Preventing and Treating Nonalcoholic Fatty Liver Disease in Children With Obesity: Why Is the Recommended Approach Being Ignored?
Authors: Tabby Khan, MD, MPH, Medical Director; Alex Enrique, Healthcare Data Analyst; Eric Mitchell, Senior Customer Success Associate
In public health, the simplest medical solutions can be some of the most challenging to implement. Pediatric obesity and nonalcoholic fatty liver disease (NAFLD) are two examples, where lifestyle factors play the biggest roles in cause and treatment. Roughly 1 in 5 children meet the criteria to be considered obese, and nearly 1 in 10 are considered severely obese. The pandemic has worsened this trend, with youth obesity having risen about 20% in the pandemic’s first year.
As the obesity epidemic continues to worsen, so do the comorbidities that come with it. NAFLD affects up to 34% of children with obesity and is the most common cause of pediatric liver disease. It’s both preventable, and reversible when caught in early stages, but is often present with no noticeable symptoms. Left unchecked, it can lead to cirrhosis and a host of related health problems, meaning screening is key for flagging and prevention. Clinical guidelines advise that all children with obesity be screened for NAFLD, in addition to children who are overweight and have other risk factors, starting between ages 9 and 11.
As with obesity, children diagnosed with NAFLD should receive lifestyle counseling. In fact, NAFLD-specific weight management counseling is the only established approach to treat NAFLD and is the primary recommendation in clinical guidelines.
To understand if and how these crucial elements of care are being applied in the treatment and management of pediatric NAFLD, Komodo Health conducted an analysis using our Prism patient journey software. We looked at the number of pediatric NAFLD patients (children and adolescents aged 6-17 with a diagnosis of any form of NAFLD, NAFL, NASH, or NASH cirrhosis), who received the recommended lifestyle modification counseling within five months of their diagnoses.
Pediatric NAFLD continues to be vastly underdiagnosed. Only 5% of children and adolescents with obesity had ever been diagnosed with NASH.
Compared to the estimation of a 34% potential prevalence of NAFLD in kids with obesity, this is a stark gap, pointing to the need for increased screening and the huge opportunity for preventive care. While lifestyle counseling is advised both for patients with obesity and NAFLD, the specific dietary recommendations can be different.
Before the pandemic’s onset, only 18% of obese pediatric patients with NAFLD received the recommended dietary counseling after their NAFLD diagnosis, and 9% received exercise counseling.
Between January 2019 and June 2020, only 18% of pediatric NAFLD patients had received dietary counseling. Only 8% received medical nutrition therapy and follow up assessments, 2% received behavioral counseling for obesity within five months of their diagnosis, and only 9% of patients received exercise counseling.
Around and after the onset of the pandemic, slightly more pediatric NAFLD patients received dietary (22%) and exercise counseling (12%).
This is an increase of 4% in the number of patients who received dietary counseling compared with the pre-pandemic period. There was an increase of 3% in the number of patients who received exercise counseling.
Many factors may have contributed to the slight uptick in lifestyle counseling during the pandemic. Provider focus on diet and exercise may have increased due to heightened awareness of rising pediatric obesity and of youth spending more time at home during closures. A recent increase in market education efforts on NAFLD and NASH may also have played a role. The increase we saw may also be an underestimation, as our time frame included the period of lockdown when routine clinical visits declined significantly. For both time periods, the commonality of lifestyle counseling in pediatric NAFLD patients may be slightly higher than what is seen in claims data, due to provider variation in medical diagnosis coding.
While a small increase in counseling shows promise, the low number of patients receiving treatment exposes a weakness in preventive care approaches and paints a stark picture of the missed opportunity to protect young people from preventable liver diseases. Changes on multiple levels could make a difference, including increasing provider education on the importance of screening and counseling, optimizing current coding to enhance the capacity to flag important moments in the patient journey, and appropriate market priming. With fewer than 1 in 5 patients currently receiving the only recommended treatment, and drugs for pediatric NAFLD a long way out, the need for a change in approach is urgent.