, fatty liver disease?

>*Response from F. Balistreri, MD*

>Professor of Medicine, University of Cincinnati College of Medicine,

>Cincinnati, Ohio; Staff Physician, Cincinnati Children's Hospital Medical

>Center, Cincinnati, Ohio

>

>The latest data suggest that 16% of children in the United States are obese

>and 32% are overweight.[1] Therefore, concern about the prevalence of

>nonalcoholic fatty liver disease (NAFLD) or the progressive form of fatty

>liver disease -- nonalcoholic steatohepatitis (NASH) -- is appropriate.

>Recent studies have indicated a progressive rise in the prevalence of NAFLD

>to its present status as the most common cause of chronic liver disease in

>adults in the United States.[2] A similar trend is anticipated for the

>pediatric population. At present, the prevalences of NAFLD and NASH in

>children are unknown because affected children are most often asymptomatic,

>perhaps manifesting only mild fatigue and obstructive sleep apnea. One clue

>to recognition is the close association between metabolic syndrome

>(hypertension, hypertriglyceridemia, and central adiposity) and NAFLD in

>children.[3] As in adults, waist circumference is a significant correlate of

>insulin resistance and fatty liver in children.[4]

>

>[snipped for brevity]

[Guest guest]

Every single child referred to the Ped's GI clinic for elevated LFTs ('fatty

liver') were overweight/obese.

Treatment = lifestyle changes for the entire family to promote healthy growth

w/o any further weight gain (or sometimes reasonable weight loss): stop the

sugar beverages (including juice), increase vegetables, whole grains (instead of

white processed foods), PORTION control, decreased fried foods, and MOVE (i.e.

get off that couch).

It's like beating my head against a wall, though. Even the 'scare' of liver

disease was not enough motivation for any of these families to follow-through

with recommendations.

 

Screen for pediatric obesity in the pediatrician's office. If they are BMI >85th

%ile, frank talk about all of the above issues. No reason for expensive lab

tests. 

 

[getting on my soap box]

 

But even that is a dead end. Every time I get a phone call from a parent (or a

pediatricians office) " my child needs to lose weight " I will explain what I do

(visit the home and review healthy family lifestyle, etc). When asked about

insurance I have to explain it's not covered by any insurance nor Medicaid. When

asked how much for this home visit, the response they give me is " I'll have to

talk it over with my husband....I'll have to get back with you " and I never hear

from them again. It feels like they want " free " magic wand that I can give them

a pill/potion that makes their child's weight go away without any cost/effort. 

Sigh.

 

 Holly

----------

Holly Lee Brewer, MS RD CDE

Pediatric Dietitian, Diabetes Educator

Medical Nutrition Therapist, Las Vegas, NV

Maj Holly Brewer, USAFR BSC http://hollyinbalad.blogspot.com

301st MDS, NAS JRB Fort Worth (Carswell), TX

Joint Base Balad, Iraq (Jan-Jul 2009)

>To: RD-USA <rd-usa >

>Sent: Tuesday, August 16, 2011 3:02 PM

>Subject: Should We Screen Children for Fatty Liver Disease?

>

>

> 

>Question

>

>With the increasing rates of obesity in children, what are the current

>recommendations for screening for, and management of, fatty liver disease?

>*Response from F. Balistreri, MD*

>Professor of Medicine, University of Cincinnati College of Medicine,

>Cincinnati, Ohio; Staff Physician, Cincinnati Children's Hospital Medical

>Center, Cincinnati, Ohio

>

>The latest data suggest that 16% of children in the United States are obese

>and 32% are overweight.[1] Therefore, concern about the prevalence of

>nonalcoholic fatty liver disease (NAFLD) or the progressive form of fatty

>liver disease -- nonalcoholic steatohepatitis (NASH) -- is appropriate.

>Recent studies have indicated a progressive rise in the prevalence of NAFLD

>to its present status as the most common cause of chronic liver disease in

>adults in the United States.[2] A similar trend is anticipated for the

>pediatric population. At present, the prevalences of NAFLD and NASH in

>children are unknown because affected children are most often asymptomatic,

>perhaps manifesting only mild fatigue and obstructive sleep apnea. One clue

>to recognition is the close association between metabolic syndrome

>(hypertension, hypertriglyceridemia, and central adiposity) and NAFLD in

>children.[3] As in adults, waist circumference is a significant correlate of

>insulin resistance and fatty liver in children.[4]

>

>[snipped for brevity]

[Guest guest]

Amen Holly!!!! Well said. It really is frustrating, and I lose clients too

when they find out they actually have to make efforts, make changes and move

more.

