Nonalcoholic fatty liver disease now common in children; experts at UK and elsewhere say causes include diet and lack of exercise

Dr. Samir Softic (Washington Post photo by Drea Cornejo)

Kentucky Health News

For uncertain reasons, nonalcoholic fatty liver disease has become more common in American children, especially in Kentucky, and “It’s the worst disease you’ve never heard of,” said Samir Softic, a pediatric gastroenterologist at the University of Kentucky Children’s Hospital, who specializes in the disease.

Softic is a main focus of a long story in The Washington Post about the disease, which is estimated to affect 5 to 10 percent of U.S. children, "making it about as common as asthma, Post reporter Ariana Eunjung Cha writes. A video with the story says Kentucky's rate "is believed to be among the highest."

Cha reports, "The crisis is especially acute in swatches of the Southeast, where rates of pediatric obesity are highest," including Appalachian Kentucky. "But obesity is only part of the puzzle. Scientists have been surprised to find that not all kids with obesity have fatty liver, and not all kids who have fatty liver disease struggle with weight."

Softic runs UK's pediatric fatty liver clinic, which this spring was "often fully booked two to six months in advance," Cha reports. The disease often has few symptoms until it becomes serious, at which point it can cause weakness, severe tiredness, weight loss, yellowing of the skin or eyes, spiderlike blood vessels on the skin and long-lasting itching," says Johns Hopkins Medicine.

"For Softic, the fatty liver crisis is as much about policy as science. He has collected a stack of letters from insurers refusing to cover some patients’ treatment with a new generation of weight-loss drugs known as semaglutides, sold under brand names including Ozempic and Wegovy. The companies say the medications are not yet proven to help with fatty liver.

"While Softic believes that fundamental changes in how we eat and exercise are needed in the long term, he said lives could be saved in the short term if these drugs were widely and cheaply available. He’s lobbying state and federal regulators to help pay for the treatments — which can cost upwards of $1,300 a month — for patients younger than 18, who arguably have the most to gain because they have more of their lives ahead of them.

Washington Post graphic frrom Trilliant Health analysis of claims

"Liver transplants in children diagnosed with fatty liver disease remain rare, but Softic recently referred a 6-year-old for a transplant evaluation. There has been a clear rise in transplants for fatty liver in people in their 20s and 30s, meaning if he can’t help his pediatric patients now, they may soon face a transplant."

Softic told Cha the disease “goes unnoticed and unrecognized, and over time it catches up. For a good number of these young transplant patients, the disease process started in childhood,” he said. “On so many levels, we are not prepared to deal with this disease in children.”

A seven-minute video with the story includes the case of Sydney Woods, a Kentucky 15-year-old with fatty liver disease who improved her liver function by "cutting out soda and making other changes to her diet . . . but it's not as easy for most families to buy less procesed food." That's especially true in rural areas, said her mother, Angela Woods, a physician's assistant.

Softic says in the video, "Eating healthy requires time, it requires money, and not everyone has those resources."

Cha reports, "Many doctors believe that our modern lifestyle — diet, the increase in sedentary activities related to technology and environmental exposures — is to blame. One of the liver’s jobs is to filter toxins, and when something in the body is out of balance, the organ can become damaged and fail. Some pediatric experts theorize there’s a mismatch between our genetics and the highly processed and sugary foods that have come to dominate childhood diets," including some types of infant formula. The video says 67% of children's diets consist of ultra-processed foods.

"It's a major problem, and it's been exacerbated by diet and inactivity," Simon Fisher, director of UK's Barnstable Brown Diabetes Center, says in the video.

Cha reports, "The escalation of pediatric fatty liver cases has unfolded in tandem with the presence among the young of other conditions once viewed as almost exclusively adult diseases: high blood pressure, high cholesterol, diabetes, even gallstones."

New nutrition labels use larger portion sizes and list added sugar, which can cause many health issues; here are ways to limit it

Nutrition fact labels are the primary source of information about what's in the food we eat, and they recently got their first update in 20 years.

The Food and Drug Administration says it based the changes on "updated scientific information, new nutrition and public health research, more recent dietary recommendations from expert groups, and input from the public."

