Common risk factors and prevention strategies

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Although metabolic dysfunction-associated fatty liver disease (MASLD) and type 2 diabetes have different symptoms, they share some common underlying causes, and many people are living with both diseases without even realizing it.

Research shows that more than 70% of people with type 2 diabetes have MASLD, previously known as nonalcoholic fatty liver disease.

Another study found that having type 2 diabetes more than doubles the risk of extensive fibrosis, or scarring, of the liver, a common complication of MASLD.

“Having type 2 diabetes doubles your risk of MASLD, and having MASLD doubles your risk of diabetes,” Scott Isaacs, MDHe is an endocrinologist and adjunct professor at Emory University School of Medicine.

Shared risk factors for MASLD and type 2 diabetes

MASLD occurs when fat builds up in the liver, causing inflammation and tissue damage. Over time, this can lead to scarring called fibrosis and severe liver disease called cirrhosis, which may require a transplant or lead to liver cancer. MASLD is not caused by excessive alcohol consumption and typically occurs in people who are overweight or obese and have metabolic disorders.

Type 2 diabetes, the most common type of diabetes, is also linked to obesity. The disease develops when the body can't use or produce enough of the hormone insulin to convert sugar into energy, causing blood sugar levels to rise over time. If untreated, type 2 diabetes can lead to complications such as blindness, kidney failure and amputations.

“MASLD and type 2 diabetes share many common risk factors,” Anastasia Stefania Alexopoulos, MBBS, MHS“It's always been common for these conditions to occur together, we're just better able to recognize the overlap than we used to,” says Dr. Bryan, an endocrinologist and assistant professor of medicine at Duke University.

Common risk factors for both conditions include obesity, high cholesterol, and insulin resistance, also known as impaired insulin sensitivity, which occurs when your body can't properly use insulin, the hormone that helps turn sugar in food into energy, says Alexopoulos.

According to a study published in 2023, insulin resistance is associated with an increased risk of developing MASLD, even in the absence of type 2 diabetes or obesity.

“Although there is still a lot we don't know about MASLD and diabetes, we do know that insulin resistance is an important part of both diseases,” Alexopoulos says.

While scientists are still trying to fully understand the relationship between type 2 diabetes and MASLD, new research suggests that the two diseases also share genetic risk factors, according to a 2024 study.

How type 2 diabetes causes MASLD and vice versa

“Each condition can lead to the other, and it is not yet clear whether more people with MASLD develop type 2 diabetes than those without, or vice versa.” Rohit Lumumba, MD, MHScChief of the Division of Gastroenterology and Hepatology at the University of California, San Diego.

Although much is still unknown about why the two diseases are related, it is clear that each disease increases the risk of the other, according to the Centers for Disease Control and Prevention (CDC).

According to the CDC, when people with type 2 diabetes don't control their blood sugar levels properly, it can damage organs throughout the body, including the liver.

At the same time, the accumulation of fat in the liver that occurs in MASLD patients can lead to elevated blood sugar levels.

Drug Treatment Options for Type 2 Diabetes and MASLD

Taking medications to manage these conditions can also help reduce fat buildup in the liver and blood sugar levels, reducing insulin resistance and preventing people with one condition from developing others, says Dr Isaacs.

According to the American Diabetes Association, there are several different types of medications, including tablets and injections, that are commonly used to manage blood sugar levels in people with type 2 diabetes.

These include:

Metformin (Glucophage): Metformin is a drug that lowers blood sugar levels by reducing the amount of glucose produced by the liver and by increasing the ability of muscles to use the hormone insulin to convert sugar into energy.
DPP-4 inhibitors (alogliptin, linagliptin, saxagliptin, sitagliptin): This group of medications lowers blood sugar levels by supporting the activity of two hormones in the body that are responsible for managing blood sugar levels (GLP-1 and GIP).
GLP-1 medications (semaglutide, exenatide, tirzepatide): These injectable medications help your body use the GLP-1 hormone more effectively to lower blood sugar. Tirzepatide helps your body use both the GLP-1 and GIP hormones.
SGLT2 inhibitors (bexagliflozin, canagliflozin, dapagliflozin, empagliflozin): These medications help lower blood sugar levels by increasing the amount of glucose excreted in the urine.
Sulfonylureas (glimepiride, glipizide): These drugs work by stimulating the pancreas to make more insulin, a hormone that helps manage blood sugar levels.
TZDs (rosiglitazone, pioglitazone): These drugs lower blood sugar levels by enabling muscle and fat tissue to use insulin more effectively and by reducing the amount of glucose produced in the liver.

Some of these drugs have also been shown to reduce fat in the liver, and it seems likely that this may also improve over time, although we are awaiting confirmation of their effect on liver fibrosis.

Lifestyle Changes for Type 2 Diabetes and MASLD

“Many of the same approaches to improving type 2 diabetes also improve MASLD, and the treatment approaches for these conditions are very similar,” Alexopoulos says. “Maintaining a healthy diet and lifestyle is important for improving both conditions.”

“For people who are obese or overweight, slow and consistent weight loss of one to two pounds per week can improve symptoms of both diseases and slow or halt the progression of MASLD and type 2 diabetes,” Alexopoulos adds.

In addition to recommended levels of exercise, there are also some specific dietary approaches that can be beneficial for both conditions, Alexopoulos says, including emphasizing whole foods, fresh foods, and plant-based proteins, and limiting intake of soda and sugary drinks, as well as ultra-processed foods like bacon, packaged snacks and treats, and deli meats.

“We advocate a universal approach and treatment that looks at the whole person, focusing on insulin resistance through lifestyle and pharmacotherapy,” Isaacs says.

Prevention strategies for MASLD and type 2 diabetes

The same approaches to managing these symptoms can also help prevent them from developing in the first place, Isaacs says, especially when it comes to maintaining a healthy weight. Avoiding weight gain, or working to lose excess weight if you're obese or overweight, can both help.

“A 5 percent weight loss reduces diabetes risk and liver fat,” Isaacs says, “but a weight loss of 10 percent or more is recommended for reduced liver fibrosis, additional effects on insulin resistance, diabetes prevention, and other effects on components of metabolic syndrome.”

Eating a low-carb, plant-based or Mediterranean diet may help prevent the development of MASLD and type 2 diabetes, even if you already have one and want to avoid the other, says Lumumba.

“The Mediterranean diet encourages consumption of plant-based foods like vegetables, whole grains, legumes, beans, nuts and olive oil, and lean protein sources like fish and poultry,” Lumumba says. “It limits sweets, processed foods and red meat. We advise patients to eliminate sugar and high fructose corn syrup from their diet, and beverages, especially soda, which are really harmful.”

Alexopoulos says exercise is also essential, even if it doesn't lead to significant weight loss.

“Exercise is key to preventing insulin resistance,” says Alexopoulos, “and it also improves heart health and longevity, which is crucial given that heart disease is the leading cause of death in people with diabetes and MASLD.”

summary

Type 2 diabetes and MASLD share many common underlying causes, which means many of the same approaches to managing one disease, such as eating right, exercising regularly, and maintaining a healthy weight, can also help with the other.

Shared risk factors for MASLD and type 2 diabetes

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