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Fatty Liver

One of the biggest problems with fatty liver is that it is hard to diagnose. While we can easily measure things like blood sugar or iron levels through blood tests, the only certain way to find out if a liver is diseased would be to take a piece of it out and analyze it.
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Fatty liver effects over a third of adults and is expected to become the top cause of liver transplants in the next decade. Fatty liver disease is one of the most pressing healthcare issues in this country despite the low level of public awareness. The good news is it's reversible with simple lifestyle steps in the majority of cases.

SHOCKING STATS

Liver disease is the fourth leading cause of death in the United States among 45-54 year olds and, sadly, affects more than 6 million children. [1] Since childhood obesity has increased, researchers are expecting it to cause more complications with kids in coming years. [2]

One of the biggest problems with fatty liver is that it is hard to diagnose. While we can easily measure things like blood sugar or iron levels through blood tests, the only certain way to find out if a liver is diseased would be to take a piece of it out and analyze it. Liver biopsies are the most accurate way to diagnose fatty liver, but because they are invasive and costly, they aren't at all practical as screening tools.

Since fatty liver is hard to diagnose without a biopsy, and we don't use biopsies to screen healthy people, how can we know how common fatty liver is?

If healthy people choose to donate liver tissue to a friend or loved one, they must submit to a liver biopsy to be sure their liver tissue is healthy enough to share. This has given us our largest body of evidence about the prevalence of fatty liver. When researchers examined 70 such biopsies from healthy relatives, they found 38.5% of the healthy relatives had fatty liver disease. Another study found that elderly individuals who were hospitalized for non-liver causes had a 46% chance of having fatty liver disease. If that's not enough, the rates of fatty liver in obese populations may be as high as 90%.

ARE THERE DIFFERENT KINDS OF FATTY LIVER?

While Non-Alcoholic Fatty Liver (NAFL) is the focus of this post, there are other types of fatty liver disease, including:

Alcoholic Fatty Liver, like its name sounds, is related to alcohol intake. This form can lead to cirrhosis. It is important to note that alcoholism can lead to cirrhosis, but normal, social use of alcohol can still be a contributor to fatty liver.

Non-alcoholic Steatohepatitis (NASH) is a much more serious form of fatty liver disease than NAFL. If left untreated, it can permanently scar your liver, or lead to death from liver failure.

Acute Fatty Liver of Pregnancy often occurs during the third trimester of pregnancy and can cause symptoms such as constant nausea and vomiting, pain in the upper right abdomen, fatigue, and jaundice. Since it can be life-threatening if untreated, you need to talk to your obstetrician about getting screened for it if you are pregnant and have any of these symptoms. Fortunately, most women completely recover from it after delivery.

HOW DOES IT HAPPEN?

When you eat, your body breaks food down into fuel, which either gets burned or stored as body fat. When you're energized, you're active and alert. Movement is effortless and life is good. On the other hand, the more fat your body stores, the more you're growing stuff you probably don't want to grow, and the more you're just running down, feeling far from your best. When you store more, you're more apt to have more fats (especially triglycerides) get stuck in your liver and enlarge it. A healthy liver has about 1-3% fat. Once it's over 5%, things start to go wrong. Once you get over 10%, disease usually sets in. All this fat can lead to problems like a poorly functioning liver, liver tissue scarring, and even liver cancer.

Today, about a third of Americans are obese, with rates projected to reach 60% in thirteen states by 2030. [3] Genes that make us more likely to have obesity or diabetes, combined with little exercise and poor diet, definitely contribute to fatty liver. Then, as the liver has trouble functioning, other symptoms start to show up, such as reduced energy levels or muscles which don't repair as readily, which make it harder to exercise or prepare healthier foods. It should come as no surprise that fatty liver is on the rise with no indication of changing anytime soon.

It's important to note that many who develop fatty liver are lean and have no apparent health issues. This is why screening is important.

WHO IS MOST AT RISK?

Fatty liver disease is more common in those who have Type 2 diabetes or who carry some extra weight. [4] Other factors linked to fatty liver disease include alcohol use, malnutrition, high cholesterol, high triglycerides, metabolic syndrome, genetic predisposition, rapid weight loss, and pregnancy. [5] Medications such as aspirin, acetaminophen (Tylenol), steroids, tetracycline, tamoxifen, and calcium channel blockers (blood pressure pills like amlodipine or diltiazem) have also been linked to this condition. [6]

WHAT ARE THE CONSEQUENCES?

