Dr. Dakshata Padhye: Reversal of Grade 3 Fatty Liver and Pre-Diabetes

Background

Early detection of prediabetes and early diabetes is vital for prevention of cardiovascular disease. Studies that used A1C to predict the progression to diabetes as defined by A1C criteria demonstrated a strong, continuous association between A1C and subsequent diabetes. In a systematic review of 44,203 individuals from 16 cohort studies with a follow-up interval averaging 5.6 years (range 2.8–12 years), those with A1C between 5.5% and 6.0% (between 37 and 42 mmol/mol) had a substantially increased risk of diabetes (5-year incidence from 9% to 25%)¹

There are effective interventions that prevent progression from prediabetes to diabetes. The one recommended by ADA is intensive lifestyle modification.  Several major randomized controlled trials, including the Diabetes Prevention Program (DPP)², the Finnish Diabetes Prevention Study (DPS)³, and the Da Qing Diabetes Prevention Study (Da Qing study)⁴, demonstrate that lifestyle/behavioral therapy featuring an individualized reduced calorie meal plan is highly effective in preventing type 2 diabetes and improving other cardiometabolic markers (such as blood pressure, lipids, and inflammation)⁵. The strongest evidence for diabetes prevention in the U.S. comes from the DPP trial². The DPP demonstrated that an intensive lifestyle intervention could reduce the incidence of type 2 diabetes by 58% over 3 years.

Case

Mr. Ram Chandel, 68-year-old male, visited Dr. Dakshata’s Diabetes Clinic in August 2018 with complains of high blood pressure and constipation. His blood pressure was 150/80 mg/dl.  His HbA1C was 5.9 which categorized him into Prediabetes according to American Diabetes Association ADA guidelines. He underwent an Executive Diabetes Health check which included liver function test and sonography. His report revealed Grade 3 Fatty Liver. His FIB-4 score calculated to 1.7. FIB-4 index is a simple, accurate, and inexpensive method for assessing liver fibrosis and proved to be concordant with FibroTest results⁶_. FIB-4 score >1.45 to <2.67 has a positive predictive value to confirm the existence of a significant fibrosis⁶.

Reviewing his family history, Mr. Chandel’s father had diabetes and his siblings had history of cardiac disease with hypertension. His diet recall suggested that he was consuming an average of 1800-2000 kcal, 6-7 meals a day. He is a vegetarian and often consumed fried and fatty foods. He never smoked or had any history of alcohol consumption. He had a very sedentary lifestyle.  He is 165 cm tall and weighed 89.9 kg. His Body Mass Index (BMI) computed to 33 kg/m².

Therapy

Mr. Chandel was suggested a complete lifestyle modification.

Diet: After nutritional assessment and intervention, he was prescribed a 1,400 kcal/day meal plan. He was suggested 3-4 servings of vegetable per day. He was advised a moderated carbohydrate (40-50 %) and low fat diet. Food items such as flaxseeds, fenugreek seeds, chia seeds, cinnamon powder were also suggested periodically.

Exercise: Mr. Chandel had limited physical activity due to osteoarthritis of the knee. Initially, he was advised to walk 30 min a day and later 45-60 min 5-6 days a week as months progressed.

Pharmacotherapy: Along with exercise and diet intervention pharmacotherapy was also initiated.

Result

Mr. Chandel was regularly followed for diet review and was constantly motivated by the nutritionist to eat healthy. At each follow-up, changes in weight were observed along with body fat analysis (table 1). After lifestyle and dietary modification, the BMI dropped from 33 to 27 kg/m² and visceral fat from 26 to 18 %.  The waist circumference reduced from 122 cm to 100 cm. His HbA1C has come down from 5.9 to 5.4. There was a reduction of FIB-4 Score from 1.7 to 1.3. His follow up sonography report showed grade 1 fatty liver. His blood pressure is also now under control (table 2).

Mr. Chandel achieved a weight loss of 15% in a span of six months and reversed his prediabetes and NASH⁷. He was later followed up for adherence to lifestyle modification. He maintained his weight and FIB-4 score.

References

1. Zhang X, et al. A1C level and future risk of diabetes: a systematic review. Diabetes Care 2010;33:1665–1673
2. Knowler WC, et al.; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393–403
3. LindströmJ  et al.; Finnish Diabetes Prevention Study Group.  Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study. Lancet 2006;368:1673–1679
4. LiG,  et al. Cardiovascular mortality, all-cause mortality, and diabetes incidence after lifestyle intervention for people with impaired glucose tolerance in the Da Qing Diabetes Prevention Study: a 23-year follow-up study. Lancet Diabetes Endocrinol 2014;2:474–480
5. NathanDM,  et al.; DPP Research Group . Does diabetes prevention translate into reduced long-term vascular complications of diabetes? Diabetologia 2019;62:1319–1328
6. Anaïs Vallet-Pichardet al. FIB-4: an inexpensive and accurate marker of fibrosis in HCV infection. comparison with liver biopsy and fibrotest, Hepatology 2007 Jul;46(1):32-6
7. Lisa M Glass Et al .Total body weight loss of ≥ 10 % is associated with improved hepatic fibrosis in patients with nonalcoholic steatohepatitis Dig Dis Sci. 2015 Apr;60(4):1024-30.