Hispanics & Liver Disease/Fatty Liver, Liver Cancer & Mortality Rates Increasing Particularly Among Blacks & Hispanics
"Among the Hispanic population, injection drug use has been identified as the most common risk factor for HCV infection.....Studies measuring hepatic triglyceride content by magnetic resonance spectroscopy identified steatosis in 45% of the Hispanic population, making NAFLD [fatty liver] 1.4 times more frequent in Hispanic than in NHW and 1.9 times more common than in African American persons"
"US liver cancer mortality rates increased with age in all racial/ethnic groups..... Among individuals aged 50-64 years, blacks had the highest mortality rate (18.6), followed by Hispanics (13.5), Asians/Pacific Islanders (13.0), and whites (7.7)." .......Incidence rates only increased among blacks, Hispanics, and white men and women aged 50+ years ......."HCC incidence (new cases): Among individuals aged 50-64 years, rates significantly increased by 9.6% per year from 2000 to 2006, then by 5.2% per year from 2006 to 2010. Among individuals aged 65+ years, rates increased 3.6% per year during
2000-2010.".......http://www.natap.org/2014/HCV/050514_01.htm.............incidence of HCC has almost tripled......HCC cases increased from 37,697 between 1990 and 1999..... to 130,366 cases between 2010 and 2019.....treatment of all infected individuals would reduce the risk by 60.4% after just 10 years. Thus, a reduction in the incidence of HCC may not be achieved unless an increasing number of patients are diagnosed and treated....".....http://www.natap.org/2014/HCV/051914_01.htm
"Williams et al also reported a significantly higher prevalence of NASH in Hispanics than Caucasians (19.4% vs 9.7%, P = 0.03) although comparison of demographics such as BMI between different ethnic groups were not available in this study".....http://www.wjgnet.com/1948-5182/full/v6/i5/274.htm
http://www.ncbi.nlm.nih.gov/pubmed/21281435.....Non-alcoholic fatty liver disease (NAFLD) is a highly prevalent condition, particularly among Hispanic Americans. A genetic variant in PNPLA3 (rs738409) has been identified as a strong predictor of hepatic fat content.......To confirm the association of this variant with NAFLD in two minority cohorts, Hispanic Americans and African Americans, in whom liver density was quantified by computed tomography (CT).......Single nucleotide polymorphism (SNP) rs738409 was strongly associated with reduced liver density (i.e. NAFLD) in Hispanic Americans (1.18 x 10¯(9) and in African Americans (P=4.99 x 10¯6)......consistent with the greater prevalence of NAFLD in Hispanic Americans (24 vs 9%).....this study adds to the growing evidence that some of the ethnic variation in NAFLD is genetic.
Chronic Liver Disease in the Hispanic Population of the United States
Clinical Gastroenterology and Hepatology
life expectancy among Hispanic people is on average 3 years greater than in NHW [whites] people. These epidemiologic characteristics of low socioeconomic status but favorable overall health outcomes are commonly referred to as "the Hispanic paradox.".....Among the Hispanic population, injection drug use has been identified as the most common risk factor for HCV infection.....Studies measuring hepatic triglyceride content by magnetic resonance spectroscopy identified steatosis in 45% of the Hispanic population, making NAFLD 1.4 times more frequent in Hispanic than in NHW and 1.9 times more common than in African American persons.....Multiple other studies also support this ethnic-related distribution of the prevalence of the disease.18, 21, 22 One limitation of current epidemiologic data is that the prevalence of NAFLD has typically been estimated using imaging studies, either to establish a presumptive diagnosis or to screen individuals subsequently evaluated with liver biopsy. For example, Williams et al23 reported the ethnic distribution of biopsy-proven NAFLD in a cohort of patients with abnormal liver ultrasounds. Similar to previous reports, Hispanic persons had the highest prevalence of NAFLD (58.3%), followed by Caucasian (44.4%), and African American (35.1%) persons......Evolution of hepatitis C is more rapid in the Hispanic compared with other ethnic groups with more extensive portal inflammation and more rapid fibrosis progression than in the NHW and African American groups.55 Faster progression rates to fibrosis among Hispanic persons persists even after adjusting for age and specific comorbid conditions such as diabetes mellitus, hyperlipidemia, and alcohol abuse
Data from the United States National Center for Health Statistics (2000-2006) identified chronic liver disease as the sixth most common cause of death in the Hispanic population.6 In contrast, liver disease is not included among the 10 most frequent causes of mortality in NHW and African American populations. Mortality from chronic liver disease in Hispanic people in the United States is nearly 50% higher than in NHW persons (13.7 per 100,000 in Hispanic persons vs 9.2 in NHW and 7.5 in African American persons).7 Furthermore, while mortality rates from chronic liver disease in the United States progressively declined during the past decade, this trend was not evident in the Hispanic population.....Nonalcoholic fatty liver disease (NAFLD) is the most prevalent chronic liver disease in Hispanic persons followed by chronic alcoholic liver disease and viral hepatitis C and B.12, 13, 14, 15 Among Hispanic persons, hepatocellular carcinoma also has a higher incidence and worse prognosis than NHW or African American persons.
