Clinical features of pediatric nonalcoholic fatty liver disease: a need for increased awareness and a consensus for screening

Highland barley β-glucan supplementation attenuated hepatic lipid accumulation in Western diet-induced non-alcoholic fatty liver disease mice by modulating gut microbiota

Non-alcoholic fatty liver disease (NAFLD) has become one of the most common chronic liver diseases worldwide. NAFLD is caused by numerous factors, including the genetic susceptibility, oxidative stress, unhealthy diet, and gut microbiota dysbiosis. Among these, gut microbiota is a key factor and plays an important role in the development of NAFLD. Therefore, modulating the composition and structure of gut microbiota might provide a new intervention strategy for NAFLD. Highland barley β-glucan (HBG) is a polysaccharide that can interact with gut microbiota after entering the lower gastrointestinal tract and subsequently improves NAFLD. Therefore, a Western diet was used to induce NAFLD in mouse models and the intervention effects and underlying molecular mechanisms of HBG on NAFLD mice based on gut microbiota were explored. The results indicated that HBG could regulate the composition of gut microbiota in NAFLD mice. In particular, HBG increased the abundance of short-chain fatty acids (SCFA)-producing bacteria (Prevotella-9, Bacteroides, and Roseburia) as well as SCFA contents. The increase in SCFA contents might activate the adenosine 5'-monophosphate (AMP)-activated protein kinase (AMPK) signaling pathway, thereby improving the liver lipid metabolism disorder and reducing liver lipid deposition.

Metabolic, behavioral health, and disordered eating comorbidities associated with obesity in pediatric patients: An Obesity Medical Association (OMA) Clinical Practice Statement 2022

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) details metabolic, behavioral health, and disordered eating comorbidities associated with obesity in children. This CPS will be followed by a companion CPS covering further comorbidities, including genetics and social consequences related to overweight and obesity. These CPSs are intended to provide clinicians with an overview of clinical practices applicable to children and adolescents with body mass indices greater than or equal to the 95th percentile for their ages, particularly those with adverse consequences resulting from increased body mass. The information in this CPS is based on scientific evidence, supported by the medical literature, and derived from the clinical experiences of members of the OMA.

Methods

The scientific information and clinical guidance in this CPS is based upon referenced evidence and derived from the clinical perspectives of the authors.

Results

This OMA statement details metabolic, behavioral health, and disordered eating comorbidities associated with obesity in children. It provides clinical information regarding identifying and treating metabolic, behavioral health, and disordered eating comorbidities associated with obesity in children over the 95th percentile of weight/height for age.

Conclusions

This OMA clinical practice statement details metabolic, behavioral health, and disordered eating comorbidities associated with obesity in children and provides an overview of current recommendations. These recommendations lay out a roadmap to the improvement of the health of children and adolescents with obesity, especially those with metabolic, physiological, and psychological complications.

Research progress on intervention effect and mechanism of protocatechuic acid on nonalcoholic fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) has become a surge burden worldwide due to its high prevalence, with complicated deterioration symptoms such as liver fibrosis and cancer. No effective drugs are available for NALFD so far. The rapid growth of clinical demand has prompted the treatment of NAFLD to become a research hotspot. Protocatechuic acid (PCA) is a natural secondary metabolite commonly found in fruits, vegetables, grains, and herbal medicine. It is also the major internal metabolites of anthocyanins and other polyphenols. In the present manuscript, food sources, metabolic absorption, and efficacy of PCA were summarized while analyzing its role in improving NAFLD, as well as the mechanism involved. The results indicated that PCA could ameliorate NAFLD by regulating glucose and lipid metabolism, oxidative stress and inflammation, gut microbiota and metabolites. It was proposed for the first time that PCA might reduce NAFLD by enhancing the energy consumption of brown adipose tissue (BAT). However, the PCA administration mode and dose for NAFLD remain inconclusive. Fresh insights into the specific molecular mechanisms are required, while clinical trials are essential in the future. This review provides new targets and reasoning for the clinical application of PCA in the prevention and treatment of NAFLD.

Pediatric Type 2 Diabetes: Not a Mini Version of Adult Type 2 Diabetes

Pediatric type 2 diabetes mellitus (T2DM) is increasing in incidence, with risk factors including obesity, puberty, family history of T2DM in a first-degree or second-degree relative, history of small-for-gestational-age at birth, child of a gestational diabetes pregnancy, minority racial group, and lower socioeconomic status. The pathophysiology of T2DM consists of insulin resistance and progression to pancreatic beta-cell failure, which is more rapid in pediatric T2DM compared with adult T2DM. Treatment options are limited. Treatment failure and nonadherence rates are high in pediatric T2DM; therefore, early diagnosis and treatment and new pharmacologic options and/or effective behavioral interventions are needed.

