Banting memorial lecture 2022: ‘Type 2 diabetes and nonalcoholic fatty liver disease: Partners in crime’

Abstract

Nonalcoholic fatty liver disease (NAFLD) was first described in the 1980s, but in the 21st century, NAFLD has become a very common condition. The explanation for this relatively recent problem is in large part due to the recent epidemic of obesity and type 2 diabetes (T2DM) increasing the risk of NAFLD. NAFLD is a silent condition that may not become manifest until severe liver damage (fibrosis or cirrhosis) has occurred. Consequently, NAFLD and its complications often remain undiagnosed. Research evidence shows that NAFLD is extremely common and some estimates suggest that it occurs in up to 70% of people with T2DM. In the last 5 years, it has become evident that NAFLD not only increases the risk of cirrhosis, primary liver cancer and end‐stage liver disease, but NAFLD is also an important multisystem disease that has major implications beyond the liver. NAFLD increases the risk of incident T2DM, cardiovascular disease, chronic kidney disease and certain extra‐hepatic cancers, and NAFLD and T2DM form part of a vicious spiral of worsening diseases, where one condition affects the other and vice versa. Diabetes markedly increases the risk of liver fibrosis and liver fibrosis is the most important risk factor for hepatocellular carcinoma. It is now possible to diagnose liver fibrosis with non‐invasive tools and therefore it is important to have clear care pathways for the management of NAFLD in patients with T2DM. This review summarises key recent research that was discussed as part of the Banting lecture at the annual scientific conference in 2022.

Nonalcoholic fatty liver disease without overlapping metabolic‐associated fatty liver disease and the risk of incident type 2 diabetes

“…It is important to note that NAFLD and T2D form part of a vicious spiral of worsening diseases, where one condition affects the other and vice versa. 46 Given that diabetes markedly increases the risk of liver fibrosis, 46,47 or liver biopsy to identify fatty liver. However, liver biopsy is neither feasible nor ethical for healthy participants, and imaging modalities such as computed tomography or magnetic resonance imaging are not practical or cost-effective for routine healthcare check-ups in this large population.…”

“…Furthermore, we excluded all who had diabetes at the study baseline. It is important to note that NAFLD and T2D form part of a vicious spiral of worsening diseases, where one condition affects the other and vice versa 46 . Given that diabetes markedly increases the risk of liver fibrosis, 46,47 excluding individuals with T2D to define the diabetes‐free at baseline might result in specific selection of those with fibrosis but not related to T2D.…”

Long-Term Adverse Effect of Liver Stiffness on Glycaemic Control in Type 2 Diabetic Patients with Nonalcoholic Fatty Liver Disease: A Pilot Study

“…Worryingly, the global prevalence of NAFLD is expected to increase dramatically in the near future, in parallel with the increasing rates of obesity and T2DM globally [ 1 ]. T2DM and NAFLD represent a “vicious circle”, whereby the presence of one condition adversely affects the other and vice versa [ 3 ]. Compared with subjects without T2DM, patients with T2DM are more likely to have or develop the more advanced forms of NAFLD, such as nonalcoholic steatohepatitis (NASH), advanced fibrosis or cirrhosis [ 4 , 5 ].…”

MASLD, MAFLD, or NAFLD criteria: have we re-created the confusion and acrimony surrounding metabolic syndrome?

“…In the last two decades, overwhelming evidence has shown that nonalcoholic fatty liver disease (NAFLD) is a multisystem disease and is a risk factor for other extrahepatic diseases that require a holistic approach to treatment [2,3] . In support of that argument, there is now evidence that NAFLD is an independent risk factor for T2DM [4] , cardiovascular disease (CVD) [5] , chronic kidney disease [6] , congestive heart failure [7] , and certain extrahepatic cancers (principally gastrointestinal cancers, breast cancers, and gynecological cancers) [8] . Many of these extrahepatic diseases share common cardiometabolic risk factors, such as central obesity, hypertension, glucose intolerance, insulin resistance and atherogenic dyslipidemia, and it has been known for several years that many of these cardiometabolic risk factors tend to cluster together in affected patients at risk of these extrahepatic disease complications [2,9] .…”