This disease is now recognized as the most frequent etiology of elevated serum aminotransferase levels in the United States.....Multiple studies have shown that NAFLD is more common in Hispanic than in NHW or African American persons of the same age with an even distribution among Hispanic men and women.....The most commonly accepted explanation for these epidemiologic variations reflects ethnic differences in prevalence of the metabolic syndrome......In general, Hispanic individuals have higher incidence rates of HCC compared with African American and NHW persons (5.7 vs 4.2 vs 2.6 per 100,000, respectively)....the mean yearly age-adjusted incidence rate of HCC is 2.7 times higher in Hispanic than in NHW individuals.....Data from the SEER database also revealed that Hispanic persons have a 9% higher mortality risk from HCC than NHW persons and, similar to African American persons, they have the shortest 1- and 3-year survival rates amongst all ethnic groups in the United States, even after adjusting for time of diagnosis, receipt of therapy, age, and gender.17 Analysis of HCC-related mortality in Texas and California (which together contain half the total Hispanic population of the United States) demonstrates that mortality rates for US-born Hispanic men are more than twice as high than those for immigrant Hispanic men in California and 65% higher in Texas.74 The authors speculated that this disparity could be attributed to a greater prevalence of risk factors for HCC (ie, HCV infection, greater alcohol consumption, NAFLD, etc.) among the more acculturated US-born Hispanic population. Data from a small retrospective study suggest that chronic HBV infection is implicated in the development of HCC in up to 44% of Hispanic compared with 28% of African American individuals with HCC.......Hispanic individuals have a higher proportion of localized HCC at the time of diagnosis compared with other ethnic groups; however, they are 34% less likely to receive local ablation or surgical resection than NHW persons.17, 74 These disparities affecting Hispanic individuals with HCC are likely to result from differences in access to healthcare services, socioeconomic inequalities, as well as important language and cultural barriers
Data from the Centers for Disease Control and Prevention (CDC) implicate alcohol in 24% of newly identified cases of chronic liver disease in the United States.37 Behavioral patterns of alcohol consumption vary extensively among Hispanic and non-Hispanic populations. Overall, Hispanic persons have lower rates of alcohol consumption than NHW persons;38 however, among heavy drinkers, Hispanic and African American persons consume greater amounts of alcohol per month and also drink for longer periods of time.39 Mexican American and Puerto Rican are the Hispanic subgroup populations with the highest documented alcohol consumption (28%-35% considered themselves heavy drinkers during a period in their lives).40 Furthermore, among most immigrant groups including Hispanic, acculturation to American society is also an important risk factor associated with greater alcohol consumption.41 However, compared with foreign-born Hispanic persons, US-born Hispanic persons have higher rates of alcohol abuse (16% vs 9.1%) and alcohol dependence (14.5% vs 6.2%).42
Gender and racial differences in nonalcoholic fatty liver disease.....World J Hepatol. 2014 May 27.........http://www.wjgnet.com/1948-5182/full/v6/i5/274.htm........According to the National Health and Nutrition Examination Survey (NHANES), 33.8% and 23.7% of the United States (US) adults are obese and have metabolic syndrome, respectively.....Due to the worldwide epidemic of obesity, NAFLD has become the most common cause of elevated liver enzymes with prevalence rates ranging from 2.8% to 46%[5,6]. Individuals with NAFLD and NASH, especially those with metabolic syndrome, have higher overall mortality, cardiovascular mortality, and liver-related mortality compared with the general population[7-9]. Liver cirrhosis secondary to NAFLD is now the second most common indication for liver transplantation in obese patients.....Among different racial and ethnic populations in the US, Hispanics (predominantly of Mexican origin) are at particular risk for NAFLD and tend to have a more aggressive disease course.....The prevalence rates of NAFLD in the US based on population-based studies are summarized in Table 1. Most of these studies were based on the third NHANES (1988-1994) data. Defined as elevated alanine aminotransferase (ALT) and/or aspartate aminotransferase (AST), NAFLD was prevalent in 2.8%-5.4% of the US population[11,12,22]. From 1999 to 2002, the prevalence of NAFLD in the US further increased to 8.1%.....a component of the higher prevalence of NAFLD and NASH observed in Hispanics may be attributed to differences in the frequency of major clinical variables such as components of metabolic syndrome or diabetes that influence the development of NAFLD.
Threat Grows From Liver Illness Tied to Obesity
By ANAHAD O'CONNOR
June 13, 2014 10:07 pm
Nancy Borowick/The New York TimesYubelkis Matias, 19, a student at Bronx Community College, lives with fatty liver disease.
Despite major gains in fighting hepatitis C and other chronic liver conditions, public health officials are now faced with a growing epidemic of liver disease that is tightly linked to the obesity crisis.
In the past two decades, the prevalence of the disease, known as nonalcoholic fatty liver, has more than doubled in teenagers and adolescents, and climbed at a similar rate in adults. Studies based on federal surveys and diagnostic testing have found that it occurs in about 10 percent of children and at least 20 percent of adults in the United States, eclipsing the rate of any other chronic liver condition.
There are no drugs approved to treat the disease, and it is quickly becoming a leading cause of liver transplants around the country.
Doctors say that the disease, which causes the liver to swell with fat, is particularly striking because it is nearly identical to the liver damage that is seen in heavy drinkers. But in this case the damage is done not by alcohol, but by poor diet and excess weight.
"The equivalent of this is foie gras," said Dr. Joel E. Lavine, the chief of pediatric gastroenterology, hepatology and nutrition at NewYork-Presbyterian Morgan Stanley Children's Hospital. "You have to force feed ducks to get fatty liver, but people seem to be able to develop it on their own."
Gavin Owenby, a 13-year-old in Hiawassee, Ga., learned he had the disease two years ago after developing crippling abdominal pain. "It's like you're being stabbed in your stomach with a knife," he said.
An ultrasound revealed that Gavin's liver was enlarged and filled with fat. "His doctor said it was one of the worst cases she had seen," said Gavin's mother, Michele Owenby. "We had no idea anything was going on other than his stomach pain."
With no drugs to offer him, Gavin's doctor warned that the only way to reverse his fatty liver was to exercise and change his diet. "They told me to stay away from sugar and eat more fruits and vegetables," Gavin said. "But it's hard."
Most patients have a less severe form of the disease, with no obvious symptoms. But having nonalcoholic fatty liver is a strong risk factor for developing heart disease and Type 2 diabetes. And in 10 to 20 percent of patients, the fat that infiltrates the liver leads to inflammation and scarring that can slowly shut down the organ, setting the stage for cirrhosis, liver cancer and ultimately liver failure. Studies show that 2 to 3 percent of American adults, or at least five million people, have this more progressive form of the disease, known as nonalcoholic steatohepatitis, or NASH.
"This is the face of liver disease in the United States," said Dr. Shahid M. Malik of the Center for Liver Diseases at the University of Pittsburgh Medical Center. "If you're at any liver transplant center in the country, there's no doubt that this is a big problem."
Three decades ago, NASH was so rare that there was no medical name for it. Many doctors assumed that fat that accumulated in the liver was fairly harmless. But today, NASH is a growing strain on liver clinics and the fastest rising cause of liver transplants.
A study by the Mayo Clinic found that the percentage of all transplants performed nationwide because of NASH had reached 10 percent by 2009, up from 1 percent in 2001, even as the rates for hepatitis C, alcoholic liver disease and other conditions remained stable. NASH is projected to surpass hepatitis C as the leading cause of liver transplants by 2020, in part because of new drugs that can effectively cure hepatitis C, but also because of the rapid growth of fatty liver disease.
Fatty liver strikes people of all races and ethnicities. But it is particularly widespread among Hispanics because they frequently carry a variant of a gene, known as PNPLA3, that drives the liver to aggressively produce and store triglycerides, a type of fat. The variant is at least twice as common in Hispanic Americans compared with African-Americans and non-Hispanic whites.
