Diabetes and Liver Disease

A 62-year-old gentleman presented to our liver center with complaints of swelling of the legs since 6 months. He also complained of generalized weakness, fatigue, and loss of appetite. He was a diabetic since the past 20 years and had been overweight in the last 5 years. He did not consume alcohol. The patient used to visit his diabetes doctor regularly and had been told to have fatty liver on an ultrasound scan 2 years ago. A liver function test had been normal. Detailed investigations and scans of the liver done in our center showed that the patient had developed liver cirrhosis and had features of liver failure. Only a liver transplant could now give him long term survival. Visit us to know more about similar medications.

The prevalence of diabetes all over the world has increased considerably in the last 20 years. 19% of the adult population in UAE has diabetes. The most important factor contributing to this rising numbers is weight gain. Most people in middle east are getting overweight and this is related to food habits, sedentary lifestyle and lack of exercise. Even young people in the late 20s and early 30s are becoming obese. The primary reason for excess calorie intake is easy access to energy dense food i.e. food items with excess calories in a small portion such as fast foods, oily foods and sweets. A simple indicator to define overweight or obesity is the body mass index (BMI). This is a ratio of a person’s weight in relation to his height. You can calculate your BMI with an online calculator (http://www.calculator.net/bmi-calculator.html). BMI is used to categorize a person as underweight (BMI<18.5), normal weight (BMI 18.5-25), overweight (BMI 25-30), or obese (BMI >30). In the UAE, according to one survey, more than 43% people are overweight and 32% are obese (BMI>30). Another specific pattern of obesity seen in Middle East and Asia is abdominal obesity i.e. accumulation of fat in and around the belly. A waist >35 inches in women and >40 inches in men is classified as abdominal obesity. A person may have a normal BMI but presence of abdominal obesity itself increases the risk of diabetes. Analysis of long term demographic data has shown that the lifetime risk of developing diabetes at age 45 for a person with normal BMI is 12%, while in individuals with a BMI >30, this risk increases to 45%. Diabetics with high BMI are at much higher risk of developing diabetic complications viz. heart disease, stroke, kidney failure, liver disease, nervous system and eye problems. Most patients with diabetes are well aware that they can develop heart, kidney and eye diseases. Most doctors who treat diabetics also monitor for these associated diseases. However, most patients and a lot of doctors are not aware that the liver can also get affected in diabetes and can lead to serious complications including liver failure in some patients.

Diabetes essentially causes accumulation of fat in the liver. Since excess alcohol consumption also causes fatty liver, the diabetic fatty liver is known as non-alcoholic fatty liver disease (NAFLD). More than 50% of patients with diabetes have NAFLD.  Diabetics who are obese and have other associated problems such as high blood pressure, increased triglycerides have a higher risk of NAFLD. The link between fatty liver and diabetes is well documented in many studies conducted in different parts of the world. About one-third of all diabetics may actually have a more severe form of fatty liver known as non-alcoholic steatohepatitis or NASH. In these patients, the fat in the liver starts causing inflammation in the liver and this may eventually lead to advanced liver disease known as cirrhosis over a period of 15-20 years. Once a patient has NASH and advanced liver disease, the risk for developing liver cancer also increases. Diabetes and obesity are also independently associated with increased risk of liver cancer.

Most diabetics are not aware that they may have fatty liver. Even if they are aware, they may not realize the significance of the disease. In general NAFLD and NASH is typically undiagnosed, because of a lack of awareness among doctors and the hidden nature of the disease. Most individuals do not have specific symptoms and are often reassured by their doctors of the benign nature of the disease. Fatty liver is very hard to detect, often eluding blood tests and physical examination. Even the liver function tests can be normal. An ultrasound scan can detect fatty liver but does not tell much about ongoing liver damage. It is extremely important to know whether a patient with fatty liver has simple fatty liver or NASH. This is not possible with an ultrasound scan and routine liver tests. The most reliable way to diagnose NASH is a liver biopsy, which is an invasive procedure, and cannot be recommended in all patients with fatty liver. There are special blood tests (Fibrotest) and Liver scans (Fibroscan) that can help diagnose NASH and assess severity of the disease.

What can you do if you are diabetic & have fatty liver?

There are a number of steps you can take to protect your liver and prevent fatty liver disease from occurring.

• Good management of your blood sugar levels, with the help of medications and insulin (if required)
• Losing excess weight, and maintaining it through a healthy diet and regular exercise
• Considering weight loss surgery if BMI is above 35 and you are unable to lose weight by diet and exercise
• Keeping blood pressurewithin recommended limits
• Keeping your LDL or “bad” cholesterol and triglycerides levels low
• Cutting your alcohol intake
• Avoid any type of herbal supplements that have potential to cause liver injury
• Talk to your doctor about specific medications that can help both diabetes and fatty liver

The key to reversing the course of fatty liver disease in diabetes is good control of blood glucose levels and weight loss. Reducing carbohydrate intake reduces fat in the liver very quickly. A loss of 10 percent of body weight is good enough to start reducing liver fat and liver inflammation.

Dr. Kaiser Raja (author) is a consultant in Liver Diseases and Transplantation associated with the Integrated Liver Care Program of the Aster DM Healthcare Group. He is available for consultation in Aster CMI Hospital, Bangalore, Aster Hospital, Mankhool, Dubai and Aster Medical Centre, Hamdan Street, Abu Dhabi