From Health Care

Liver Illness Strikes Latino Children Like A ‘Silent Tsunami’

Saira Diaz uses her fingers to count the establishments selling fast food and sweets near the South Los Angeles home she shares with her parents and 13-year-old son. “There’s one, two, three, four, five fast-food restaurants,” she says. “And a little mom and pop store that sells snacks and sodas and candy.”

In that low-income, predominantly Latino neighborhood, it’s pretty hard for a kid to avoid sugar. Last year, doctors at St. John’s Well Child and Family Center, a nonprofit community clinic seven blocks away, became alarmed by the rising weight of Diaz’s son, Adrian Mejia. They persuaded him to join an intervention study run by the University of Southern California and Children’s Hospital Los Angeles (CHLA) that weans participants off sugar in an effort to reduce the rate of obesity and diabetes among children.

It also targets a third condition fewer people have heard of: fatty liver disease.

Linked both to genetics and diets high in sugar and fat, “fatty liver disease is ripping through the Latino community like a silent tsunami and especially affecting children,” said Dr. Rohit Kohli, chief of gastroenterology, hepatology and nutrition at CHLA.

Recent research shows about 1 in 4 people in the U.S. have fatty liver disease. But among Latinos, especially of Mexican and Central American descent, the rate is significantly higher. One large study in Dallas found that 45% of Latinos had fatty livers.

The illness, diagnosed when more than 5% of the liver’s weight is fat, does not cause serious problems in most people. But it can progress to a more severe condition called nonalcoholic steatohepatitis, or NASH, which is linked to cirrhosis, liver cancer and liver failure. This progressive form of fatty liver disease is the fastest-growing cause of liver transplants in young adults.

The USC-CHLA study is led by Michael Goran, director of the Diabetes and Obesity Program at CHLA, who last year made an alarming discovery: Sugar from sweetened beverages can be passed in breast milk from mothers to their babies, potentially predisposing infants to obesity and fatty livers.

Called HEROES, for Healthy Eating Through Reduction of Excess Sugar, his program is designed to help children like Adrian, who used to drink four or more sugary drinks a day, shed unhealthy habits that can lead to fatty liver and other diseases.

Fatty liver disease is gaining more attention in the medical community as lawmakers ratchet up pressure to discourage the consumption of sugar-laden drinks. Legislators in Sacramento are mulling proposals to impose a statewide soda tax, put warning labels on sugary drinks and bar beverage companies from offering discount coupons on sweetened drinks.

“I support sugar taxes and warning labels as a way to discourage consumption, but I don’t think that alone will do the trick,” Goran said. “We also need public health strategies that limit marketing of sugary beverages, snacks and cereals to infants and children.”

William Dermody, a spokesman for the American Beverage Association said: “We understand that we have a role to play in helping Americans manage consumption of added sugars, which is why we are creating more drinks with less or no sugar.”

Michael Goran is the director of the Diabetes and Obesity Program at Children’s Hospital Los Angeles and the principal investigator for the HEROES study. “I support sugar taxes and warning labels as a way to discourage consumption,” Goran says, “but I don’t think that alone will do the trick.” (Rob Waters for KHN)

In 2016, 45 deaths in Los Angeles County were attributed to fatty liver disease. But that’s a “gross underestimate,” because by the time people with the illness die, they often have cirrhosis, and that’s what appears on the death certificate, said Dr. Paul Simon, chief science officer at the L.A. County Department of Public Health.

Still, Simon said, it was striking that 53% of the 2016 deaths attributed to fatty liver disease were among Latinos — nearly double their proportion of total deaths in the county.

Medical researchers consider fatty liver disease a manifestation of something called metabolic syndrome — a cluster of conditions that include excess belly fat and elevated blood pressure, blood sugar and cholesterol that can increase the risk of heart disease, stroke and diabetes.

Until 2006, few doctors knew that children could get fatty liver disease. That year Dr. Jeffrey Schwimmer, a professor of pediatrics at the University of California-San Diego, reviewed the autopsies of 742 children and teenagers, ages 2 to 19, who had died in car crashes or from other causes, and he found that 13% of them had fatty liver disease. Among obese kids, 38% had fatty livers.

