South Dakota ranks second in the nation for the rate at which its residents die of liver diseases, and the fatality rate is rising overall with many experts now blaming poor lifestyle and eating habits in addition to heavy alcohol use as causes of the illnesses.
While heavy alcohol consumption remains a major cause of deaths due to liver ailments, doctors are also seeing more liver disease caused by diabetes, obesity and the viral infection Hepatitis C or a combination of all four. Data show that liver disease is also striking at a younger age than in the past, with a particularly high death rate among people 30 to 39 years of age.
Popular perception places the blame for liver disease on alcohol abuse, but a deeper look shows the causes are more broad than that. In fact, the most common chronic liver ailment in the U.S. is a disease called non-alcoholic fatty liver disease, which can be related to diabetes or obesity.
Experts estimate that around 30 percent of Americans – roughly 100 million people – have non-alcoholic fatty liver disease. About 3 million to 5 million people might develop cirrhosis from the condition, said Dr. Adnan Said, program director of transplant hepatology at the University of Wisconsin School of Medicine. Said also is a member of the National Medical Advisory Committee for the American Liver Foundation.
“Population-wise, I think fortunately, or unfortunately, a lot of liver disease can be affected by our life choices,” Said said.
Only New Mexico higher
According to the federal Centers for Disease Control and Prevention, South Dakota’s death rate due to liver disease was about 17.5 deaths per 100,000 people in 2017, the last year for which data is available. Only New Mexico’s liver disease death rate was higher at 26.8 per 100,000.
For people between the ages of 30 and 39, liver disease was the third-leading cause of death in South Dakota from 2013 to 2017, following only accidents and intentional self-harm. For people age 40 to 59, liver disease was the fourth-leading cause of death behind cancer, heart disease and accidents. Chronic liver diseases and cirrhosis are the state’s 10th overall leading cause of death; the average age of death from liver disease in South Dakota is 55.
The rate of liver disease deaths is generally trending upward in South Dakota. In 2009, the state’s liver disease death rate was 9.7 per 100,000 people. The rate grew every year until 2017 when it fell from 2016’s rate of 18.3 to 17.5. The number of deaths in South Dakota due to liver ailments in 2017 was 153; from 2013 to 2017, 696 people died.
More than alcohol
Chronic alcohol abuse remains the leading cause of fatal liver diseases. But South Dakotans may be affected more by other factors.
South Dakotans binge drink more than the rest of the country, according to the CDC. Binge drinking is classified as men having more than five drinks or women having more than four drinks at a time.
But according to the CDC’s Behavioral Risk Factors Surveillance System, a phone survey in which adults self-report their behaviors, South Dakota residents are less likely to be heavy drinkers than those in the rest of the country. The CDC classifies heavy drinking as consuming eight drinks per week for women or 15 drinks a week for men.
The viral infection Hepatitis C is also a growing concern for the medical community when it comes to combatting liver illnesses.
An estimated 3 million to 5 million Americans have Hepatitis C, but because it can take decades before symptoms to show up, as many as 75 percent of infected people don’t know they are sick, increasing the chance of spreading the disease from person to person.
Baby Boomers are at the highest risk for the disease, though often through no fault of their own. The Hepatitis C virus wasn’t well screened for or understood prior to 1992. People who got blood transfusions, organ transplants or tattoos or used unclean needles for injections could unknowingly have been exposed to the disease.
The disease also is having a disproportionate effect on Native Americans, who make up about 30 percent of the state’s Hepatitis C cases but only about 15 percent of the state population.
There is also a growing number of younger people contracting Hepatitis C in South Dakota. The average age of someone diagnosed with Hepatitis C in the state is 44. Causes for the rising infection rate among younger people isn’t well understood, said South Dakota Epidemiologist Joshua Clayton.
Doctors are also concerned about diet and alcohol and how poor lifestyle choices are causing liver ailments at younger ages.
“I have seen in South Dakota some of the youngest cirrhotics I have seen in my career,” said Dr. Christine Pocha, a transplant hepatologist, or liver specialist, at Avera McKennan Hospital in Sioux Falls.
Almost any food or beverage consumed will have an effect on liver health. A main function of the liver is to clean the bloodstream of toxins. The liver also is the first stop most nutrients make before heading off to other parts of the body. When someone spends a lifetime eating a diet overly heavy in processed sugar, bread and trans fats, the liver eventually gets a little sick. The condition is called non-alcoholic fatty liver disease.
The American Liver Foundation estimates nearly one-third of Americans, about 100 million people, have at least some level of non-alcoholic fatty liver disease. Very few people will actually develop liver failure due to that disease alone, but it can and does make other diseases of the liver worse. When combined with too much alcohol and not enough exercise, fatty liver disease can be deadly. It also makes people with Hepatitis C more likely to develop cirrhosis.