Treatment = lifestyle changes for the entire family to promote healthy growth

w/o any further weight gain (or sometimes reasonable weight loss): stop the

sugar beverages (including juice), increase vegetables, whole grains (instead of

white processed foods), PORTION control, decreased fried foods, and MOVE (i.e.

get off that couch).

It's like beating my head against a wall, though. Even the 'scare' of liver

disease was not enough motivation for any of these families to follow-through

with recommendations.

The real problem lies with the food and beverage industry. Why aren't they

being targeted? Why is it that they are producing lethal foods, advertising it

to the hilt, then the people who are eating it get ushered right into

medications to solve the

critical health problems that occur as a result of food processing and food

manipulation. How is THAT being allowed? I am convinced there is a direct link

between the food and beverage industry and Pharma - they are working hand in

hand to herd people like cattle, right into the arms of lifetime drugs!!!

Does anyone else concur?

Jacquelyn A. Pressly, RD, CLT

The NATURAL dietitian

Specializing in Wellness and Prevention, Personal Nutrition Coaching

and Designer Lifestyle Plans to help you get on the health track

Northeast Ohio & Western Pennsylvania

Internet and telecounseling available for distance clients

jpress50@...

If you are what you eat, then dietitians are the doctors of the future

Should We Screen Children for Fatty Liver Disease?

>

>

>

>Question

>

>With the increasing rates of obesity in children, what are the current

>recommendations for screening for, and management of, fatty liver disease?

>*Response from F. Balistreri, MD*

>Professor of Medicine, University of Cincinnati College of Medicine,

>Cincinnati, Ohio; Staff Physician, Cincinnati Children's Hospital Medical

>Center, Cincinnati, Ohio

>

>The latest data suggest that 16% of children in the United States are obese

>and 32% are overweight.[1] Therefore, concern about the prevalence of

>nonalcoholic fatty liver disease (NAFLD) or the progressive form of fatty

>liver disease -- nonalcoholic steatohepatitis (NASH) -- is appropriate.

>Recent studies have indicated a progressive rise in the prevalence of NAFLD

>to its present status as the most common cause of chronic liver disease in

>adults in the United States.[2] A similar trend is anticipated for the

>pediatric population. At present, the prevalences of NAFLD and NASH in

>children are unknown because affected children are most often asymptomatic,

>perhaps manifesting only mild fatigue and obstructive sleep apnea. One clue

>to recognition is the close association between metabolic syndrome

>(hypertension, hypertriglyceridemia, and central adiposity) and NAFLD in

>children.[3] As in adults, waist circumference is a significant correlate of

>insulin resistance and fatty liver in children.[4]

>

>[snipped for brevity]

[Guest guest]

Amen Holly!!!! Well said. It really is frustrating, and I lose clients too

when they find out they actually have to make efforts, make changes and move

more.

Treatment = lifestyle changes for the entire family to promote healthy growth

w/o any further weight gain (or sometimes reasonable weight loss): stop the

sugar beverages (including juice), increase vegetables, whole grains (instead of

white processed foods), PORTION control, decreased fried foods, and MOVE (i.e.

get off that couch).

It's like beating my head against a wall, though. Even the 'scare' of liver

disease was not enough motivation for any of these families to follow-through

with recommendations.

The real problem lies with the food and beverage industry. Why aren't they

being targeted? Why is it that they are producing lethal foods, advertising it

to the hilt, then the people who are eating it get ushered right into

medications to solve the

critical health problems that occur as a result of food processing and food

manipulation. How is THAT being allowed? I am convinced there is a direct link

between the food and beverage industry and Pharma - they are working hand in

hand to herd people like cattle, right into the arms of lifetime drugs!!!

Does anyone else concur?

Jacquelyn A. Pressly, RD, CLT

The NATURAL dietitian

Specializing in Wellness and Prevention, Personal Nutrition Coaching

and Designer Lifestyle Plans to help you get on the health track

Northeast Ohio & Western Pennsylvania

Internet and telecounseling available for distance clients

jpress50@...

If you are what you eat, then dietitians are the doctors of the future

Should We Screen Children for Fatty Liver Disease?

>

>

>

>Question

>

>With the increasing rates of obesity in children, what are the current

>recommendations for screening for, and management of, fatty liver disease?