After Schwimmer’s study was released, Goran began using MRIs to diagnose fatty liver in living children.

A 2008 study by another group of researchers nudged Goran further. It showed that a variant of a gene called PNPLA3 significantly increased the risk of the disease. About half of Latinos have one copy of that high-risk gene, and a quarter have two copies, according to Goran.

He began a new study, which showed that among children as young as 8, those who had two copies of the risky gene and consumed high amounts of sugar had three times as much fat in their livers as kids with no copy of the gene. Now, in the USC-CHLA study, he is testing whether reduced consumption of sugar decreases the fatty liver risk in children who have the PNPLA3 gene variant.

At the start of the study, he tests kids to see if they have the PNPLA3 gene, uses an MRI to measure their liver fat and catalogs their sugar intake. A dietitian on his team educates the family about the impact of sugar. Then, after four months, they measure liver fat again to assess the impact of the intervention. Goran expects to have results from the study in about a year.

More recently, Goran has been investigating the transmission of sugar from mothers to their babies. He showed last year that in nursing mothers who drank beverages sweetened with high-fructose corn syrup — the primary sweetener in standard formulations of Coca-Cola, Pepsi and other sodas — the fructose level in their breast milk rose and stayed elevated for several hours, ensuring that the baby ingested it.

This early exposure to sugar could be contributing to obesity, diabetes and fatty livers, based on previous research that showed fructose can enhance the fat storage capacity of cells, Goran said.

At Torrance Memorial Medical Center, Dr. Karl Fukunaga meets with a patient, Margarita Marrou, a retired medical clerk originally from Peru. She was diagnosed several years ago with a severe form of fatty liver disease and has cut down her sugar consumption and lost weight. (Rob Waters for KHN)

In neighborhoods like South Los Angeles, where Saira Diaz and Adrian Mejia live, a lack of full-service markets and fresh produce makes it harder to eat healthily. “Access to unhealthy food options — which are usually cheaper — is very high in this city,” Derek Steele, director of health equity programs at the Social Justice Learning Institute in Inglewood, Calif., told Kaiser Health News.

The institute has started farmers markets, helped convert two corner stores into markets with healthier food options and created 109 community gardens on public and private lands in South L.A. and neighboring Inglewood, which has 125 liquor and convenience stores and 150 fast-food outlets.

At Torrance Memorial Medical Center, 10 miles down the road, Dr. Karl Fukunaga, a gastroenterologist with Digestive Care Consultants, said he and his colleagues are seeing so many patients with fatty liver disease that they plan to start a clinic to address it. He urges his patients to avoid sugar and cut down on carbohydrates.

Adrian Mejia and his mother received similar advice from a dietitian in the HEROES program. Adrian gave up sugary beverages, and his liver fat dropped 43%. Two months ago, he joined a soccer league.

“Before, I weighed a lot and it was hard to run,” he said. “If I kept going at the pace I was going, probably later in my life I would be like my [diabetic] grandma. I don’t want that to happen.”


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Watch: Price of a Brace Brings Soccer Player to His Knees

Telemundo News featured KHN’s recent Bill of The Month story about a soccer player who was stuck paying big bucks for a fancy hinged knee brace. Paula Andalo, KHN’s ethnic media editor, offered advice about how to avoid overpaying for medical equipment you may not need.

You can read KHN’s full story here.

Watch: Price of a Brace Brings Soccer Player to His Knees

Telemundo News featured KHN’s recent Bill of The Month story about a soccer player who was stuck paying big bucks for a fancy hinged knee brace. Paula Andalo, KHN’s ethnic media editor, offered advice about how to avoid overpaying for medical equipment you may not need.

You can read KHN’s full story here.

Podcast: KHN’s ‘What The Health?’ You Have Questions, We Have Answers

This week, KHN’s “What the Health?” panelists answered questions submitted by listeners.

