Amanda Wilde (Host): More than 40% of adults in the United States have what's called fatty liver disease, where fat builds up in the liver and starts to damage the organ. A study published last year led by VCU hepatologist Dr. Arab revealed that this disease hits Hispanics harder than other groups. Some 47% of Hispanics have fatty liver disease. That's a dramatic increase from a 2014 study that showed a prevalence of 29% among Hispanics making this a pressing public health concern. This is Healthy with VCU Health. I'm Amanda Wilde.

Dr. Juan Pablo Arab of VCU Health is the Director of Alcohol Sciences at VCU's Stravitz-Sanyal Institute of Liver Disease and Metabolic Health. He is a hepatologist or liver expert. One of his specialties is studying the genetic and social factors that may raise the risk of liver disease among Hispanics. Dr. Arab, welcome to the podcast. Thanks for being here to share your expertise.

Juan Pablo Arab, MD: Thank you very much, Amanda. Thank you for the invitation.

Host: Well, first of all, how do we define liver disease? Are there different types?

Juan Pablo Arab, MD: Yeah, so liver disease basically means that the liver is inflamed, is scarred and cannot do its job. So, the liver does more than 200 functions, like filtering toxins, making proteins, helping digestion. So, there is many types. So fatty liver disease that now is called steatosis is one of them, but also is alcohol related liver disease, viral hepatitis A, B, C, D, and E, autoimmune and genetic conditions.

There is also disease that affect the bile ducts or drug related liver injury. And when the liver disease is severe and there is scarring tissue in the liver that is called cirrhosis.

Host: How do you diagnose what type of liver disease someone has?

Juan Pablo Arab, MD: So usually the way to do it is through the history, asking to the patient regarding exposure to different toxins that may affect the liver, and then blood work and imaging. So, an ultrasound is the first approach, but also could be other type of imaging such as CT scans or MRIs.

Host: Tell us more about fatty liver disease. What is it and who gets it?

Juan Pablo Arab, MD: It is when extra fat builds up in the liver and start to cause damage, it's very common. So, as you said, four in 10 US adults will have it and anyone can get it. Although it is more frequent in people with overweight or obesity or diabetes, and particularly common in Hispanics.

Host: What are the most common types of liver disease affecting the Hispanic population? Is it fatty liver disease then and what are the typical symptoms?

Juan Pablo Arab, MD: So usually the big ones are fatty liver disease and alcohol related liver disease. If you take, like worldwide, these two will explain like 85% of liver diseases. Viral hepatitis was very common in the past, are more common in Asia, but still are frequent. And the symptoms are probably one of the important things because this disease tend to be silent for many years.

So, there is no symptoms, maybe fatigue or maybe right upper belly discomfort, but so many people will not know that they have liver disease until it's very advanced and they develop other symptoms such as jaundice or yellowish skin. And then leg swelling or confusion or easy bruising. So, liver disease in general is a disease that you need to look for it. You need to have blood tests because if not, you may miss it.

Host: Are there risk factors that particularly raise the prevalence of fatty liver disease in Hispanics?

Juan Pablo Arab, MD: Yes. So, the main risk factor for fatty liver disease is central obesity or overweight, Type 2 diabetes or pre-diabetes, high blood pressure, high cholesterol, high triglycerides, sleep apnea, sedentary lifestyles and then especially diets high in sugary drinks and refined carbs. There is also some medications and yield that can play a role, but it's usually everything around the metabolic syndrome.

Host: That is true for everyone who has fatty liver disease, correct?

Juan Pablo Arab, MD: Correct.

Host: So, in Hispanics are there other risks as far as genetics or anything like that?

Juan Pablo Arab, MD: Yeah, we know that there is higher rates of diabetes and obesity in Hispanic population. There is also what we call the social determinant of health, so barriers to access healthy food and preventive care. And also, as you mentioned, some common genetic variants. There is one that is called the PNPLA3 that is very common in Hispanic population.

To give you an idea, this genetic polymorphism is present in 2% of the population in Africa. Like 6% of the population in Europe, 20 or 30% of the population in North America. But if you go to like Native American Hispanic population, it can be as high as 80%. So, the genetic component is very important.

Host: Are there ways for individuals to reduce their risk of fatty liver disease?

Juan Pablo Arab, MD: The general treatment or the general advice that we will recommend is trying to reduce your risk of metabolic dysfunction or metabolic syndrome. What this means is, so, weight loss, how much you? We usually recommend aiming seven to 10% of weight loss over one year. Try to move your body, your body most days.

So, this means 150 to 200 minutes of moderate intensity activity per week. This is one hour, three times per week, or half an hour every day, and even walking counts, but needs to be walking fast, walking to do moderate intensity activity. And then as we were discussing, although the disease used to be called fatty liver disease, it's not about fat, it's about sugar.

So, cutting down sugary drinks, ultra processed foods and reducing all carbohydrates. And carbohydrates are not only sweets and cakes: is bread, potato, rice, noodle, pasta, corn. So, all the starch. And then, of course if the patient has diabetes or high blood pressure or cholesterol, those diseases need to be properly managed.

And then limiting alcohol consumption because, when you have fatty liver disease, alcohol consumption on top of the fatty liver disease seems to be worse, than both of them separately.

Host: Yes. If you look it up online, alcohol will be the first thing you see, but you have mentioned so much more that is daily for so many more of us. Can you reverse the buildup of fat in the liver that causes fatty liver disease by taking the measures you just mentioned?

Juan Pablo Arab, MD: Yes. So, it depends on how advanced it is, the liver disease. So, the liver usually starts with the buildup of fat in the liver. This is called a steatosis. Then when there is inflammation is called the steatohepatitis. And then is when you are liver enzymes are going to be up and then you start accumulating scar tissue in the liver.

This is called fibrosis. When the liver is full of scars, this is called cirrhosis. And when you have cirrhosis, you can have all the complications including liver cancer and maybe need a liver transplant. Of course, the earlier we catch the disease, it is easier to reverse. But even if you are in the cirrhosis stage and you implement all these changes, there is a chance of reversing the scarring tissue.

Maybe not back to normal, but maybe from very advanced fibrosis or cirrhosis to initial stage. So, I think there is always opportunity to reverse and there is always good to implement changes despite how advanced is the liver disease.

Host: Because at the very least you may stop it from advancing further. Are there other treatments medically that you give in tandem with these lifestyle changes? Are there treatments available for someone with fatty liver disease?

Juan Pablo Arab, MD: Correct. So now there is two FDA approved medications. One is called resmetirom which basically is a drug that is similar to the thyroid hormone. So, it basically activates the metabolism in the liver and it helps to get rid of the fat, but not only of the fat, also of the scar tissue in the liver.

That's one option that was approved by the FDA last year. And only two weeks ago, we got a second drug approved, which is semaglutide. This are a family of drugs called GLP-1s, they are drugs that has been used for diabetes and for weight loss, but now it was also shown that it not only helps with diabetes and weight loss, but also helps with the fat in the liver and with the scar tissue in the liver.

So now it's also approved by the FDA, and there are more drugs coming. So, I think, it's going to be more opportunities and more options for patients. But again, the cornerstone is still a diet, which is called the Mediterranean style diet, weight loss, avoiding alcohol, doing more exercise.

Host: How effective are these medications if you are doing those other things yourself?

Juan Pablo Arab, MD: The main thing is weight loss is always difficult, right? And implementing these changes and maintaining these changes is always difficult. So, everyone that has tried a diet, we know that it's easier the first couple of weeks and then your willpower starts wearing off after, you know, a couple of weeks or months.

So, for reversing scar tissue in the liver, we are talking about years, right? Where you need at least one year or two years of sustained changes and treatment. And I think there is where this medication helps, and especially to reverse the scar tissue. When you don't try with this medication, it can be 20, 30%, but with medication can be 60, 70%.

So, I think it helps an additional group of patients to really have effective changes and maintain those changes over time.

Host: Understood. So, the most effective preventive measures, again, have to do with diet, exercise, weight loss. Are there also screenings for liver disease in the Hispanic population so that it doesn't get to the more advanced stages?

Juan Pablo Arab, MD: I think the main issue is since the liver doesn't have any symptoms, and you know, the liver disease is silent; we need to look for it. So, for example, it's the same with sugar. So, there is the hemoglobin A1C, that kind of check how your sugars has been over the last three months. We have something similar, for the liver to see if there is a scar tissue in the liver or not.

 It's called the FIB-4 score. It's a very simple score that you combine age, the liver enzymes and platelets and give you what is your likelihood of having advanced scar tissue of the liver. This was developed actually at VCU 20 years ago. It is basically the cheapest of the tests because it doesn't use anything sophisticated, this is normal labs that everyone can have.

