Clinical Practice Approach to Nonalcoholic Fatty Liver Disease by Pediatric Gastroenterologists in the United States

Objectives: : Nonalcoholic fatty liver disease (NAFLD) is common; however, no information is available on how pediatric gastroenterologists in the United States manage NAFLD. Therefore, study objectives were to: (1) understand how pediatric gastroenterologists in the US approach the management of NAFLD (2) identify barriers to care for children with NAFLD. Methods: : We performed structured one-on-one interviews to ascertain each individual pediatric gastroenterologist's approach to the management of NAFLD in children. Responses were recorded from open-ended questions regarding screening for comorbidities, recommendations regarding nutrition, physical activity, medications and perceived barriers to care. Results: : Response rate was 72.0% (486/675). Mean number of patients examined per week was 3 (standard deviation (SD) 3.5). Dietary intervention was recommended by 98.4% of pediatric gastroenterologists. Notably, 18 different dietary recommendations were reported. A majority of physicians provided targets for exercise frequency (72.6%, mean 5.6 days/week, SD 1.6) and duration (69.9%, mean 40.2 minutes/session, SD 16.4). Medications were prescribed by 50.6%. Almost one-half of physicians (47.5%) screened for type 2 diabetes, dyslipidemia, and hypertension. Providers who spent more than 25 minutes at the initial visit were more likely to screen for comorbidities (p = 0.003). Barriers to care were reported by 92.8% with 29.0% reporting ≥ 3 barriers. Conclusions: : The majority of U.S. pediatric gastroenterologists regularly encounter children with NAFLD. Varied recommendations regarding diet and exercise highlight the need for prospective clinical trials. NAFLD requires a multidimensional approach with adequate resources in the home, community, and clinical setting. Address correspondence and reprint requests to Jeffrey B. Schwimmer, MD, Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of California, San Diego, 3020 Children's Way, MC 5030 San Diego, CA 92123 (e-mail: jschwimmer@ucsd.edu). Received 2 May, 2018 Accepted 10 October, 2018 Grant Support: The project described was partially supported by the National Institutes of Health grants UL1TR000100 and UL1TR001442. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Disclosures: The authors have nothing to disclose Writing assistance: None. Author contributions: Warren L. Shapiro – Study concept and design; generation of data; collection of data; analysis and/or interpretation of data; drafting and/or revision of manuscript; approval of final version of manuscript Elizabeth L. Yu – Generation of data; collection of data; analysis and/or interpretation of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Jennifer Collins Arin – Study concept and design; assembly of data; administrative, technical or material support; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Karen Murray – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Sabina Ali – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Nirav Desai – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Stavra Xanthakos – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Henry Lin – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Naim Alkhouri – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Reham Abdou – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Stephanie Abrams – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Megan W. Butler – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Sarah Ann Faasse – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Lynette A. Gillis – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Timothy Ardell Hadley – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Ajay K. Jain – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Marianne Kavan – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Kattayoun Kordy – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Peter Lee – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Jennifer Panganiban – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript John Pohl – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Carol Potter – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Bryan Rudolph – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Shikha S. Sundaram – Generation of data; collection of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Shivali Joshi – Assembly of data; analysis and/or interpretation of data; drafting and/or revision of manuscript; approval of final version of manuscript James Proudfoot – Assembly of data; analysis and/or interpretation of data; statistical analysis; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Nidhi P. Goyal – Generation of data; collection of data; analysis and/or interpretation of data; drafting and/or revision of manuscript; approval of final version of manuscript Kathryn E. Harlow – Generation of data; collection of data; analysis and/or interpretation of data; critical revision of the manuscript for important intellectual content; approval of final version of manuscript Kimberly P. Newton – Study concept and design; generation of data; collection of data; analysis and/or interpretation of data; drafting and/or revision of manuscript; approval of final version of manuscript Jeffrey B. Schwimmer – Study concept and design; study supervision; generation of data; collection of data; analysis and/or interpretation of data; drafting and/or revision of manuscript; approval of final version of manuscript © 2019 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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