Among the topics covered were what might happen to parts of the Affordable Care Act if a lawsuit now working its way through the courts succeeds in declaring the health law unconstitutional, and how Medicare and Medicaid deal with surprise medical bills from out-of-network providers.

This week’s panelists are Julie Rovner of Kaiser Health News, Jennifer Haberkorn of the Los Angeles Times, Joanne Kenen of Politico and Kimberly Leonard of the Washington Examiner.

The panel addressed questions including the following:

  • What would happen to the Medicare Part D “doughnut hole” if the entire ACA is struck down, and would newer bills, such as the Bipartisan Budget Act, which helped close the coverage gap for brand-name drugs one year early, prevent this feature of the ACA from being eliminated?
  • Will the Health Insurance Portability and Accountability Act (HIPAA) of 1996 remain if the ACA is completely overturned?
  • Since surprise medical bills aren’t allowed in Medicare and Medicaid, what happens when an anesthesiologist or contract emergency room doctor who doesn’t accept Medicare or Medicaid treats an enrolled patient? Do they take a lower rate? Does the hospital make up the difference? Why can’t this be applied to all out-of-network arrangements?
  • Statistics show that approximately 5% to 10% of the population accounts for about 50% of total health care spending. Who makes up this population? Are there any reasonable proposals to address the health of this population and perhaps reduce spending while improving outcomes?

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: Kaiser Health News’ “Lethal Plans: When Seniors Turn To Suicide In Long-Term Care,” by Melissa Bailey and JoNel Aleccia

Jennifer Haberkorn: The New York Times’ “Insurers Want to Know How Many Steps You Took Today,” by Sarah Jeong

Joanne Kenen: Vox.com’s “Walmart’s $25 Insulin Can’t Fix the Diabetes Drug Price Crisis,” by Julia Belluz

Kimberly Leonard: The [Columbia, S.C.] State’s “SC Inmate’s Baby Died in Toilet: Lawsuits Allege Rampant Medical Neglect in Prisons,” by Emily Bohatch

And, The Atlanta Journal-Constitution’s “For Some in Ga. Prisons and Jails, Diabetes Has Meant a Death Sentence,” by Danny Robbins

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher, Google Play or Spotify.

Podcast: KHN’s ‘What The Health?’ You Have Questions, We Have Answers

This week, KHN’s “What the Health?” panelists answered questions submitted by listeners.

Among the topics covered were what might happen to parts of the Affordable Care Act if a lawsuit now working its way through the courts succeeds in declaring the health law unconstitutional, and how Medicare and Medicaid deal with surprise medical bills from out-of-network providers.

This week’s panelists are Julie Rovner of Kaiser Health News, Jennifer Haberkorn of the Los Angeles Times, Joanne Kenen of Politico and Kimberly Leonard of the Washington Examiner.

The panel addressed questions including the following:

  • What would happen to the Medicare Part D “doughnut hole” if the entire ACA is struck down, and would newer bills, such as the Bipartisan Budget Act, which helped close the coverage gap for brand-name drugs one year early, prevent this feature of the ACA from being eliminated?
  • Will the Health Insurance Portability and Accountability Act (HIPAA) of 1996 remain if the ACA is completely overturned?
  • Since surprise medical bills aren’t allowed in Medicare and Medicaid, what happens when an anesthesiologist or contract emergency room doctor who doesn’t accept Medicare or Medicaid treats an enrolled patient? Do they take a lower rate? Does the hospital make up the difference? Why can’t this be applied to all out-of-network arrangements?
  • Statistics show that approximately 5% to 10% of the population accounts for about 50% of total health care spending. Who makes up this population? Are there any reasonable proposals to address the health of this population and perhaps reduce spending while improving outcomes?