Fatty liver can lead to early death from liver damage. Among fatal diseases, it is the only one that has been causing more deaths year after year since the 1940s. [7]

Those with a fatty liver are also at higher risk for liver cancer, diabetes, and heart disease. In fact, the most common cause of death in those with fatty liver is heart disease.

HOW DO I KNOW IF I HAVE IT?

Get your liver function tested annually.

As many as 80% of people with fatty liver don't even know they have it. A common way one learns they have fatty liver is their doctor finds abnormal liver enzyme levels during an ALT test. While we can see clues of fatty liver disease from a physical exam, ultrasound, or a liver biopsy, fatty liver is most often diagnosed when a doctor finds abnormal ALT test results. [8]

Most blood tests include a metabolic panel, also known as a "chem panel", which includes liver enzymes. ALT, or alanine aminotransferase, is an enzyme found in your liver. When liver cells are naturally breaking down, they release some of their contents into your bloodstream. While some of these enzymes in your bloodstream are perfectly healthy, a liver inflamed with excess triglycerides, or one that is injured, causes ALT scores to creep up.

ALT levels greater than 19 for women and 30 for men are suggestive of fatty liver. Both patients and doctors often miss this because you can be above this cut off, but still in the normal range. [8]

Some patients develop symptoms that bring them to our clinic. These can include vague pain and discomfort on the upper right portion of the abdomen or an increase in bloating, gas, or heartburn. Sometimes patients tell us they have pain in the right shoulder.

IS THERE HOPE?

Yes!

Unchecked, the disease can lead to liver transplant and possible fatality. The good news is that in the vast majority of cases, fatty liver can be managed, or even reversed, through a few simple action steps.

Here are the top 10 keys to manage fatty liver disease:

#1. Know your ALT level. If you're a woman, your ALT should be below 19 and, if you're a man, it should be below 30. If your ALT level is higher than that, talk to your doctor about the possibility of fatty liver. Of course, there are other causes of increased liver enzymes, but in the absence of other causes, fatty liver is the most likely culprit. If your ALT is high for no other reason, take the steps below and retest every three months.

#2. Stop drinking alcohol. If you have fatty liver disease, or are even at risk for it, there is NO safe amount of alcohol.

#3. Lose weight (slowly). Not everyone with fatty liver is overweight, but for those who are, losing just 5-10 pounds may be enough to radically improve liver function. Studies have shown fatty liver responds well to diets that are low enough in calories to cause 1-1.5 pounds per week of weight loss. [9] Low-carb or low-fat diets can work equally well as long as they are low in calories, but not too low. Rapid weight loss of more than two pounds per week can make things worse.

#4. Manage your blood sugar. Eating foods high in fiber and lean protein, as well as eating small, frequent meals, can help heal your liver by balancing your blood sugar resistance. Fiber has a double benefit for those with fatty liver. It helps blood sugar and binds with toxins that would otherwise go from your colon into your liver. The highest sources include white beans, split peas, lentils, artichokes, broccoli, blackberries, and Brussel sprouts.

#5. Avoid fructose. Yes, this does include fresh fruit. Even though fruit is delicious and is a better choice than candy or sugary soda, fructose is the type of sugar that is most apt to harm your liver.

#6. Limit saturated fat. The largest meta-analysis to date on diet and fatty liver suggests saturated fat is a bad thing, even without excess calories. If you're eating a low carb diet, monounsaturated and polyunsaturated fats (such as those found in fish, nuts, or avocados) appear to be safer for those with fatty liver. [9]

#7. Cut trans-fatty acids. Primarily found in processed foods and baked goods, trans fats can cause liver damage. Some big sources are fried foods, pie crusts, margarine, shortening, frosting, pancake mixes, non-dairy creamer, microwave popcorn, animal fat, store bought cookies, biscuits, creamy frozen drinks, and crackers. [9]