“We spend most of our time teaching patients about lifestyle,” said Dr. Ali Al-Hajjaj, a transplant hepatologist with Avera Health in Sioux Falls.
Healthy food habits such as eating more fruits, vegetables and legumes while cutting down on salt, sugar and alcohol, Al-Hajjaj said, can go a long way toward staving off liver diseases. Trying to get at least 60 minutes of exercise a day is essential too, he said.
If all that sounds familiar, it’s because eating a better diet and getting exercise is part of the chronic disease reduction gospel. A healthy diet and exercise can help prevent everything from heart disease to diabetes. Doctors have been preaching it for decades, and Avera liver doctors are no different.
“Like all patients, some listen, some don’t,” said Dr. Jeffery Steers, a liver and kidney and transplant surgeon working for Avera McKennan Hospital in Sioux Falls.
A big part of the problem, Al-Hajjaj said, is that high-sugar, high-calorie processed foods often are much easier to find and tend to be cheaper than more nutritious options. South Dakota’s rural nature means there are significant portions of the state’s population who have to drive long distances to get to a full-service grocery store.
“It’s easier to find a chocolate bar and a beer than it is to find a good meal,” Al-Hajjaj said.
Do we drink more?
Alcohol has long been known to cause liver damage. Exactly how and why the damage occurs isn’t well understood. Genetic differences play a role as does diet, according to the National Institute on Alcohol Abuse and Alcoholism.
South Dakota, according to a 2018 report from the institute, was 10th in the nation in terms of alcohol consumed per capita. Still, state residents reported a slightly lower rate of heavy drinking on average than the rest of the country. North Dakota residents drank the most, according to the study.
Data gathered by the South Dakota Department of Health shows the poorest of the state’s citizens drink less often than the more well off. About 47 percent of those whose household income is less than $35,000 a year reported being regular drinkers, which means they consumed alcohol within 30 days of being surveyed. The number climbs to 74 percent for people whose yearly household income is $75,000 or more.
Nearly 60 percent of white people surveyed reported having a drink in the last 30 days. In the Native American community, only 40 percent of respondents reported drinking in the past month. About 47 percent of Hispanic people, meanwhile, said they drank in the last 30 days.
The DOH data shows 13 percent of women and 24 percent of men reported binge drinking at some point. Meanwhile, 6 percent of men and 5 percent of women reported drinking heavily.
About 19 percent of people making $35,000 a year or less said they had binged on alcohol in the last 30 days, but about 22 percent of people making $75,000 or more per year reported binge drinking.
There are three well-known types of viral hepatitis, all of which affect the liver. Two of them, Hepatitis A and Hepatitis B, have been very well controlled in the U.S. through vaccinations. Both are part of the regular recommended course for children in the U.S.
Hepatitis C is a greater concern. The blood-borne disease doesn’t have a vaccine. About 30 percent of people infected with the disease are likely to develop liver damage and up to 6 percent may develop liver failure. There also is a worry that because decades can pass before any symptoms become readily apparent, someone who is infected can spread the disease further without knowing it.
The disease can be spread through contact with an infected person’s blood. Transmission can happen through such activities as injection drug use, accidental needle stick or sexual contact.
About 75 percent of Americans infected with Hepatitis C are Baby Boomers, those born between 1946 and 1964. The CDC estimates that about 3 percent of all Baby Boomers have the disease, which is a significantly higher percentage than any other age group.
But there’s a growing number of Hepatitis C cases being found in younger adults. The average age of people infected with Hepatitis C in South Dakota is 44. The disease also is having a disproportionate effect on the state’s Native American population. The average age of a Native American diagnosed with Hepatitis C is 39, compared to 49 in the state’s non-Native population.
While prevention is the best option, the disease can be cured. Over the last 10 years or so, a group of medications called “direct acting antivirals” has been developed. Those drugs can cure up to 95 percent of Hepatitis C infections.
A full six- to eight-week course of Hepatitis C medications can cost anywhere from $26,000 to $90,000 if purchased directly from the manufacturer.
Access to proper medical care can affect the treatment of liver disease regardless of the cause.
For specialty care such as hepatology, patients have to travel either to Sioux Falls or Rapid City. If a patient’s liver fails and they need a new one, Sioux Falls is the only option.
“I think people need to understand that the liver is just as important as the heart,” Pocha said.
Steers said there is no machine that can make up for a failing liver, once it goes, it goes and, “if you’re not a good candidate for a transplant, it’s a slow and painful death.”
This story was produced by South Dakota News Watch, a non-profit news organization. Find more in-depth stories at www.sdnewswatch.org.