New Program for Nonalcoholic Fatty Liver Disease
Nonalcoholic fatty liver disease (NAFLD) is now the most common cause of chronic liver disease in the United States, affecting 25% of the population. Without intervention, it can lead to significant liver damage in a smaller group of those patients.
The severity of NAFLD can range from fat storage in the liver to inflammation (called NASH or nonalcoholic steatohepatitis). When scar tissue builds up, the diagnosis is NASH-related cirrhosis.
“Fatty Liver has become a public health issue and affects people suffering from obesity, diabetes, and high cholesterol – but it isn’t limited to those high risk groups,” says Julia Wattacheril, MD, MPH, Director of the Non-Alcoholic Fatty Liver Disease program. To serve this growing patient population, NYP/Columbia has a dedicated clinic for the study and management of NAFLD.
“We partner with referring physicians to provide long-term care of these individuals with NAFLD” says Dr. Wattacheril, “We’ve piloted this approach for a year now. And we became nationally recognized for our multidisciplinary approach to this condition, drawing on the expertise not just of hepatologists and gastroenterologists, but our colleagues in cardiology, endocrinology, internal medicine and bariatric surgery and nutrition. We are looking forward to developing relationships in the behavioral sciences and exercise physiology. The theme of our program is collaboration and it isn’t just limited to healthcare providers and researchers; our patients are 100% collaborators in the program and its development.”
Advances in Biopsy and Risk Assessment
The most common question referring physicians ask the Columbia experts is: When and how do we decide to biopsy a patient?
“There are many non-invasive means to better define a patient’s risk for NAFLD,” says Dr. Wattacheril. “Our referral form includes an online calculator for the NAFLD Fibrosis Score (NAFLD-FS). Evaluating metabolic risk (especially insulin resistance) is also key. It is very important that we think about the liver’s role in metabolism.”
In addition, Columbia offers Vibration Controlled Transient Elastography (VCTE), or FibroScan®. This non-invasive imaging tool helps the Columbia team to estimate fat and stiffness, and gauge the amount of scar tissue in the liver.
FibroScan can also help determine whether a patient is a good candidate for a clinical trial. “In addition, it provides a good interim assessment of patients who are afraid of biopsies,” says Dr. Wattacheril, “though biopsy remains the standard to diagnose NASH.”
A Comprehensive Treatment Program
“Our NAFLD Program is continually developing new modalities to foster important lifestyle changes,” Dr. Wattacheril says. “A weight loss of 7-10 percent has been shown to improve the disease and the metabolic risk factors associated with it. That said, weight loss is not just hard to achieve, it is difficult to sustain ― like most aspects of behavior change. While we equip patients with the information they need to understand their disease and its treatment, achieving their goals requires a day-in, day-out commitment to the process that is fostered by a network of supports in the exercise and psychological realms. Right now, those resources are outside our center. Our patients joke about the ‘homework’ we give them, but they know the hard work starts when they leave our center.”
Innovative services include:
- On site nutritionist who evaluates every new patient (at no charge to patient or insurance) This service is available to families as needed, as determined by a consult
- Partnership with weight management centers to support patients who are obese or overweight
- Detailed exercise counseling
- Widespread use of mobile apps to assist with motivation, accountability and awareness of exercise and nutrition goals
- Screening and enrollment in clinical trials
- Collaboration with Columbia’s Center for Metabolic and Weight Loss Surgery for patients needing bariatric procedures to address obesity, improve diabetes and lower cardiac risk
- Strong emphasis on translational research leading to better treatment and cures
- Seamless transition to transplant services if needed (all hepatologists are transplant certified)
In the Vanguard of Research and Clinical Trials
Dr. Wattacheril is currently the local leader for the liver initiative for Columbia’s Precision Medicine Initiative and Institute of Genomic Medicine, but with NAFLD as a strategic focus. “Under the direction of David Goldstein, PhD and Ali Gharavi MD, our goal is to better understand the biology of NAFLD using an integrated genomics approach,” she says. “In addition, we are partnering with industry using precision medicine approaches to come up with new treatments for NASH. We’re not just interested in what makes a person sick and how to make them better. We also are interested in what keeps people well.”
“We have a robust portfolio of clinical trials for NASH that run anywhere from 18 months to 5 years, longer than most liver disease trials done in the past,” says Dr. Wattacheril. “These studies often require multiple biopsies and monitoring every three months so we can assess changes over time. Establishing and maintaining a trustworthy relationship with our patients is key and keeping them interested and motivated is very important to us. Our patients help us innovate and we welcome their participation as we develop the highest standards of care. The team we have assembled to help with this effort is world-class.”