Manufacturers with $10 million or more in annual sales were required to switch to the new label by Jan. 1, those with less annual food sales have another year to comply.

One of the biggest changes on the labels is that they now show a serving size based on the amount most people eat and drink, instead of a suggested serving size.

This change was made to reflect the larger portions people eat and drink now, compared to those in 1993 when the previous size requirements were published. For example, the new serving size for ice cream is 2/3 cup, compared to 1/2 cup on the old label.

And for products that could be consumed in one sitting, like a 24-ounce bottle of soda or a pint of ice cream, manufacturers must now provide a "dual column" label to show calories and nutrients for both "per serving" and"per package" amounts.

The labels also show the calories and serving size in larger and bolder type. This change was made to address the growing obesity problem in the United States, which is associated with heart disease, stroke, certain cancers and diabetes.

The new labels will no longer include calories from fat, but will instead show the types of fat a product contains. This change was made to reflect research that shows the type of fat you consume is more important than the amount.

The labels now include potassium and Vitamin D, along with calcium and iron. Vitamins A and C have become optional for listing, since most Americans get enough of those nutrients in their diets. They also reflect updated requirements for the amount of nutrients we need, shown in both the actual amount and the percent daily value. An updated footnote explains the meaning of percent daily value.

The FDA added Vitamin D and potassium because research shows these are nutrients that Americans don't always get enough of, and when lacking, are associated with increased risk of chronic disease.

Added sugars have also been added to the label. The most recent dietary guidelines recommends you consume less than 10% of your daily calories from added sugars.

The American Heart Association recommends no more than six teaspoons of added sugar per day for women and nine teaspoons for men. The recommended rate for children varies between three and six teaspoons per day, depending on age and caloric need. One teaspoon of sugar equals four grams on the label.

Health risk of added sugar

Most people have no idea how much added sugar they consume, because it's in nearly 70% of packaged foods and is found in breads, health foods, snacks, yogurts, most breakfast foods and sauces. Tara Parker-Pope reports for The New York Times. She says the average American eats about 17 teaspoons of added sugar a day -- not counting the sugars that occur naturally in foods like fruit or dairy products.

A physician who was one of the first to raise the alarm about the health risks of added sugar told Parker-Pope that it's not just about the added calories, but also about the many health risks that come with eating too much added sugar.

“It’s not about being obese, it has to do with metabolic health,” Dr. Robert Lustig, professor of pediatric endocrinology at the University of California, San Francisco, told Parker-Pope. “Sugar turns on the aging programs in your body. The more sugar you eat, the faster you age.”

A number of health authorities, including the World Health Organization and the Office of Disease Prevention and Health Promotion, which issues national dietary guidelines for Americans, agree that cutting back on added sugars is a good idea, Parker-Pope reports, adding that these views have come under attack by groups with ties to the food industry.

Parker-Pope writes that while many scientists believe added sugar is the leading culprit in the obesity epidemic, they also say that even people of normal weight can suffer the same health problems associated with eating too much sugar, including heart disease, Type 2 diabetes, cancer, stroke and even Alzheimer's disease.

Too much added sugar can also damage your liver, similarly to the way that alcohol does, leading to a condition that is called "sugar belly," in which your waist is bigger than your hips.

Parker-Pope points to the difference between the sugar, or fructose, found naturally in foods, which are good to eat, and those that have been added to foods.

She writes that our bodies can handle fructose when it's eaten as a whole fruit because it comes with a number of micronutrients plus fiber, which slows the rate at which the sugar enters your bloodstream. But when we eat the fructose found in ultra-processed foods and beverages, it doesn't have the fiber to slow it down and "your body gets a big dose of fructose that can wreak havoc," she writes.

Further, she reports that high consumption of processed fructose can result in a dulled response to a hormone called leptin, which is a natural appetitie suppressant, leading to weight gain and that it can create changes in the brain similar to those found in people who are addicted to cocaine and alcohol.

Gary Taubes, author of The Case Against Sugar and an advocate of low-carbohydrate eating, doesn't agree with the food industry's recommendation that added sugars be consumed in moderation.

