What You Should Know About Fatty Liver Disease

An increasing number of obesity cases is driving an epidemic of a condition of excessive fat build-up in the liver. It is commonly called fatty liver disease (FLD) or hepatic steatosis.

A healthy liver contains a small amount of fat but when extra fat builds up in the liver and reaches 5% to 10% of your liver’s weight, it becomes a problem. Thus, understanding, diagnosing, and treating this progressive condition are becoming health priorities.

The Liver

The liver is a reddish-brown, wedge-shaped, unequal two-lobed organ located just below the diaphragm, to the right of the stomach, and overlies the gallbladder. It is around 6 inches wide, and weighs approximately 3.3 pounds, making it one of the largest and heaviest organs in our body.

The liver is responsible for up to 500 separate functions, usually in combination with other body organs and systems. Various liver functions are carried out by the hepatocytes (liver cells). Given its size, the liver has multiple life-supporting functions such as:

• Producing bile that helps with the digestion

• Producing proteins necessary for growth

• Storing iron needed by our red blood cells

• Regulating glycogen storage and converting nutrients into energy

• Producing substances that help blood clot for wound healing

• Producing immune factors for immunity

• Removing bacteria and toxins in our body for detoxification

Types of Fatty Liver Disease

Fatty liver disease has two types:

• Non-alcoholic fatty liver disease (NAFLD)

• Alcoholic liver disease

NAFLD is further subdivided into:

• Simple fatty liver

• Non-alcoholic steatohepatitis (NASH)

Don't let these terms get you confused. It is important to distinguish between simple fatty liver and NASH. Why? Because having a simple fatty liver does not cause liver-related sickness whereas having NASH means you have an inflammation or injury in your liver cells. NASH increases the risk of progression to more serious conditions like fibrosis (scarring) of the liver, liver cirrhosis, and liver cancer.

Statistics

It is not yet clear why some people with NAFLD develop simple fatty liver and others develop NASH. Most people with NAFLD have simple fatty liver and not NASH. In the U.S., about 3% to 7% only of the US population has NASH.

Fatty liver occurs more often in adult males. It also affects about 10% of children in the U.S. NAFLD affects about 30% of people in Western countries and 10% of people in Asia. Fatty liver is more prevalent in Hispanic people than Caucasians, while Black people have the lowest susceptibility. Therefore, you have a greater chance of developing the fatty liver disease if you are Hispanic or Asian.

For people with NAFLD, there is about an 80% 10-year survival or recovery rate. However, the rate of progression of fibrosis is estimated to be 1 per 7 years in NASH and 1 per 14 years in NAFLD, with an increasing speed.

More than 90% of heavy drinkers develop fatty liver while about 25% develop the more severe alcoholic hepatitis.

Recently, the term Metabolic dysfunction-Associated Fatty Liver Disease (MAFLD) has been proposed to replace NAFLD. MAFLD is a more inclusive diagnostic name as it is based on the detection of fatty liver by biopsy, medical imaging, or blood tests but should be accompanied by either overweight/obesity, type 2 diabetes mellitus, or metabolic dysregulation. The new definition no longer excludes alcohol consumption or the coexistence of other liver diseases. Using this more inclusive definition, the global prevalence of MAFLD rises to 50.7%.

If we use the "old" NAFLD definition, 80% of obese people, 35% of whom progress to NASH, and up to 20% of normal-weight people have NAFLD despite no evidence of excessive alcohol consumption.

Signs, Symptoms, Diagnosis

Most individuals with fatty liver are asymptomatic. If there are symptoms, it may be occasional tiredness or pain in the upper right side of the abdomen. Thus, fatty liver disease is usually detected by accident when an abdominal ultrasound, CT scan, or MRI is requested for another reason or unrelated medical conditions and your doctor may be the first one to spot it. Because fatty liver disease often has no symptoms, people would only know it until the disease progresses to liver cirrhosis.

Elevated liver enzymes on a blood test for other conditions may raise a red flag. It is a sign of possible liver injury. To make a diagnosis, your doctor may order:

• Ultrasound or CT scan to get a picture of the liver.

• Liver biopsy to determine how far advanced the liver disease has progressed.

Elevated liver enzymes are found in 50% of patients with simple steatosis. A simple blood test may help to determine the magnitude of the disease by assessing the degree of liver fibrosis. Histological diagnosis by liver biopsy is the most accurate measure of fibrosis and liver fat progression as of 2018. It takes a liver biopsy to know if a person has simple fatty liver or NASH. But the infrequent complications and cost of a liver biopsy make this impractical for people with NAFLD.

Causes

Fatty liver is commonly associated with diabetes, hypertension, obesity, and dyslipidemia, but can also be due to any one of these:

• Alcohol use - it is one of the causes of fatty liver due to the production of toxic metabolites like aldehydes during the metabolism of alcohol in the liver.

