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by Celine Fournier, Chief Medical Officer, Echosens

Most women don’t give their liver a fleeting thought. But new warnings of the looming epidemic of non-alcoholic fatty liver disease (NAFLD) are a signal that the time has come for greater vigilance.

NAFLD is an umbrella term describing those liver diseases that aren’t related to alcohol consumption. Whereas consumption of too much alcohol over a period of several years is known to damage the liver, NAFLD is directly related to too much fat in the liver cells.

One of the biggest challenges is that NAFLD is asymptomatic, meaning that it can cause liver damage without anyone even being aware of it.

The American Liver Foundation1 estimates that about 100 million Americans -- over 30 percent of the U.S. population -- have NAFLD. Estimates are that if this trend continues, NAFLD will become the main cause of liver transplants in the country, with the number of healthy livers available for transplants likely to decline2.

Youngsters are developing fatty liver disease3, through over consumption of sugars, sodas, fructose, corn syrup and lack of exercise. Children as young as five and adolescents are forewarned, so watch your daughters (and sons!).

But thanks to the efforts of liver disease advocacy organizations and the medical community, there appears to be growing awareness of the problem. More positive news is the recent introduction and adoption of new non-invasive screening methods that can detect NAFLD even in the absence of indications or warning signs from your body.

This new painless approach – with no harmful radiation or X-rays – can be done right in the doctor’s office as part of an annual exam. It’s covered by Medicare, Medicaid and many insurance plans. Screening results can offer peace of mind that your liver is normal and in many cases may obviate the need for a painful liver biopsy or further testing. Test scores also provide your doctor with the information needed to make a referral to a specialist or recommend further testing.

Either way, a screening test is critical to informed decision-making regarding the health of your liver. In fact, a yearly NAFLD screening is becoming recognized as parallel to the need for other testing, including mammography or A1C blood sugar testing.

Know Your Risk of NAFLD

As stated above, there is an alarming amount of Americans that have NAFLD, some of which don’t even know they have it. Being overweight and obese are primary risk factors for NAFLD. Women of childbearing age tend to store fat in the lower body, while men and post-menopausal women store fat around the abdomen. Fat around the middle—the “apple” shape that many women take on in “mid-life” — is more likely to lead to fatty liver than fat around the hips and thighs, the “pear” shape. As we gain weight, our livers suffer.

The National Institute of Diabetes and Digestive and Kidney Diseases4 reports about 1 in 4 (26.5 percent) women are considered to be overweight and obesity is higher in women (about 40 percent) than men (35 percent).

Harvard Health Letter5 estimates as many as 20 percent of American adults have some degree of fatty liver disease, a condition that used to occur almost exclusively in people who drink excessively. In reality, excess fat may be just as dangerous to the liver as excess alcohol, making the disease so threatening.

Certain ethnic groups6, such as Hispanics, are at higher risk of progressive fatty liver disease, while African Americans are less likely to have this progressive disease.

And for those still wondering, “To drink or not to drink?” New reports on the impact of alcohol consumption7 among patients with NAFLD conclude:

Modest alcohol consumption is associated with a significant decrease in all‐cause mortality, whereas drinking ≥1.5 drinks per day is associated with an increase in mortality.

Understanding NAFLD

Our livers are incredibly vital, responsible for more than 150 bodily functions, such as controlling blood sugar levels and producing proteins important for blood clotting.

NAFLD is the result of poor eating habits and a sedentary lifestyle. In some cases, the fat in the liver cells builds up to the point where the liver cells swell and eventually cause inflammation. But there are usually no symptoms at this point.

Persistent inflammation causes scar tissue to form in the liver and in the surrounding blood vessels, which is also known as “fibrosis.” As the inflammation continues, over time it leads to a condition that is called “non-alcoholic steatohepatitis” (NASH). This leads to a most serious stage of the disease called “cirrhosis,” a scarring of the liver that can lead to liver failure – the number one reason for liver transplants for end stage liver disease or liver cancer.

NASH’s most troubling characteristic is its silence. It doesn’t present symptoms until well advanced when the damage may be irreparable. Many patients with NASH don’t know they have the condition until the consequences are dire. Since many patients show no symptoms, many physicians and clinicians do not screen for NASH, although expectations are that with new non-invasive screening devices, this will change.

A Treacherous Trifecta: Obesity + Diabetes + NAFLD

It’s no surprise that the projected prevalence of NAFLD joins the “twin epidemics” of diabetes and obesity. Nationwide, more than half of adults8 with NAFLD are obese, and 30 percent or more are overweight. Conversely, overweight or obesity is responsible for causing about 85 percent of fatty liver disease9.

Unfortunately, obesity is a risk factor for diabetes:

Obesity can cause insulin resistance10, which results in a buildup of blood sugar and increases the amount of free fatty acids circulating in the blood or accumulating inside the liver cells. The Hepatitis B Foundation11 also advises that buildup of fat in the liver is common in those with type II diabetes, increasing the risk of liver cirrhosis and liver cancer.

This wicked combination of conditions can create a very unhealthy situation. Until NAFLD becomes quite severe, it has no symptoms. If you have it, most likely you have no clue that your health is deteriorating. With the advent of screening and greater focus on preventive care, this situation is changing.

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Other Risk Factors -- Just for Women

Female Hormones

Some studies suggest that women may be at a higher risk for NAFLD, while others report that men are more susceptible. As with heart disease, female hormones may have a protective effect. But once women go through menopause and estrogen levels drop, there is increased risk.