>*Response from F. Balistreri, MD*

>Professor of Medicine, University of Cincinnati College of Medicine,

>Cincinnati, Ohio; Staff Physician, Cincinnati Children's Hospital Medical

>Center, Cincinnati, Ohio

>

>The latest data suggest that 16% of children in the United States are obese

>and 32% are overweight.[1] Therefore, concern about the prevalence of

>nonalcoholic fatty liver disease (NAFLD) or the progressive form of fatty

>liver disease -- nonalcoholic steatohepatitis (NASH) -- is appropriate.

>Recent studies have indicated a progressive rise in the prevalence of NAFLD

>to its present status as the most common cause of chronic liver disease in

>adults in the United States.[2] A similar trend is anticipated for the

>pediatric population. At present, the prevalences of NAFLD and NASH in

>children are unknown because affected children are most often asymptomatic,

>perhaps manifesting only mild fatigue and obstructive sleep apnea. One clue

>to recognition is the close association between metabolic syndrome

>(hypertension, hypertriglyceridemia, and central adiposity) and NAFLD in

>children.[3] As in adults, waist circumference is a significant correlate of

>insulin resistance and fatty liver in children.[4]

>

>[snipped for brevity]

[Guest guest]

I think we need to start with the SNAP(foodstamps)and other gov't programs

(school lunch, etc.). SNAP is a huge program and if you take those foods

out of the program companies will follow with healthier foods IMHO. Not sure

we need more gov't intervention.

> **

>

>

> Amen Holly!!!! Well said. It really is frustrating, and I lose clients too

> when they find out they actually have to make efforts, make changes and move

> more.

>

> Treatment = lifestyle changes for the entire family to promote healthy

> growth w/o any further weight gain (or sometimes reasonable weight loss):

> stop the sugar beverages (including juice), increase vegetables, whole

> grains (instead of white processed foods), PORTION control, decreased fried

> foods, and MOVE (i.e. get off that couch).

> It's like beating my head against a wall, though. Even the 'scare' of liver

> disease was not enough motivation for any of these families to

> follow-through with recommendations.

>

> The real problem lies with the food and beverage industry. Why aren't they

> being targeted? Why is it that they are producing lethal foods, advertising

> it to the hilt, then the people who are eating it get ushered right into

> medications to solve the

> critical health problems that occur as a result of food processing and food

> manipulation. How is THAT being allowed? I am convinced there is a direct

> link between the food and beverage industry and Pharma - they are working

> hand in hand to herd people like cattle, right into the arms of lifetime

> drugs!!!

>

> Does anyone else concur?

>

> Jacquelyn A. Pressly, RD, CLT

> The NATURAL dietitian

> Specializing in Wellness and Prevention, Personal Nutrition Coaching

> and Designer Lifestyle Plans to help you get on the health track

> Northeast Ohio & Western Pennsylvania

> Internet and telecounseling available for distance clients

>

> jpress50@...

>

> If you are what you eat, then dietitians are the doctors of the future

>

>

> Should We Screen Children for Fatty Liver Disease?

> >

> >

> >

> >Question

> >

> >With the increasing rates of obesity in children, what are the current

> >recommendations for screening for, and management of, fatty liver disease?

> >*Response from F. Balistreri, MD*

> >Professor of Medicine, University of Cincinnati College of Medicine,

> >Cincinnati, Ohio; Staff Physician, Cincinnati Children's Hospital Medical

> >Center, Cincinnati, Ohio

> >

> >The latest data suggest that 16% of children in the United States are

> obese

> >and 32% are overweight.[1] Therefore, concern about the prevalence of

> >nonalcoholic fatty liver disease (NAFLD) or the progressive form of fatty

> >liver disease -- nonalcoholic steatohepatitis (NASH) -- is appropriate.

> >Recent studies have indicated a progressive rise in the prevalence of

> NAFLD

> >to its present status as the most common cause of chronic liver disease in

> >adults in the United States.[2] A similar trend is anticipated for the

> >pediatric population. At present, the prevalences of NAFLD and NASH in

> >children are unknown because affected children are most often

> asymptomatic,

> >perhaps manifesting only mild fatigue and obstructive sleep apnea. One

> clue

> >to recognition is the close association between metabolic syndrome

> >(hypertension, hypertriglyceridemia, and central adiposity) and NAFLD in

> >children.[3] As in adults, waist circumference is a significant correlate

> of

> >insulin resistance and fatty liver in children.[4]

> >

> >[snipped for brevity]

>

>

[Guest guest]

Should We Screen Children for Fatty Liver Disease?