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: Kaiser Health News’ “Lethal Plans: When Seniors Turn To Suicide In Long-Term Care,” by Melissa Bailey and JoNel Aleccia

Jennifer Haberkorn: The New York Times’ “Insurers Want to Know How Many Steps You Took Today,” by Sarah Jeong

Joanne Kenen: Vox.com’s “Walmart’s $25 Insulin Can’t Fix the Diabetes Drug Price Crisis,” by Julia Belluz

Kimberly Leonard: The [Columbia, S.C.] State’s “SC Inmate’s Baby Died in Toilet: Lawsuits Allege Rampant Medical Neglect in Prisons,” by Emily Bohatch

And, The Atlanta Journal-Constitution’s “For Some in Ga. Prisons and Jails, Diabetes Has Meant a Death Sentence,” by Danny Robbins

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher, Google Play or Spotify.

Ups And Downs Of Artificial Intelligence: IBM Stops Sales, Development Of Watson For Drug Discovery; Hospitals Learn From EHRs

While revenue and earnings have been lackluster for Watson for Drug Discovery, other companies are making profits in developing software that improves the clinical trials process for drugs. Also in the news: Hospitals are making improvements by using data from certain electronic health record systems.

Ups And Downs Of Artificial Intelligence: IBM Stops Sales, Development Of Watson For Drug Discovery; Hospitals Learn From EHRs

While revenue and earnings have been lackluster for Watson for Drug Discovery, other companies are making profits in developing software that improves the clinical trials process for drugs. Also in the news: Hospitals are making improvements by using data from certain electronic health record systems.

Supreme Court Asked To Take Up Louisiana Abortion Law Requiring Doctors To Have Admitting Privileges

The justices voted in February to put the law on hold. It is similar to a Texas law the court struck down in 2016. News on abortion looks at a Florida bill requiring parental consent, an investigation into family planning funding for anti-abortion groups, and plans of a civil rights protector to defend abortion opponents, as well

Supreme Court Asked To Take Up Louisiana Abortion Law Requiring Doctors To Have Admitting Privileges

The justices voted in February to put the law on hold. It is similar to a Texas law the court struck down in 2016. News on abortion looks at a Florida bill requiring parental consent, an investigation into family planning funding for anti-abortion groups, and plans of a civil rights protector to defend abortion opponents, as well

Faced With High Deductibles, Patients Are Delaying Health Care So As Not To Rack Up High Bills

Even with insurance, health care bills can be daunting and prompt people to delay care for problems that could have been caught earlier. Women with low incomes who had high-deductible insurance plans waited an average of 1.6 months longer for diagnostic breast imaging, 2.7 months for first biopsy, 6.6 months for first early-stage breast cancer diagnosis and 8.7 months for first chemotherapy, compared with low-income women with low-deductible plans.

Faced With High Deductibles, Patients Are Delaying Health Care So As Not To Rack Up High Bills

Even with insurance, health care bills can be daunting and prompt people to delay care for problems that could have been caught earlier. Women with low incomes who had high-deductible insurance plans waited an average of 1.6 months longer for diagnostic breast imaging, 2.7 months for first biopsy, 6.6 months for first early-stage breast cancer diagnosis and 8.7 months for first chemotherapy, compared with low-income women with low-deductible plans.

Scam Alert: Seniors, Low-Income Neighborhoods Targeted By People Claiming To Collect DNA Swab Samples

People are going to these communities in vans and offering to swab residents’ cheeks purportedly for DNA checks for cancer and other diseases. It’s not clear who is behind the reported activity. In other public health news: asbestos, candida auris, prostate drugs, three-parent pregnancies, syphilis, and more.

Scam Alert: Seniors, Low-Income Neighborhoods Targeted By People Claiming To Collect DNA Swab Samples

People are going to these communities in vans and offering to swab residents’ cheeks purportedly for DNA checks for cancer and other diseases. It’s not clear who is behind the reported activity. In other public health news: asbestos, candida auris, prostate drugs, three-parent pregnancies, syphilis, and more.

‘It’s A Game Changer’: Scientists Find Success In Using Gene Therapy To Treat ‘Bubble Boy’ Syndrome Without Causing Cancer

The process aimed at helping patients born with a severe immune-system deficiency involves removing some blood cells, using a modified HIV virus to insert a missing gene, and returning the cells through an IV. When doctors first tried it 20 years ago, the treatment had unintended effects on other genes, and some patients later developed leukemia.

