Time to consider a holistic approach to the treatment of non-alcoholic fatty liver disease in obese young people?

During the last decade, evidence has accumulated to show that nonalcoholic fatty liver disease (NAFLD) is a ‘multisystem’ disease often associated with obesity and other cardiometabolic disorders.1 NAFLD increases risk of liver-related complications and increases risk of developing type 2 diabetes (T2D),2 cardiovascular disease (CVD),3 chronic kidney disease4 and certain extrahepatic cancers.5 Thus, there is now important evidence to support a holistic approach to the treatment of NAFLD in adulthood and that approach extends to risk management of other diseases beyond the liver. With the burgeoning 21st century problem of obesity in childhood, it is now apparent that NAFLD is also a common disease in young people with overweight or obesity.6 Bearing in mind the evidence in adults that NAFLD increases risk of extrahepatic diseases, this also raises the possibility that NAFLD in childhood may not be harmless and that NAFLD may also have important implications for the health of young people as they grow older.7 Simon et al8 have previously reported important data from a nationwide cohort of Swedish adults with histologically confirmed NAFLD and without pre-existing CVD at baseline (n=10 422). In that retrospective cohort study, the authors showed that over a median of 13.6 years of follow-up, NAFLD was associated with a ~65% increased risk of major adverse cardiovascular events (MACEs) (even after adjustment for common cardiometabolic risk factors). Furthermore, risk of incident MACE increased monotonically with worsening of NAFLD severity. In Gut, Simon et al have extended that previous analysis. Using the same nationwide cohort that included all Swedish children and young adults ≤25 years old with histologically confirmed NAFLD, and without underlying CVD at baseline (n=699), the authors investigated multivariable-adjusted HRs and 95% CIs for incident MACE outcomes (ie, ischaemic heart disease, stroke, heart failure or cardiovascular mortality).9 In secondary analyses, the authors also explored rates of cardiac arrhythmias. In parallel to their study in adults, NAFLD was defined from prospectively recorded histopathology and further categorised as simple steatosis or steatohepatitis. Patients with NAFLD were matched to ≤5 population controls without NAFLD (n=3353)....