So, I will say to everyone that is listening ask your primary doctor for this liver check. It's called FIB-4, for Fibrosis-4. So, it's basically a blood test and it will tell you if you are low risk, high risk, or then in the intermediate zone. And either if you are in the intermediate zone or in the high risk, probably you need to get additional testing, like an ultrasound or a test that is called FibroScan, or transient elastography to see if you have scar tissue in the liver.

So those are things that can be done. Same with, for example, hepatitis C. So, everyone should be tested for hepatitis C at least once in your life, or hepatitis B. Remember that October is the liver awareness month, so next month is perfect time for schedule your visit and get your liver checked.

This is for everyone, not only for Hispanics, although Hispanics have a higher risk of advanced liver disease.

Host: This study that I referred to in the introduction that found this incredible increase of fatty liver disease among Hispanics, you headed that study and is there anything else that you would like to emphasize from your recent findings about this prevalence and its implications for public health strategies?

Juan Pablo Arab, MD: We found that 10 years ago, in 2014, the prevalence in Hispanics of fatty liver was around 29%, and now closer to 2018, which is the last iteration of the data that we have, was close to 50%, was 47% in Hispanic adults. This is not really surprising because if you look how obesity has been increasing, how the rate of diabetes has been increasing in the U.S., I think this goes hand with hand with those other two.

But it's concerning. It's concerning that half of the adult population, in Hispanic, but is like 38% in the non-Hispanic population. So, this is still pretty high. It will have some initial liver disease. So, I think this calls for early screening, so looking, if people have liver disease or not, and then, culturally tailored nutrition intervention, right?

Because, uh, the other reason why Hispanics may have more fatty liver disease is because their diet is very high in starch, very high in corn like tortillas and those kinds of things, right? So, I think we need to adjust all these recommendations of Mediterranean diet and doesn't need to be on specific Mediterranean diet, but Mediterranean style diet where there is very low in carbohydrates and more higher in proteins.

So, I think healthier food. And then, we need to look this as a primary care liver. We cannot wait until we see this patient with advanced liver disease in the liver clinic. So, I think we need to reach the community, have more education on preventing progression of the liver disease on better diet, more exercise and, and in general, like a healthier lifestyle.

So that way is the only way that we will be able to prevent the progression to cirrhosis and liver cancer, that we see daily in our liver clinics. So, I think the main finding of this study is raising the alarm that the liver disease, especially fatty liver disease, is progressing very quickly and in one decade, these numbers almost doubled.

So, we need to pay attention on what we are doing from a public health perspective.

Host: And how do you support patients through that process? Because it sounds like a lot of change.

Juan Pablo Arab, MD: Yeah, we know that all behavioral changes are very difficult because, sometimes it's even in the culture, it's the way that we eat. We celebrate with food or with alcohol, we mourn with food or alcohol. So, understanding also, and this is called motivational interview. And a motivational therapy, is understanding what is your motivations for change.

Because if the patient is not really convinced that they want to do a change and you don't understand the motivation to do it or not do it, it's difficult to implement those changes. So, I think everything is start for understanding, what is the patient agenda? So, what are your motivations for change, what you want to achieve?

And then it's putting goals that are realistic, right? So, if I tell you that you need to lose 50 pounds by the next month, you will feel discouraged. But we say, well, let's just start with five pounds by next visit and then go from there. And now we are very hopeful in all these new medications and new class of drugs that are really helping people to achieve goals that before were very difficult.

Host: So doable pieces, small steps, and medical support, and remembering that you're doing this for your future self.

Juan Pablo Arab, MD: Correct. That's the key.

Host: Dr. Arab, thank you so much for sharing your insights on liver disease. Thank you for this enlightening conversation.

Juan Pablo Arab, MD: Thank you very much for the invitation.

Host: That was Dr. Juan Pablo Arab, Director of Alcohol Sciences at VCU's  Stravitz-Sanyal Institute of Liver Disease and Metabolic Health. To make an appointment with a VCU Health hepatologist, please contact VCU Health toll free at 833-828-5487. To learn more about the efforts of the  Stravitz-Sanyal Institute to research and develop new treatments for liver patients, visit its website at liverinstitute.medschool.vcu.edu. To listen to other podcasts from VCU Health, visit VCUhealth.org/podcasts. This is Healthy with VCU Health.