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Maintain the Health of Your Liver – Latest ADA Standards of Care

Updated: 5/16/22 1:23 pmPublished: 5/16/22
By Hope Warshaw

Did you know that type 2 diabetes and excess weight can put you at risk for certain types of liver diseases? Learn why experts are becoming more concerned about the connection between type 2 diabetes and two liver diseases: non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH). 

Since the 1980s, the number of people with type 2 diabetes who are diagnosed with a form of liver disease not related to alcohol consumption has increased steadily. (see “Striking stats” below). For the first time ever in its 2022 Standards of Care, the ADA added recommendations about how to prevent, diagnose and manage liver disease.

“Nonalcoholic Fatty Liver Disease (NAFLD) serves as an umbrella term for a range of liver diseases that progress if no diagnosis is made or interventions initiated,” says Dr. Kenneth Cusi, chief of the Division of Endocrinology, Diabetes & Metabolism at the University of Florida in Gainesville, Florida, and a leading voice in raising awareness about NAFLD and a lead author on the newly released guidelines for the diagnosis and care of NAFLD from the American Association of Clinical Endocrinology. NAFLD occurs first and can progress to Nonalcoholic steatohepatitis (NASH) if it is not diagnosed and managed (see definitions below).

The good news is that the same self-care behaviors detailed in our other ADA standards of care articles can be put into action to prevent or manage these conditions too. The same message rings true – don’t delay, act now.     

Striking stats

It’s now estimated that one quarter of the general population across the globe may have NAFLD. More than 60% of people with type 2 diabetes are estimated to have NAFLD, and approximately 30% to 40% of people with type 2 diabetes could have NASH. Excess weight, particularly around the midsection of the body, is very common in people with type 2 diabetes and increases the risk for these liver diseases. On the other hand, people who develop NAFLD first are more likely to subsequently develop type 2 diabetes. And no surprise, people with NAFLD are at a higher risk of heart and blood vessel disease, as well.

What is liver disease?

Some key terms to know:  

Liver: The liver filters blood; it holds on to what is needed by the body and disposes of the rest. The liver also produces nutrients the body needs for health and breaks down some medications.

Nonalcoholic Fatty Liver Disease (NAFLD): A condition in which fat builds up in the liver. “It’s defined as at least five percent fat in the liver, yet there is no inflammation or changes to the liver cells at this point,” says Colleen Dawkins, family nurse practitioner and registered dietitian at Big Sky Medical Wellness in Lakeside, Montana. NAFLD is becoming the most common cause of chronic liver disease globally.

Nonalcoholic steatohepatitis (NASH):NASH is defined as at least five percent fat in the liver, with inflammation and changes to the cells including fibrosis [scar tissue that forms in the liver],” adds Dawkins. Unfortunately, without adequate treatment, NASH can progress to cirrhosis (see below) or liver failure. Less commonly, NASH can be linked to liver cancer. With treatment to reduce the inflammation, NASH can revert back to NAFLD. However, being older, having excess weight around the midsection, type 2 diabetes, and high blood pressure are all associated with increasing amounts of fibrosis (scar tissue).

Cirrhosis: A condition in which the liver is scarred and permanently damaged. Scar tissue replaces healthy liver tissue and prevents the liver from working normally. Cirrhosis can cause liver failure and is linked with liver cancer.

Connection between type 2 diabetes and liver damage

Liver damage due to type 2 diabetes can occur without warning, and like most diabetes complications, progresses over many years. It is the result of having excess weight, high glucose levels, abnormal blood lipid levels (typically low HDL-cholesterol, and high triglycerides and LDL-cholesterol) and high blood pressure. 

Knowledge about the connection between type 2 diabetes and liver disease is relatively new. Our understanding about how it occurs, and how to detect and manage it, is limited. “Liver disease, as a complication of diabetes, is underdiagnosed and underappreciated,” says Dr. Robert Gabbay, chief science & medical officer for the American Diabetes Association. Gabbay adds, “ADA is raising awareness among people with diabetes and healthcare providers to diagnose and treat this condition realizing it is more common, dangerous, and concerning.”

This year was the first that the ADA discussed these liver issues in its annual Standards of Care. According to Gabbay, the ADA has also collaborated with the American Gastroenterological Association to raise global awareness about this impending epidemic.

Until the recent publication of the AACE guidelines, according to Cusi, there have been no clinical guidelines for healthcare providers to follow to manage NAFLD.  

Type 1 diabetes and liver damage

You may wonder whether people with type 1 diabetes are at risk for developing NAFLD. Cusi notes, “This type of liver damage is not well studied in people with type 1 diabetes. If a person with type 1 diabetes remains lean through the years, it’s likely they will not deal with this complication. However, today an increasing number of people with type 1 diabetes have [excess] weight or obesity.” 

Getting screened for and diagnosed with liver disease

Since early detection offers the best chance of reversing the progression of liver disease, knowing your individual risk level is crucial. Unfortunately, there are very few associated signs or symptoms, which makes detection and diagnosis a challenge. Cusi and Dawkins agree that some, but not all people may experience pain on the right side of their abdomen. Dawkins added that feeling fatigued or experiencing unexplained weight loss may also be telltale signs. 