In Los Angeles, liver disease is diagnosed in one out of two obese Hispanic children, and it is a leading cause of premature death in Hispanic adults.
At the University of California, Los Angeles, home to one of the largest liver transplant centers in the world, nearly 25 percent of all liver transplants are performed because of NASH, up from 3 percent in 2002. If the prevalence of NASH continues to increase at its current rate and effective treatments are not found, about 25 million Americans will have the disease by 2025, and five million will need new livers, said Dr. Ronald W. Busuttil, chief of the division of liver transplantation at the David Geffen School of Medicine at U.C.L.A.
"I'm really afraid that the explosion of this condition is going to overrun the resources available to the transplant centers around the country," Dr. Busuttil said. "In the United States right now, we do about six to seven thousand liver transplants a year. Can you imagine if we have millions of people on the list? It's unfathomable."
With NASH rates rising rapidly, drug companies are racing to produce the first drug to treat it.
In January, Intercept Pharmaceuticals, a small biotechnology firm, announced that its clinical trial of obeticholic acid showed promise in treating NASH, causing its stock price to soar. The National Institutes of Health, which sponsored the trial, are expected to present results from it later this year.
Another company, Galectin Therapeutics, was granted a special fast-track designation by the Food and Drug Administration to speed its development of GR-MD-02, a drug that may help reverse some of the more advanced symptoms of the disease.
But it will be several years before any drugs for NASH reach the market, said Dr. Kathleen Corey, the director of the Massachusetts General Hospital Fatty Liver Clinic, which was founded four years ago.
"We see patients with undiagnosed cirrhosis in their teens and 20s," she said. "That's something we never would have thought was possible in the past."
Yubelkis Matias, 19, an honors student at Bronx Community College, was told she has NASH several years ago. She is reminded of the trouble brewing in her liver by the sharp abdominal pains that come and go. Like Gavin, she has been told by her doctors that diet and exercise may be her only shot at reversing the disease. But at 5-foot-5 and 200 pounds, she finds every day a struggle.
"I'm on a roller coaster," she said. "I eat healthy, then not healthy - pizza, McDonalds, the usual. My doctor told me I have to quit all of that. But it's cheap, and it's always there."
Like many hepatologists, Dr. Corey helps her patients manage their high cholesterol, blood sugar and other metabolic problems that coincide with fatty liver. She counsels them to avoid sugar and alcohol, and she offers them high dosages of vitamin E, an antioxidant that studies show can relieve some symptoms of the disease. And she urges them to lose weight, the only proven way to reduce fat in the liver.
In adults, the rising prevalence of fatty liver has mirrored the increase in obesity. But in children, fatty liver is increasing at a rate "faster and above" the increase in childhood obesity, said Dr. Miriam Vos, the lead author of a study in The Journal of Pediatrics last year that estimated that one in 10 adolescents have the disease.
"That suggests that there's something else going on," said Dr. Vos, a pediatric hepatologist at Children's Healthcare of Atlanta. "We don't know, but some of the research has shown there may be early exposures in pregnancy or diet exposures that could be helping to drive this."
In studies, Dr. Vos and other researchers have found that when children with fatty liver consume sugar, they produce far more triglycerides than children without the disease, and this may be exacerbating fat accumulation in the liver. Cutting out sugary drinks often leads to "a big improvement" in her patients, Dr. Vos said. "But I don't know if that improvement is specifically because of the sugar or because they cut back on a lot of calories" and have lost weight.
Some researchers believe that insulin resistance, a hallmark of Type 2 diabetes, may be an underlying cause of fatty liver. But not everyone who has the disease is insulin resistant. Nor is every fatty liver patient overweight. People of Asian descent, for example, develop the disease at a lower body mass index than others, said Dr. Rohit Loomba, a fatty liver specialist at the University of California, San Diego, School of Medicine.
Doctors are also trying to figure out why some people with fatty liver progress to NASH and cirrhosis, while others do not. Dr. Loomba said that continual weight gain seems to be one driving force behind the progression.
As a result, doctors who treat fatty liver stress the urgency of diet and exercise to their patients. But many find it too hard, especially those who are obese and in the late stages of the disease, said Dr. Malik at the University of Pittsburgh.
"A lot of times when I see a patient with fatty liver," he said, "the first thing out of their mouth is, 'Well, is there a pill for this?' And there's not. There just isn't. You have to make lifestyle changes, and that's a much more difficult pill for people to swallow."