Sounding The Alarm About Fatty Liver Disease in Children
Dr. Charina Ramirez and Dr. Isabel Rojas sound the alarm about fatty liver disease in children.
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Learn more about Isabel Rojas, MD
Charina Ramirez, MD, is a gastroenterologist at Children’s Health℠ and an associate professor of pediatrics at UT Southwestern Medical Center. After receiving her medical degree from the UT Medical Branch at Galveston, Dr. Ramirez completed an internship and residency training in pediatrics at Children’s Medical Center. Dr. Ramirez completed her fellowship in pediatric gastroenterology, hepatology and nutrition at UT Southwestern and Children’s Medical Center. She also served as a research fellow studying lipid metabolism during this time. Dr. Ramirez’s research interest involves cholesterol transport in the murine models of Nieman-Pick Type C disease and Lysosomal Acid Lipase Deficiency. Currently, she’s evaluating the effects of a low carbohydrate diet in pediatric patients with metabolic syndrome and non-alcoholic fatty liver disease.
Learn more about Charina Ramirez, MD
Isabel Rojas, MD | Charina Ramirez, MD
Isabel Rojas, MD, is a gastroenterologist at Children’s Health and an assistant professor of Pediatric Gastroenterology at UT Southwestern. Dr. Rojas received her medical degree at Universidad del Rosario in Bogota, Colombia. She completed her residency program in Pediatrics at University of Oklahoma in Tulsa and finished her fellowship in Pediatric Gastroenterology, Hepatology and Nutrition at UT Southwestern. Her clinical expertise includes general pediatric gastroenterology and hepatology with focus in liver diseases such as cholestasis and acute liver failure. She also focuses special attention on capsule endoscopy and polyposis.Learn more about Isabel Rojas, MD
Charina Ramirez, MD, is a gastroenterologist at Children’s Health℠ and an associate professor of pediatrics at UT Southwestern Medical Center. After receiving her medical degree from the UT Medical Branch at Galveston, Dr. Ramirez completed an internship and residency training in pediatrics at Children’s Medical Center. Dr. Ramirez completed her fellowship in pediatric gastroenterology, hepatology and nutrition at UT Southwestern and Children’s Medical Center. She also served as a research fellow studying lipid metabolism during this time. Dr. Ramirez’s research interest involves cholesterol transport in the murine models of Nieman-Pick Type C disease and Lysosomal Acid Lipase Deficiency. Currently, she’s evaluating the effects of a low carbohydrate diet in pediatric patients with metabolic syndrome and non-alcoholic fatty liver disease.
Learn more about Charina Ramirez, MD
Transcription:
Sounding The Alarm About Fatty Liver Disease in Children
Bill Klaproth (Host): Nonalcoholic fatty liver disease or NAFLD is on the rise in children. So, what is it, why is this happening and what can be done to treat it? We’re going to cover all of that as we sound the alarm about fatty liver disease in children.
This is Pediatric Insights, Advances and Innovations with Children’s Health where we explore the latest in pediatric care and research. I’m Bill Klaproth and with me is our experts Dr. Charina Ramirez, Pediatric Gastroenterologist at Children’s Health and Associate Professor at UT Southwestern and Dr. Isabel Rojas, Pediatric Gastroenterologist at Children’s Health and Assistant Professor at UT Southwestern. Ladies, thank you so much for joining me today. Dr. Ramirez, let’s start with you. So, what is nonalcoholic fatty liver disease or NAFLD and then what is nonalcoholic steatohepatitis or NASH?
Charina Ramirez, MD (Guest): Okay. So, NAFLD is the inclusive term that encompasses the full spectrum of the disease, so we call it an umbrella term. And it is subdivided into four different categories and so underneath that includes just NAFL which is just steatosis and that’s what happens when there’s more than five percent of the affected hepatocytes that contain fat and the fat that is accumulated within the liver is called triglycerides. So, NASH is then the next step in this disease process where there’s fat present as well as evidence of inflammation and also injury to the hepatocytes such as ballooning and that’s the progressive form, and that’s known as nonalcoholic steatohepatitis.
And then from there it will continue to progress to fibrosis and eventually cirrhosis and perhaps even a liver transplant.
Host: And Dr. Ramirez if I could stay with you, could you just tell us the basic difference between NAFLD and NASH?
