The Hidden Risk of Liver Disease From Diabetes

Medically Reviewed by Hansa D. Bhargava, MD on March 06, 2019
From the WebMD Archives

If you have type 2 diabetes, a growing body of research suggests that it's important to monitor your liver for a condition called nonalcoholic fatty liver disease (NAFLD). The name pretty much sums it up: Excess fat accumulates in the liver, the football-size organ under the ribcage and over the stomach. NAFLD is especially common in people who are obese or have type 2 diabetes (or both), explains endocrinologist Kenneth Cusi, MD, of the University of Florida College of Medicine.

As scientists build their knowledge of NAFLD, they're learning that it may play a role in the development of prediabetes and type 2 diabetes, Cusi says. One of the liver's many jobs is regulating blood sugar, but fat in the liver makes that organ less responsive to insulin, leaving too much glucose in the blood, which can lead to type 2 diabetes.

Having type 2 diabetes raises your odds of having a more severe form of NAFLD known as nonalcoholic steatohepatitis (NASH). In this case, liver fat triggers harmful inflammation that creates scar tissue there. "This can lead over time to cirrhosis and end-stage liver disease," Cusi says. But many people who have NAFLD or NASH don't know it. "About three in four patients with type 2 diabetes or prediabetes have too much fat in their liver, and about half of them have this inflammation and scarring, but in many cases they're unaware of it," Cusi says.

Unfortunately, NAFLD has few symptoms, making it tough to diagnose. Some people feel pain in the upper right part of the abdomen, just below the rib cage. Sometimes bloodwork will show an unexplained spike in liver enzymes that prompts the doctor to take a closer look. Or patients might have a scan for another problem that shows there’s too much fat in the liver. A new type of ultrasound used by liver specialists can estimate the fat content of the liver and check liver tissue for stiffness, a sign of scarring.

If NAFLD and NASH are caught early, it's possible to stop and in some cases reverse them, mainly through weight loss, Cusi stresses. Studies show that losing 10% of your body weight can halt NAFLD and NASH, but he says losing at least 7% has benefits, and bariatric (weight loss) surgery could be one way to do that. Cusi also did a study that showed that an inexpensive type 2 diabetes drug called pioglitazone reverses NASH in some cases. He also is studying new drugs for this purpose.

Cusi urges people who have type 2 diabetes to talk with their doctors about liver disease. "There is a lack of awareness among doctors and their patients, and very little is being done to treat the disease," he says. Given the dangers of cirrhosis and end-stage liver disease, "there's a real urgency to identify patients who have this problem and consider treatment with lifestyle [changes] and medications."

Ask Your Doctor

Are my liver enzymes elevated?

If bloodwork shows that your liver enzymes are above 30 IU/L, ask your doctor to consider that you might have nonalcoholic fatty liver disease (NAFLD), Cusi says. Other possible causes of elevated liver enzymes include alcohol abuse, hepatitis B and C, and medications.

Is there fat on my liver?

Anytime you have an ultrasound or other imaging technique, "if there's fat in the liver, that should be a huge red flag," Cusi says. "Many times, doctors are not doing anything about it, but they should."

Can you check me for fatty liver disease?

Some hospitals now have a specialized ultrasound device called a FibroScan, which can check for evidence of liver disease, including fat on the liver.

Can you help me reach a healthy weight?

Losing weight is the best way to halt NAFLD and its more aggressive form, NASH. Your doctor may refer you to a registered dietitian and support groups to aid your weight loss journey. Bariatric surgery might also be effective, Cusi says.

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Show Sources


Kenneth Cusi, MD, chief of the division of endocrinology, diabetes, and metabolism, University of Florida College of Medicine.

Diabetes Care: “Management of Nonalcoholic Fatty Liver Disease in Patients With Type 2 Diabetes: A Call to Action.”

Harvard Health Publishing: "Fatty Liver Disease: What It Is and What to Do About It."

Mayo Clinic: "Diabetes: How Do I Protect my Liver?"

National Institute of Diabetes and Digestive and Kidney Diseases: "Diagnosis of NAFLD and NASH."

National Institute of Diabetes and Digestive and Kidney Diseases: "Treatment of NAFLD and NASH."

UFHealth: "UF Health researchers study association between type 2 diabetes and fatty liver disease."

UF Diabetes Institute: "Fatty Liver and Type 2 Diabetes."

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