“If I start to allow sugars into my life, there is a slippery slope,” Taubes told Parker-Pope “I think for many people, getting control of their sugar habit is the most important thing they can do for their health. If they can’t do it through abstinence, then mostly-abstinence is a good thing to achieve.”

The New York Times has offered a 7-Day Sugar Challenge to help people reduce the added sugar in their diet. For example, the first day in the challenge offers tips on how to cut out sugar from your breakfast. Parker-Pope stresses that it's not easy, and the cravings for sweets will be worse in the first five days -- but the payoff is worth it.

Lustig recommends three weeks of no added sugar to get your brain’s dopamine system back to normal. “Then you can introduce something back in,” he told Parker-Pope. “But it’s got to be under your control, not the food industry’s control.”

Americans eat way too much salt, mostly from 25 commonly consumed foods; cutting back reduces risk of high blood pressure

Americans eat too much salt, and a new study found that most of it comes from 25 commonly consumed foods. The top five culprits are bread, pizza, sandwiches, cold cuts and other cured meats, and soup. Salty snacks came in seventh, behind burritos and tacos, says the study.

Salt helps the body maintain its fluid balance, but too much of it increases the risk for high blood pressure, which then increases the risk for heart attack and stroke. Thirty-nine percent of Kentucky adults have high blood pressure and the state ranks 47th for heart disease, according to America's Health Rankings.

Hypertension in Kentucky adults, 2013-2015 (Map and chart from www.KentuckyHealthFacts.org)

The study found that in 2013-14, Americans ate about 3,400 mg of salt daily, far exceeding the Healthy People 2020 goal of 2.300 mg and the "ideal limit" of 1,500 mg recommended by the American Heart Association.

"If everyone reduced the amount of sodium in their diet by 1,200 mg per day, up to 99,000 heart attacks and 66,000 strokes could be prevented in the United States every year," according to the CDC.

Data for the Centers for Disease Control and Prevention study comes from the 2013-14 National Health and Nutrition Examination Survey. It only measured salt consumed in foods and did not take into account any salt added at the table. One teaspoon of table salt has 2,300 mg of sodium.

The study found that most dietary salt (61 percent) comes from packaged, processed and restaurant foods, the report said.

While most foods have a moderate amount of salt, the problem is that they are eaten all day long, Zerleen Quader, lead researcher, told Steven Reinberg of HealthDay.

"When cooking at home, use fresh herbs and other substitutes for salt. When eating out, you can ask for meals with lower salt," she said, adding that it's important to read food labels, and to choose the lowest salt option available. She also said the food industry needs to lower the amount of salt it adds to its products.

The study found that 44 percent of the salt people eat comes from just 10 foods and 70 percent of salt in the diet comes from 25 foods. Some other foods in the top 25 include bacon, casserole type dishes, salad dressing, French fries and cereal

Samantha Heller, a senior clinical nutritionist at New York University Medical Center in New York City, said that processed foods not only raise blood pressure, but may also increase the risk for cancer, noting that the World Health Organization classifies processed meats, like bologna, ham, bacon, sausages and hot dogs, as carcinogens.

"Parents need to understand that feeding hot dogs, fries, and ham and cheese sandwiches to their kids (and themselves) is significantly increasing their risk for certain cancers, hypertension and heart disease," Heller told Reinberg.

The CDC offers tips for reducing salt intake:

• Choose a heart-healthy diet like the "Dietary Approaches to Stop Hypertension," diet (DASH). Click here for more details.
• Buy fresh, frozen or no salt canned vegetables
• Use fresh meats, rather than canned or processed meats
• Read labels, choose product with lowest sodium content
• If you eat two servings, then account for two servings of salt
• Limit sauces, mixes and "instant" product"
• Choose spices and seasonings that do not list sodium on their label

When eating out:

• Choose restaurants that offer low-sodium options
• Ask server if sodium information is available
• Request that no salt be added to your food
• Ask for salad dressings and sauces on the side

Study indicates fast food contains industrial chemicals linked to health problems such as infertility, diabetes and allergies

People who eat a lot of fast food have higher levels of chemicals that "have been linked to a number of adverse health outcomes, including higher rates of infertility," especially among men, Roberto Ferdman reports for The Washington Post.

