About two decades ago, Maria Rita Lepe-Suastegui, MD, was just starting out as a gastroenterologist. Back then, most of her patients with serious liver disease were in their 70s or 80s. But that’s no longer the case.
“Not only is it affecting the entire Hispanic population, but we see it in really young people,” said Lepe-Suastegui, an assistant professor at UT Southwestern Medical Center specializing in liver disease and Latine health disparities. “I see patients in their 20s with cirrhosis and liver failure, and unfortunately some of them die from this disease.”
Cirrhosis means that scarring has overtaken healthy tissue in the liver. It can lead to liver failure or cancer. Cirrhosis is the most severe stage of fatty liver disease, a condition tearing through the Latine population. About 45% of Latine adults and 38% of Latine children and young adults ages 12-29, especially Mexican Americans, have fatty liver disease.
Compare that to the broad population – fatty liver disease affects roughly 25% of adults and 5%-10% of children in the U.S. – and you see the problem.
Also known as metabolic dysfunction-associated steatotic liver disease (MASLD), fatty liver is exactly what it sounds like: Too much fat builds up in the liver. It’s often linked to other health conditions, especially obesity and type 2 diabetes, and it can lead to heart attacks, strokes, and chronic kidney disease, according to Lepe-Suastegui. Because fatty liver disease is taking hold in younger age groups, even “from infancy,” it can create challenges throughout people’s lives, she said.
Latine people may be more vulnerable to fatty liver disease for various reasons. Genes can play a role, but many also struggle to get nutritious foods that can help prevent the disease. Cultural and language barriers can make it harder to find doctors they trust, delaying treatment. Others lack health insurance because of costs or documentation status. But even among people who get regular checkups, fatty liver disease can progress for decades without being noticed.
“This disease is a little bit sneaky,” Lepe-Suastegui said. “A lot of [patients] tell me, ‘I've been going to my doctor all these years. Why did this not get picked up?’”
Below, Lepe-Suastegui answers questions about fatty liver disease and its effect on her community. This conversation has been edited for clarity.
Fatty liver disease has a reputation as a “silent killer.” That makes sense. While some people with the disease have abdominal pain or abnormal liver enzyme levels, others have what’s considered normal liver function results and no symptoms. But why has this become a growing problem among younger people, and how have they been overlooked?
The most important thing with this disease is to see how much scar tissue somebody has. There's specific testing that needs to be done to stratify a patient with fatty liver. We can have a patient with 50% fat and no scar tissue. We're not worried about those folks. We're worried about folks that have advanced scarring.
Traditionally, it had been brushed off as, “You have fatty liver, lose weight, not a problem.” But because we didn’t pay it the attention it deserved, young kids had been progressing. And now we have a big problem in a very young population. Kids are having more problems with obesity than in the past, since the 1980s. We're seeing children who have been overweight since age 8, for example. I see them as adults, but they've had maybe 10 to 15 years of a problem that is not addressed. [Now] we're trying to identify people who are more at risk of getting advanced disease and refer them to the proper specialist or at least intervene at an earlier stage.
Those interventions could help as long as people have access to doctors and can afford care. Neither is a given for a significant proportion of the Latine population. Latine adults are more than twice as likely as non-Latine white adults to be uninsured. Texas, where you practice, has the highest uninsured rates for adults (21.7%) and children (11.9%) anywhere in the U.S. How have you seen this challenge complicating care for your patients?
A lot of the time, kids are becoming adults without knowing they have fatty liver. They [reach] the age where they can drink alcohol. And alcohol and fatty liver is a very bad combination. When you have both of these conditions in the same individual who also is Hispanic and has a predisposition to fibrosis (scarring), you can get cirrhosis within a very short period of time. And at age 22 or 23, a lot of these kids don't have health insurance. They don't like to go to the doctor, especially males – especially in a Latino population, that’s sometimes seen as unmanly.
And they might not know they’re genetically predisposed to fatty liver. Research has linked the disease to a variation in the PNPLA3 gene, which is more common in Latine populations. Not everyone who has this gene goes on to develop fatty liver disease though. What should people know about this gene?
PNPLA3 is more prevalent in Latinos, but other groups also have it. This mutation is more common in people who have elevated liver enzymes. It’s also associated with a more aggressive form of fatty liver, the one that's going to get scarring and cirrhosis. Just having a high-calorie [or] high-sugar diet is going to make this process worse. It’s going to activate cells in the liver that make scar tissue.
What we eat can help encourage or prevent two of the major risk factors for fatty liver disease: obesity and type 2 diabetes. But 1 in 5 of Latine households experience food insecurity, meaning they have limited access to nutritious foods, compared to 9.3% of white households. Food insecure adults are two to three times more likely to have type 2 diabetes. Women who experience food insecurity may be more prone to obesity. How can food insecurity complicate fatty liver disease prevention and management for patients and doctors?
Latinos in general have different socioeconomic statuses. But if they're relying on food stamps or food pantries, the food being distributed is often canned goods that have high salt, sugar, and fat content. As physicians, sometimes we forget that and say, “You need to do this, that, and the other.” We need to look at their socioeconomic status and what they have available to them.
A doctor’s advice could be even less impactful if they don’t speak Spanish, research suggests. Additionally, 57% of U.S. health care workers have witnessed discrimination against patients who speak mostly in a language other than English, according to a recent survey by The Commonwealth Fund. How have you seen cultural barriers and discrimination affect Latine patients with fatty liver disease?
I am originally from Mexico City. I have family members with fatty liver disease, so I understand it from a cultural perspective and it's something that I live very close to. Not only is the language important, but also having more physicians that are culturally competent. You have to understand the patient [and] where they're coming from. I've had situations where [providers] say, “The patient was noncompliant,” and it’s not that they’re not compliant, it’s that they understood different instructions, or the instruction was not in a language they understood.
Also, Latino populations may have some distrust of providers, particularly if they don't speak the language or they perceive that they're not being listened to. So they may hold back some information that is needed. Or they may not even go to the doctor and rely more on what their neighbor told them, or use herbal medicine or supplements.
All of this adds up to a very complicated challenge that often affects multiple generations within families. Pregnant women with fatty liver disease are more vulnerable to complications, like eclampsia and preterm birth. Their children are also at a greater risk for the most common risk factors for MASLD. Depending on their mother’s diet, infants who drink breast milk can have fatty liver. You and your son have co-authored two books for young readers whose parents have liver disease. Given these impacts, what more is needed to help individuals and families confronting this disease?
We need to really prioritize this as a health problem because otherwise, we're going to see a lot of people die from this disease. I see this problem starting a lot in childhood, and that is when we can intervene the most. There’s now [medication for a worsened form of MASLD called metabolic dysfunction-associated steatohepatitis, or MASH] but not everybody can afford it; not everybody's going to have access to it. If you have the gene, you can't change your genes, but you definitely can change your diet and how that affects you.
A lot of parents that I talk to know what needs to be done. They know that their kid needs to eat healthier, but it's very challenging because there are a lot of opposing forces. These families need support from schools, providers, [and] community centers to help them get their children where they need to be.