• Abnormal metabolism - aside from the mentioned metabolic syndromes, abetalipoproteinemia, glycogen storage diseases, Weber–Christian disease, acute fatty liver of pregnancy, and lipodystrophy are considered to cause fatty liver.

• Nutritional causes - obesity, insulin resistance, and malnutrition are the most common nutritional causes of fatty liver. Total parenteral nutrition, severe weight loss, refeeding syndrome, jejunoileal bypass, gastric bypass, jejunal diverticulosis with bacterial overgrowth may also cause fatty liver.

• Drugs and toxins such as amiodarone, methotrexate, diltiazem, expired tetracycline, highly active antiretroviral therapy, glucocorticoids, tamoxifen, environmental hepatotoxins (e.g., phosphorus, mushroom poisoning)

• Other causes such as celiac disease, inflammatory bowel disease, HIV, hepatitis C (especially genotype 3), and alpha 1-antitrypsin deficiency

Some people get the fatty liver disease without having any pre-existing conditions. But these risk factors make you more likely to develop it:

• Being obese or overweight.

• Having Type 2 diabetes or insulin resistance.

• Having metabolic syndrome (insulin resistance, high blood pressure, high cholesterol, and high triglyceride levels).

• Taking certain prescription medications, such as amiodarone, diltiazem, tamoxifen, or steroids.

Risks & Complications

Fatty liver disease doesn’t cause major problems for most people. However, it can turn into a more serious problem if it progresses into liver cirrhosis. Untreated liver cirrhosis eventually leads to liver failure or liver cancer.

NAFLD is intimately related to conditions like diabetes and obesity. It’s also linked to an increased risk of cardiovascular disease. The primary risks include alcohol, type 2 diabetes, and obesity. Other risk factors include certain medications such as glucocorticoids and hepatitis C.

Less than 10% of people with cirrhotic alcoholic FLD will develop hepatocellular carcinoma, the most common type of primary liver cancer in adults. But up to 45% of people with NASH without cirrhosis can develop hepatocellular carcinoma.

Treatment

If you have been diagnosed with fatty liver disease, it is important to keep your liver as healthy as possible and avoid anything that can further damage your liver. Treatment of NAFLD is generally by dietary changes and exercise to bring about weight loss. Decreasing caloric intake by at least 30% or by approximately 750–1,000 kcal/day results in an improvement in hepatic steatosis. In more serious cases, medications that decrease insulin resistance, hyperlipidemia, and those that induce weight loss such as bariatric surgery as well as Vitamin E have been shown to improve or resolve liver function. For those who are severely affected, a liver transplant may be an option.

Here are some important things you should do:

• Don’t drink too much alcohol. How much is too much remains debatable, but it’s probably best to avoid alcohol completely.

• Make sure that none of your medications are toxic to the liver. Even acetaminophen may be harmful if you take too much for too long.

• Get vaccinated to protect against hepatitis A and B.

• Control other health conditions that might also affect your liver, and check with your doctor if you might have other underlying, treatable diseases contributing to your fatty liver.

• Get regular screening tests for liver cancer if you already have cirrhosis.

Unfortunately, there are no FDA-approved medications for fatty liver disease. So far, the two best drug options affirmed by the American Association for the Study of Liver Diseases for biopsy-proven NASH are vitamin E (an antioxidant) and pioglitazone (used to treat diabetes). However, not everyone will benefit from these treatments, and there has been some concern about safety and side effects. If you have NASH, it’s best to ask your doctor whether these treatments are appropriate for you, as they are not for everyone.

Conclusion

Our body has an amazing ability to repair itself. So is our liver. Thus, fatty liver can be reversed. If you avoid alcohol, lose weight, and change your diet it is possible to reduce liver fat, inflammation, and reverse liver damage.

If you have questions regarding fatty liver disease, feel free to schedule a consultation. I will help and work with you and suggest changes that would help you. Who knows? One of the plans we offer might suit your needs. Or if you want to hear from me talk about Lifestyle Medicine, feel free to listen to our podcast or contact us.

Sources:

Armand, Wynne. 2019. “Fatty Liver Disease: What It Is and What to Do About It” Harvard Health Blog. January 10, 2019.

Castera, Laurent, Mireen Friedrich-Rust, and Rohit Loomba. 2019. “Noninvasive Assessment of Liver Disease in Patients with Nonalcoholic Fatty Liver Disease.” Gastroenterology 156 (5): 1264-1281.e4.

Francque, Sven M., Giulio Marchesini, Achim Kautz, Martine Walmsley, Rebecca Dorner, Jeffrey V. Lazarus, Shira Zelber-Sagi, et al. 2021. “Non-Alcoholic Fatty Liver Disease: A Patient Guideline.” JHEP Reports: Innovation in Hepatology 3 (5): 100322.