Utility of MR proton density fat fraction and its correlation with ultrasonography and biochemical markers in nonalcoholic fatty liver disease in overweight adolescents

Background Clinical or biochemical markers that have good correlation with magnetic resonance proton density fat fraction (MR PDFF) can be used as simple tools for the screening for nonalcoholic fatty liver disease (NAFLD) and in determining the degree of fatty infiltration of the liver. The objective of this study was to determine the degree of relationship between MR PDFF and ultrasonography (USG) grades of fatty liver, and clinical and biochemical parameters of adolescents and to determine the sensitivity and specificity of USG for diagnosis of NAFLD. Methods This prospective study included 34 overweight adolescents (mean age, 12.1 ± 1.5 years; range, 10-15.1 years; 10 girls and 24 boys) who underwent both USG and magnetic resonance imaging (MRI). Correlation analysis was performed between MR fat fraction and USG grades of fatty liver, and clinical and biochemical parameters of fatty liver disease. Results MR fat fraction had a moderate positive correlation with serum alanine transaminase (ALT) and aspartate transaminase (AST) (ρ = 0.634, p < 0.001, ρ = 0.516, p = 0.002, respectively) and had a negligible or weak correlation with body mass index (BMI), BMI standard deviation score (SDS), waist circumference (WC), fasting insulin, homeostatic model assessment of insulin resistance (HOMA-IR), serum triglyceride, low-density lipoprotein (LDL), high-density lipoprotein (HDL) and total cholesterol levels. The sensitivity and specificity of USG in the diagnosis of NAFLD were 81% (95% confidence interval 54%-95%) and 50% (27%-73%), respectively. The MR fat fraction had a moderate positive correlation with ultrasound grades of fatty liver (ρ = 0.487, p = 0.003). Conclusions Serum ALT and AST are potential biochemical markers to assess the degree of hepatic steatosis in NAFLD, which needs validation in further studies. USG can be used as a screening tool for NAFLD, but the diagnosis should be confirmed by estimating the MR fat fraction.

Challenges in Screening for Pediatric Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of elevated liver enzymes in children in the United States. Screening for NAFLD in children with obesity is recommended by several published guidelines, but the application of these recommendations in pediatric weight management programs is uncertain. Our study aimed to describe the screening practices for NAFLD in a large pediatric weight management program. During 2014, 1312 patients were seen, with a liver enzyme panel obtained in 847 (64.5%). Only 47/847 (5.5%) had elevated liver enzymes twice the upper limit of normal. Of the 47, 33 (70%) patients had persistently elevated liver enzymes. Of those 33, 22 (67%) had further exclusionary laboratory testing. Screening for NAFLD is challenging even in a pediatric weight management program with clearly established protocols. Those with elevated liver enzymes do not always complete recommended exclusionary testing. Barriers to completing further evaluation need to be addressed.

Serum Alanine Aminotransferase Trends and Their Relationship with Obesity and Metabolic Syndrome in United States Adolescents, 1999-2014

INTRODUCTION

Nonalcoholic fatty liver disease (NAFLD), characterized by hepatocyte dysfunction, fat accumulation, and fibrosis, is the most common cause of chronic liver disease in children. Elevated levels of serum alanine aminotransferase (ALT) are used clinically to identify potential liver dysfunction. Our goal was to assess for changes in the national prevalence of elevated ALT over time and potential relationship to trends in the metabolic syndrome (MetS) severity and elevated body mass index (BMI).

MATERIALS AND METHODS

We studied 5411 non-Hispanic white, non-Hispanic black, and Hispanic adolescents aged 12-19 with complete MetS Z-score and ALT data from the National Health and Nutrition Examination Survey 1999-2014. Elevated ALT levels were defined by two different cutoffs: one for both sexes (30 U/L) and another that was sex specific (22 U/L girls; 25 U/L boys). MetS severity was assessed using a sex- and race-/ethnicity-specific MetS Z-score.

RESULTS

We did not find a statistically significant linear increase in either mean ALT or the prevalence of elevated ALT differed over time. As expected, ALT levels were significantly correlated with BMI Z-score and MetS Z-score (P < 0.0001). Over time, BMI Z-scores increased and MetS severity Z-score decreased.

