Always stay happy because with age beauty fades but inner charecter shines forever so always maintain your BMI and BMR also check fasting blood sugar every month.

1. NON-ALCOHOLIC FATTY LIVER
DISESE :THE OVERLOOKED
COMPLICATION IN TYPE 2
DIABETES

2. Guided by:
Dr. Sanjib Kumar Kar
M.D. (Medicine),D.M.(Gastroenterology & Hepatology)
INDIAN INSTITUTE OF GASTROENTEROLOGY &
HEPATOLOGY,CUTTACK,ODISHA

3. Objectives:-
 Understand the epidemiologic significance of NAFLD in T2DM
 Appreciate the basic pathophysiology of NAFLD and it's
relationship to T2DM
 Appreciate the clinical features and diagnostic approach to fatty
liver disease in diabetic patients
 Review the treatment implications of concomitant T2DM and
NAFLD

4. Diabetes - A Growing Problem:-
 Diabetes is a disease that affects how you body handles sugar (glucose) • “A
metabolic disease in which the body’s inability to produce any or enough
insulin causes elevated levels of glucose in the blood.”
 Most common form of diabetes – about 90% of cases – Previously called adult
onset, non insulin dependent diabetes – Body produces insulin, but does not
use it properly • glucose doesn’t move into cells, they pile up in the
bloodstream.
 In people without diabetes, glucose stays in a healthy range because – Insulin
is released at the right time and in right amounts – Insulin helps glucose enter
cell
 In diabetes, blood glucose builds up for several possible reasons – Too little
insulin is made – Cells can’t use insulin well – Liver releases too much glucose
 WHO predicts WW prevalence of 6.4% by 2030, a 60% increase since 1 995
and a 39% rise from 2000

5. Diabetes and NAFLD – Epidemiology:-
 Liver disease is a major contributor to diabetes-related morbidity and mortality
 DM is the leading cause of liver disease in Eastern India
 Standardized mortality ratio for cirrhosis vs. CVD is 2.57 vs. 1.34
 Cirrhosis is the 4th leading cause of death among diabetics, accounting for 5%
of mortality
 NAFLD is common
 20-30% of adults in the Eastern India are estimated to have NAFLD
 NAFLD is present in 34-74% of all diabetic patients and in nearly 100% of
obese diabetics
 Among patients with NAFLD, 50% have NASH and 1 9% have cirrhosis at the
time of diagnosis

6. NAFLD - What is it?
 Defined as fatty liver disease in the absence of EtOH
consumption greater than 20g/day
 (NAFLD refers to a condition where the liver accumulates excess fat, but this
fat buildup is not caused by consuming more than 20 grams of alcohol per
day)
 Encompasses a spectrum or liver pathology
 Steatosis - simple fatty infiltration of the liver
 NASH / steatohepatitis - steatosis plus inflammation,
and fibrosis
 Progresses to cirrhosis in up to 20% of patients

7. NAFLD/NASH:-

8. Relationship Between NAFLD With Type 2
diabetes & CVD:-

9. Clinical Features
 NAFLD is seen in patients with features of the metabolic syndrome
 Obesity: 70-100% have NAFLD
 T2DM: 34-75%
 Hyperlipidemia: 20-80%
 Metabolic syndrome: one-third
 Most patients are asymptomatic; signs of chronic liver disease are rare
 Liver enzymes fluctuate in NAFLD
 Within normal limits at any given time in -80% of patients
 Mild elevations are typical

10. NASH - Clinical Features
 Patients who progress to NASH typically remain asymptomatic
 Serum AST and ALT are increased in ~90% of patients
 AST/ALT ratio is usually < 1, a ratio > 1 suggests advanced
disease
 AlkP and Bilirubin are less frequently elevated
 Liver enzyme elevation does not correlate with liver histology

11. NASH/NAFLD-Diagnosis:-
 Suspect NAFLD in any diabetic
 Present in >50% of patients
 Check liver enzymes in all diabetics
 Consider co-existing liver pathology: alcoholic viral & autoimmune hepatitis,
hemachromatosis, Wilson's disease and a-antitrypsin deficiency
 Consider contributing factors, particularly drugs
 Other:, intestinal bypass surgery, rapid weight loss, HIV infection, bacterial
overgrowth, PCOS,

12. NASH/NAFLD-Diagnosis:-
 Scoring systems have been proposed to determine if fibrosis is present in the setting of
NAFLD
 BARD score:-
 Body Mass Index (BMI) ≥ 28: 1 point
 AST/ALT ratio (AAR) ≥ 0.8: 2 points
 Presence of Diabetes (type 2): 1 point
 The BARD score ranges from 0 to 4. Here’s what it means:
 Score 0-1: Low risk of advanced fibrosis.
 Score 2-4: Higher risk of advanced fibrosis.
 Fibroscan:-
 Non-invasive: No needles or cuts
 Measures Liver Stiffness: Like checking how flexible your liver is.
 Helps Detect Liver Fibrosis: Scar tissue that can harm the liver.