Wikipedia Contributors. 2019a. “Liver.” Wikipedia. Wikimedia Foundation. July 6, 2019.

———. 2019b. “Fatty Liver Disease.” Wikipedia. Wikimedia Foundation. November 2, 2019. https://en.wikipedia.org/wiki/Fatty_liver_disease.

Lifestyle Medicine: The Foundation of Conventional Medicine

This website mentioned in one of the pages that Lifestyle Medicine is the foundation of conventional medicine. When you think about it, it is true. Lifestyle Medicine is a new subspecialty although it has been practiced for thousands of years.

The current COVID-19 pandemic --- together with its consequential imposed safety protocols, quarantines, and community lockdowns --- has forced us to return to the basics and evaluate our current lifestyles. It has changed our approach to everything and that includes a heightened understanding of the importance of exercise, nutrition, stress management, sleep, social relationships, and avoiding toxic substances. Suddenly, the six main focus of Lifestyle Medicine became the center of public consciousness. This article will explain why and how it is so and will describe the basic structure of Lifestyle Medicine as a medical discipline.

Historical Perspective

To understand better the origins of Lifestyle Medicine, let us compare the causes of death between 1900 and 2019. The figure below shows a big difference.

During the 1900’s, acute and infectious diseases ranked high among the causes of death. You will see that all forms of pneumonia ranked first followed by all forms of tuberculosis.

At that time, the technology in medicine focused on the discoveries of cures. The identification of bacteria, the creation of antibiotics and vaccines, and the improvements in sanitation and hygiene that started in the late 19th century trickled down to the early 1900s in the race for eradicating these infectious diseases.

Yet, in 1918, the Spanish flu pandemic came and caused 20 million deaths worldwide in less than one year. This clearly illustrates how unpredictable the emergence of diseases could be. The appearance of AIDS, the re-emergence of multidrug-resistant TB strains during the 1980s and early 1990s provide additional evidence that as long as microbes can evolve, new diseases will appear. Who would have thought that COVID-19 could be this dangerous?

These infectious diseases underscore the importance of disease prevention through continual monitoring of underlying factors.

However, as time went on, the modern post-industrial era resulted in changes of living conditions and lifestyle behaviors. Scientific and technological advances played a major role and became the foundation for today's disease surveillance and control systems.

But despite the technological advances, by 2019, the leading causes of death became chronic in nature. You will see that heart diseases ranked first followed by all forms of cancer. It is even disturbing that suicide ranked tenth. Studies indicated that most chronic diseases are the result of lifestyles fueled by poor nutrition and physical inactivity. It just shows that there is a correlation between modernity and technologies that developed over time during the 20th and early 21st centuries and the changes in human lifestyles.

Chronic diseases are also responsible for most of our health care expenditures. Since 2010, nearly 18% of the US gross national product has been spent on health care, which exceeded $3.0 trillion in 2015. And with the current COVID-19 pandemic, our healthcare system might be on the verge of bankruptcy. If 1 in 10 individuals in the United States would adopt a healthy lifestyle, the amount of money saved could result in billions of dollars saved.

And that is what medical experts have been talking about the past decades until now. Lifestyle medicine first became a movement then later on it developed into a medical discipline.

Lifestyle Medicine vs. Conventional Medicine

Medical experts defined Lifestyle Medicine as the application of the principles on environment, behavior, and motivation, including self-care and self-management, in the management of chronic diseases which were lifestyle-related in a clinical setting. As mentioned in this website, Lifestyle Medicine is also an evidence-based approach. Below is a comparison between conventional medicine as we know it and Lifestyle Medicine as a discipline.

As you can see, the focus has shifted to the patient himself as it emphasizes self-care and self-management. The doctor acts only as the coordinator and motivator.

In order to prevent further complications of chronic diseases and chronic diseases itself, lifestyle medicine should become the primary approach to its management and prevention. It is time to change the destiny of our health by shifting our attitude toward a healthy lifestyle. That shift should also provide a positive impact which should be carried forward to our children as they mature. It is also our aim that the younger population should be exposed to this healthy lifestyle approach and should begin at a very young age.

The idea that many chronic diseases are simply the result of aging must be corrected. Hypertension, heart disease, diabetes, and osteoarthritis are not inevitable outcomes of aging, but are an end product of poor lifestyles.

There are four areas in conventional medicine where lifestyle medicine could be added: 1) the science (the epidemiology), 2) the art (the skills), 3) the materials (the tools) and 4) the procedures (the actions).