CONCLUSION

Prevalence of elevated ALT did not exhibit a linear change between 1999 and 2014 in U.S. adolescents, potentially due to divergent trends regarding BMI and MetS severity. Continued vigilance in monitoring BMI and ALT levels is advised for the U.S. adolescent population. MetS Z-score could act as an additional tool to monitor risk of elevated ALT and subsequent development of NAFLD.

AISF position paper on nonalcoholic fatty liver disease (NAFLD): Updates and future directions

This review summarizes our current understanding of nonalcoholic fatty liver disease (NAFLD), a multi-factorial systemic disease resulting from a complex interaction between a specific genetic background and multiple environmental/metabolic "hits". The role of gut microbiota, lipotoxicity, inflammation and their molecular pathways is reviewed in-depth. We also discuss the epidemiology and natural history of NAFLD by pinpointing the remarkably high prevalence of NAFLD worldwide and its inherent systemic complications: hepatic (steatohepatitis, advanced fibrosis and cirrhosis), cardio-metabolic (cardiovascular disease, cardiomyopathy, arrhythmias and type 2 diabetes) and neoplastic (primary liver cancers and extra-hepatic cancers). Moreover, we critically report on the diagnostic role of non-invasive biomarkers, imaging techniques and liver biopsy, which remains the reference standard for diagnosing the disease, but cannot be proposed to all patients with suspected NAFLD. Finally, the management of NAFLD is also reviewed, by highlighting the lifestyle changes and the pharmacological options, with a focus on the innovative drugs. We conclude that the results of ongoing studies are eagerly expected to lead to introduce into the clinical arena new diagnostic and prognostic biomarkers, prevention and surveillance strategies as well as to new drugs for a tailored approach to the management of NAFLD in the individual patient.

Relationships Between Alanine Aminotransferase, Serum Triglycerides, Body Mass Index and Nonalcoholic Fatty Liver Disease in an Outpatient Pediatric Clinic Population

Nonalcoholic fatty liver disease (NAFLD) is the most prevalent chronic liver disease in children and adolescents. The goal of this study was to describe the demographic, anthropometric and biochemical data of children and adolescents diagnosed with NAFLD during a seven-year period in an outpatient pediatric clinic in the Southwest region of the US and to evaluate relationships between race, BMI, ALT, triglyceride levels, age and gender with a diagnosis of NAFLD. A retrospective medical record review of patients who attended an outpatient pediatric clinic with a billing diagnosis ICD-9 code of 571.8 was conducted. Forty-one patients met these criteria. The majority was male (74%) Hispanic (32%), Hispanic/Latino (68%) and obese. The small number of patients diagnosed with NAFLD in our study is consistent with previously reported results. Our results indicate that the population of this culturally diverse, high-risk population has significant clinical markers that are indicative of NAFLD.

Normal range of hepatic fat fraction on dual- and triple-echo fat quantification MR in children

Objectives

To evaluate hepatic fat fraction on dual- and triple-echo gradient-recalled echo MRI sequences in healthy children.

Materials and Methods

We retrospectively reviewed the records of children in a medical check-up clinic from May 2012 to November 2013. We excluded children with abnormal laboratory findings or those who were overweight. Hepatic fat fraction was measured on dual- and triple-echo sequences using 3T MRI. We compared fat fractions using the Wilcoxon signed rank test and the Bland-Altman 95% limits of agreement. The correlation between fat fractions and clinical and laboratory findings was evaluated using Spearman’s correlation test, and the cut-off values of fat fractions for diagnosing fatty liver were obtained from reference intervals.

Results

In 54 children (M:F = 26:28; 5–15 years; mean 9 years), the dual fat fraction (0.1–8.0%; median 1.6%) was not different from the triple fat fraction (0.4–6.5%; median 2.7%) (p = 0.010). The dual- and triple-echo fat fractions showed good agreement using a Bland-Altman plot (-0.6 ± 2.8%). Eight children (14.8%) on dual-echo sequences and six (11.1%) on triple-echo sequences had greater than 5% fat fraction. From these children, six out of eight children on dual-echo sequences and four out of six children on triple-echo sequences had a 5–6% hepatic fat fraction. When using a cut-off value of a 6% fat fraction derived from a reference interval, only 3.7% of children were diagnosed with fatty liver. There was no significant correlation between clinical and laboratory findings with dual and triple-echo fat fractions.

Conclusions

Dual fat fraction was not different from triple fat fraction. We suggest a cut-off value of a 6% fat fraction is more appropriate for diagnosing fatty liver on both dual- and triple-echo sequences in children.