Fatty Liver - A Dangerous Complication Of Obesity

Amongst the long list of medical complications of obesity, one very common complication that is not considered often enough is fatty liver.

Non alcoholic fatty liver disease (NAFLD) is the most common cause of liver disease worldwide.  It is divided into:

• fatty liver (fat deposition) only
• fatty liver with inflammation (steatohepatitis)
• fatty liver with inflammation and scarring (fibrosis), which in the most severe cases is called liver cirrhosis 

A recent review by Mary Rinella in the Journal of the American Medical Association (JAMA) reports some sobering statistics on this problem:

• non alcoholic fatty liver disease (NAFLD) affects 30% of the American population - in other words, between 75 million to 100 million Americans likely have this disease
• liver cirrhosis is the third most common cause of death in patients with NAFLD
• 66% of patients age 50 or older with diabetes or obesity are thought to have advances fibrosis (scarring) of the liver

The diagnosis of NAFLD presents a number of challenges.  Liver enzyme tests (ALT and AST) are normal in 30-60% of patients with fatty liver plus inflammation (steatohepatitis) on liver biopsy, so we clearly cannot rely on these blood tests to make the diagnosis.  Ultrasound can catch many cases of fatty liver, but can miss the milder ones.  MRI is the best non invasive test to detect fat in the liver, but is unfortunately expensive and in limited supply.  

To look for scarring (fibrosis) in the liver, a special kind of test called a Fibroscan (vibration-controlled transient elastography) can be done in a liver specialist's office and is fairly accurate.  MRI elastography may be more reliable, but again is costly and not widely available.  

The best test to look for fatty liver, inflammation, and scarring is a liver biopsy - but of course, this is not without risk.  

In terms of treatment, the only good therapy we are currently aware of is weight loss.   A weight loss of 10% has been shown to decrease liver inflammation.  It also appears that a lower carbohydrate diet is important.  Vitamin E has been shown to have some benefit, but may be associated with a higher risk of prostate cancer and hemmoragic (bleeding type) stroke.  A number of medications have been looked at (including pentoxyfylline, obeticholic acid, and pioglitazone), but none have been found to be sufficiently effective, and/or have too high of a side effect risk profile. 

It is important for health care providers to consider fatty liver as a possible medical condition in any patient with obesity.  As for treatments, we have a long way to go, but the importance of healthy lifestyle changes seems more important than ever.

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2015

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New Obesity Medication - Liraglutide On The SCALE

Liraglutide, a medication that we currently use to treat type 2 diabetes, will soon become available in Canada as a treatment for obesity.  Hot off the presses, the biggest clinical trial to study liraglutide as an obesity treatment has just been published this week in the New England Journal of Medicine.

This SCALE obesity trial enrolled just over 3700 participants, and evaluated the effect of liraglutide 3.0mg vs placebo on body weight, with both groups receiving counselling on lifestyle modification.  To participate in the study, patients had to have a BMI of at least 30, or a BMI of 27 plus high blood pressure or high cholesterol (treated or untreated).  After a year, patients on liraglutide lost 8.4kg of body weight, compared to 2.8kg in the placebo group.

We generally consider a weight loss of 5% to be clinically important, in that a 5% loss of body weight has been shown to be associated with a decreased risk of developing many complications of obesity.  In the SCALE trial, 63% of patients lost at least 5% body weight, compared with 27% in the placebo group.

While patients with type 2 diabetes were not included in this study, patients with prediabetes were included, and were equal between groups receiving medication vs placebo at the start of the study.  After a year on liraglutide, 70% of patients who had prediabetes at the start of the study had normal blood sugar levels; after a year on placebo, only a third of patients with prediabetes at the start of the study had normal blood sugar levels.

In terms of side effects, the most common side effect in the liraglutide group was gastrointestinal side effects (such as nausea or vomiting); 94% of these symptoms were mild to moderate in nature.  Gallbladder related side effects were also more common on liraglutide.  Pancreatitis occurred in 0.4% of patients on liraglutide vs less than 0.1% of patients on placebo; the majority of these cases were related to gallstone disease.


Liraglutide will become available as an obesity treatment in Canada later this summer, and is already available in USA.  As the first obesity medication approved by Health Canada in 19 years, it will provide a useful tool in our toolbox to treat obesity, in addition to permanent lifestyle changes.  Our next challenge is now to convince payors (both provincial and private insurance companies) of the need to truly consider obesity as a chronic disease, and accordingly provide financial coverage for obesity medications.

Disclaimer: I was involved in the research trials of liraglutide as an obesity treatment.  I receive honoraria as a continuing medical education speaker and consultant from the makers of liraglutide (Novo Nordisk). I am involved in research of medications similar to liraglutide for the treatment of type 2 diabetes.

Follow me on twitter! @drsuepedersen

www.drsue.ca © 2015

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