Endocrine Society Reading Room | Non-alcoholic fatty liver disease is still underrecognized in people with poorly controlled T2D

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disorder. Although not exclusively associated with insulin resistance and type 2 diabetes (T2D), the link is quite compelling.

Cardiovascular disease (CVD) is the most common cause of morbidity and mortality in NAFLD. The NAFLD spectrum includes nonalcoholic steatohepatitis (NASH), which is prevalent in about one-fifth of patients with NAFLD. NASH eventually leads to extensive fibrosis and cirrhosis, which may also predispose to hepatocellular carcinoma (HCC) in some patients.

Since NAFLD is asymptomatic, various non-invasive tools such as NAFLD fibrosis score (NFS) and fibrosis score (FIB)-4 have been developed and validated. These scoring tools have been recommended by several international organizations, including the American Association for the Study of Liver Diseases (AASLD), the European Association for the Study of the Liver (EASL), and the National Institute of Clinical Excellence ( NICE). The objective is to screen high-risk patients in order to identify those who need additional investigations and/or referral to specialized services.

A study by Alexopoulos et al in the Journal of the Endocrine Society is a sub-analysis of the Practical Telehealth to Improve Control and Engagement for Patients with Clinic-Refractory Diabetes Mellitus (PRACTICE-DM) study. The overall study is a randomized controlled trial evaluating the effectiveness of a comprehensive home telehealth intervention on improving HbA1 C in patients with T2D between 2018 and 2020.

In this observational study of 228 patients (mean age 58.1 years, 68.5% Black or African American) with poorly controlled diabetes (mean HbA1 C 9.8%), only 15 had an established diagnosis of NAFLD. However, in the remaining 213 patients, although a third had an abnormal liver enzyme test during the study period, very few (

The results of the study from two centers in the developed world are disappointing – but somewhat expected as NAFLD remains the least detected complication associated with diabetes. The most likely reason for these findings is lack of awareness among physicians. The paucity of therapeutic interventions to prevent or reverse NAFLD also remains a major barrier. While lifestyle interventions pioglitazone and vitamin E have shown positive results, results from trials with new glucagon-like peptide-1 receptor agonists (GLP-1 RA) have shown some promise with the added benefit of decreasing the risk of CVD.

Muhammad Fahad Arshad, MBBS, MRCP, is a Clinical Research Fellow at the University of Sheffield, UK

Read the study here and an interview with the lead author here.

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