Author Archives: gutsandgrowth

Unknown's avatar

About gutsandgrowth

I am a pediatric gastroenterologist at GI Care for Kids (previously called CCDHC) in Atlanta, Georgia. The goal of my blog is to share some of my reading in my field more broadly. In addition, I wanted to provide my voice to a wide range of topics that often have inaccurate or incomplete information. Before starting this blog in 2011, I would tear out articles from journals and/or keep notes in a palm pilot. This blog helps provide an updated source of information that is easy to access and search, along with links to useful multimedia sources. I was born and raised in Chattanooga. After graduating from the University of Virginia, I attended Baylor College of Medicine. I completed residency and fellowship training at the University of Cincinnati at the Children’s Hospital Medical Center. I received funding from the National Institutes of Health for molecular biology research of the gastrointestinal tract. During my fellowship, I had the opportunity to work with some of the most amazing pediatric gastroenterologists and mentors. Some of these individuals included Mitchell Cohen, William Balistreri, James Heubi, Jorge Bezerra, Colin Rudolph, John Bucuvalas, and Michael Farrell. I am grateful for their teaching and their friendship. During my training with their help, I received a nationwide award for the best research by a GI fellow. I have authored numerous publications/presentations including original research, case reports, review articles, and textbook chapters on various pediatric gastrointestinal problems. In addition, I have been recognized by Atlanta Magazine as a "Top Doctor" in my field multiple times. Currently, I am the vice chair of the section of nutrition for the Georgia Chapter of the American Academy of Pediatrics. In addition, I am an adjunct Associate Clinical Professor of Pediatrics at Emory University School of Medicine. Other society memberships have included the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN), American Academy of Pediatrics, the Food Allergy Network, the American Gastroenterology Association, the American Association for the Study of Liver Diseases, and the Crohn’s and Colitis Foundation. As part of a national pediatric GI organization called NASPGHAN (and its affiliated website GIKids), I have helped develop educational materials on a wide-range of gastrointestinal and liver diseases which are used across the country. Also, I have been an invited speaker for national campaigns to improve the evaluation and treatment of gastroesophageal reflux disease, celiac disease, eosinophilic esophagitis, hepatitis C, and inflammatory bowel disease (IBD). Some information on these topics has been posted at my work website, www.gicareforkids.com, which has links to multiple other useful resources. I am fortunate to work at GI Care For Kids. Our group has 17 terrific physicians with a wide range of subspecialization, including liver diseases, feeding disorders, eosinophilic diseases, inflammatory bowel disease, cystic fibrosis, DiGeorge/22q, celiac disease, and motility disorders. Many of our physicians are recognized nationally for their achievements. Our group of physicians have worked closely together for many years. None of the physicians in our group have ever left to join other groups. I have also worked with the same nurse (Bernadette) since I moved to Atlanta in 1997. For many families, more practical matters about our office include the following: – 14 office/satellite locations – physicians who speak Spanish – cutting edge research – on-site nutritionists – on-site psychology support for abdominal pain and feeding disorders – participation in ImproveCareNow to better the outcomes for children with inflammatory bowel disease – office endoscopy suite (lower costs and easier scheduling) – office infusion center (lower costs and easier for families) – easy access to nursing advice (each physician has at least one nurse) I am married and have two sons (both adults). I like to read, walk/hike, bike, swim, and play tennis with my free time. I do not have any financial relationships with pharmaceutical companies or other financial relationships to disclose. I have helped enroll patients in industry-sponsored research studies.

How Colonoscopy & Preps are Indicative of Patient Activation and Health Care Decision-Making

Posted on by

I found two recent studies on bowel preps interesting primarily because of how they help us understand problems with utilization and problems with patient motivation.

The first study (Clin Gastroenterol Hepatol 2014; 12: 443-50) utilized a 5% random national sample of Medicare claims data.  The authors determined that among 57,597 Medicare beneficiaries 66 years and older that underwent screening colonoscopy (not therapeutic) 24.8% of these procedures were performed in individuals with a life expectancy <10 years.  Given the nature of the study (eg. relying on administrative data), there were several limitations.  However, the implication of the study is that there are a lot of unnecessary colonoscopies.  That is, screening colonoscopies are intended to interrupt a sequence of adenoma to adenocarcinoma that can take years; even when cancer is present, it can take several years before the onset of clinical symptoms.  Currently, the US Preventive Services Task Force (USPSTF) recommends against routine screening in those aged 75-84, precisely because the benefits of screening may be outweighed by the risks of screening.”  The authors note that “people with multiple comorbidities (and therefore lower life expectancy) are more likely to visit multiple providers, which increases the chances of receiving testing.”