Estrogen levels may influence body fat distribution11 and many women in the early menopausal years gain fat mass as their estrogen levels drop. More than 60 percent of menopausal and post-menopausal women suffer from obesity due to the drop in their estrogen levels.

Moreover, women going through menopause are more likely to be diagnosed with NAFLD than men. Studies show12 that decreased levels of estrogen specifically target the liver and alter metabolic processes that cause fat accumulation. Interestingly, one study13 showed the prevalence of NAFLD in women increases with age, but does not alter with age in men.

Research scientists are now studying these issues, with earlier studies in 2012 assessing the value of taking birth control pills or hormone replacement therapy (HRT):

Scientists reporting14 on an analysis of 4,000+ women aged 20-65 found the prevalence of NAFLD was lower in women using birth control pills than those not using them.

Additional research15 evaluated the relevance between NAFLD and post-menopausal women and the relationship between HRT and NAFLD, hypothesizing that HRT could be a protective factor against the disease – while acknowledging more study was needed.

Polycystic Ovarian Syndrome

Polycystic ovarian syndrome (PCOS) is a condition in which women have imbalanced or decreased levels of the female hormones estrogen and progesterone. This causes the growth of ovarian cysts, or other issues like irregular menstrual periods, excess hair on the face and chest, acne, and sometimes, infertility.

Women with PCOS16 are often overweight or have diabetes, high blood pressure and high cholesterol levels. They may also be at a higher risk for NAFLD.

Fatty Liver Disease and Metabolic Syndrome

Underneath all these connections is “metabolic syndrome,” a condition frequently present in those with NAFLD, PCOS and diabetes.

Metabolic syndrome is the name for a group of risk factors that increases risk for heart disease and all those related problems described earlier -- diabetes, stroke, fatty liver disease, and more. Risk increases as a person ages, and is believed to affect one out of every six people.

In 201517, researchers reported almost 25 percent of the women with PCOS were diagnosed with NAFLD, and metabolic syndrome was present in between 32.7 percent and 44.6 percent of the patients with PCOS. In women with both PCOS and NAFLD, metabolic syndrome was “highly prevalent.”

Early Detection Allows Time to Change Your Lifestyle

Because it is asymptomatic and until recently, not generally screened for by physicians, millions of people are at risk of developing chronic liver diseases and cancer. But NAFLD is reversible if caught in the early stages and accompanied by lifestyle changes. Screening and early detection can help to prevent18 more serious conditions such as end-stage liver disease or liver cancer.

While most patients are asymptomatic, NAFLD is sometimes associated with fatigue, weakness, loss of appetite, nausea, weight loss and abdominal pain. Increased blood enzymes may be associated with the disease, but are not always a sign of liver disease.

Physicians can do a blood test to look for liver proteins released after a liver cell dies, which can hint at inflammation. But today’s gold standard is a liver sample, allowing doctors to see signs of scar tissue and ballooning under a microscope to determine how far the disease has progressed. This method has been brought into question not only for its invasiveness, but also its inaccuracy19.

Some scientists estimate that more than 30 percent of biopsy diagnoses may be wrong. These shortcomings are the principal barrier to people accessing proper medical care, says Arun Sanyal20, a gastroenterologist who studies liver disease at Virginia Commonwealth University.

Today, there is a painless, quick -- less than 10 minutes -- noninvasive technology that allows physicians to accurately check for NAFLD. This noninvasive method allows healthcare providers to assess and track patients with liver disease over time.

FibroScan®, for example, is one liver blood test technique that can be used to measure the amount of liver stiffness and the controlled attenuation parameter (CAP). It can be used to rule out the need for further assessment, like a painful liver biopsy, saving time and resources for people who don’t need further assessment.

An interim look at an ongoing study of 10,000 patients with no history of liver disease was conducted in community-based endoscopy centers. Only 43 percent of patients evaluated had what is considered normal livers, while the remainder had some form of liver abnormality, ranging from elevated liver fat to liver fibrosis. This analysis of the first 367 patients suggests a significant rate of undiagnosed steatohepatitis liver disease in the population studied.

These results underscore the importance of identifying asymptomatic patients who may be at risk for advancing disease for earlier intervention. This high prevalence of disease, a dramatic rise from observations made in previous years, were indicative of the critical need for ongoing assessment.

Best Defense: A Healthy Lifestyle

In the fight against a liver disease epidemic, and in the absence of drugs made specifically to treat NASH, the time has come for women to become more aware of NAFLD, learn if they are at risk and understand how to prevent and reverse liver damage.

NAFLD Prevention Check List:

  • During your next check-up, ask your personal doctor about the new non-invasive technology for evaluating the liver as a basic element of the physical exam.
  • Follow a nutritious diet: eliminate processed fructose21 and other added sugars from the diet, control blood sugar and triglycerides.
  • Exercise regularly.
  • Maintain a healthy weight: In one study22, linking weight loss to NASH, those who lost more than seven percent of their body weight experienced a beneficial change in their NASH disease state. To resolve the condition and experience improvements in liver fibrosis and portal inflammation, required a weight loss of at least 10 percent of body weight.


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  16. Florentino, Gesira, et al. “Hormone Replacement Therapy in Menopausal Women: Risk Factor or Protection to Nonalcoholic Fatty Live Disease?” Http://
  17. Zhang, Jianhai, et al. Experimental and Therapeutic Medicine, D.A. Spandidos, May 2018,
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