Dr. Ramirez: So, NAFLD is the umbrella term and that’s what we use when we say okay this person has fatty liver disease but then underneath that, then we can categorize whether they have just simple steatosis which is if you stay within the stage then that’s really not dangerous but then if you have the progressive form which can occur in about 30% of that population; then that’s the one that becomes dangerous and that will then lead on to fibrosis and scarring and then cirrhosis and sometimes in rare cases hepatocellular carcinoma.
Host: Well thanks Dr. Ramirez. I just wanted to make sure we articulated the main differences between NAFLD and NASH. Dr. Rojas, I’m going to turn to you now. So, why is NAFLD on the rise in children and what causes it?
Isabel Rojas, MD (Guest): Yeah, unfortunately nowadays we have seen that obesity in children is on the rise and that is the most significantly risk factor for the development of NAFLD. NAFLD itself, is more like a wide spread underlying metabolic dysfunction that is strongly associated from metabolic risk factors. And those include the insulin resistance, dyslipidemia, cardiovascular disease and as I said before, obesity. So, we see patients as young as two years old that have been documented before but usually these patients present around ten years of age. And they are diagnosed mainly between 11 and 13 years old.
We start these patient is screened these patients with AFT and that is one of the liver enzymes and then depending on how they are doing on the numbers, so we continue the workup testing to make sure the patients are not falling any other liver disease. Unfortunately this is the most prevalent chronic liver disease in children nowadays.
Host: Wow that is an amazing stat you see this as early as two years old. And most of the time you said it presents around 10 years of age. So, Dr. Ramirez, what are the dangers of this then?
Dr. Ramirez: So, the dangers are twofold. One is NAFLD is what you call like an entry level disease into metabolic syndrome which what Dr. Rojas said that includes type two diabetes, cardiovascular problems, hypertension and so, when you have a patient that has fatty live disease, if their weight is not controlled, then the next step is typically type two diabetes and then after that hypertension, dyslipidemia. Some of them will have sleep apnea as well as reflux and depression. So, there’s a lot of other comorbidities that go along with having fatty liver disease. And so that’s the first part of it.
Now the second part is that if the fatty liver disease is not corrected early on, then it will progress like we talked about into NASH and so these patients are the ones that are in danger of having fibrosis and cirrhosis and as children and adolescents it’s not that bad because they typically don’t have symptoms, so they don’t feel that they are sick. However, as they become adults, then it becomes a big problem because right now NASH is the leading indication for liver transplantation among women and it’s the second cause of liver transplantation among men. And that changed between 2016 and 2018 and so those are the two big dangers is that the comorbidities that exist with it once if it’s not controlled and then the danger of needing a liver transplant and even developing liver cancer.
Host: Well you certainly don’t want this to progress and then develop those comorbidities. So, Dr. Rojas, can this be reversed and if so, how?
Dr. Rojas: Yes, fortunately yes, this can be reversed, and the liver is one of the few organs that regenerates by itself. So, changes in lifestyle modifications, following a healthy diet, lowering fat and carbohydrates. That is very important to not forget about the carbohydrates. And exercise almost like every day exercise can reverse the disease. So, this is important also to work with a dietician to help the patients to have a good plan for their healthy diet. Because, as I said before, this can be reversed.
Host: That is really good news and I’m glad to hear that. So, Dr. Ramirez, what can medical providers do to stay aware and vigilant about this?
Dr. Ramirez: So, right now, the American Academy of Pediatrics recommends that cholesterol be checked between ages 9 to 11 and recently, our own North American Pediatric Society for Gastroenterology, Hepatology and Nutrition called NAPSGHAN has made recommendations to also start screening patients who have a body mass index of 85% or more with risk factors or body mass index of 95% or more and you can screen with just an ALT which is a simple bloodwork that can be tagged on to what the American Academy of Pediatrics already recommends.
Of course, if there is family history of fatty liver disease, the body mass index is important as a cutoff but if you have someone who has a body mass index of close to 85% but you know that they have fatty liver disease in the family, it may be a good idea to go ahead and screen those children as well. There’s a small portion, about 8% of adolescents that can develop fatty liver disease who are lean, but their blood work is very similar to patients who are obese with high LDL which is the bad cholesterol and low HDL which is the good cholesterol and they also have fatty liver disease. So, trying to identify the patients at least at the time when they have screening labs, is really a good chance for the pediatricians to be able to start providing interventions because the younger you are, when you provide interventions, the more responsive and then like Dr. Rojas said, it’s reversible.
