HUNTINGTON — Appalachia’s obesity crisis is well-documented, as are the poor health conditions it has triggered.
In West Virginia, where 35.2 percent of adults are obese, a battery of related diseases like heart disease, diabetes, hypertension and certain cancers have created one of the sickest populations in the country.
But lost behind the more commonly mentioned cardiovascular conditions is the deadly strain obesity places on a person’s liver. Widespread liver disease, sparked by obesity, has silently ballooned into its own epidemic over the past 25 years — potentially affecting tens of thousands in the Tri-State alone over the next decade.
As it stands, the region’s hospitals do not have the capacity to handle the rising tide of liver disease, explained Dr. Uma Sundaram, vice dean of research and graduate education at Marshall University’s Joan C. Edwards School of Medicine.
“The obesity epidemic in our state has more far-reaching consequences than just the obesity aspect of it,” Sundaram said from his office within the Edwards Comprehensive Cancer Center, in Huntington. “We’re just starting to see the tip of the iceberg in terms of what we have to do to take care of these patients.”
Obesity is a major contributing factor in developing non-alcoholic fatty liver disease (NAFLD), or the buildup of excess fat around the liver.
NAFLD is split into two different conditions: non-alcoholic fatty liver (NAFL), which typically does not damage the liver; and non-alcoholic steatohepatitis (NASH), which includes liver inflammation (hepatitis) and can lead to life-threatening disease like cirrhosis, liver failure and liver cancer.
About 10 percent of otherwise-benign NAFL cases typically progress to NASH, neither of which have any overt symptoms.
Nationally, between 28 percent and 30 percent of adults are at risk for developing NAFLD, but that rate pales in comparison to what Marshall has found among its own patients locally.
In a study of every patient through the doors of Marshall Health’s main campus, Cabell Huntington Hospital, and the Edwards Comprehensive Cancer Center, between 56 percent and 60 percent are at risk for NAFLD, Sundaram said. That’s more than twice the national average.
That represents more than 130,000 individuals in the Tri-State area alone with the potential to develop NAFLD, and almost none of them are aware of it.
“Now just imagine if 10 percent of them progress on to NASH in the next five to 10 years, which is the approximate time period,” Sundaram added. “That’s 13,000 patients, potentially, just from Cabell Huntington.”
Staggering costs, tangled red tapeThe sheer volume of potential NASH cases — now the top cause for a liver transplant in the nation, surpassing hepatitis C — creates a more dire situation considering the crushing financial burden of treating liver disease. It all still remains a developing science, but the cutting edge is far from West Virginia.
A typical liver transplant is generally the single most expensive operation in the United States, costing on average between $600,000 and $1 million for the liver to be replaced and just six months of aftercare. That’s to say nothing of the “crazy expensive” immunosuppressive medication a patient must then take for the rest of their lives, Sundaram added.
“So you’re talking 13,000 patients, just here [in the Tri-State], times a million dollars,” he said of the potential local price tag.
Aside from the liver itself and the operating room time, the cost stems in part from the massive quantities of blood that need to be administered to the patient, he explained. The liver is the most vascular organ in the body, meaning blood literally pours out during an operation.
A living donor procedure — where a piece of liver is taken from a live person and transplanted to another — is possible, but it’s almost as expensive and dangerous for the donor as it is for the recipient.
Even if a patient had the means to afford one, no centers in West Virginia currently perform liver transplants — nor are there active plans to start — due to the sheer cost of starting one up, Sundaram explained.
This means patients in West Virginia must be transferred to regional, out-of-state facilities in Columbus, Ohio, Pittsburgh or Baltimore — most of which do not accept the West Virginia Medicaid that the majority of at-risk patients would need to afford the procedure.
While West Virginia accepts out-of-state Medicaid “without blinking an eye,” Sundaram added, working out a reciprocal agreement with those states for West Virginia’s patients has been a bureaucratic mess.
“Try getting West Virginia’s Medicaid through Kentucky, Pennsylvania, Maryland, Ohio,” he shook his head. “Good luck.”
West Virginia is dead last in access to state-of-the-art treatment for obesity and its complications, he added. The patients who most need those resources are here, but the state’s institutions often get overlooked for public and private help. The local population itself, he continued, is too often content in simply taking whatever services it can get, rather than demanding the best medical care.
