The liver is a marvel of human biology, performing more than 500 essential functions (1) and having the superpower of regeneration. It is the only human organ that can regrow itself to its original size, even if up to 90% of it has been removed (2). Yet despite an impressive list of functions and abilities, certain conditions can "harm it beyond the point of repair” (2). One of the health conditions that can compromise a liver is fatty liver disease (FLD), a potentially hazardous state of health that, if caught early, can be slowed down and even restored to complete health.
At Temecula Center for Integrative Medicine (TCIM), our approach is to discover potential health issues early, so there is time to bring our patients back to a healthy state before they suffer life-threatening health situations. We can do just that through various screenings at the executive physical. There are several health conditions that most people won't have; however, the few people that do could face very grave consequences. We can catch those developing health conditions early in our executive physicals by additional screening for those who need it. We're particularly passionate about screening the liver because FLD is a common "silent disease.” Despite rising numbers in the US population, fatty liver disease can be reversed (3, 4). The sooner FLD is detected, the better odds there are of reversing the condition completely. The key is prevention and regular screening!
Fatty Liver Disease - How Does it Develop? Is it Serious?
The liver does an extraordinary amount of work in the human body, including certain vital functions that include (1):
Rendering toxic substances in the blood safe through a 2-step detoxification process
Clearing and breaking down medications from the blood
Producing transporters of fats (cholesterol)
Removing bilirubin from the blood
The liver needs energy to perform its many functions, so it converts dietary carbohydrates, proteins, and fats for its own use. Sometimes the liver has more potential energy coming in from food than it can process and use. In this situation, the liver gets overwhelmed (especially with over-consumption of sugars), so it converts and then stores the resulting fat in its own tissues rather than converting the food particles to substances that can leave the liver. A normal, healthy liver will always have a small percentage of fat. A liver that gets overwhelmed by excess food molecules gets increasingly fatty until the percentage of fat is so high it can be diagnosed as fatty liver disease (FLD).
The majority of people will escape the negative repercussions of a fatty liver, so most people will never have to grapple with this situation. However, statistics indicate that a percentage of people, estimated between seven and thirty percent, will develop more severe problems (5).
The liver can produce scar tissue where it is damaged, leading to a thickening of the tissue called fibrosis. When the conditions that create fibrosis continue for long periods and are left undiscovered and untreated, it increases the risk of liver cirrhosis, a disease characterized by extensive, irreversible scarring (5).
Addressing the health condition early prevents the extensive scarring that limits optimal liver performance, preventing a negative feedback loop that could end in liver failure or even organ death.
Types of Fatty Liver Disease
Fatty liver diseases are typically sorted into two categories depending on whether or not alcohol is involved.
1. Alcohol-related FLD - Alcohol-related fatty liver disease affects about 5% of the US population (5). Alcohol damages liver tissue even as the liver attempts to detoxify it. The liver prioritizes processing alcohol over many of the liver's other functions, so fat gets deposited into nearby tissues at increasing rates.
When diagnosed with alcohol-related FLD, the consequence to be aware of is liver scarring. Typically, the liver swells with inflammation while it detoxifies alcohol. Afterward, the liver shrinks back to its average size. It is thought that the process of repeatedly swelling and shrinking contributes to the thickening of the liver tissue (fibrosis). With prolonged consumption or extreme amounts of alcohol (typical in cases of alcohol abuse), this damage can cause extensive scar tissue called alcoholic cirrhosis. Cirrhosis is a dangerous medical condition that requires intense medical supervision.
2. Non-Alcoholic Fatty Liver Disease (NAFLD) - In NAFLD, the fatty liver is not due to alcohol. The effect is similar to alcohol-related fatty liver, as the liver creates fat deposits in its own tissue in a way that could become detrimental. The exact cause of NAFLD is unknown, though multiple risk factors stemming from diet, lifestyle, and genetics have been identified (5). Non-alcoholic fatty liver disease is much more prevalent than alcohol-related fatty liver - nearly a third of adults and a tenth of children in the US have NAFLD (5). This is an alarming statistic because having untreated NAFLD increases the risk of liver cancer (5).
One source explains that NAFLD, a term used since the early 1980s, is now being replaced with the term MAFLD, "metabolic associated fatty liver disease” (6), which highlights the frequent involvement of metabolic disorders as drivers for the disease. However, the vast amount of online literature is still using the term NAFLD up to this day, but both terms refer to the same disease state.