The second study (Clin Gastroenterol Hepatol 2014; 12: 451-57) showed that patients with lower “patient activation” are much more likely to have a poor colonoscopy preparation.  Patient activation is defined as “an individual’s knowledge, skill, and confidence for managing his/her own health and health care.”  The author’s note that the “Patient Activation Measure (PAM) is a validated scale developed…to measure this construct.” This cross-sectional study took place in Chicago between 2008-2010 at either an academic practice or a ‘federally qualified health center.’ Key findings:

  • One-third of patients (n=134/462 adults) had suboptimal quality of bowel preparations. Of these, 15% (n=62) were fair quality and 17% (n=72) were poor quality.
  • After multivariable analysis and adjustments, patient activation (OR 2.12) and diabetes (OR 2.45) were independent predictors of suboptimal bowel preparation quality.
  • Health literacy (a measure of cognitive skill) was not correlated with patient activation (a measure of patient engagement).

Also noted in same journal issue: Clin Gastroenterol Hepatol 2014; 12: 470-77.  “In a supervised setting, nurse endoscopists perform colonoscopies (after a minimum of 100) according to quality and safety standards that are comparable with those of physician endoscopist and can substantially reduce costs.”

Take-home messages:

  1. Poor bowel preparations are common.  In studies of adult patients, split-dose preparations can help.  The associated editorial (pg 458-462) recommends delaying case and considering further oral prep or enemas for patients arriving with stool that is not clear or yellow.
  2. Colonoscopies are performed too frequently in some patients and not frequently enough in others.  Thus, something as simple as a colonoscopy is not so simple.

Related blog posts:

Zip Code or Genetic Code -which is more important for longevity?

Posted on by

From NY Times: http://t.co/fNm0nFOUdK

An excerpt:

Fairfax County, Va., and McDowell County, W.Va., are separated by 350 miles, about a half-day’s drive. Traveling west from Fairfax County, the gated communities and bland architecture of military contractors give way to exurbs, then to farmland and eventually to McDowell’s coal mines and the forested slopes of the Appalachians. Perhaps the greatest distance between the two counties is this: Fairfax is a place of the haves, and McDowell of the have-nots. Just outside of Washington, fat government contracts and a growing technology sector buoy the median household income in Fairfax County up to $107,000, one of the highest in the nation. McDowell, with the decline of coal, has little in the way of industry. Unemployment is high. Drug abuse is rampant. Median household income is about one-fifth that of Fairfax.

One of the starkest consequences of that divide is seen in the life expectancies of the people there. Residents of Fairfax County are among the longest-lived in the country: Men have an average life expectancy of 82 years and women, 85, about the same as in Sweden. In McDowell, the averages are 64 and 73, about the same as in Iraq….           

There have long been stark economic differences between Fairfax County and McDowell. But as their fortunes have diverged even further over the past generation, their life expectancies have diverged, too. In McDowell, women’s life expectancy has actually fallen by two years since 1985; it grew five years in Fairfax.

“Poverty is a thief,” said Michael Reisch, a professor of social justice at the University of Maryland, testifying before a Senate panel on the issue. “Poverty not only diminishes a person’s life chances, it steals years from one’s life.”

That reality is playing out across the country. For the upper half of the income spectrum, men who reach the age of 65 are living about six years longer than they did in the late 1970s. Men in the lower half are living just 1.3 years longer.

This life-expectancy gap has started to surface in discussions among researchers, public health officials and Washington policy makers. The general trend is for Americans to live longer, and as lawmakers contemplate changes to government programs — like nudging up the Social Security retirement age or changing its cost-of-living adjustment — they are confronted with the potential unfairness to those who die considerably earlier.

The link between income and longevity has been clearly established. Poor people are likelier to smoke. They have less access to the health care system. They tend to weigh more. And their bodies suffer the debilitating effects of more intense and more constant stress. Everywhere, and across time, the poor tend to live shorter lives than the rich, whether researchers compare the Bangladeshis with the Dutch or minimum-wage workers with millionaires.

But is widening income inequality behind the divergence in longevity over the last three decades? …

Living in Fairfax is different than living in McDowell.