Question

With the increasing rates of obesity in children, what are the current

recommendations for screening for, and management of, fatty liver disease?

*Response from F. Balistreri, MD*

Professor of Medicine, University of Cincinnati College of Medicine,

Cincinnati, Ohio; Staff Physician, Cincinnati Children's Hospital Medical

Center, Cincinnati, Ohio

The latest data suggest that 16% of children in the United States are obese

and 32% are overweight.[1] Therefore, concern about the prevalence of

nonalcoholic fatty liver disease (NAFLD) or the progressive form of fatty

liver disease -- nonalcoholic steatohepatitis (NASH) -- is appropriate.

Recent studies have indicated a progressive rise in the prevalence of NAFLD

to its present status as the most common cause of chronic liver disease in

adults in the United States.[2] A similar trend is anticipated for the

pediatric population. At present, the prevalences of NAFLD and NASH in

children are unknown because affected children are most often asymptomatic,

perhaps manifesting only mild fatigue and obstructive sleep apnea. One clue

to recognition is the close association between metabolic syndrome

(hypertension, hypertriglyceridemia, and central adiposity) and NAFLD in

children.[3] As in adults, waist circumference is a significant correlate of

insulin resistance and fatty liver in children.[4]

The pathogenesis of NAFLD is the subject of multiple ongoing studies. One

element that has become abundantly clear is the strong influence of genetic

susceptibility. Schwimmer and colleagues documented fatty liver in 59% of

the siblings of children with NAFLD and in 78% of their parents; this was a

significantly higher incidence than that seen in siblings (17%) and parents

(37%) of children without NAFLD.[5] Furthermore, recent studies suggest that

specific genetic variation in *PNPLA3* (a variant that confers genetic

susceptibility to liver damage) is associated with increased levels of liver

enzymes in children.[6,7] This predisposition to NAFLD is strongly

influenced by the environment, including a high intake of added sugar and

consumption of fructose-sweetened beverages.[8]

Unfortunately, no guidelines on screening strategies for fatty liver have

been established. Obviously, the first step is recognition that a child is

overweight or obese. Although clear definitions for body mass index exist, a

large percentage of overweight and obese children and adolescents remain

undiagnosed.[9]

The next step -- case finding for fatty liver disease -- is equally

challenging because the ideal test is lacking.[10] NAFLD is not consistently

or easily recognized. Traditionally, the diagnosis has relied on the

detection of markers of liver injury such as aspartate aminotransferase

(AST)/alanine aminotransferase (ALT) levels, fatty infiltration (on

ultrasound or MRI), or assessment of fibrosis through the use of stiffness

measurements.[11] However, these currently used methods cannot distinguish

NASH from NAFLD, thus liver biopsy remains the gold standard for staging and

grading. Multiple novel noninvasive methods for diagnosis and monitoring of

NASH and NAFLD have been proposed, such as clinical scoring systems based on

markers of fibrosis or fibrinogenesis.[12] These methods may help sort out

which patients are candidates for liver biopsy.

The question that ultimately arises is: why should we be concerned about

this disorder? We have recognized rapid progression of fibrosis in children

with NASH/NAFLD over a short period of time.[13] Therefore, early detection

with an attempt at intervention is clearly warranted. This may be the only

way to forestall the projected epidemic of NASH cirrhosis in young adults in

the next decade.

With respect to management, the Institute of Medicine has recently released

early childhood obesity prevention policies that outline specific goals,

recommendations, and potential actions.[14] The major objective is

prevention through lifestyle modifications, such as promoting exercise and

ensuring adequate nutrition for children, including the avoidance of added

sugars. This is coupled with the minimization of " screen time " (TV and

computers). Lifestyle modification is clearly warranted for all children

with NAFLD because these measures have proven to be effective if adherence

can be achieved, as shown in a recent study.[15] In this prospective cohort

study, liver enzymes and steatosis decreased during a rigorous program of

weight reduction through dietary and exercise recommendations.[15] In

desperate situations, with significant comorbidities, bariatric surgery has

been shown to lead to regression of advanced fibrosis.[16]

