NAILBA Perspectives - May/June 2014 - (Page 34)

agency resources Nonalcoholic Fatty Liver Disease (NAFLD) HANK GEORGE, FALU, CLU, FLMI Why devote an entire article to NAFLD? Well, for openers, it is the most common liver disorder in the world. That is, of course, if you consider it to be a primary liver disease. Many now hold that NAFLD is just one manifestation of a process triggered by excess circulating insulin, and that its implications are mainly cardiovascular rather than liver-related. How does NAFLD impact your clients? Every day, applicants with known or suspected NAFLD are unnecessarily rated or erroneously approved "preferred" because the underwriter: ■■ Did not recognize its presence (despite telltale clues) ■ ■ Overstated its insurability significance ■■ Did not know the red flags for high risk of silent advanced pathology What is NAFLD? It is the result of a significant fat buildup in the liver cells of persons who either do not drink alco- holic beverages or do so only in modest amounts. If the same findings were present in a heavy drinker or someone with an alcohol use disorder, it would be dubbed "alcoholic fatty liver disease" (AFLD). Because people commonly understate their alcohol use, some alleged NAFLD cases are actually AFLD. NAFLD comes in two basic forms: ■■ Steatosis (fatty liver)-over 85% of NAFLD cases consist solely of fatty liver. ■■ Nonalcoholic steatohepatitis (NASH)-fatty liver plus inflammation and cell destruction (necrosis), usually accompanied by some degree of liver fibrosis. What factors predispose to developing NAFLD? The two main culprits are obesity (only 10% of patients are normal weight) and type 2 diabetes. Prediabetes is also common. Impaired fasting glucose (IFG), impaired glucose tolerance (IGT), and gestational diabetes mellitus (GDM) are the three presentations of prediabetes. Other prevalent features include high blood pressure, high triglycerides, low HDL-C, albuminuria, and polycystic ovary syndrome (PCOS). All components of the metabolic syndrome (MS) are found among these risk factors. Hence, applicants meeting the criteria for MS are at high risk for also having NAFLD. What is the most common manifestation of NAFLD? Isolated ALT elevation or raised levels of both ALT and AST, with an AST-to-ALT ratio < 1.0 (in other words, ALT being proportionally higher than AST). If the patient is symptomatic (and most with steatosis only or early NASH are not), the most com- 34 perspectives MAY/JUNE 2014 mon complaint is a sense of fullness or mild discomfort in the upper right quadrant of the abdomen. The liver is sometimes palpable but this does not assure that it is enlarged. How is the diagnosis made? Technically, it can only be established definitively by liver biopsy. Nevertheless, primary care physicians diagnose most NAFLD cases based on risk factors, elevated ALT, and typical findings on a liver ultrasound test. One problem here is that it is seldom possible to distinguish between steatosis only versus NASH based on ultrasound alone. The other issue is that ALT is not always elevated in NAFLD. It may be "high normal" or fluctuate between normal and elevated over a series of measurements. How is NAFLD treated? Many patients are not treated directly for NAFLD. Rather, the focus is on managing the risk factors with lifestyle changes as well as medical interventions. When physicians do prescribe medication for NAFLD, the one they mainly rely on is metformin. This is the most widely used oral prescription for diabetes and is effective in reducing the burden of fat stored in the liver, even in nondiabetics. The diabetic drugs pioglitazone and rosiglitazone may also be prescribed for NAFLD, although physicians are shying away from the latter because of growing evidence that it is associated with a substantially increased risk of cardiac events. Vitamin E supplementation works quite well for NAFLD, but the patient must also have sufficient vitamin C levels because C is needed to maximize the efficiency of E. When bariatric surgery is done for obesity, NAFLD often recedes.

Table of Contents for the Digital Edition of NAILBA Perspectives - May/June 2014

NAILBA Perspectives - May/June 2014
Contents
Chairman’s Corner
CEO Insights
How to Train New Marketing Reps
Reading Ahead
Life Happens
The 3M Formula for BGA Marketing Success
NAILBA Charitable Foundation
Member Profiles
Agency Successor Networking Group
Agency Resources
member Profiles
MDRT Annual Meeting
Legislative Update
Calendar of Events
Index of Advertisers

NAILBA Perspectives - May/June 2014