In Fairfax, there are ample doctors, hospitals, recreation centers, shops, restaurants, grocery stores, nursing homes and day care centers, with public and private entities providing cradle-to-grave services to prosperous communities…

The jobs tend to be good jobs, providing health insurance and pensions, even if there is a growing low-wage work force of health aides, janitors, fast-food workers and the like. “It’s a knowledge-based work force,” Mr. Fuller said. “And we have an economy built on services, technology-intensive services.”

…350 miles away, …

Coal miners still dig into and blast off the tops of steep Appalachian hills. But the industry that once provided thousands of jobs is slowly disappearing, and the region’s entrenched poverty has persisted. The unemployment rate is 8.8 percent, down from more than 13 percent in the worst of the recession. The current number would be even higher if more residents hadn’t simply given up looking for work.

Government assistance accounts for half of the income of county residents. Social workers described shortages of teachers, nurses, doctors, surgeons, mental health professionals and addiction-treatment workers. There is next to no public transportation…

Many people … have multiple woes: “Diabetes. Obesity. Congestive heart failure. Drug use. Kidney problems. Lung conditions from the mines.” Problems often start young and often result in shorter lives, she said. Earlier that day, she handed me a list of recent funerals with about half highlighted in yellow; they signified that the deceased was under 50…

But dollars in a bank account have never added a day to anyone’s life, researchers stress. Instead, those dollars are at work in a thousand daily-life decisions — about jobs, medical care, housing, food and exercise — with a cumulative effect on longevity…

As such, the health statistics for Fairfax and McDowell are as striking as their income data. In Fairfax, the adult obesity rate is about 24 percent and one in eight residents smokes. In McDowell, the adult obesity rate is more than 30 percent and one in three adults smokes. And the disability rate is about five times higher in McDowell.

In both counties, food availability matters. There are only two full-size grocery stores in McDowell; minimarts and fast-food restaurants are major sources of nutrition. “We don’t have gyms or fitness centers,” said Pamela McPeak, who grew up in McDowell getting creek water to flush her family’s toilet. “It’s cheaper to buy Cheetos rather than apples.” She now runs a nonprofit program that provides tutoring and helps high school students get into college.

Education is also correlated with longevity, as it is with income and employment. Educated individuals are much more likely to work, and much more likely to have higher incomes. In McDowell, about one in 18 adults has a college degree; in Fairfax, the share is 60 percent.

Finally, and perhaps most powerfully, researchers say that a life in poverty is a life of stress that accumulates in a person’s very cells. Being poor is hard in a way that can mean worse sleep, more cortisol in the blood, a greater risk of hypertension and, ultimately, a shorter life…

It is hard to prove causality with the available information. County-level data is the most detailed available, but it is not perfect. People move, and that is a confounding factor. McDowell’s population has dropped by more than half since the late 1970s, whereas Fairfax’s has roughly doubled. Perhaps more educated and healthier people have been relocating from places like McDowell to places like Fairfax. In that case, life expectancy would not have changed; how Americans arrange themselves geographically would have…

In particular, changes in smoking and obesity rates may help explain the connection between bigger bank accounts and longer lives. “Richer people and richer communities smoke less, and that gap is growing,” said Dr. Murray at the Institute for Health Metrics and Evaluation…

To some extent, the broad expansion of health insurance to low-income communities, as called for under Obamacare, may help to mitigate this stark divide, experts say. And it is encouraging that both Republicans and Democrats have recently elevated the issues of poverty, economic mobility and inequality, But the contrast between McDowell and Fairfax shows just how deeply entrenched these trends are, with consequences reaching all the way from people’s pocketbooks to their graves.

Related blog posts:

Feeling Guilty about Stopping Breastfeeding? (Part 2)

Posted on by

Another study (J Pediatr 2014; 164: 487-93, editorial pg 440-42) echoes yesterday’s study.

Design: The authors used a nationally representative sample in a longitudinal survey of 7500 children.  In addition to breastfeeding practices, the authors explored parenting behaviors including putting an infant to bed with a bottle and frequency of reading.

Results: “there is a positive relationship between predominant breastfeeding for 3 months or more and child reading skills, but this link is the result of cognitively supportive parenting behaviors and greater levels of education among women who predominantly breastfed. We found little-to-no relationship between infant feeding practices and the cognitive development of children with less-educated mothers. Instead, reading to a child every day and being sensitive to a child’s development were significant predictors of math and reading readiness outcomes.”

