By Allan Peng, First-year student

It was a pleasure to have Dr. Arun J. Sanyal speak at Eastern Mennonite University. His lecture focused on “Fatty Liver Disease: A Silent Killer in Our Communities.” He works as a professor of medicine in the division of gastroenterology, hepatology, and nutrition at the Virginia Commonwealth University (VCU). His research focuses on nonalcoholic fatty liver disease (NAFLD), the role of the microbiome in NAFLD and nonalcoholic steatohepatitis (NASH), and the development of effective therapy for NASH.

NAFLD is a liver disease without attribution to alcohol. These patients have a fatty liver, which is diagnosed in about 1 in 4 adults in the United States. NAFLD may also lead to NASH which predisposes an individual to a 15-20% of developing cirrhosis. Four percent of those with cirrhosis will die every year at an alarming rate due to risks, in progressing order, of cardiovascular disease, hepatocellular carcinoma, and finally decompensation. Currently, organ transplants are an option, but it only delays the disease.

Projections predict that the number of patients who suffer from cirrhosis and those that become decompensated will triple over the next 15 years (3 million and 300 thousand respectively). Liver cancer rate related to obesity is increasing at 3% annually and has the lowest survival rate among all cancers. Thus, NASH education and proper intervention are crucial.

Dr. Sanyal rationalizes that NAFLD management can be simplified to 3 questions: 1) Is NAFLD present? 2) is intervention needed? and 3) what intervention should be implemented? NAFLD is categorized by disease activity and its stage. The activity is the genetic and environmental factors that may injure the liver. The stage categorizes the progression of cirrhosis, thus sub segmenting fatty liver patients into sub-populations. His research concludes that patients with obesity and T2DM are at the highest risk of liver disease. Therefore, high-risk patients are recommended to undergo lab tests to rule out NAFLD. Standard liver tests can quickly identify one’s risk for liver disease. Patients may also elect for a magnetic resonance elastography, which is the “gold standard” in clinical prediction and determination of advanced fibrosis in patients with NAFLD. This test measures the stiffness level of the patient’s liver.

So why should we be concerned about liver disease if we feel fine? The short answer is “yes.” What is frightening is that fatty liver patients may be asymptomatic until 80% of the liver is decompensated. As such, screening of diabetic or overweight patients is necessary to identify high-risk NASH patients. Patients with fatty liver and T2DM already have a 20% chance of advanced fibrosis (i.e., stage 2 or higher).

It is easy to be frightened when one sees all of the possible diseases secondary to or downstream of liver disease. However, we should not panic, but rather approach this in the step-wise manner as stated above. Medications can only do so much work to treat downstream diseases of obesity (e.g., cardiac disease, hepatocellular cancer). He proposes that we, instead, hunt for the root of heart disease, diabetes, and NASH. This would be obesity. When one is obese, he or she suffers from abnormal metabolism. The “sewage system” of the body is put under chronic stress, which essentially poisons the body. This leads to inflammation and scarring of the tissue. Additionally, those who are obese with a fatty liver have a higher chance of becoming diabetic.

To resolve a cascade of diseases, Dr. Sanyal urges us, from a public health standpoint, to focus our effort on issues upstream of liver disease – obesity. If an overweight patient loses 10% of his or her body weight, tissue scarring can be reversed. The healthiest way to do this is diet modification—a 30% reduction of dietary energy intake to lose weight. Lifestyle is also important. Sleep duration, sleep quality, and sedentary lifestyles can contribute to the risk of NASH, even if we objectively are not overweight.

As a current student seeking to enter future professional work as a future physician assistant, I found Dr. Arun Sanyal’s lecture quite eye-opening. I most appreciated Dr. Arun Sanyal’s realistic and public health approach. It is easy to focus on the black and white, whether we have a disease or no disease. However, he concludes his lecture with some wisdom from Huang Dee, 2600 BC, and the first medical text: “superior doctors prevent the disease, mediocre doctors treat the disease before evident, and inferior doctors treat the full-blown disease.” As future health care providers and as citizens of a community, we can do better to educate each other, to encourage healthy dieting, to reduce obesity rates, and to defeat fatty liver disease—the silent killer in our communities.