Case Scenario

A 52-year-old woman was employed as a busy engineer and often traveled for work, frequently ate fast food, and reported having no time for exercise. She had a body mass index of 29 kg per m² and borderline hypertension that she attributed to white coat syndrome. A few years ago, her A1C was high (6.5%), and type 2 diabetes mellitus was diagnosed. Her physician recommended a healthier diet and regular exercise for diabetes management. The patient tried to adhere to the recommendations, but her weight and A1C did not decrease.

Last year, her A1C increased to 7.1%, and her aspartate and alanine transaminase levels increased to nearly 100 U per L (1.67 μkat per L). She agreed to start metformin, be more careful about what she ate, and stop drinking wine with dinner. Three months later, her A1C improved to 6.6%, but her weight and transaminase levels were stable. She had not consumed alcohol, although she admitted to not adhering to a diabetes-friendly diet. She did not have abdominal pain, nausea, or changes in bowel movements. Liver ultrasonography showed hepatic steatosis consistent with non-alcoholic fatty liver disease (NAFLD). Results of tests for other causes of liver dysfunction, including viral hepatitis, were normal. The patient was very concerned that she had liver disease. She insisted on being referred to a hepatologist and was so worried about the possibility of developing cirrhosis that she broke down in tears.