Take-home message: the editorial states that parents should not be concerned that being unable to breastfeed will be detrimental to a child’s cognitive function. But, “encouragement of breastfeeding for other reasons, including health benefits to the infant and enhancement of mother-infant attachment”…merit recommendation along with good parenting practices (eg. reading to infants).

Feeling Guilty about Stopping Breastfeeding?

Posted on by

From NY Times, Link: http://t.co/rBXCORx3mM

Excerpt:

Many women who are unable to breast-feed feel guilty about it and worry they may be depriving their children of a range of benefits. Groups like the American Academy of Pediatrics and the World Health Organization recommend six months of exclusive breast-feeding for all infants, citing studies that show breast milk is easily digestible and has nutrients that are superior to or absent from infant formulas, including immunological substances that reduce rates of infection and fatty acids important in brain development.

But now a new study suggests that many of the long-term benefits attributed to breast-feeding may be an effect not of breast-feeding or breast milk itself but of the general good health and prosperity of women who choose to breast-feed.

Researchers at Ohio State University compared 1,773 sibling pairs, one of whom had been breast-fed and one bottle-fed, on 11 measures of health and intellectual competency. The children ranged in age from 4 to 14 years.

The researchers recorded various health and behavioral outcomes in the sibling pairs, including body mass index, obesity, asthma, hyperactivity, reading comprehension, math ability and memory-based intelligence. The study, published online in Social Science & Medicine, found no statistically significant differences between the breast-fed and bottle-fed siblings on any of these measures.

By studying “discordant” siblings — one of whom had been breast-fed and the other not — the authors sought to minimize the possibility that racial, socioeconomic, educational or other differences between families could affect the results. Many earlier studies on breast-feeding failed to control for such factors, they say.

… researchers have consistently found large socioeconomic and racial disparities in breast-feeding rates. A C.D.C. survey in 2008 found that 75 percent of white infants and 59 percent of black infants were ever breast-fed, and in 2013, the agency reported that 47 percent of white babies but only 30 percent of black babies were still being breast-fed at 6 months. Compared with bottle-fed infants, breast-fed babies are more likely to be born into families with higher incomes, have parents with higher educational attainments, and live in safer neighborhoods with easier access to health care services.

Still, sibling studies such as this latest one do not solve all the problems of bias…

Geoff Der, a statistician at the University of Glasgow who has worked with the same data in previous studies, said that the findings in the present study were robust and the authors’ method for eliminating selection bias was powerful…“In a society with a clean water supply and modern formulas,” he said, “a woman who isn’t able to breast-feed shouldn’t be feeling guilty, and the likelihood that there’s any harm to the baby is pretty slim.”

Related blog posts:

Active Video Games –Part of Weight Loss Program?

Posted on by

From JAMAPediatrics (full article): http://t.co/CmwQjCyhdJ

An excerpt:

Design, Setting, and Participants      Group-randomized clinical trial conducted during a 16-week period in YMCAs and schools .. Seventy-five overweight or obese children (41 girls [55%], 34 whites [45%], 20 Hispanics [27%], and 17 blacks [23%]) enrolled in a community-based pediatric weight management program. Mean (SD) age of the participants was 10.0 (1.7) years; body mass index (BMI) z score, 2.15 (0.40); and percentage overweight from the median BMI for age and sex, 64.3% (19.9%).

Interventions      All participants received a comprehensive family-based pediatric weight management program (JOIN for ME). Participants in the program and active gaming group received hardware consisting of a game console and motion capture device and 1 active game at their second treatment session and a second game in week 9 of the program. Participants in the program-only group were given the hardware and 2 games at the completion of the 16-week program…

Results      Participants in the program and active gaming group exhibited significant increases in moderate-to-vigorous (mean [SD], 7.4 [2.7] min/d) and vigorous (2.8 [0.9] min/d) physical activity at week 16 (P < .05). In the program-only group, a decline or no change was observed in the moderate-to-vigorous (mean [SD] net difference, 8.0 [3.8] min/d; P = .04) and vigorous (3.1 [1.3] min/d; P = .02) physical activity. Participants in both groups exhibited significant reductions in percentage overweight and BMI z scores at week 16. However, the program and active gaming group exhibited significantly greater reductions in percentage overweight (mean [SD], −10.9% [1.6%] vs −5.5% [1.5%]; P = .02) and BMI z score (−0.25 [0.03] vs −0.11 [0.03]; P < .001).

Conclusions and Relevance      Incorporating active video gaming into an evidence-based pediatric weight management program has positive effects on physical activity and relative weight.

