NAFLD screening falls short of guidelines for children with obesity
Most children with obesity who are at high risk for non-alcoholic fatty liver disease are not being screened, possibly leading to underdiagnosis of the condition, according to a speaker at ObesityWeek Interactive.
“Despite screening guidelines, most children with excess weight at high risk for NAFLD did not have a screening lab result,” Alyson Goodman, MD, MPH, medical epidemiologist in the division of nutrition, physical activity and obesity at the Centers for Disease Control and Prevention, told Healio. “Alanine aminotransferase results were often high and NAFLD diagnostic codes were rare among children with excess weight, suggesting that NAFLD may be common and underdiagnosed.”
According to the 2017 Pediatric Gastroenterology Guidelines, children aged 9 years and older with overweight and risk factors such as central adiposity or prediabetes, and children with obesity, should be screened for NAFLD using ALT. Earlier screening is recommended for children with severe obesity or family history risk factors.
Goodman and colleagues created an algorithm to analyze 2017 data from the IQVIA Ambulatory Electronic Medical Record. Children aged 2 to 19 years with at least one recorded BMI were included in the study, with BMI calculated using same-day height and weight measurements. Researchers collected data on height and weight, ALT results, NAFLD diagnostic codes, medication orders and demographics. ALT results, NAFLD diagnostic codes and medication orders were collected for 1 year before and 1 year after the recorded BMI date in 2017.
Youths were categorized as having elevated ALT if the result was 22 IU/L or higher for girls and 26 IU/L or higher for boys. Researchers defined suspected NAFLD as any participant with a BMI in the 85th percentile or higher and an elevated ALT, or any participant with a NAFLD-related diagnosis.
Of 2.4 million children in the study population, 16% had overweight, 18% had obesity, and 6% had severe obesity. Only 3% of children had a recorded ALT result. Only 0.2% of children in the study population had a NAFLD-related diagnosis, including just 0.1% of children with overweight or obesity.
“Given that 34% of our study population had overweight or obesity, an indication for a screening ALT, and that some of the reported ALTs were likely for other reasons, such as acute gastrointestinal illness, this 3% suggests that guideline recommended screening might be infrequent,” Goodman said during the presentation.
For those with a test result, the prevalence of ALT increased as weight increased. Among children with heathy weight, 26% had an elevated ALT, while 33% of participants with overweight had an elevated ALT and 49% with obesity reported a high ALT result.
When broken down by age, 50% of children with obesity aged 9 years and older had an elevated ALT, compared with 41% of children with obesity aged 2 to 8 years. For those with severe obesity, children 9 years and older also had a higher prevalence compared with younger children (58% vs. 51%). Elevated ALT was more prevalent in boys than girls in the obesity category (55% vs. 44%) and the severe obesity group (64% vs. 50%). Children with Asian ethnicity and participants categorized as “other” for ethnicity had a higher prevalence for elevated ALT than Black, white and Hispanic children in the overweight, obesity and severe obesity weight categories.
There were 14,602 participants identified with suspected NAFLD, of which 10,911 had obesity and 5,745 severe obesity. In youths with obesity and suspected NAFLD, 89% were 9 years or older and 54% were boys.
Goodman said the findings reveal shortcomings in the current screening practices for NAFLD and further research is needed to better understand the barriers providers and families face with screening and identifying the disease.
“There is substantial room for improvement in clinical screening and diagnosis of NAFLD, which can lead to early identification of NAFLD and initiation of treatment with evidence-based weight management interventions,” Goodman told Healio.