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Doctors talk about nonalcoholic fatty liver disease

Lehigh Gastroenterology Associates LLC is venturing into a new direction, one they hope will help their patients battle the bulge and nonalcoholic fatty liver disease, or NAFLD.

For many people, NAFLD won’t cause any serious health conditions, but for 6.5%, the disease can progress into nonalcoholic steatohepatitis, according to the National Institute of Diabetes and Digestive and Kidney Diseases in the U.S. Department of Health and Human Services. NASH occurs when NAFLD progresses into an inflammation of the liver and liver damage. This damage can progress in fibrosis, which is scarring of the liver. NASH can also progress into cirrhosis of the liver, which can then develop into liver cancer. When that happens, a person’s greatest hope for survival is a liver transplant.

Up to 70% of people who are overweight have NAFLD and more than 90% of people with extreme obesity have the disease, according to NIH. Even 10% of children have NAFLD.

BMI is an indicator

A body mass index between 18.5 and 24.9 is considered normal. A BMI between 25 and 29.9 is considered overweight. A BMI of 30 to 39.9 is obese, and a BMI over 40 is extreme obesity.

BMI is calculated by calculate BMI by dividing weight in pounds by height in inches squared and multiply by a conversion factor of 703 or use the NIH calculator on their website at www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm.

“Anybody who has a BMI of more than 30, I can bet you they have fatty liver, and that’s a lot of people,” said Dr. Ahmed Hasan, a gastroenterologist at Lehigh Gastroenterology Associates and affiliated with St. Luke’s University Health Network.

“Even if you lost 20 pounds, you will be going in the right direction.”

Treatment for NAFLD

Hasan said there are no medications that can reduce the amount of fat in the liver. The only way to treat NAFLD is to lose weight.

For this reason, Hasan, who also has a master’s degree in public health, became interested in helping his patients lose weight. He and Dr. Mahreema Jawairia, another physician in his practice, attended the Blackburn Harvard Obesity Course in Boston. There they learned a method to help their patients lose weight.

They developed a program for their medical practice in which to enroll 100 patients to start, and help them over the course of six months to lose weight. They applied for a grant from the Pennsylvania Medical Society that concentrates on preventive medicine, and were awarded it.

Hasan said the society awarded them the grant, because there was not any other program in the state that was as comprehensive. Money from the grant goes toward gym memberships, an app for the patients enrolled in the program, and nutrition counseling. Medical insurance should cover most of the cost, because NAFLD is a medical disease, he said.

Losing weight can also help some people with diabetes get off their medication, as well as reduce the need for knee or hip surgery because extra weight is taken off the body’s frame and helps to reduce sleep apnea, Hasan said.

“It’s like a whole package by just losing weight,” he said.

Board certified in obesity medicine through the American Board of Obesity Medicine, Dr. Jawairia is leading the program at Lehigh Gastroenterology Associates.

The program begins with a detailed assessment. This includes an evaluation that focuses on the patient’s history, body composition, energy expenditure, concomitant medications use, plus a physical exam and laboratory tests.

Some symptoms of NAFLD are feeling full without eating a whole meal, or pain in the right upper quadrant where the liver is located. Symptoms of NASH can include this same pain and elevated liver enzymes. Liver enzymes are not routinely checked by a primary care physician, Hasan said. If the liver enzymes are elevated, then an ultrasound is ordered. People with fatty liver can have normal liver enzymes.

“By the time you see elevated liver enzymes, that means the inflammation has set in,” Hasan said. He wants to catch people before the enzymes develop.

What can be done

Jawairia said that patients will be put on either a low-calorie diet, very low-calorie diet, Mediterranean diet or other, depending on the patient and his or her comorbid medical conditions. They will keep track of their calorie intake using a free app that will allow them to log their daily calorific intake, water intake and body weight as well as physical activity level.

Patients will also be asked to exercise, which will be tailored based on their physical and medical issues.

“Physical activity level will be encouraged to increase weekly depending on their progress, since it improves metabolic, musculoskeletal, cardiovascular, pulmonary and mental health,” Jawairia said.

Over the long term, patients should aim for losing 1 to 2 pounds a week. In order to do this, most people need to burn 500 to 1,000 calories more each day than they consume.

The patients will come into the office for weekly visits, which will focus on what they are logging and any barriers that have come up. Jawairia said they will work with the patients to help them overcome those barriers.

After 3 to 6 months, a sonogram will be taken of the right upper quadrant in order to monitor improvement of the liver.

Hasan said he thinks this program is better than going straight to bariatric surgery, because he teaches people how much to eat, what to eat, and the amount of exercise they need to live a healthy life.

“We shouldn’t take the shortcut. We should talk to them,” he said.

Dr. Ahmed Hasan
Dr. Mahreema Jawairia
Nonalcoholic fatty liver disease is the second most common reason for liver cancer. Doctors said weight loss can help. METROGRAPHICS