Non-Alcoholic Fatty Liver Disease (NAFLD) in Children: Causes and Recommendations

Author: Lauren Grieco, MS, RD

Caroline Wang

Shuhua Bloom, MS

Mentor: Dr. Henry Sun

Date: October 16, 2021

Background

What is Non-alcoholic Fatty Liver Disease (NAFLD)?

According to the National Institute of Health, NAFLD is a condition in which we store excess fat in the liver¹. In NAFLD, storage of fat is not related to excessive intake of alcohol. There are two types of NAFLD, nonalcoholic fatty liver (NAFL) and nonalcoholic steatohepatitis (NASH). NAFL is a form of NAFLD, in which there is little to no inflammation or liver damage. However, there may be pain from excess fat on the liver and liver enlargement. NASH is also a form of NAFLD, in which there is liver damage and liver inflammation. This inflammation and damage may cause fibrosis, or scarring of the liver, and in some cases, progressing into permanent damage and cirrhosis. Cirrhosis may lead to liver cancer.

Furthermore, NAFLD is usually diagnosed in individuals with other chronic diseases, associated with central fatness, hypertriglyceridemia, hypercholesterolemia, hypertension, and hyperglycemia².

The incidence of NAFLD has persistently increased globally over the last twenty years. Worldwide, “NAFLD affects 25% of the international adult population, with a range of 13.5% in Africa and 31.8% in the Middle East”³. The United States has an increasing prevalence of NAFLD from 15% in 2005 to 25% in 2010⁴. Furthermore, NAFLD is one of the most common causes of liver disease in the United States¹.

NAFLD is the leading cause of liver disease in children. Due to the rise of childhood obesity and NAFLD, it is important for parents, government officials, healthcare providers, and more to understand the causes of pediatric NAFLD.

NAFLD in adults has been found to be related to being overweight, having high blood pressure, having diabetes, having high triglycerides or high cholesterol levels. Research should continue to monitor causes of NAFLD among both adults and in children.

Hypothesis

NAFLD in children shows that it is related with weight status, dietary eating patterns, and physical activity. Children with unhealthy eating patterns (high intake of saturated fats, simple sugars, fast foods) and sedentary lifestyles may be a potential trigger for NAFLD.

Methods and Results

During the pandemic time, most of the students are studying from home, either alone or with adults. We created the questions such as:  how they take their meals at lunch?

Cook by themselves, order deliveries, eat leftovers from last night, prepared by the parent before leaving home to work, or the adult parent/grandparent cook for them?

If it was not freshly prepared, can their food intake, maintain a good nutritional balance and avoid overeating those fast foods dense in calories?

We have questioned 36 students/ neighbors one by one in the P&W Communities, wore the mask, and kept a 6 ft distance as required, outside in the Backyard, Playground, Tennis court, Outdoor Summing pool, etc.

The results that we found almost 97% of students like eating Chips, French fries, Ice Cream, Cheesecake, Candy, Hamburger, Starbucks, Coca-Cola, Pepsi, and Soda.

Students claim that eating sweets are more satisfying and make them happy, while not being too concerned with nutritional value.

82% of them play games for more than 2 hours every day.

20% of them do exercise more than 6 hours per week.

75% of them do exercise less than 3 hours per week.

Most of them aren’t aware of NAFLD among their age group, they think it’s related to their parents, not them.

Discussion:

This study connects weight status and NAFLD, current research is investigating the development of NAFLD in childhood, as childhood obesity continues to rise. Childhood obesity is currently a very serious problem in the United States and worldwide, putting children and adolescents at risk for poor health. For children and adolescents aged 2-19 years in 2017-2018, the prevalence of obesity was 19.3% and affected about 14.4 million children and adolescents¹. Duplicating the increasing prevalence of obesity in the pediatric population, NAFLD is projected to become one of the most common causes of end-stage liver disease in both children and young adults.

According to the NIH, children who have certain conditions, including obesity and conditions that are related to obesity, are indeed more likely to develop NAFLD or NASH¹. Furthermore, NAFLD can occur in children of all races and ethnicities, however, it has been found to be most prevalent in Hispanic and Asian American children, while being less common in African American children.

Children with NAFLD tend to be asymptomatic pathophysiology, with no complaints of pain, fatigue, or nausea. Furthermore, the exact cause and rate of progression of disease are still being researched and explored. However, NAFLD/NASH in children may signify a more severe form of NAFLD that would benefit from early diagnosis and treatment. Silent symptoms and a benefit in early identification further increases the importance of understanding potential risk factors, receiving healthcare checkups, and understanding your child’s health status.

According to studies, the most important risk factors for NAFLD in children are insulin resistance and central obesity, representing the key relationship between weight and health outcomes. Thus, indicating that maintaining a healthy weight status, dietary pattern, and physical activity can work to reduce risk of NAFLD.