Comment: The costs of the games and game consoles were about $350 according to the authors.  Since this was a short study (16-weeks), it is not clear that this will be cost-effective.  However, any tools that may help kids become more active are certainly welcome.

Related Blog Posts:

Think Like a Doctor –Another Reason for Cyclic Vomiting

Posted on by

When cyclic vomiting pattern starts in young adults, the differential diagnosis is different than in toddlers.  A case in point is a recent think like a doctor column from NY Times.

The initial presentation described a 25-year-old man who gets sweaty and nauseated and starts vomiting uncontrollably every few weeks.

1st the link with the case challenge: challenged Well readers to figure out

A big clue in this case was the fact that hot showers ameliorated his symptoms.

Now the answer, full link: http://nyti.ms/1lcPJKj 

“The correct diagnosis is…

 

 

 

Cannabinoid hyperemesis caused by smoking synthetic marijuana.”

Related blog post: Diet or drugs for cyclic vomiting syndrome | gutsandgrowth

Briefly Noted…Scoliosis, Cystic Fibrosis, Specific Carbohydrate Diet, GGT, Surgeon General

Posted on by

“Net effect of scoliosis surgery on gastric emptying, upper gastrointestinal symptoms, and clinical nutritional status was minimal”  according to this prospective study of 31 children: JPGN 2014; 58: 38-45.

Lactobacillus reuteri ATCC55730 was associated with reduced pulmonary exacerbations (but not improved FEV1) in 61 patients with cystic fibrosis who were enrolled in a prospective randomized, double-blind, placebo-controlled study over 6 months between 2007-2009 (JPGN 2014; 58: 81-86).

A retrospective chart review of seven children with Crohn disease who were treated with the specific carbohydrate diet with an average diet duration of 14.6 months showed that all symptoms resolved and laboratory studies improved or normalized.  (JPGN 2014; 58: 87-91). More studies on this diet are expected to be published soon.

Data from 200 preterm infants and 383 term infants help provide updated GGT (gamma-glutamyl transferase) reference values.  In preterm infants during 1st 7 days: 141 ± 89 U/L, then between days 8-28: 131 ± 85 U/L.  In term infants the values were similar 140 ±86 U/L and 145 ± 87 U/L respectively. (JPGN 2014; 58: 99-101).

And from NEJM twitter feed, Congress may allow the NRA veto power in the selection the next surgeon general: http://nej.md/1nECFlM.

Revising the Textbooks on Isoniazid Hepatotoxicity

Posted on by

Previously, isoniazid (INH) hepatoxicity has generally been described as “idiosyncratic.”  New research shows that INH-induced hepatotoxicity is often associated with anti-INH and anti-cytochrome P450 antibodies (Hepatology 2014; 59: 1084-93, editorial 746-48).

Background: INH is a crucial treatment for tuberculosis.  About 10% of patients receiving monotherapy may develop mild elevations (<3-fold the upper limit of normal) of alanine aminotransferase.  However, 0.5-1% develop overt hepatitis and some develop acute liver failure (ALF).  Risk factors for ALF include female gender, age >35 years, cotreatment with other tuberculosis medications, INH dose >50 mg/kg, ethanol use, and slower metabolic pathways (slow acetylator N-acetyltransferase 2 or cytochrome (CYP) P450 2E1 genotype).

The authors utilized two patient groups: 19 from the ALF study group registry who had >50% likelihood of IHN toxicity and 20 control patients who were receiving INH prophylaxis.  In this control group, 15 had no liver injury and 5 had mild hepatitis. The authors utilized several immunoassays.

Key findings:

  • 15 of 19 cases of INH-associated ALF had detectable antibodies: 8 anti-INH and 11 had antiCYP2E1 Abs.
  • None of these antibodies were detected from INH-treated controls

Bottomline: from the authors of the study “Although the presence of these antibodies only in INH-induced liver failure suggests that INH-induced liver injury is immune mediated, there is no evidence that these Abs are actually responsible for the liver injury.”

In this same issue is a lengthy guideline on the “Evaluation for Liver Transplantation in Adults”: http://t.co/AnnJHHVNh0

Related blog post:

Liver toxicity -where to look online | gutsandgrowth

Training Not Meeting Procedure Thresholds for Fellows

Posted on by

With expanding numbers of pediatric GI trainees, it is even more concerning that training centers have had difficulty providing adequate experience for their trainees.  In a recent study (JPGN 2014; 58: 27-33), not one of 12 centers was able to meet the threshold for all of the procedures.