NAFLD can be sorted further into two types:
Non-Alcoholic Fatty Liver (NAFL) - This condition is characterized by fatty deposits in the liver, but very little (or no) inflammation or liver tissue damage. This is a less severe version of NAFLD that presents some risks and yet may not result in complications, especially if caught and treated early (7). Fortunately, this is the most prevalent form of NAFLD.
Non-Alcoholic Steatohepatitis (NASH) - NASH is the more severe form of NAFLD which not only includes fatty deposits but also indicates high levels of tissue inflammation and liver cell damage (7). NASH is characterized as aggressive and can end in the extensive scarring of cirrhosis (as alcohol-related liver disease might) or even failure of the liver (8). Fortunately, this more severe form is not very common; only about 1.5% to 6.5% of adults in the US get diagnosed with NASH (7).
Fatty liver disease can be insidiously quiet, developing without noticeable symptoms. By the time symptoms occur, it can be quite far into the disease process, generally when cirrhosis has developed. Symptoms may include (9):
Nausea, weight loss, little or no appetite
Abdominal pain or pain below the right ribcage
Jaundice (yellow tinge of skin and eyes from bilirubin not being removed from the blood by the liver)
Edema (swelling of the legs and extremities)
Ascites (painful, abnormal swelling of the abdomen)
Disorientation or confusion
Risk Factors for Non-Alcoholic Fatty Liver Disease
Many factors can increase the risk of developing a fatty liver, and although the exact causes of non-alcoholic fatty liver have not been determined, numerous risk factors have been identified (5).
As the body's primary detoxifier, the liver processes all medications. Unfortunately, some medications are known to be harsh on the liver. A comprehensive list of prescribed and over-the-counter medications (ranked by level of concern for damaging the liver) is listed on the FDA website.
Besides processing beneficial medications, the liver also processes toxins such as alcohol and tobacco, and recreational drugs (12). With that in mind, here are some additional risk factors (5, 8, 12-13):
Taking particular medications from broad classes, such as antibiotics, over-the-counter pain medications (such as acetaminophen), and some drugs for treating cancer, anxiety, and immune disorders
Being of Asian or Hispanic race
Being obese, especially if there is a large amount of excess weight around the middle
Having certain chronic diseases: insulin resistance, prediabetes, diabetes, high cholesterol, high blood pressure, metabolic syndrome
Experiencing sleep apnea (interruption of airflow during sleep)
Having underactive glands (thyroid or pituitary)
For alcohol-related fatty liver, the cause is the over-consumption of alcohol. There may be other factors combined, but the deciding factor for this category is the addition of drinking alcohol. "Heavy drinking" of alcohol is said to be 8+ drinks for women and 15+ drinks for men per week (10). Consistent heavy drinking increases risks for various health conditions, including liver diseases. Over 90% of those who consume between 4 and 5 alcoholic beverages daily develop steatosis (fatty deposits in the liver) (11). Besides consistent heavy drinking, consuming a high number of alcoholic drinks within a short period of time (4-5 drinks in under 2 hours, also known as "binge drinking") can also drive steatosis (11).
Combining high alcohol intake with any of the risk factors of non-alcoholic fatty liver could speed up damage to the liver.
Prevention - How Can I Avoid This Whole Scenario?
Taking care of key health aspects can keep you active and vibrant for more years, saving you time, money, and heartache. TCIM has identified five pillars of health, which we cover in our article on strengthening immunity. Mastery of these five aspects of health provides a firm foundation for becoming the healthiest you can be. Preventing fatty liver disease may also include (5):
1) Annual ultrasound screenings - During an executive physical, a TCIM doctor may encourage a non-invasive ultrasound scan to confirm healthy liver tissue (free of large fatty deposits or fibrosis). Since fatty liver often has no symptoms, this is a simple but powerful way to confirm liver health.
2) Exercise (one of the five pillars of health) helps reduce fatty liver - An analysis of results from 28 trials confirmed that exercise reduced the number of fatty deposits in those with NAFLD, and reduced indications of liver damage in blood tests (16). One easy way to increase the impact of exercise is through high intensity interval training (HIIT). HIIT involves alternating high effort followed by low effort in cycles, which helps condition the heart, increase metabolism, and burn more fat. HIIT walking would involve walking fast for 30 seconds followed by 90 seconds of walking slowly or standing still, then repeating this cycle up to eight times. Many people may be doing this while walking their dog without even thinking about it!