Watching Media Coverage Of Mass Shootings Becomes Vicious Cycle In Terms Of Mental Health Trauma

A new report finds that people watching the coverage can develop symptoms of post-traumatic stress — but they just can’t look away from the news. And the stress from being glued to coverage ends up spreading through the society like a virus. In other news, as the Columbine anniversary approaches, survivors of that school shooting reach out to help other victims. And the woman who sparked a massive manhunt over possible threats to Colorado schools was found dead.

As Syphilis Invades Rural America, A Fraying Health Safety Net Is Failing To Stop It

When Karolyn Schrage first heard about the “dominoes gang” in the health clinic she runs in Joplin, Mo., she assumed it had to do with pizza.

Turns out it was a group of men in their 60s and 70s who held a standing game night — which included sex with one another. They showed up at her clinic infected with syphilis.

That has become Schrage’s new normal. Pregnant women, young men and teens are all part of the rapidly growing number of syphilis patients coming to the Choices Medical Services clinic in the rural southwestern corner of the state. She can barely keep the antibiotic treatment for syphilis, penicillin G benzathine, stocked on her shelves.

Public health officials say rural counties across the Midwest and West are becoming the new battleground. While syphilis is still concentrated in cities such as San Francisco, Atlanta and Las Vegas, its continued spread into places like Missouri, Iowa, Kansas and Oklahoma creates a new set of challenges. Compared with urban hubs, rural populations tend to have less access to public health resources, less experience with syphilis and less willingness to address it because of socially conservative views toward homosexuality and nonmarital sex.

In Missouri, the total number of syphilis patients has more than quadrupled since 2012 — jumping from 425 to 1,896 cases last year — according to a Kaiser Health News analysis of new state health data. Almost half of those are outside the major population centers and typical STD hot spots of Kansas City, St. Louis and its adjacent county. Syphilis cases surged at least eightfold during that period in the rest of the state.

At Choices Medical Services, Schrage has watched the caseload grow from five cases to 32 in the first quarter of 2019 alone compared with the same period last year. “I’ve not seen anything like it in my history of doing sexual health care,” she said.

Back in 1999, the Centers for Disease Control and Prevention had a plan to eradicate the sexually transmitted disease that totaled over 35,000 cases nationwide that year. While syphilis can cause permanent neurological damage, blindness or even death, it is both treatable and curable. By focusing on the epicenters clustered primarily throughout the South, California and in major urban areas, the plan seemed within reach.

Instead, U.S. cases topped 101,500 in 2017 and are continuing to rise along with other sexually transmitted diseases. Syphilis is back in part because of increasing drug use, but health officials are losing the fight because of a combination of cuts in national and state health funding and crumbling public health infrastructure.

“It really is astounding to me that in the modern Western world we are dealing with the epidemic that was almost eradicated,” said Schrage.

Grappling With The Jump

Craig Highfill, who directs Missouri’s field prevention efforts for the Bureau of HIV, STD and Hepatitis, has horror stories about how syphilis can be misunderstood.

“Oh, no, honey, only hookers get syphilis,” he said one rural doctor told a patient who asked if she had the STD after spotting a lesion.

In small towns, younger patients fear that their local doctor — who may also be their Sunday school teacher or basketball coach — may call their parents. Others don’t want to risk the receptionist at their doctor’s office gossiping about their diagnosis.

Some men haven’t told family members they’re having sex with other men. And still more have no idea their partner may have cheated on them — and their doctors don’t want to ask, according to Highfill.

It’s even hard to expect providers who haven’t seen a case of syphilis in their lifetime to automatically recognize the hallmarks of what is often called the “great imitator,” Highfill said. Syphilis can manifest differently among patients, but frequently shows up for a few weeks as lesions or rashes — often dismissed by doctors who aren’t expecting to see the disease.

Since 2000, the current syphilis epidemic was most prevalent among men having sex with men. Starting in 2013, public health officials began seeing an alarming jump in the number of women contracting syphilis, which is particularly disturbing considering the deadly effects of congenital syphilis — when the disease is passed from a pregnant woman to her fetus. That can cause miscarriage, stillbirth or birth deformities.

Among those rising numbers of women contracting syphilis and the men who were their partners, self-reported use of methamphetamines, heroin or other intravenous drugs continues to grow, according to the CDC. Public health officials suggest that increased drug use — which can result in a pattern of risky sex or trading sex for drugs — worsens the outbreaks.

That perilous trend is playing out particularly in rural Missouri, argues Dr. Hilary Reno, an assistant professor of medicine at Washington University School of Medicine in St. Louis who is researching syphilis transmission and drug use in the state. Tracking cases from 2015 through June 2018, she found that more than half of patients outside of the major metropolitan areas of Kansas City and St. Louis reported using drugs.

Less Money, More Problems

Federal funding for STD prevention has stayed relatively flat since 2003, with $157.3 million allocated for fiscal year 2018. But that amounts to a nearly 40% decrease in purchasing power over that time, according to the National Coalition of STD Directors.

In Missouri, CDC annual funding has been cut by over $354,000 from 2012 to 2018 — a 17% decrease even as the number of cases quadrupled, Highfill said.

Iowa, too, has seen its STD funding cut by $82,000 over the past decade, according to Iowa Department of Health’s STD program manager George Walton.

“It is very difficult to get ahead of an epidemic when case counts are steadily — sometimes rapidly — increasing and your resources are at best stagnant,” Walton said. “It just becomes overwhelming.”

Highfill bemoaned that legislatures in Texas, Oregon and New York have all allocated state money to raise awareness or provide transportation to local clinics. Missouri has not allocated anything.

Schrage says she can barely keep the antibiotic treatment for syphilis, penicillin G benzathine, stocked on her shelves.(Bruce Stidham for KHN)

A New Playing Field

In the digital age, fighting syphilis is much harder for public health responders, said Rebekah Horowitz, a senior program analyst on HIV, STDs and viral hepatitis at the National Association of County and City Health Officials.

The increased use of anonymous apps gives people greater access to more sexual partners, she said. Tracking down those partners is now much harder than camping out at the local bar in town.

“We can’t get inside of Grindr and do our traditional public health efforts,” she said.

That’s not to say Highfill’s department hasn’t tried. It has engineered a series of educational ads on Instagram, Grindr and Facebook displaying messages such as “Knowledge looks good on you.”

Highfill would love to do more — if Missouri had the money.

Public health clinics nationwide have also had to limit hours, reduce screening and increase fees that can reach $400. And some run by health departments across the country have been forced to close — at least 21 in 2012 alone, according to CDC data.

In Missouri, restrictions on Planned Parenthood’s Medicaid reimbursements that were passed last year in the legislature, and are again under debate, mean the nonprofit organization cannot be reimbursed for STD treatment for some patients.

That is another crack in the already failing public health infrastructure, said Reno, the Washington University professor who also serves as the medical director of the St. Louis County Sexual Health Clinic.

“We have a system that’s not even treading water,” she said. “We are the ship that is listing to the side.”

What you need to know about syphilis:

  • Syphilis is a bacterial infection spread through oral, vaginal and anal sex. It is treatable and curable with antibiotics.
  • Syphilis causes sores that are usually painless but can spread the bacterium to other people. It can also be passed from an infected pregnant woman to her fetus, risking miscarriage, stillbirth or birth deformities. The second phase of the disease can cause a skin rash, swollen lymph nodes and fever. Final stages of the disease can cause permanent neurological damage, blindness or death.
  • Despite a Centers for Disease Control and Prevention plan in 1999 to eradicate the disease, infectious syphilis cases have skyrocketed in recent years, jumping 76% nationally from 2013 to 2017.
  • A combination of cuts in national and state funding, crumbling public health infrastructure, greater mobility, continued stigma and increasing drug use is driving the uptick.
  • The best way to prevent syphilis among those who are sexually active is to use latex condoms or dental dams during sex.