The authors provide NASPGHAN procedural competency guidelines in Table 2. The 2013 guidelines lowered the threshold for almost all procedures in comparison to the 1999 guidelines.  One notable exception was foreign bodies which was increased to 10. Then, the authors examined the frequency of procedures actually performed between 2009-2011.

Key findings (with the lower thresholds)

  • Polypectomy (threshold, n=10) 67% of programs meeting 2013 NASPGHAN guidelines
  • Control of nonvariceal bleeding/Sclerotherpy/Variceal band ligation (threshold, n=15) 17% of programs meeting 2013 NASPGHAN guidelines. Mean number per fellow of nonvariceal bleeding cases was 2 procedures. Mean number per fellow of banding/sclerotherapy was 7 procedures. With the 1999 guidelines, the threshold had been 35 for these procedures combined.
  • Esophageal, pyloric and duodenal stricture dilatation (threshold, n=15) 42% of programs meeting 2013 NASPGHAN guidelines
  • PEG (threshold, n=10) 42% of programs meeting 2013 NASPGHAN guidelines (training not available at 42% of these institutions)
  • Percutaneous liver biopsy (threshold, n=15) 67% of programs meeting 2013 NASPGHAN guidelines
  • Foreign-body removal (threshold, n=10) 58% of programs meeting 2013 NASPGHAN guidelines

It is noted that the 2013 guidelines “reclassified control of variceal and nonvariceal bleeding from a level 2 to a level 1 procedure, stressing that expertise in hemostasis should be achieved during fellowship.” “Without supplemental training, none of these programs, which are likely representative of most programs, were able to provide sufficient opportunities to meet the NASPGHAN guidelines.” Besides spending more time working with adult gastroenterologists, other potential ways to gain more experience includes simulators and hands-on training courses.

Take-home message: Pediatric gastroenterology training centers are not providing enough procedural experience and need to make rotating with adult gastroenterologists mandatory. It is unfair to trainees and vulnerable patients to consider their training complete with these obvious deficiencies.

When families ask the newly trained pediatric gastroenterologist how many cases like this that they have completed, how will they feel if the honest answer is two?

Related blog post:

Training for Tomorrow | gutsandgrowth

The Liver –Front and Center

Posted on by

Before proceeding with today’s post, those who read yesterday’s post may be interested in Atul Gawande’s take on the NEJM checklist publication -here’s the link (from Atul Gawande’s twitter feed): bit.ly/1d6v31z. 

A recent review “Extrahepatic Complications of Nonalcoholic Fatty Liver Disease” (NAFLD)(Hepatology 2014; 59: 1174-97) seems to position the liver as the center of a multitude of problems rather than one of many associated problems.

It is known that NAFLD increases the risk of end-stage liver disease and hepatocellular carcinoma.  However, the majority of deaths among individuals with NAFLD are attributed to cardiovascular disease and malignancy.  This lengthy review describes in great detail the associations between NAFLD and the risk of developing cardiovascular disease (CVD), type 2 diabetes mellitus (T2DM), chronic kidney disease (CKD), and colorectal neoplasm.  The presence of NAFLD appears to convey an independent increase in risk for these conditions.

Key points:

  • “The aggregated evidence provides strong evidence that individuals with NAFLD are at increased “independent” risk of developing CVD.  The risk of CVD mortality may be greater in subgroups of subjects with NASH and advanced fibrosis, compared to those with simple steatosis.”
  • “USS-defined NAFLD is associated with a 2- to 5-fold risk of developing T2DM after adjustment of several lifestyle and metabolic confounders.”
  • “NAFLD (in particular, biopsy-proven NASH) is associated with a greater prevalence of CKD (20% to 50% of patients). USS-defined NAFLD carries a 1.5- to 2-fold adjusted risk of incident CKD.”
  • “A true causal relationship between and NASH and colorectal cancer cannot be confirmed.”
  • Other potential extrahepatic manifestations: hypothyroidism, polycystic ovarian syndrome, obstructive sleep apnea syndrome, and osteoporosis.

Take-Home Message: NAFLD has independent associations for greater risk of CVD, hyperglycemia, and malignancy.  Whether these associations are simply an epiphenomenon  of more aggressive metabolic syndrome or whether the liver injury primarily causes these additional risks remains unclear.

Related blog posts: