Fatty liver disease includes a spectrum of liver conditions characterized by excess fat accumulation in the liver of individuals. It encompasses a range of conditions, from simple steatosis (fatty liver) to nonalcoholic steatohepatitis (NASH), as well as nonalcoholic fatty liver disease (NAFLD) which can progress to cirrhosis, liver failure, and hepatocellular carcinoma. Globally, more than 1 in 4 people are impacted by NAFLD, and of those, 1 in 5 will go on to develop the more advanced condition NASH.

Contributing Factors to Fatty Liver Disease in Veterans

Veterans are at an increased risk of developing NAFLD due to various factors, including:

1. Military-related exposures: Exposure to environmental toxins and hazardous substances during deployments or service-related duties can contribute to liver damage.

2. Lifestyle factors: High-calorie diets, limited access to nutritious foods during deployments, and irregular eating and sleeping patterns common among military personnel can exacerbate the risk of NAFLD.

3. Co-occurring conditions: Veterans often face comorbidities such as obesity, diabetes, metabolic syndrome, mental health conditions, and substance use disorder, which are significant risk factors for NAFLD.

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Over the past decade, the prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD, previously known as nonalcoholic fatty liver disease/NAFLD) in children has seen a concerning rise. Pediatric fatty liver disease is a serious liver disease that not only affects adults but also a concerning proportion of children. In fact, pediatric fatty liver disease affects nearly 10% of the general pediatric population. Furthermore, in children affected by obesity, fatty liver disease affects as many as 40%. Despite its growing prevalence, there still isn’t a definitive cure for fatty liver disease. However, ongoing research has illuminated the crucial role that nutrition plays in both the development and exacerbation of this condition. While the exact causes of NAFLD are multifaceted, research highlights various factors, including genetic predisposition, sedentary lifestyle, and notably, dietary composition.

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Exploring Fatty Liver in Lean Individuals

Although fatty liver disease has been on the rise over the last two decades, along with the increasing prevalence of obesity, it has also been observed that fatty liver disease is increasing among individuals with normal weight, defined as a body mass index (BMI) below 25 kg/m2 in Caucasians and below 23 kg/m2 in Asians. It is important to note that BMI is an imperfect measure of health and doesn’t account for ethnic and sex differences, so a more individualized approach for assessing disease status is needed. Approximately 10–20% of individuals with NAFLD have lean NAFLD. Despite their lower BMI, these individuals may still have high body fat, particularly visceral fat, which accumulates deep within the abdomen and surrounds vital organs. While some visceral fat is essential for health, excessive amounts can pose a risk and contribute to the development of fatty liver disease. People with lean NAFLD typically have a smaller waist circumference and a more favorable metabolic profile characterized by lower levels of dyslipidemia, diabetes, hypertension, glycemia, and insulin resistance compared to obese individuals. Despite this advantageous phenotype, lean NAFLD patients may experience a worse outcome and faster disease progression.

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Food Systems and Chronic Diseases

There is a close link between obesity, fatty liver disease, and the food system. The state of agriculture and food production has shifted dramatically over the decades. In the 1950s, American farmers grew a variety of fruits and vegetables. However, since then, farming policies have incentivized the growth of corn and soybeans – which feature predominantly in processed foods – to the detriment of other crops. The federally subsidized, low cost of these commodity crops has contributed to the proliferation and staying power of processed foods, which are designed to be highly palatable and maximize consumption. This shift has contributed significantly to the obesity epidemic by transforming the options available to shoppers at the supermarket. Though this trend might be slowly reversed through the passage of policies that subsidize the production of fresh produce rather than the commodity crops common in processed foods, both political will and substantial infrastructure changes would be necessary to support this change.

Processed foods, often rich in sugar and additives, create cravings, withdrawal, and tolerance similar to addictive substances – and an estimated 73% of food available at grocery stores can be considered ultra-processed. This raises concerns about the food industry’s role in creating and promoting foods that have damaged their customer’s health for their own financial profit. Ultra-processed foods, ubiquitous in modern diets, have been linked to metabolic and other health issues, including fatty liver disease, obesity, and type 2 diabetes. The food industry’s resources for both marketing and development far exceed those of public health institutions, allowing those for-profit businesses to dominate the market and influence consumer behavior. Aggressive marketing, especially to children, overshadows educational efforts to promote healthy eating.

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This series of bite-sized episodes will provide important information on MASLD and MASH in patients with type 2 diabetes. Drs. Naim Alkhouri and Robert Eckel and physician assistant Tessa Janovsky discuss best practices for screening, diagnosis, treatment, and management of MASH/MASLD.

Accreditation and Credit Designation Statements

In support of improving patient care, Global Learning Collaborative (GLC) is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the healthcare team.

Global Learning Collaborative (GLC) designates this MinuteCE activity for a maximum of 1 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Global Learning Collaborative (GLC) designates this activity for 1 nursing contact hours. Nurses should claim only the credit commensurate with the extent of their participation in the activity.

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Health Care Providers (HCPs) in the endocrinology specialty setting are challenged to be knowledgeable of the pathophysiology of MASLD (metabolic dysfunction-associated steatotic liver disease) and MASH (metabolic dysfunction-associated steatohepatitis) and its associated risk factors, as well as feel confident around how and when to order noninvasive diagnostic tests to prevent the emergence of more severe complications and stay on top of current guidelines and emerging treatment options.

Explore this interactive learning format, Build Your Own Case Study. By participating in this activity, you will gain valuable insights into effectively addressing MASLD/MASH for improved patient health.

Accreditation and Credit Designation Statements

In support of improving patient care, Medical Learning Institute, Inc. is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physicians, PAs, and nurses can earn up to 1.0 CME credit for participating in this educational activity, which also provides 1.0 MOC point for ABIM certification and 1.0 IPCE credit for interprofessional learning.

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