The quest for the " magic pill " to treat NAFLD has been less fruitful, with

most proposed treatment strategies shown to be ineffective when subjected to

placebo-controlled trials. A recent study of adults with NASH showed that

vitamin E therapy (compared with placebo) was associated with a reduction in

serum AST and ALT levels and a documented reduction in steatosis (*P* =

..005) and lobular inflammation (*P* = .02) but no improvement in fibrosis

scores (*P* = .24).[17]

In a similar fashion, the results of a study of the effect of vitamin E or

metformin for treatment of NASH/NAFLD in children and adolescents (the

Treatment of Nonalcoholic Fatty Liver Disease in Children [TONIC] trial)

were recently published.[18] Neither vitamin E nor metformin was superior to

placebo in achieving the primary outcome of a sustained reduction in ALT

levels after 2 years. However, children with biopsy-proven NASH treated with

vitamin E had significant improvement in secondary histologic outcomes,

specifically an improvement over placebo in the degree of hepatocellular

ballooning degeneration. This suggests that perhaps long-term administration

of this antioxidant may lead to resolution of NASH.

The bottom line is that, just like in adults, NAFLD may now be the most

common form of chronic liver disease in children. The incidence is likely to

increase given the unabated epidemic of pediatric obesity. Treatment options

are limited and pediatric screening and management guidelines are lacking.

As in many pediatric diseases, the most effective strategy is prevention.

www.medscape.com

--

Ortiz, MS, RD

*The FRUGAL Dietitian* <http://www.thefrugaldietitian.com>

Check out my blog: mixture of deals and nutrition

Join me on Facebook <http://www.facebook.com/TheFrugalDietitian?ref=ts>

* " If it works and research proven, it wouldn't be called Alternative " *

[Guest guest]

Should We Screen Children for Fatty Liver Disease?

Question

With the increasing rates of obesity in children, what are the current

recommendations for screening for, and management of, fatty liver disease?

*Response from F. Balistreri, MD*

Professor of Medicine, University of Cincinnati College of Medicine,

Cincinnati, Ohio; Staff Physician, Cincinnati Children's Hospital Medical

Center, Cincinnati, Ohio

The latest data suggest that 16% of children in the United States are obese

and 32% are overweight.[1] Therefore, concern about the prevalence of

nonalcoholic fatty liver disease (NAFLD) or the progressive form of fatty

liver disease -- nonalcoholic steatohepatitis (NASH) -- is appropriate.

Recent studies have indicated a progressive rise in the prevalence of NAFLD

to its present status as the most common cause of chronic liver disease in

adults in the United States.[2] A similar trend is anticipated for the

pediatric population. At present, the prevalences of NAFLD and NASH in

children are unknown because affected children are most often asymptomatic,

perhaps manifesting only mild fatigue and obstructive sleep apnea. One clue

to recognition is the close association between metabolic syndrome

(hypertension, hypertriglyceridemia, and central adiposity) and NAFLD in

children.[3] As in adults, waist circumference is a significant correlate of

insulin resistance and fatty liver in children.[4]

The pathogenesis of NAFLD is the subject of multiple ongoing studies. One

element that has become abundantly clear is the strong influence of genetic

susceptibility. Schwimmer and colleagues documented fatty liver in 59% of

the siblings of children with NAFLD and in 78% of their parents; this was a

significantly higher incidence than that seen in siblings (17%) and parents

(37%) of children without NAFLD.[5] Furthermore, recent studies suggest that

specific genetic variation in *PNPLA3* (a variant that confers genetic

susceptibility to liver damage) is associated with increased levels of liver

enzymes in children.[6,7] This predisposition to NAFLD is strongly

influenced by the environment, including a high intake of added sugar and

consumption of fructose-sweetened beverages.[8]

Unfortunately, no guidelines on screening strategies for fatty liver have

been established. Obviously, the first step is recognition that a child is

overweight or obese. Although clear definitions for body mass index exist, a

large percentage of overweight and obese children and adolescents remain

undiagnosed.[9]

The next step -- case finding for fatty liver disease -- is equally

challenging because the ideal test is lacking.[10] NAFLD is not consistently

or easily recognized. Traditionally, the diagnosis has relied on the

detection of markers of liver injury such as aspartate aminotransferase

(AST)/alanine aminotransferase (ALT) levels, fatty infiltration (on

ultrasound or MRI), or assessment of fibrosis through the use of stiffness

measurements.[11] However, these currently used methods cannot distinguish

NASH from NAFLD, thus liver biopsy remains the gold standard for staging and

grading. Multiple novel noninvasive methods for diagnosis and monitoring of

NASH and NAFLD have been proposed, such as clinical scoring systems based on

markers of fibrosis or fibrinogenesis.[12] These methods may help sort out

which patients are candidates for liver biopsy.