Researchers at George Washington University in Washington, D.C., say the connection could have "great public health significance," Ferdman writes. "Specifically, the team found that people who eat fast food tend to have significantly higher levels of certain phthalates, which are commonly used in consumer products such as soap and makeup to make them less brittle. . . . The danger, the researchers believe, isn't necessarily a result of the food itself, but rather the process by which the food is prepared."

Here's how the study was done: Researchers analyzed diet and urinalysis data for nearly 9,000 people, collected as part of federal nutrition surveys in 2003-2010. "Food eaten at or from restaurants without waiters or waitresses was considered fast food. Everything else — food eaten at sit-down restaurants and bars or purchased from vending machines — was not," Ferdman writes. "The first thing the researchers found was that roughly one-third of the participants said they had eaten some form of fast food over the course of the day leading up to the urine sample collection," which fits with government estimates.

People who said they had eaten fast food in the previous 24 hours "tended to have much higher levels of two separate phthalates," Ferdman reports. Those who said they ate only a little fast food had levels 15 and 25 percent higher than those who said they had eaten none. "For people who reported eating a sizable amount, the increase was 24 percent and 39 percent, respectively. And the connection held true even after the researchers adjusted for various factors about the participants' habits and backgrounds that might have contributed to the association between fast-food consumption and phthalate levels."

The study was reported in Environmental Health Perspectives, a peer-reviewed journal funded by the National Institutes of Health.

"There is little consensus on the harms of phthalates, which are widely used in commerce and give materials such as food packaging added flexibility, except that exposure to them is widespread," Ferdman writes, citing the federal Centers for Disease Control and Prevention. "But there is growing concern that the chemicals could pose a variety of risks, particularly when observed in the sort of levels seen in the study."

Noting several other studies, such as those linking the chemicals to diabetes and allergies, Ferdman reports, "Many governments have moved to limit exposure to the industrial chemicals. Japan disallowed the use of vinyl gloves in food preparation for fear that their use was compromising health. The European Union, which limits the use of the chemical, has been nudging manufacturers to replace it. And the United States restricted its use in toys."

So, why do people who eat fast food seem to have much higher levels of these chemicals? That is unclear, Ferdman writes, "but it's easy enough to guess: the sheer amount of processing that goes into food served at quick-service restaurants. The more machinery, plastic, conveyor belts, and various forms of processing equipment that food touches, the more likely the food is to contain higher levels of phthalates. And fast food tends to touch a good deal more of these things than, say, the food one purchases at a local farmers' market."

Ferdman concludes, "It certainly seems as though eating fast food is more toxic than avoiding it, and not for the obvious reasons." He quotes Marion Nestle, the Paulette Goddard professor of nutrition and food studies at New York University: "Traditional fast food was never meant to be daily fare, and it shouldn’t be," said  "It’s too high in calories and salt and, as we now know, the chemicals that get into our food supply through industrial food production."

Kentucky's local food movement is booming, but some say home-processing laws places undue burden on qualified entrepreneurs

The local food movement is alive and well in Kentucky, which leads the nation in federally funded local food projects, Janet Patton reports for the Lexington Herald-Leader.

In 2014, "Local food sales topped $11.7 billion, according to the United States Department of Agriculture, which has invested more than $800 million into local food businesses and infrastructure in the last six years," Patton reports. "Kentucky leads the nation in participation in federally funded local food projects, with 1,659 projects including high tunnels that extend the growing season, microloans for smaller farmers, and direct funding for food hubs, farmers' markets and other local food enterprises."

Kentucky's bipartisan nonprofit initative, Shaping Our Appalachian Region, has as one of its initiatives is "to identify local and regional food systems as opportunities to create new jobs and new entrepreneurships" in Kentucky's Appalachian counties, Agriculture Secretary Tom Vilsack noted.

Two communities in Kentucky, Barbourville and Hazard, were chosen to participate last year in the federal "Local Food, Local Places" initiative, which "helps communities develop action plans that use local foods to support healthy families and communities to drive downtown and neighborhood revitalization," says the website.

A second round of funding for this initiative is now available. The application deadline is Sept. 15. Click here for more information.

