NAILBA Perspectives - May/June 2014 - (Page 34)
Nonalcoholic Fatty Liver Disease (NAFLD)
HANK GEORGE, FALU, CLU, FLMI
Why devote an entire article
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
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
■■ 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
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:
85% of NAFLD cases consist
solely of fatty liver.
(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
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
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
How to Train New Marketing Reps
The 3M Formula for BGA Marketing Success
NAILBA Charitable Foundation
Agency Successor Networking Group
MDRT Annual Meeting
Calendar of Events
Index of Advertisers
NAILBA Perspectives - May/June 2014