A Q&A With Dr. Niviann Blondet

Nonalcoholic fatty liver disease (NAFLD) – the accumulation of fat in the liver – is the most common liver disorder in the United States, affecting approximately 10% of children. Although incidence is increasing, this condition is uniquely difficult to diagnose.

To address this issue, Seattle Children’s has opened a new Fatty Liver Clinic to treat patients with a multidisciplinary approach.

“We estimate about 10 million children have fatty liver disease, but there’s a large population that goes undiagnosed,” said Dr. Niviann Blondet, a gastroenterologist at Children’s. “It’s not until they develop cirrhosis that they seek medical attention.”

Dr. Blondet offers the following information to providers in hopes that patients might be diagnosed sooner and treated more effectively.

What are the risk factors of NAFLD?

Obesity is the most significant risk factor. There is a direct correlation between NAFLD and body mass index (BMI). However, the disease can occur in children within a normal weight range.

The prevalence of NAFLD increases throughout childhood, possibly because BMI increases with age in children.

Studies have also shown an association with insulin resistance. NAFLD increases the risk of developing type 2 diabetes and may worsen glycemic control in children with diabetes and contribute to the development and progression of chronic diabetic complications.

Gender can also be a contributing factor. NAFLD is approximately 40% more common in boys than girls.

Is NAFLD more common among certain ethnicities?

Yes, the highest rates are seen in Hispanic children (12% to 14%). Other ethnicities, such as African American children, have higher rates of obesity and diabetes but significantly lower rates of NAFLD (2% to 6%). We aren’t sure why this is, but recent research suggests the prevalence may be explained by genetic polymorphisms.

What we have seen with fatty liver is what we call a two-hit hypothesis, meaning patients get fat infiltration in the liver, but it may not cause inflammation until a second hit happens, such as a worsening of diet, development of worsening obesity or diabetes. Hispanics tend to have the predisposition to accumulate fat in their liver compared to other ethnicities.

What should providers know about the Hispanic culture to better care for these patients?

Family is very important in the Hispanic culture, and food is an integral part of family life. Being obese or overweight can be viewed as a sign of good health in this culture.

I am Hispanic, and all three of my brothers were obese. Still, my mom denies that they were ever fat. Even though we had called my baby brother “Gordito,” she is offended by the suggestion that he was overweight.

When I see Hispanic children with a high BMI, I ask the parents about their dietary habits at home. I ask about the grandparents and other caregivers, too. I once had a patient who had lost 20 pounds over 6 months, then went to Grandma’s house for Christmas and in 1 month gained those 20 pounds back.

Is there a stigma around this disease?

Families sometimes get offended when we call this disease fatty liver, because they think of “fat” as a derogatory term. But obesity does affect health. We need to call it what it is and explain to the families how they can approach food in a healthier way.

What are the long-term impacts of this disease?

Fatty liver disease is going to become the most common cause for liver transplant in the adult setting in the next 10 years. If patients are obese, they’re not going to qualify for a transplant. It’s going to become a logistical and ethical challenge to identify who will benefit from a liver transplant for fatty liver, especially in cases where doctors have been advising their patients to lose weight for decades.

We need to increase awareness of NAFLD so we can intervene while our patients are still children.

Why is NAFLD difficult to diagnose?

There are no standardized guidelines to screen for NAFLD and professional society recommendations are conflicting. At Children’s, we align with the American Academy of Pediatrics (AAP) recommendation that all obese children, 12 and older, should have their liver enzymes checked.

Unfortunately, this is not always an effective screening method. Patients who have NAFLD can still have normal biomarkers. They may have an infiltration of fat in their liver but it is not yet affecting them enough to influence their alanine transaminase (ALT) and aspartate transaminase (AST).

These patients are particularly susceptible to serious liver damage because they are less likely to be retested in the future. They feel fine and their families see them as healthy, so they don’t establish care with a liver doctor who can monitor their disease.

What makes this disease difficult to treat?

Treating NAFLD effectively requires patients to lose weight. It can be difficult to convince patients and families to make lifestyle changes. In some cases, the patient doesn’t feel sick and their families view them as happy and healthy, so they continue being sedentary and gaining weight.

Additionally, many children who have fatty liver disease are depressed. Studies have found that children and adults with NAFLD report significantly lower quality-of-life and mental health scores than the general population.

Often, these patients don’t participate in any activities and are inside the house much of the time. They don’t have a lot of friends to engage with. They lack the motivation and direction to make healthy lifestyle changes.

How is Children’s new Fatty Liver Clinic going to address these issues?

Children’s offers a multidisciplinary approach to treating NAFLD disease, which includes addressing their underlying obesity. We work closely with Dr. Grace Kim, an endocrinologist who has a special interest in this population. We have also partnered with Nutrition, Psychology and personal trainers to help our patients lose weight.

How can referring providers and primary care physicians help?

Have a high level of suspicion. Think about fatty liver in all obese children. Follow the AAP guidelines and screen all obese patients over age 12 for elevated liver enzymes. If they are abnormal, even if it’s in the lower level of abnormality, send them to see Children’s Gastroenterology and Hepatology. If they’re normal, repeat the test in a year.