13. NASH/NAFLD-Diagnosis:-
 Liver biopsy:-
 Severity can also be determined
 Liver biopsy is not routinely suggested, consider if:
 Uncertainty regarding diagnosis
 Manifestations of chronic liver disease
 Splenomegaly

16. Calorie calculation:- The Mifflin-St Jeor formula was developed in 1990, and
it is considered to be more accurate and reliable than the Harris-Benedict formula for
estimating BMR
For men: BMR = 10W + 6.25H - 5A + 5
For women: BMR = 10W + 6.25H - 5A - 161
 Let’s assume the age is 30 for both men and women. Then, the BMR for a
man of 70 kg and 177 cm is:
 BMR = 10 x 70 + 6.25 x 177 - 5 x 30 + 5
 BMR = 700 + 1106.25 - 150 + 5
 BMR = 1661.25 kcal
 Similarly, the BMR for a woman of 70 kg and 177 cm is:
 BMR = 10 x 70 + 6.25 x 177 - 5 x 30 - 161
 BMR = 700 + 1106.25 - 150 - 161
 BMR = 1495.25 kcal
 BMR-Basal Metabolic Rate
 W-Weight , H-Height ,A -Age

17. For a example:-
 2 scrambled eggs: 12g of protein, 0g of crabs , 10g of fat
 2 slices of whole wheat toast: 8g of protein, 28g of crabs , 4g of fat
 1 tbsp of butter: 0g of protein, 0g of crabs , 12g of fat
 1 cup of orange juice: 2g of protein, 26g of crabs , 0g of fat
 Now, multiply each macronutrient by its caloric equivalent:
 Protein: (12 + 8 + 2) x 4 = 88 kcal(Each gram of protein provides 4 calories similarly
22gm protein gives 88 calories from different types of foods )
 Crabs: (0 + 28 + 26) x 4 = 216 kcal
 Fat: (10 + 4 + 12) x 9 = 234 kcal
 Finally, add up the calories for each macronutrient:
 Total calories: 88 + 216 + 234 = 538 kcal

18. NAFLD/NASH Management-Lifestyle Modification
 A recent (2024) RCT demonstrated significant improvement by way of lifestyle
modification among patients with NASH
 28 patients, randomized 2:1 to intervention vs. placebo (65 patients screened)
 Inclusion criteria: elevated AST or ALT, BMI 25-40, no other liver disease
 Q 12 week fasting blood glucose
 Placebo group attended group session providing basic education regarding NASH,
physical activity, diet and weight control
 Intervention group: "intensive, state-of-the-art weight loss intervention" based
on the Diabetes Prevention Program, LOOK AHEAD"
 Target 7-10% weight loss over 6 months and then maintain
 Diet: 25% fat; 1000-1200kcal for <2001bs; 1200-1500 for >2001bs
 Unsupervised, moderate exercise focusing on walking (goal of 200min/week)

19. NAFLD/NASH Management-Lifestyle Modification
 Results
 Groups were similar for Age,Sex,Height,Waist,HC,WC,BMI, Fasting,LFTs,
RFTs,lipid profile,HbA1C
 All but one patient completed the study (intervention group)
 Weight: -8.7kg vs. -0.5kg (p~.005)
 Greater weight loss was achieved by non-diabetics
 Liver enzymes: ALT improved significantly in the intervention group; there
was no significant difference in AST
 Percent weight loss from baseline decreased steatosis and decreased NASH
disease activity

21. Bariatric Surgery:-
 Bariatric surgery is a surgical intervention that reduces the
size of the stomach or bypass part of the digestive tract to
induce weight loss and metabolic changes
 Bariatric surgery has been shown to significantly improve NAFLD
and NASH in the short term , by reducing liver fat ,inflammation ,
and fibrosis.

22. Liver Disease & Diabetes Management Principles:-
 Liver disease does not significantly change the general
approach to management of the diabetic patient
 Diet and exercise remain a foundation for management
 The approach to pharmacologic therapy is essentially
unchanged
 Hepatic drug metabolism is relatively preserved until patients
have evidence of liver failure (ascites, coagulopathy,
encephalopathy)

23. Liver Disease & Diabetes Management Principles:-
 Insulin
 Reasonable to use in patients with significant hepatic impairment
 Factors affecting insulin requirements are significant - monitor patients and
adjust doses carefully

24. Pharmacotherapy
 Metformin:-
 Cochrane Review concluded "improvement in liver enzymes and steatosis
without effect on liver histology"
 Improve liver enzymes / steatosis
 Long-term treatment - concern regarding CHF, ? hepatotoxcity
 Vitamin E:-
 Conflicting results ranging from no benefit to improved enzymes and
steatosis
 Debate continue

25. Pharmacotherapy
 Ursodeoxycholic Acid (UDCA):-
 Cochrane Review - no significant improvement in LFTs or mortality
 Statins:-
 Generally safe to use in NASH, but no proven hepatic benefit.
 Recommended only for lipid-related risk factor modification