April is minority health awareness month: Important time to screen patients with diabetes for liver disease
April 26, 2021
By Jon Gingrich
The United States is becoming increasingly diverse, with approximately 36% of the population belonging to a racial or ethnic minority group. While health indicators have improved for most Americans, some minority groups experience a disproportionate burden of preventable disease, death and disability compared with non-minorities.
One major area of concern is non-alcoholic fatty liver disease (NAFLD), the most common chronic liver disease in the United States. NAFLD is likely to increase from 83.1 million to 100.9 million by 2030, while its more severe from nonalcoholic steatohepatitis (NASH) is expected to increase from 16.52 million to 27 million. A meta‐analysis reports that the prevalence of NAFLD and progression to NASH was highest among Hispanics.
For healthcare executives and administrators, the financial burdens of liver disease are well-documented. NASH has created a global treatment market projected to reach $21.5 billion by 2025, and is on track to becoming the leading cause of liver transplantation in the United States.
National Minority Health Month presents an opportunity to build awareness about the disparate burden of premature death and illness in minority populations and encourage action through health education, early detection and control of disease complications. The nation’s liver disease epidemic will continue to impact millions of Americans as the rates of obesity and diabetes accelerate.
Minorities at increased risk for diabetes
NASH, which is associated with necrosis, inflammation and fibrosis, has few symptoms and often normal plasma aminotransferases. Nevertheless, it is a leading cause of end-stage liver disease and hepatocellular carcinoma (HCC), and significantly increases the risk of developing Type 2 diabetes.
Prevalence of diagnosed diabetes was highest among American Indians/Alaska Natives (14.7%), people of Hispanic origin (12.5%), and non-Hispanic blacks (11.7%), followed by non-Hispanic Asians (9.2%) and non-Hispanic whites (7.5%).
In a recent study, NAFLD was found in 50% of patients with Type 2 diabetes who had normal aminotransferase levels. The prevalence of NAFLD was 56% in patients with obesity and 36% in patients without obesity. Increasing body mass index was significantly associated with a greater prevalence of NAFLD (P=0.001).
One study found that the demographics of patients seen at Federally Qualified Health Centers (FQHCs) from 2005 and 2014 had shifted to where the population of young, low-income, uninsured or Medicaid-insured, racial and ethnic minority Americans increased more rapidly than other demographic groups. Proportions of minority and racial groups, largely Hispanic and Black populations, seen by FQHCs also saw an increased rate of change. The minority group with the largest growth rate was the population of Hispanic Americans, increasing from 11.2 percent in 2007 to 13.4 percent in 2014.
The 2019 Standards of Medical Care in Diabetes issued by the American Diabetes Association recommend that patients with Type 2 diabetes or pre-diabetes and elevated liver enzymes or fatty liver on ultrasound should be screened for the presence of liver disease.
Value of screening and early detection
A growing number of physicians – particularly at FQHCs which treat a significant number of minority patients -- are acquiring the noninvasive technique of vibration-controlled transient elastography (VCTE): an ultrasound-based technology that is now a tool of choice for detecting and monitoring liver disease.
Recent studies show that VCTE is a non-invasive and quick way for clinicians to quantify the stiffness of liver tissue and estimate liver fat at the point of care. VCTE-defined hepatic fibrosis is associated with multiple cardiovascular risk factors, including obesity, metabolic syndrome, diabetes, hypertension and high-density lipoprotein cholesterol.
A recent retrospective cohort study also determined that VCTE technology correlates well with the presence of advanced liver fibrosis and clinically significant portal hypertension in patients with hepatitis C virus (HCV) infection. This technology can be used to measure liver stiffness either before or after anti-viral treatment, making it a critical tool in determining the development of HCC, decompensated liver disease and death. Patients with NAFLD also have an increased risk of coronary artery disease compared to the general population.
Fortunately, VCTE is covered by Medicare, Medicaid and many insurance plans, and can be operated by a medical assistant for immediate interpretation by a healthcare professional.
Because NAFLD and NASH are so tightly intertwined with obesity, diabetes and lifestyle, a “whole person” approach to patient engagement is necessary to support behavioral changes that will result in better outcomes across the co-morbid conditions affecting the individual patient.
Diet and exercise interventions can be effective at reversing steatosis and modifying cardio-metabolic risk factors related to metabolic syndrome. For many patients, a 3% reduction in body weight has been associated with reversal of steatosis and a reduction of greater than 7% may resolve NASH in many patients. Disease progression is typically slow, and patients can be managed well by primary care physicians.
Choosing a VCTE partner
Healthcare leaders interested in adopting VCTE technology should look for tools that produce numeric measurements—not images—for simplified interpretation and consistency of measurement. This enables clinicians to monitor changes in liver tissue over time. Experts anticipate that rapid tools that provide consistent liver measurements will be performed as a routine part of patient management.
Given health and demographic trends across the nation, more health care professionals are heeding the urgent call to implement cost-effective and efficient technology designed to provide an accurate, cohesive and first-line approach to assessing and managing patients at risk of liver damage—and addressing health disparities among minority groups.
About the author: Jon Gingrich is the CEO of Echosens North America.