#8. Get enough magnesium. Since the soil has been farmed out and water is often stripped of its mineral content, eat foods high in it, and consider taking a magnesium supplement. Surprisingly, magnesium acts as an antioxidant within the liver. The best food sources include adzuki beans, pumpkin seeds, avocados, oysters, and spinach. [10]

#9. Take 400-1200 international units of Vitamin E every day. This is above the amount found in foods. Mixed tocopherol versions of vitamin E are best. Studies of liver biopsies have found this level of Vitamin E can halt the progression of fatty liver disease within five months. [11]

#10. Use betaine, a naturally occurring substance found in beets (also called trimethylglycine). It's been found to lower ALT levels by 40-50% for most people. Using fresh or powdered beet juice is a great option, as are betaine supplements. [12]

TAKEAWAY POINTS

Fatty liver is common and deadly. Thankfully, the pathway back to health is fairly simple. Subtract alcohol, fructose, and trans fats from your diet. Then, add some of the nutrients we mentioned earlier. Eating strategically will give you the energy you need to fuel a healthy lifestyle. Make sure you talk to your doctor about your ALT level and encourage your loved ones to do the same.

Even more so than other parts of your body, your liver can regenerate if you give it a chance. As always, learn about your own health, and never give up!

References:

[1] "United States of America," Health in the Americas, Pan American Health Organization, 2012 Edition: Country Volume: 643.

[2] Manco M, Bottazzo G, DeVito R, Marcellini M, Mingrone G, Nobili V, "Nonalcoholic fatty liver disease in children," Journal of the American College of Nutrition, 2008 Dec;27(6):667-76.

[3] Finkelstein EA, Khavjou OA, Thompson H, Trogdon JG, Pan L, Sherry B, Dietz W, "Obesity and severe obesity forecasts through 2030," American Journal of Preventative Medicine, 2012 Jun;42(6):563-70. doi: 10.1016/j.amepre.2011.10.026.

[4] Firneisz G, "Non-alcoholic fatty liver disease and type 2 diabetes mellitus: The liver disease of our age?" World Journal of Gastroenterology, 2014 Jul 21. doi: 10.3748/wjg.v20.i27.9072.

[5] Kneeman JM, Misdraji J, Corey KE, "Secondary causes of nonalcoholic fatty liver disease," Therapeutic Advances in Gastroenterology, 2012 May; 5(3): 199-207, doi: 10.1177/1756283X11430859

[6] Patrick L, "Nonalcoholic Fatty Liver Disease: Relationship to Insulin Sensitivity and Oxidative Stress. Treatment Approaches Using Vitamin E, Magnesium, and Betaine," Alternative Medicine Review, vol. 7, num. 4, 2002.

[7] Williams R, Aspinall R, Bellis M, et al. "Addressing liver disease in the UK: a blueprint for attaining excellence in healthcare for liver disease and reducing premature mortality from the major lifestyle issue of excess alcohol consumption, obesity, and viral hepatitis," Lancet 2014; published online Nov 27, 2014, http://dx/doi.org/10.1016/S0140-6736(14)61838-9.

[8] Dyson JK, Anstee QM, McPherson S, "Non-alcoholic fatty liver disease: a practical approach to diagnosis and staging," Frontline Gastroenterology, 2014;5:211-218 doi:10.1136/flgastro-2013-100403.

[9] Sullivan S, "Implications of diet on nonalcoholic fatty liver disease," Current Opinion in Gastroenterology, 2010 Mar; 26(2): 160-164, doi: 10.1097/MOG.0b013e3283358a58.

[10] Turecky L1, Kupcova V, Szantova M, Uhlikova E, Viktorinova A, Czirfusz A.
Serum magnesium levels in patients with alcoholic and non-alcoholic fatty liver. Bratisl Lek Listy. 2006;107(3):58-61.

[11] Pacana T, Sanyal AJ. Vitamin E and nonalcoholic fatty liver disease. Curr Opin Clin Nutr Metab Care. 2012 Nov;15(6):641-8. doi: 10.1097/MCO.0b013e328357f747. Review.

[12] Patrick L. Nonalcoholic fatty liver disease: relationship to insulin sensitivity and oxidative stress. Treatment approaches using vitamin E, magnesium, and betaine. Altern Med Rev. 2002 Aug;7(4):276-91. Review.