The Science

The dictionary defines “epidemiology” as a branch of medical science that deals with the incidence, distribution, and control of disease in a population. Simply put, it understands the causes of the disease and where the disease is, plus it includes its control and prevention. It was rather easy for infectious diseases to study its epidemiology because medical experts can pinpoint to a single biological cause and can also pinpoint the corresponding cure.

However, when it comes to chronic diseases, it is rather complex. Medical experts cannot pinpoint a single cause, but rather defines its epidemiology in collective terms like “determinants”, “markers”, or “risk factors”. Also, in a recent medical study, the term “anthropogens” surfaced. It is defined as “man-made environments, their by-products and/or lifestyles encouraged by those environments, some of which have biological effects which may be detrimental to human health”. The figure below shows how determinants or risk factors could become chronic diseases over time.

Therefore, a Lifestyle Medicine physician would study the interactions between these determinants of chronic diseases and conditions because all influences, and not just the obvious, need to be managed for optimal health. However, through the decades, leading proponents of lifestyle medicine have faced resistance or marginalization. Yet, studies show that more than 80% of chronic diseases could be avoided by recommending changes to a healthy lifestyle. Also, 80% of the population wants to live in a better state of health but do not know how to pursue it.

The Art

It was only during the last few decades that medicine was considered not just a science but also an art. The practice of Lifestyle Medicine requires huge amounts of motivation which includes both academic and professional skills in behavioral science and change. These skills are used in persuasion, motivation, education, and coaching.

Also, Lifestyle Medicine focuses on the risk factors rather than the disease itself although medical prescriptions are still an adjunct to therapy and medical intervention.

It also zeroes into the problem of poor lifestyle choices based on misinformation. Most patients typically gather their food and nutrition information from popular media rather than from clinicians, many of whom may have limited knowledge of lifestyle interventions. Another factor is the limited time provided in the traditional one-on-one medical consultation.

The Tools

Digital technologies has resulted in an array of lifestyle tools that help monitor and provide feedback to individuals. These self-operated digital gadgets are available to the public and most health-conscious individuals use these to monitor their blood pressure, blood sugar, heart rate, etc. This behavior has shifted the patients’ role from a minimally-informed recipient to an active collaborator. Thus, Lifestyle Medicine tools center on the concept of the “quantified self”. Patients now have the responsibility and control to measure what needs to be measured and monitored.

The Procedures

There are still several existing procedures in conventional medicine such as referrals, medication, and surgery (if needed) that are used in the practice of Lifestyle Medicine. I incorporate Lifestyle Medicine in my practice of Internal Medicine although there are new procedures that are unique to Lifestyle Medicine like shared medical appointments for the Group Starter Program and telephone triaging during the free medical consultation.

Integrating Lifestyle Medicine into clinical practice in the areas of food, nutrition, exercise, and stress reduction is now common. Creating change takes courage and a willingness to think creatively as we shift our medical system.

There are professional associations in Lifestyle Medicine in 18 countries around the world and still counting. The structure and pedagogy of Lifestyle Medicine as a medical discipline is still in its infancy. That is why sharing best practice models among peers will result in the most effective care of our patients.

Conclusion

Chronic diseases predominate the leading causes of death in the recent decade. But since there is no single cause for chronic diseases, medical experts describe its epidemiology collectively as risk factors. Studying these risk factors points out to lifestyle as the bottom line and over time, what first became a movement became a medical discipline called Lifestyle Medicine. Also, Lifestyle Medicine adds to the science, the art, the tools and the procedures of conventional medicine. Although Lifestyle Medicine is now recognized worldwide, it is still a medical discipline in progress.

Should you be interested in Lifestyle Medicine, feel free to schedule a consultation. Who knows? There is a health program that might suit your need. If you want to hear from me discuss more about Lifestyle Medicine, feel free to listen to my podcast. If you want to be updated with news and features from this website, subscribe to my newsletter or reach out using the contact form below.

Sources:

Birrell, Fraser. 2020. “Inaugural Lifestyle Medicine Editorial.” Wiley Lifestyle Medicine. May 15, 2020.

Bodai, Balazs, Therese Nakata, William Wong, Dawn Clark, and Steven Lawenda. 2017. “Lifestyle Medicine: A Brief Review of Its Dramatic Impact on Health and Survival.” The Permanente Journal. September 17, 2017.

Centers for Disease Control and Prevention. n.d. “Leading Causes of Death, 1900-1998.” Centers for Disease Control and Prevention. Accessed March 17, 2021.

---. “Leading Causes of Death.” National Center for Health Statistics, Centers for Disease Control and Prevention.

Egger, Garry. 2019. “Lifestyle Medicine: The ‘Why’, ‘What’ and ‘How’ of a Developing Discipline.” Australian Journal of General Practice. October 2019.

Merriam-Webster, Inc. n.d. “Epidemiology.” Merriam-Webster Dictionary. Accessed March 19, 2021.