So, if you can approach them the earlier age the better just because then their eating habits can change. Because the main thing about this is really behavioral changes. It’s easy for us as providers to be able to tell them heh, don’t drink as much juice, don’t drink soda, start moving around more, but for them to really enact it, they have to be motivated. The family has to be motivated and so, that’s one of the big things for this to be successful in treating the patients is getting your patient and the family to buy in. And as medical providers, I think it’s really important to not scold the patient or the family because they already feel guilty. They already know, they’ve been told by so many different providers like you are – your child is obese. It’s because it’s your fault but rather than approaching it that way; teaming up with the family and with their children is going to probably have a better effect. I think as human beings, we tend to respond better to positive feedback.
Host: We all do, that’s very true. So, Dr. Ramirez, sticking with you, so it sounds like it’s safe to say finding this early is crucial in reversing this before it turns into NASH, is that correct?
Dr. Ramirez: That’s right. That’s right and so, in our patient population in Texas, fortunately we have not had to transplant anybody with fatty liver disease but there are other areas in the nation like in San Diego where they picked up patients in their teens that have had progressive disease and who have needed liver transplants.
Host: And as we wrap up Dr. Rojas, what are we doing at Children’s Health to stay aware and vigilant about this?
Dr. Rojas: Well here at Children’s Health we have a multidisciplinary team that includes a physician, so the gastroenterologists as Dr. Ramirez and myself, also including dieticians and psychology support and we also have the different modalities for diagnosis and follow up for these patients. It starts with the labwork that we need in the beginning and then running the liver biopsy that can be done by interventional radiology or we have now the opportunity to do it endoscopically where the patient doesn’t have like a scar or anything on the body, so it is inside. And the addition now of the MRI and the ultrasound with [00:14:35] agraphy that help us to assess if the liver is getting more damaged, if it is becoming more fibrotic to the point that as Dr. Ramirez was saying, that they develop cirrhosis. So those are the modalities that now we have here at Children’s Health to help the kids with this disease.
Dr. Ramirez: And I just want to add in addition to the other things that we are doing here at Children’s Health is Children’s Health has teamed up with the YMCA to develop the Get Up and Go Program. That’s been in existence for several years but this year, the YMCA has received extra funding and have partnered with other companies so that this program could be more successful and so it’s a 10 week program where families and their children go and they get a complimentary YMCA membership during that 10 week program but then they also learn how to eat healthy, exercise and it’s offered in both Spanish and English and it’s in various locations around the Metroplex and the different YMCAs.
The second part is that there is bariatric program that’s there so, if weightloss is not achieved or healthy eating and exercise does not help the patient out because they are really struggling and we use our psychologists, and our dieticians; then bariatric surgery is available, and Dr. Karachi is the bariatric surgeon who leads that team. And then during the summer, we offer Camp Ka ana [00:13:15] which is another partnership between Children’s and the YMCA where they have children who are obese so not necessarily just having fatty liver but obese children between the ages of 10 and 14 can go there and have a two week camp where they learn to eat healthy and they also learn to order like a 500 calorie meal if you go to some fast food chain and then they also do fun activities that you typically do during the summertime.
Host: Well those are really great programs that we all should know about. So, thanks for sharing those and Dr. Ramirez and Dr. Rojas thank you so much for your time today.
Dr. Ramirez: Thank you very much.
Dr. Rojas: Oh no, my pleasure, thank you.
Host: That’s Dr. Charina Ramirez and Dr. Isabel Rojas and thank you for listening to Pediatric Insights. For more information, please visit www.childrens.com/fattyliver, that’s www.childrens.com/fattyliver. And if you found this podcast helpful, please rate and review or share the episode and please follow Children’s Health on your social channels. This is Pediatric Insights, Advances and Innovations with Children’s Health. Thanks for listening.
Sounding The Alarm About Fatty Liver Disease in Children
Bill Klaproth (Host): Nonalcoholic fatty liver disease or NAFLD is on the rise in children. So, what is it, why is this happening and what can be done to treat it? We’re going to cover all of that as we sound the alarm about fatty liver disease in children.
This is Pediatric Insights, Advances and Innovations with Children’s Health where we explore the latest in pediatric care and research. I’m Bill Klaproth and with me is our experts Dr. Charina Ramirez, Pediatric Gastroenterologist at Children’s Health and Associate Professor at UT Southwestern and Dr. Isabel Rojas, Pediatric Gastroenterologist at Children’s Health and Assistant Professor at UT Southwestern. Ladies, thank you so much for joining me today. Dr. Ramirez, let’s start with you. So, what is nonalcoholic fatty liver disease or NAFLD and then what is nonalcoholic steatohepatitis or NASH?