The question that ultimately arises is: why should we be concerned about

this disorder? We have recognized rapid progression of fibrosis in children

with NASH/NAFLD over a short period of time.[13] Therefore, early detection

with an attempt at intervention is clearly warranted. This may be the only

way to forestall the projected epidemic of NASH cirrhosis in young adults in

the next decade.

With respect to management, the Institute of Medicine has recently released

early childhood obesity prevention policies that outline specific goals,

recommendations, and potential actions.[14] The major objective is

prevention through lifestyle modifications, such as promoting exercise and

ensuring adequate nutrition for children, including the avoidance of added

sugars. This is coupled with the minimization of " screen time " (TV and

computers). Lifestyle modification is clearly warranted for all children

with NAFLD because these measures have proven to be effective if adherence

can be achieved, as shown in a recent study.[15] In this prospective cohort

study, liver enzymes and steatosis decreased during a rigorous program of

weight reduction through dietary and exercise recommendations.[15] In

desperate situations, with significant comorbidities, bariatric surgery has

been shown to lead to regression of advanced fibrosis.[16]

The quest for the " magic pill " to treat NAFLD has been less fruitful, with

most proposed treatment strategies shown to be ineffective when subjected to

placebo-controlled trials. A recent study of adults with NASH showed that

vitamin E therapy (compared with placebo) was associated with a reduction in

serum AST and ALT levels and a documented reduction in steatosis (*P* =

..005) and lobular inflammation (*P* = .02) but no improvement in fibrosis

scores (*P* = .24).[17]

In a similar fashion, the results of a study of the effect of vitamin E or

metformin for treatment of NASH/NAFLD in children and adolescents (the

Treatment of Nonalcoholic Fatty Liver Disease in Children [TONIC] trial)

were recently published.[18] Neither vitamin E nor metformin was superior to

placebo in achieving the primary outcome of a sustained reduction in ALT

levels after 2 years. However, children with biopsy-proven NASH treated with

vitamin E had significant improvement in secondary histologic outcomes,

specifically an improvement over placebo in the degree of hepatocellular

ballooning degeneration. This suggests that perhaps long-term administration

of this antioxidant may lead to resolution of NASH.

The bottom line is that, just like in adults, NAFLD may now be the most

common form of chronic liver disease in children. The incidence is likely to

increase given the unabated epidemic of pediatric obesity. Treatment options

are limited and pediatric screening and management guidelines are lacking.

As in many pediatric diseases, the most effective strategy is prevention.

www.medscape.com

--

Ortiz, MS, RD

*The FRUGAL Dietitian* <http://www.thefrugaldietitian.com>

Check out my blog: mixture of deals and nutrition

Join me on Facebook <http://www.facebook.com/TheFrugalDietitian?ref=ts>

* " If it works and research proven, it wouldn't be called Alternative " *

[Guest guest]

Should We Screen Children for Fatty Liver Disease?

Question

With the increasing rates of obesity in children, what are the current

recommendations for screening for, and management of, fatty liver disease?

*Response from F. Balistreri, MD*

Professor of Medicine, University of Cincinnati College of Medicine,

Cincinnati, Ohio; Staff Physician, Cincinnati Children's Hospital Medical

Center, Cincinnati, Ohio

The latest data suggest that 16% of children in the United States are obese

and 32% are overweight.[1] Therefore, concern about the prevalence of

nonalcoholic fatty liver disease (NAFLD) or the progressive form of fatty

liver disease -- nonalcoholic steatohepatitis (NASH) -- is appropriate.