“We just don’t get the latest and greatest coming to our population, which is sad because our patients probably need it more than people in Vermont, Maryland, Utah or wherever,” Sundaram said.
NASH trial and future prevention
A new clinical trial in Huntington to help contain and reverse NASH may attract some needed national attention to offer up-and-coming care. Marshall’s experts have begun building their own capacity to treat what they expect to become a massive situation locally over the next decade.
In May 2018, the university started enrolling patients in a clinical trial testing a new medication created to stop and reverse the effects of NASH. Prior to last year, no drug existed to treat NASH specifically — leaving doctors to simply wait and see if it would progress to cirrhosis, then treat it.
Marshall is one of about 300 sites around the globe chosen by pharmaceutical maker Allergan to pilot the drug — and the only one in West Virginia or Kentucky. Each site is expected to test 20 to 30 patients over the eight-year study.
The drug itself is a once-daily oral pill that is aimed at decreasing the amount of scar tissue on the patient’s liver, explained Nicole Finley, the NASH trial’s lead coordinator at Marshall. So far, they’ve seen promising signs of regression up to Stage III NASH — right before the disease becomes irreversible.
“It’s an important thing to remember that it is unfortunately a silent disease, so you probably don’t know you’re sick until you’re too far along sometimes,” Finley said.
The trial is free to patients, but it carries some amount of risk, requiring a liver biopsy. The major catch is that one-third of participants receive a placebo. Still, researchers have seen positive outcomes even for the placebo patients, Finley added, likely because they’re simply more attentive to their own well-being.
“A lot of that is patient education along with the study,” she added.
Sundaram added he hopes the trial will be a larger statement that West Virginia’s institutions like Marshall or West Virginia University can be at the cutting edge with anyone in the nation.
But for now, delivering a promising new drug to a community that desperately needs it is just as valuable, if not more so.
“I don’t consider this research as much as I consider this providing advanced care to our patients,” Sundaram said of the NASH trial.
Fortunately, the liver is a forgiving organ. Even with only 10 percent functioning, a person can live a completely normal life, he continued, and there’s plenty of margin for an individual to reverse the outcome.
Research suggests a modified diet rich in antioxidants and daily exercise can help prevent NAFLD — the same as obesity — though an individual does not need to be obese to develop the disease. Obesity is, however, the definitive top cause for NAFLD in the Tri-State, Sundaram said.
Changing it on a larger scale clearly requires more awareness of the issue, he continued. West Virginia tops the nation for childhood obesity, meaning prevention must start long before adulthood.
“It’s certainly a fixable picture,” Sundaram said. “It’s a long way to get to NASH, and there are certainly chances to change course at every step.”
Obesity, culture and a slow death
The Huntington area has made notable progress in decreasing its obesity rate in the decade since being declared “America’s fattest and unhealthiest city” in a 2008 report by The Associated Press.
About a third (32.6 percent) of adults in the Huntington-Ashland metro area are obese — down 13 percent from the 2006 data used when the city was named the country’s fattest city, according to the Centers for Disease Control and Prevention’s latest figures published in 2018. Huntington is now below the West Virginia state average for obese adults (35.2 percent), but still above the national average (29.5 percent).
But the potential for widespread obesity is, in many ways, written in the cultural fabric of Appalachia, Sundaram continued.
Traditionally, the region’s economy was driven by manually taxing careers like coal mining, metalworking and farming. The men and women who lived those lives decades earlier required mountains of caloric energy in the diet, and the traditional Appalachian taste for all foods buttered, salted and fried served that purpose for most of the 20th century, Sundaram said.
But when the economy phased out those physical jobs for lower-energy ones, the eating habits stayed the same, he continued, largely explaining the Tri-State’s sharp increase in adult obesity from the 1990s forward.
It’s particularly hard on low-income earners, who don’t have access or the means for the most nutritious foods, or the luxury to exercise regularly.
“I just think those are part of our culture, and those things are hard to change,” Sundaram said.
When widespread obesity ultimately sets off a wave of new NASH cases, it will not only impact the region’s life expectancy, but drive down the quality of life, he continued.
Cirrhosis and eventual liver failure kill very slowly, and that impact on the surrounding family can be dramatic.
“Imagine being a teenager and watching their grandfather throw up bright red blood — and not just a little bit, and then trying to get them from McDowell County up to Cabell Huntington,” Sundaram said.
Even with treatment, cirrhosis typically kills an individual within five years.