Pediatric NAFLD is chronic hepatic steatosis in children ages 18 or younger and is the most common cause of liver disease in children⁵. A 2010 study showed that the prevalence of NAFLD among junior high school students was estimated at approximately 4% in certain areas of Japan⁶. Pediatric NAFLD is most often diagnosed in children between the ages of 12 and 13; however, it has been reported in children as young as 2 years, with NASH-related cirrhosis noted as early as 8 years of age⁵.

It is important to understand risks and causes of liver disease as the beginning stages often go undetected or are silent. Below are the studied risk factors and causes of NAFLD:

• Being overweight or obese
• Having high blood fat levels, either triglycerides or LDL (“bad”) cholesterol
• Having diabetes or prediabetes
• Having high blood pressure
• Genetics
• Environmental triggers

Conclusion

Due to the high prevalence of childhood obesity and the possible negative consequences, it is important for parents to be aware of its risks, seeking preventions, and changing for better, then take actions.  It is also crucial to stop NAFLD at its early stages and prevent the development into cirrhosis.

Recommendation

Parents and children should be motivated to break old habits and value the importance of maintaining a healthy diet, encourage therapeutic lifestyle change, particularly physical activities whenever possible. The below recommendations will aid to reduce risk factors listed in the previous section.

• Reducing screen time (TV, cell phone, or other digital devices) to guarantee quality sleep time and setting up consistent bedtime. Try limiting after school TV or videogame time to one hour a night.
• No digital devices at mealtimes or bedtimes by enforcing charging technology devices in other rooms.
• Family meals should include a variety of fruits and vegetables (in different colors and seasonal products). Fruits and vegetables should make up 50% of the meal. Make protein ¼ of the plate to decrease the amount of saturated fat and increase the consumption of more monounsaturated fats. Grains should be ¼ of the plate, choosing whole grains first to increase fiber and vitamin and mineral intake.
• Sugar sweetened beverages are caloric dense and rarely add nutrients. Choose water, unsweetened tea, low fat milk, homemade smoothies, or 100% fruit juice as beverages for your family.
• Having healthy and available snacks ready in the home (low fat yogurt, sliced up bell pepper, carrot sticks, hummus, whole grain pita, apples). This way children are less likely to eat quick calorie dense snacks like chips, cookies, and processed foods.
• Reduce simple sugar and refined carbohydrate consumption. When choosing carbohydrate choices, look for fibrous grains, whole wheat, fruits, and vegetables.
• Increase physical activity, aiming around 150 minutes of moderately intensive exercises weekly – can be in a choice of 5 days of 30 minutes or 3 days of 50 minutes (particularly on weekends); try introducing family physical exercise challenges, goals, awards, etc.
• Creating or setting up app(s) or other recording system to track daily calorie and nutrition intake, exercise minutes. Work with a healthcare provider to develop calorie and exercise goals to ensure safe health outcomes.
• Ensure daily health checkups for the entire family to assess for NAFLD risk and other chronic diseases.
• “Nutrition” subject should be an independent lesson added to a High School study.
• Promotional “Eating Health Post” should post on the wall at the school, such as educational content.
• Drinking water should be encouraged by parents, teachers, and coaches.
• Parents should visit the Dietary Guidelines for Americans recommendations to assess how to make proper nutrition changes for the family.

Reference:

1. Definition & Facts of NAFLD & NASH | NIDDK. National Institute of Diabetes and Digestive and Kidney Diseases. Accessed August 16, 2021. https://www.niddk.nih.gov/health-information/liver-disease/nafld-nash/definition-facts
2. Nobili V, Marcellini M, Devito R, et al. NAFLD in children: A prospective clinical-pathological study and effect of lifestyle advice. Hepatology. 2006;44(2):458-465. doi:10.1002/hep.21262
3. Younossi ZM, Marchesini G, Pinto-Cortez H, Petta S. Epidemiology of Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis: Implications for Liver Transplantation. Transplantation. 2019;103(1):22-27. doi:10.1097/TP.0000000000002484
4. Perumpail BJ, Khan MA, Yoo ER, Cholankeril G, Kim D, Ahmed A. Clinical epidemiology and disease burden of nonalcoholic fatty liver disease. World J Gastroenterol. 2017;23(47):8263-8276. doi:10.3748/wjg.v23.i47.8263
5. Smith SK, Perito ER. Nonalcoholic Liver Disease in Children and Adolescents. Clin Liver Dis. 2018;22(4):723-733. doi:10.1016/j.cld.2018.07.001
6. Tsuruta G, Tanaka N, Hongo M, et al. Nonalcoholic fatty liver disease in Japanese junior high school students: its prevalence and relationship to lifestyle habits. J Gastroenterol. 2010;45(6):666-672. doi:10.1007/s00535-009-0198-4