Recent studies have indicated a progressive rise in the prevalence of NAFLD

to its present status as the most common cause of chronic liver disease in

adults in the United States.[2] A similar trend is anticipated for the

pediatric population. At present, the prevalences of NAFLD and NASH in

children are unknown because affected children are most often asymptomatic,

perhaps manifesting only mild fatigue and obstructive sleep apnea. One clue

to recognition is the close association between metabolic syndrome

(hypertension, hypertriglyceridemia, and central adiposity) and NAFLD in

children.[3] As in adults, waist circumference is a significant correlate of

insulin resistance and fatty liver in children.[4]

The pathogenesis of NAFLD is the subject of multiple ongoing studies. One

element that has become abundantly clear is the strong influence of genetic

susceptibility. Schwimmer and colleagues documented fatty liver in 59% of

the siblings of children with NAFLD and in 78% of their parents; this was a

significantly higher incidence than that seen in siblings (17%) and parents

(37%) of children without NAFLD.[5] Furthermore, recent studies suggest that

specific genetic variation in *PNPLA3* (a variant that confers genetic

susceptibility to liver damage) is associated with increased levels of liver

enzymes in children.[6,7] This predisposition to NAFLD is strongly

influenced by the environment, including a high intake of added sugar and

consumption of fructose-sweetened beverages.[8]

Unfortunately, no guidelines on screening strategies for fatty liver have

been established. Obviously, the first step is recognition that a child is

overweight or obese. Although clear definitions for body mass index exist, a

large percentage of overweight and obese children and adolescents remain

undiagnosed.[9]

The next step -- case finding for fatty liver disease -- is equally

challenging because the ideal test is lacking.[10] NAFLD is not consistently

or easily recognized. Traditionally, the diagnosis has relied on the

detection of markers of liver injury such as aspartate aminotransferase

(AST)/alanine aminotransferase (ALT) levels, fatty infiltration (on

ultrasound or MRI), or assessment of fibrosis through the use of stiffness

measurements.[11] However, these currently used methods cannot distinguish

NASH from NAFLD, thus liver biopsy remains the gold standard for staging and

grading. Multiple novel noninvasive methods for diagnosis and monitoring of

NASH and NAFLD have been proposed, such as clinical scoring systems based on

markers of fibrosis or fibrinogenesis.[12] These methods may help sort out

which patients are candidates for liver biopsy.

The question that ultimately arises is: why should we be concerned about

this disorder? We have recognized rapid progression of fibrosis in children

with NASH/NAFLD over a short period of time.[13] Therefore, early detection

with an attempt at intervention is clearly warranted. This may be the only

way to forestall the projected epidemic of NASH cirrhosis in young adults in

the next decade.

With respect to management, the Institute of Medicine has recently released

early childhood obesity prevention policies that outline specific goals,

recommendations, and potential actions.[14] The major objective is

prevention through lifestyle modifications, such as promoting exercise and

ensuring adequate nutrition for children, including the avoidance of added

sugars. This is coupled with the minimization of " screen time " (TV and

computers). Lifestyle modification is clearly warranted for all children

with NAFLD because these measures have proven to be effective if adherence

can be achieved, as shown in a recent study.[15] In this prospective cohort

study, liver enzymes and steatosis decreased during a rigorous program of

weight reduction through dietary and exercise recommendations.[15] In

desperate situations, with significant comorbidities, bariatric surgery has

been shown to lead to regression of advanced fibrosis.[16]

The quest for the " magic pill " to treat NAFLD has been less fruitful, with

most proposed treatment strategies shown to be ineffective when subjected to

placebo-controlled trials. A recent study of adults with NASH showed that

vitamin E therapy (compared with placebo) was associated with a reduction in

serum AST and ALT levels and a documented reduction in steatosis (*P* =

..005) and lobular inflammation (*P* = .02) but no improvement in fibrosis

scores (*P* = .24).[17]

In a similar fashion, the results of a study of the effect of vitamin E or

metformin for treatment of NASH/NAFLD in children and adolescents (the

Treatment of Nonalcoholic Fatty Liver Disease in Children [TONIC] trial)

were recently published.[18] Neither vitamin E nor metformin was superior to

placebo in achieving the primary outcome of a sustained reduction in ALT

levels after 2 years. However, children with biopsy-proven NASH treated with

vitamin E had significant improvement in secondary histologic outcomes,

specifically an improvement over placebo in the degree of hepatocellular

ballooning degeneration. This suggests that perhaps long-term administration

of this antioxidant may lead to resolution of NASH.

The bottom line is that, just like in adults, NAFLD may now be the most

common form of chronic liver disease in children. The incidence is likely to

increase given the unabated epidemic of pediatric obesity. Treatment options

are limited and pediatric screening and management guidelines are lacking.

As in many pediatric diseases, the most effective strategy is prevention.

www.medscape.com

--

Ortiz, MS, RD

*The FRUGAL Dietitian* <http://www.thefrugaldietitian.com>

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