Charina Ramirez, MD (Guest): Okay. So, NAFLD is the inclusive term that encompasses the full spectrum of the disease, so we call it an umbrella term. And it is subdivided into four different categories and so underneath that includes just NAFL which is just steatosis and that’s what happens when there’s more than five percent of the affected hepatocytes that contain fat and the fat that is accumulated within the liver is called triglycerides. So, NASH is then the next step in this disease process where there’s fat present as well as evidence of inflammation and also injury to the hepatocytes such as ballooning and that’s the progressive form, and that’s known as nonalcoholic steatohepatitis.
And then from there it will continue to progress to fibrosis and eventually cirrhosis and perhaps even a liver transplant.
Host: And Dr. Ramirez if I could stay with you, could you just tell us the basic difference between NAFLD and NASH?
Dr. Ramirez: So, NAFLD is the umbrella term and that’s what we use when we say okay this person has fatty liver disease but then underneath that, then we can categorize whether they have just simple steatosis which is if you stay within the stage then that’s really not dangerous but then if you have the progressive form which can occur in about 30% of that population; then that’s the one that becomes dangerous and that will then lead on to fibrosis and scarring and then cirrhosis and sometimes in rare cases hepatocellular carcinoma.
Host: Well thanks Dr. Ramirez. I just wanted to make sure we articulated the main differences between NAFLD and NASH. Dr. Rojas, I’m going to turn to you now. So, why is NAFLD on the rise in children and what causes it?
Isabel Rojas, MD (Guest): Yeah, unfortunately nowadays we have seen that obesity in children is on the rise and that is the most significantly risk factor for the development of NAFLD. NAFLD itself, is more like a wide spread underlying metabolic dysfunction that is strongly associated from metabolic risk factors. And those include the insulin resistance, dyslipidemia, cardiovascular disease and as I said before, obesity. So, we see patients as young as two years old that have been documented before but usually these patients present around ten years of age. And they are diagnosed mainly between 11 and 13 years old.
We start these patient is screened these patients with AFT and that is one of the liver enzymes and then depending on how they are doing on the numbers, so we continue the workup testing to make sure the patients are not falling any other liver disease. Unfortunately this is the most prevalent chronic liver disease in children nowadays.
Host: Wow that is an amazing stat you see this as early as two years old. And most of the time you said it presents around 10 years of age. So, Dr. Ramirez, what are the dangers of this then?
Dr. Ramirez: So, the dangers are twofold. One is NAFLD is what you call like an entry level disease into metabolic syndrome which what Dr. Rojas said that includes type two diabetes, cardiovascular problems, hypertension and so, when you have a patient that has fatty live disease, if their weight is not controlled, then the next step is typically type two diabetes and then after that hypertension, dyslipidemia. Some of them will have sleep apnea as well as reflux and depression. So, there’s a lot of other comorbidities that go along with having fatty liver disease. And so that’s the first part of it.
Now the second part is that if the fatty liver disease is not corrected early on, then it will progress like we talked about into NASH and so these patients are the ones that are in danger of having fibrosis and cirrhosis and as children and adolescents it’s not that bad because they typically don’t have symptoms, so they don’t feel that they are sick. However, as they become adults, then it becomes a big problem because right now NASH is the leading indication for liver transplantation among women and it’s the second cause of liver transplantation among men. And that changed between 2016 and 2018 and so those are the two big dangers is that the comorbidities that exist with it once if it’s not controlled and then the danger of needing a liver transplant and even developing liver cancer.
Host: Well you certainly don’t want this to progress and then develop those comorbidities. So, Dr. Rojas, can this be reversed and if so, how?
Dr. Rojas: Yes, fortunately yes, this can be reversed, and the liver is one of the few organs that regenerates by itself. So, changes in lifestyle modifications, following a healthy diet, lowering fat and carbohydrates. That is very important to not forget about the carbohydrates. And exercise almost like every day exercise can reverse the disease. So, this is important also to work with a dietician to help the patients to have a good plan for their healthy diet. Because, as I said before, this can be reversed.
Host: That is really good news and I’m glad to hear that. So, Dr. Ramirez, what can medical providers do to stay aware and vigilant about this?
Dr. Ramirez: So, right now, the American Academy of Pediatrics recommends that cholesterol be checked between ages 9 to 11 and recently, our own North American Pediatric Society for Gastroenterology, Hepatology and Nutrition called NAPSGHAN has made recommendations to also start screening patients who have a body mass index of 85% or more with risk factors or body mass index of 95% or more and you can screen with just an ALT which is a simple bloodwork that can be tagged on to what the American Academy of Pediatrics already recommends.
