Individuals with type 2 diabetes (T2DM) are at high risk for nonalcoholic fatty liver disease (NAFLD), and evidence suggests that poor glycemic control is linked to heightened risk of progressive NAFLD. We conducted an observational study based on data from a telehealth trial conducted in 2018-2020. Our objectives were to: 1) characterize patterns of NAFLD testing/care in a cohort of individuals with poorly-controlled T2DM; and 2) explore how lab-based measures of NAFLD (e.g., liver enzymes, fibrosis-4 [FIB-4]) vary by glycemic control. We included individuals with poorly-controlled T2DM (n=228), defined as hemoglobin A1c (HbA1c) ≥ 8.5% despite clinic-based care. Two groups of interest were: 1) T2DM without known NAFLD; and 2) T2DM with known NAFLD. Demographics, medical history, medication use, glycemic control (HbA1c) and NAFLD testing/care patterns were obtained by chart review. Among those without known NAFLD (n=213), most were male (78.4%) and self-identified as Black race (68.5%). Mean HbA1c was 9.8%. Most had liver enzymes (85.4%) and platelets (84.5%) ordered outpatient over a 2-year period that would allow for FIB-4 calculation, yet only 2 individuals had FIB-4 documented in clinical notes. Approximately one third had abnormal liver enzymes at least once over a 2-year period, yet only 7% had undergone liver ultrasound and 4.7% had referral placed to Hepatology. Among those with known NAFLD (n=15), mean HbA1c was 9.5%. Only 4 individuals had undergone transient elastography, half of whom had advanced fibrosis. NAFLD is underrecognized in poorly-controlled T2DM, even though this is a high-risk group for NAFLD and its complications.

Nonalcoholic fatty liver disease (NAFLD) and its complications disproportionately impact individuals with T2DM. NAFLD prevalence is thought to be 60-70% in T2DM. In response to this, guidelines now recommend additional liver testing and risk stratification of NAFLD in patients with T2DM who have elevated liver enzymes or steatosis seen on ultrasound. In this secondary analysis of data from a randomized trial of a telehealth intervention, we investigated NAFLD testing and care patterns in a cohort of Veterans with poor T2DM control across two VA sites (n=244) over a 2-year period (2018-2020). Mean HbA1c and BMI were 9.8% (SD 1.5%) and 35.0 kg/m2 (SD 6.3), respectively. Only 6.6% (n=16) had a documented diagnosis of NAFLD. Excluding those with known NAFLD or other liver diseases (i.e., hepatitis B/C [n=14], alcohol overuse [n=6]), the majority of patients had documented liver enzyme (87%, n=184) and platelet (89%, n=187) testing. Based on established lab criteria for NAFLD diagnosis (i.e., at least two ALT ≥ 40 IU/mL in men, ≥ 31 IU/mL in women, ≥ 6 months apart), 17% (n=36) had undiagnosed NAFLD. Despite available lab data, no patients had a lab-based risk stratification score (such as the fibrosis-4 index or NAFLD fibrosis score) documented in clinical notes or electronic problem lists. Only 7% of patients had undergone liver ultrasound (n=15) and 2.4% Fibroscan (n=5), which are the usual first-line imaging modalities for diagnosis and risk stratification of NAFLD, respectively. Of patients with persistently elevated liver enzymes (n=36), only 14% (n=5) were referred to Hepatology. In summary, this study highlights the underrecognition of NAFLD in T2DM, even in patients with poor glycemic control and obesity who are exceedingly high risk of NAFLD complications. Since Endocrinologists commonly see patients with high metabolic risk, this study also highlights an important role for Endocrinologists in the proactive detection and risk stratification of NAFLD in T2DM. Disclosure A. Alexopoulos: None. R. Duffy: None. E. A. Kobe: None. C. A. Moylan: None. A. S. Jeffreys: None. C. Coffman: None. D. Soliman: None. J. German: None. M. Crowley: None.