Kentucky has "73 farmers markets and direct-to-consumer outlets accept SNAP or food stamps now," Patton reports, with "nearly $80,000 in SNAP benefits redeemed at Kentucky's farmers markets last year, according to the USDA."

www.extension.org

But despite this boom in the local food movement, "Kentucky joins Delaware and Rhode Island as the three most restrictive states in the country for cottage food sales," Rachel Hurd Anger reports for LEO Weekly, a Louisville publication.

Cottage foods are produced in a person's home and are considered safe to be prepared in the average kitchen, like jams and jellies, candy, fruit butter, doughnuts, cakes and breads.

Until 2003, it was not legal for Kentuckians to sell home-processed foods, but this changed with the passage of House Bill 391, which allows farmers to grow, harvest and process food products and sell them from their homes and at approved farmers markets and farm stands. The law also requires home-based processors to register for one of two separate processing categories and follow specific kitchen guidelines.

The problem with this law, according to Anger, is that it "restricts the sale of low-risk cottage foods made in common kitchens, unless the homeowner grows the main ingredient themselves," which is "intentionally restricting skilled people from launching businesses."

As the law is written, Kentuckians who do not grow the primary ingredient in the product they wish to sell must get a Commercial Food Manufacturing permit and prepare their product in a "permitted kitchen that meets commercial food manufacturing requirements," according to the University of Kentucky Family and Consumer Sciences Extension website.

Anger also notes that this law does not apply to those who belong to Kentucky Proud, a free state marketing program for agricultural products that farmers must apply for, who "are allowed to produce and sell cottage foods from ingredients grown on their farms or elsewhere."

"Skilled Kentuckians deserve an inclusive cottage food law that allows for legal participation in the marketplace alongside our farmer friends," Anger writes. "Whether our cottage foods come from local harvests or just local hands, many gardeners, bakers, canners and other hobbyists have skills and generations of knowledge they crave to share with the community for a humble profit."

Kids are still eating too much sugar, regardless of parents' income, and they're getting most of it at home

By Tara Kaprowy
Kentucky Health News

American children's sugar consumption is down, but kids are still eating too much sugar, and they are getting most of it at home.

So says a new study from the National Center for Health Statistics, which also found parent income is not playing a part in how much sugar kids are consuming. "We found that all kids are eating a lot of added sugars," said Cynthia Ogden, the study's co-author and an epidemiologist with the Centers for Disease Control and Prevention. (One study found kids in low-income families are drinking more juice than recommended, however.)

The study found sugar consumption has dropped to 17 percent of total caloric intake, from 22 percent, but 17 percent is still well higher than federal guidelines, which say total discretionary calories, including added sugar and solid fat, should account for only 5 to 15 percent of total daily caloric intake.

Sugar consumption may have declined because kids are consuming less sugar when they're not at home, thanks to bans or limits on sugary drinks at schools, said Dr. Wendy Slusser, an associate clinical professor of medicine at the Mattel Children's Hospital at the University of California. Kentucky has such a ban.

Most of the sugar is coming from food, not beverages, Linda Carroll reports for MSNBC. About 16 percent of kids' calorie intake comes from "added sugars," such those added to breads, cakes, jams, chocolate and ice cream. Those numbers do not include sugars that naturally occur in food, such as in fruit or fruit juice.

Going forward, the goal is to address how parents are feeding their children. "This is an opportunity for families," Slusser said. "There are estimates now that we could shift children's weights back to 1970s levels if we could just take 350 calories out of a kid's diet each day."

One way to do so is using water to replace sports drinks and those with 10 percent fruit juice. Giving kids Cheerios rather than Honey Nut Cheerios — or any cereal that's lower in sugar — also helps. Reading nutrition labels, avoiding processed foods and planning ahead for healthy snacks and nutritious dinners can also solve the problem. "Once there's a routine, parents can integrate healthier foods into their children's diets," Slusser said. "When you're always eating on the fly, you end up eating too many processed foods." (Read more)

Kentucky Health News is a service of the Institute for Rural Journalism and Community Issues, based in the School of Journalism and Telecommunications at the University of Kentucky, with support from the Foundation for a Healthy Kentucky.