When your healthcare provider checks for diabetes-related eye or kidney disease, ask about your FIB-4. This is a number that can indicate your risk for liver disease. “Screening should include your medical history, a physical exam and the FIB-4 (fibrosis) calculation,” Cusi says. FIB-4 includes four numbers: a person’s age, liver enzyme results (ALT and AST), and blood platelet level. The calculation gives a single number that indicates the risk of advanced fibrosis. People with a FIB-4 score below 1.3 are thought to be at low risk and those with a score above 2.67 are thought to be at high risk for NAFLD. People at intermediate risk of the disease may need additional tests, including one or more of these listed below by Dawkins.

One indicator can be a blood test that includes measurements of two liver enzymes that show how the liver is functioning. 

  • Ultrasound of the abdomen, which can miss liver fat.
  • Vibration-Controlled Transient Elastrography, called a Fibroscan, which is an ultrasound that can more accurately measure fat in the liver.
  • Computed Tomography (CT) or Magnetic Resonance Imaging (MRI).
  • Liver biopsy, considered the “gold standard” to determine if there is fat in the liver and whether liver tissue is fibrotic.

Liver disease treatment options 

The treatment for NAFLD and NASH includes several familiar lifestyle changes and self-care behaviors recommended to prevent and delay other diabetes-related complications. These include losing weight, healthy eating, and regular physical activity. Discuss these strategies with your healthcare provider to determine which changes best align with your diabetes management.

Dawkins explains these lifestyle changes with this additional information:

  • Weight loss: Managing your weight is absolutely a must! Losing at least five percent of your initial body weight may improve and reduce fat deposits in the liver. Losing seven to 10 percent is usually necessary to improve tissue scarring associated with NASH. In collaboration with their healthcare providers, people may consider taking a medication that can assist with weight loss or having bariatric or metabolic surgery.

  • Healthy eating: People can reduce the amount of fat deposited in their liver by reducing refined sources of carbohydrates, such as sugary foods, desserts, and drinks, as well as ultra-processed foods. The AACE guidelines also encouraged a reduction of saturated fat consistent with healthy eating guidance for diabetes. Dawkins suggests eating fiber-packed sources of carbohydrates including vegetables, fruits and grains, along with lean protein and healthy fats. Similarly, Dawkins endorses the Mediterranean eating plan.

  • Alcohol: To date there is no clear consensus on whether drinking alcohol is okay or not. The default recommendation is to avoid alcohol. However, some studies show that light to moderate alcohol intake (what amounts to 10 to 15 drinks or alcohol equivalents per week) may be okay for those with a low or intermediate risk for NAFLD.  

  • Physical activity: Daily movement is very important to improve the way the body uses glucose and insulin, and to reduce the amount of fat deposited in the liver and damage to liver cells. Consistent aerobic and resistance training exercises are recommended, with the amount and intensity varying based on what is best for you. The goal is to increase to 150 minutes of exercise per week, but any regular movement is good.

Diabetes medications that may help prevent liver disease

Regarding medications, at this point there are no specific medications for diabetes related liver disease. However, studies with some familiar glucose lowering medications and other new medications are ongoing.

Cusi currently recommends using one of the newer glucose lowering medications, a GLP-1 receptor agonist, mainly because they assist with weight loss. The other class of glucose-lowering medication he recommends is SGLT2- inhibitors. According to Cusi, either of these medications offer benefits for the prevention of heart and blood vessel diseases, kidney disease, and NASH.

However, these medications are quite expensive and out of reach for many people. Both Cusi and Gabbay point to use of an older glucose-lowering medication, pioglitazone, as being more affordable and accessible. Cusi says that pioglitazone, while not causing the weight loss of a GLP-1 receptor agonist or SGLT-2 inhibitor, can improve glucose, reduce fat in the liver and improve NASH.  

In closing, if you are told you have NAFLD or NASH, be sure to take the next steps quickly. Don’t delay! These problems will likely progress without timely self-care, lifestyle changes, and using medication.

Editor’s note: Alert about Vitamin E 

You may hear and read about the use of vitamin E supplements to treat NASH, but both Cusi and Dawkins agree that this should not be used if you have diabetes. 

Editor’s Note: Alert about hepatitis C virus (HCV)

Infection with hepatitis C virus (HCV), a virus that targets the liver, is associated with a higher risk for type 2 diabetes. Type 2 diabetes is seen in up to a third of people with chronic HCV. This seems to occur because the virus may impair how glucose is handled by the body in several ways. The use of a newer antiviral medication to treat HCV leads to a cure of the virus in nearly all cases and also seems to improve elevated glucose levels too.  

About this series:

Each year the American Diabetes Association (ADA) updates its Standards of Medical Care in Diabetes. These Standards of Care or Standards are updated by the ADA’s Professional Practice Committee (PPC), based on reviews of recent research and consultation with subject matter experts. ADA publishes its revised Standards each January as a supplement in Diabetes Care as well as online. ADA also maintains “Living Standards.” These interim updates are published as necessary, based on new science, regulatory changes, new medication or technology approvals, etc.

This series of articles translates the what’s and how to’s on diabetes complications based on the ADA Standards. Our goal at diaTribe is to help you be in the know so you may take actions to prevent or slow the progression of any and all complications as soon as possible. Research shows the central tenets to prevent diabetes complications are to keep your glucose levels, blood pressure and blood lipids in the recommended target ranges as much of the time as possible. Plus, get the regular recommended diabetes-specific exams, and, if a problem is detected, take the recommended actions to prevent or delay further progression and problems.

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About the authors

Hope Warshaw, MMSc, RD, CDCES, BC-ADM, is a nationally recognized registered dietitian and certified diabetes care and education specialist. She has spent her career, now spanning more than 40 years,... Read the full bio »