Of course, if there is family history of fatty liver disease, the body mass index is important as a cutoff but if you have someone who has a body mass index of close to 85% but you know that they have fatty liver disease in the family, it may be a good idea to go ahead and screen those children as well. There’s a small portion, about 8% of adolescents that can develop fatty liver disease who are lean, but their blood work is very similar to patients who are obese with high LDL which is the bad cholesterol and low HDL which is the good cholesterol and they also have fatty liver disease. So, trying to identify the patients at least at the time when they have screening labs, is really a good chance for the pediatricians to be able to start providing interventions because the younger you are, when you provide interventions, the more responsive and then like Dr. Rojas said, it’s reversible.
So, if you can approach them the earlier age the better just because then their eating habits can change. Because the main thing about this is really behavioral changes. It’s easy for us as providers to be able to tell them heh, don’t drink as much juice, don’t drink soda, start moving around more, but for them to really enact it, they have to be motivated. The family has to be motivated and so, that’s one of the big things for this to be successful in treating the patients is getting your patient and the family to buy in. And as medical providers, I think it’s really important to not scold the patient or the family because they already feel guilty. They already know, they’ve been told by so many different providers like you are – your child is obese. It’s because it’s your fault but rather than approaching it that way; teaming up with the family and with their children is going to probably have a better effect. I think as human beings, we tend to respond better to positive feedback.
Host: We all do, that’s very true. So, Dr. Ramirez, sticking with you, so it sounds like it’s safe to say finding this early is crucial in reversing this before it turns into NASH, is that correct?
Dr. Ramirez: That’s right. That’s right and so, in our patient population in Texas, fortunately we have not had to transplant anybody with fatty liver disease but there are other areas in the nation like in San Diego where they picked up patients in their teens that have had progressive disease and who have needed liver transplants.
Host: And as we wrap up Dr. Rojas, what are we doing at Children’s Health to stay aware and vigilant about this?
Dr. Rojas: Well here at Children’s Health we have a multidisciplinary team that includes a physician, so the gastroenterologists as Dr. Ramirez and myself, also including dieticians and psychology support and we also have the different modalities for diagnosis and follow up for these patients. It starts with the labwork that we need in the beginning and then running the liver biopsy that can be done by interventional radiology or we have now the opportunity to do it endoscopically where the patient doesn’t have like a scar or anything on the body, so it is inside. And the addition now of the MRI and the ultrasound with [00:14:35] agraphy that help us to assess if the liver is getting more damaged, if it is becoming more fibrotic to the point that as Dr. Ramirez was saying, that they develop cirrhosis. So those are the modalities that now we have here at Children’s Health to help the kids with this disease.
Dr. Ramirez: And I just want to add in addition to the other things that we are doing here at Children’s Health is Children’s Health has teamed up with the YMCA to develop the Get Up and Go Program. That’s been in existence for several years but this year, the YMCA has received extra funding and have partnered with other companies so that this program could be more successful and so it’s a 10 week program where families and their children go and they get a complimentary YMCA membership during that 10 week program but then they also learn how to eat healthy, exercise and it’s offered in both Spanish and English and it’s in various locations around the Metroplex and the different YMCAs.
The second part is that there is bariatric program that’s there so, if weightloss is not achieved or healthy eating and exercise does not help the patient out because they are really struggling and we use our psychologists, and our dieticians; then bariatric surgery is available, and Dr. Karachi is the bariatric surgeon who leads that team. And then during the summer, we offer Camp Ka ana [00:13:15] which is another partnership between Children’s and the YMCA where they have children who are obese so not necessarily just having fatty liver but obese children between the ages of 10 and 14 can go there and have a two week camp where they learn to eat healthy and they also learn to order like a 500 calorie meal if you go to some fast food chain and then they also do fun activities that you typically do during the summertime.
Host: Well those are really great programs that we all should know about. So, thanks for sharing those and Dr. Ramirez and Dr. Rojas thank you so much for your time today.
Dr. Ramirez: Thank you very much.
Dr. Rojas: Oh no, my pleasure, thank you.
Host: That’s Dr. Charina Ramirez and Dr. Isabel Rojas and thank you for listening to Pediatric Insights. For more information, please visit www.childrens.com/fattyliver, that’s www.childrens.com/fattyliver. And if you found this podcast helpful, please rate and review or share the episode and please follow Children’s Health on your social channels. This is Pediatric Insights, Advances and Innovations with Children’s Health. Thanks for listening.