3) A healthy diet (one of the five pillars of health) helps- One specific example is the Mediterranean diet. Studies show that it helps a variety of chronic illnesses and has a positive impact on the liver (17). The Harvard Health Publishing site shows an example of how to implement a Mediterranean diet. Low amounts of sugar, fresh vegetables, whole grains, and healthy fats characterize the Mediterranean menu. Working with a Nutritionist can help tailor your diet in small steps.
4) Maintain a healthy weight for your frame - Being overweight is associated with a higher risk for many chronic illnesses (which create higher risks for liver disorders). TCIM can provide medical and non-medical help to reduce weight, if necessary.
5) Reduce or eliminate alcohol consumption - There was a time that moderate drinking was considered protective of health. However, two recent studies have challenged that thinking (18). If you don't drink, there appears to be less reason to begin. If you do drink, it's advised to restrict it to a maximum of one drink a day for women and two drinks a day for men (10). Most people recognize when they have a drinking problem, and we highly encourage people with this issue to seek help for quitting. TCIM can offer medical and non-medical support during alcohol withdrawal or refer you to resources for additional assistance.
6) Manage chronic diseases- Having prediabetes or diabetes, high blood pressure, high cholesterol (especially high triglycerides), or metabolic syndrome increases the risks for FLD. Getting proper treatment for these diseases can not only make you feel better and help you lose weight- but can also reduce risks for FLD and many other conditions.
7) Quit Smoking- Cigarettes contain many chemicals that the liver must break down to render harmless, including acetone, arsenic, tar, and carbon monoxide (which is also found in car exhaust). If you're a smoker and ready to quit, we'll help you find (and stick to) a cessation program.
Diagnosis & Potential Treatments:
The diagnosis of NAFLD, NAFL, or NASH can be accomplished through various tests, analysis of symptoms, patient history, and physical examination. The doctor may decide the best test to determine the liver's health would be to "look" directly at the organ using ultrasound. Ultrasound scans of the liver can detect tissue damage, including the hardened, thickened tissue that indicates fibrosis. Large fatty deposits can also be seen, and if they are large enough, their size can be measured. This rather direct visual inspection (which TCIM can do during an executive physical) can aid the early detection of a problem, giving the doctor and patient plenty of time to head off complications.
There is no standard medical treatment for NAFLD (9). In some circumstances, medications may be advised because there is a net benefit- especially when other chronic illnesses are involved. However, Integrative Medicine offers many things besides prescribed medications that can help ease the burden on a liver and help it heal. For example:
Nutrition consultation - Since a fatty liver indicates an overwhelmed or dysfunctional liver, small but impactful changes to your diet can detoxify, nourish, and help reduce the burden on the liver. Additionally, many nutritional supplements reduce inflammation with few or no side effects. Our team can help select the best supplements and dosages for your situation. Berberine, milk thistle, and antioxidants (such as vitamin C and glutathione) all have long histories of addressing liver ailments.
IV therapy - Antioxidants, oxygen (in the form of ozone), and vitamins can be delivered to tissues directly through the blood, which can help reduce inflammation, giving the liver what it needs to help heal and repair itself.
Coffee enemas or colon hydrotherapy - Enemas and colon hydrotherapy help the body flush wastes out. Coffee enemas can also help purge the ducts between the liver and the gallbladder, assisting the body to clean and heal itself.
Schedule an Appointment for an Executive Physical
Liver testing can be done during TCIM's two-part Executive Physical if your risk factors are high or your lifestyle habits or symptoms indicate it's prudent. We highly encourage heavy drinkers to request a liver ultrasound so it can be part of the discussion during the appointment. This one act of being proactive could help us, as a team, to strengthen and protect your liver, steering you towards better health and away from potential harm. If your last physical was long ago or you didn't get a liver ultrasound, please consider calling and scheduling your Executive Physical today.
Jonathan Vellinga, MD is an Internal Medicine practitioner with a broad interest in medicine. He graduated Summa cum laude from Weber State University in Clinical Laboratory Sciences and completed his medical degree from the Medical College of Wisconsin.
Upon graduation from medical school, he completed his Internal Medicine residency at the University of Michigan. Dr. Vellinga is board-certified with the American Board of Internal Medicine and a member of the Institute for Functional Medicine.
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