Most of my male patients over forty reports a diagnosis of mild fatty liver. The prevalence of Non-alcoholic fatty liver (NALFD) has been significantly underestimated. Currently, around a third of the world’s population is thought to have some fatty liver.[1]
In Asia, the prevalence of fatty liver is also significantly rising. One study from 2022 stated that NAFLD is a significant health problem as a once-low prevalence has now increased to thirty-five per cent.[2]
Initially, fatty liver is asymptomatic.
This lack of apparent symptoms means, for many, you won’t even know it’s developing.
Based on this and the possibility that fatty liver may occur despite “normal” liver function tests, several studies have shown the underdiagnosis of fatty liver.[3]
Most men who attend my clinic remember to tell me at the end of their initial or second sessions that they have “mild fatty liver.”
In some unfortunate cases, just a comment about mild fatty liver is as far as it goes when it comes to taking action.
In this article, we’ll break down what fatty liver is, how it’s diagnosed, why you need to know about it early, the best tests to do beyond your blood exams, and finally, what the evidence says about how natural medicine can help.
Until recently, non-alcoholic fatty liver disease has been the preferred definition. However, fatty liver, for most, is primarily a metabolic issue. For example, we discussed above that around thirty-five per cent of people globally have a fatty liver to some degree. In people living with obesity, this prevalence can increase to over fifty per cent.[4]
These statistics have the international consensus recommending a new term – metabolic-associated fatty liver disease (MAFLD).[5] Another particularly appropriate statistic, in this case, is that those with MAFLD have a two-fold risk of developing type-2 diabetes.[6]
My interpretation of this is that there could be a third of the world’s population who are unknowingly prediabetic.
I don’t want to sound alarmist or overly exaggerated about it, but if I see an overweight male over forty in the clinic, I expect some form of fatty liver.
Crazy, isn’t it?
How to check if you feel you have fatty liver.
I mentioned earlier that typically, fatty liver is asymptomatic. There is evidence to suggest that people with fatty liver generally have a poorer quality of life.
A study released in 2022 found that people with fatty livers commonly experience daytime sleepiness. This daytime drowsiness contributes to the poor health-related quality of life.[7]
Aside from these more subjective symptoms, which other things could cause, most people learn about their fatty liver from their annual blood test.
Within the liver function panel, three liver enzymes marked as ALT, AST and GGT. In the test, these markers will often appear elevated—the ALT marker, in particular, a signature of a fatty liver.
Now here is where there seems to be a crossroads when it comes to underdiagnosis.
For some cases, these mildly elevated markers will result in a comment of “mild fatty liver.”
And that’s it.
“Let’s recheck how things are going next year.”
Natural medicine sees these tests a little differently.
Not better. Just different.
In our modality, we look at blood tests to help diagnose things that need attention and, in some cases, referral. More importantly, in the context of our fatty liver conversation, we look at trends that could help us catch something early.
Referring back to the elevated ALT, AST and GGT enzymes above. Generally, if we see these trending above twenty across the board, we look to take action even though they are considered normal in a pathological sense.
Why?
The first reason is simple – prevention is the best form of cure. The second reason is that if we see markers trending above twenty now, where might they be in six months or next year when the next annual check comes around?
Now, fortunately, instead of rushing into treatment at this point, you can define what a “mild fatty liver” actually means using a special kind of ultrasound can be used called a Fibroscan.
A fibroscan can help us find out two things.
The first is a percentage of how “fatty” the liver really is. The second represents how the fatty liver has progressed into a more serious place called fibrosis. In short, fibrosis represents the potential of the fatty liver to move into something called non-alcoholic steatohepatitis (NASH). NASH is classically harder to reverse, but also where cancer [8] and cardiovascular risk derived from fatty liver goes up.[9]
From a diagnostic and treatment point of view, it’s then possible to have a clearer idea of which interventions are necessary.
For example, for those whose fibroscan results show over half their liver to be fatty, dietary measures and natural medicine prescriptions might be necessary to get the best results.
What treatments help fatty liver?
Ideally, if it is a parallel issue, weight loss should be the primary aim. For some, it may not be as simple as just going away and getting it done. So let’s deconstruct some of the more practical recommendations.
Weight loss equal to five per cent improves liver fat and liver enzymes.[10] Weight loss equal to or above seven per cent, particularly equal to ten per cent or above, saw NASH resolution and fibrosis improvement.[11]
An important note is that in the previous study, which saw weight loss equal to or over ten per cent, the lifestyle changes lasted for one year!
It goes to show that losing weight is often easier said than done. It can take time.
What’s one of the vital things to do regarding weight loss for fatty liver?
Sometimes the first thing is to get a clearer idea of the goal. For example, if your current weight is 80 kilograms, then ten per cent equals eight kilograms.
Five per cent equals four kilograms!
Remember, for fatty liver, even a five per cent change can help bring down some of the liver enzymes and be corrective for the “milder” versions of fatty liver.
One evidence-based dietary change seems to be agreed upon to help with fatty liver.
And that’s restricting dietary sources of fructose or fruit sugar. Consumption of fructose in people with fatty liver was nearly two to three times higher than healthy controls when studied in 2008.[12]
High levels of fructose in the western diet come from high-fructose corn syrups used in soft drinks and other processed foods. Out of all the sugars, fructose seems to trigger the generation of fat cells in the body the most. High levels of fructose can lead to inflammation in the liver as well.[13]
What foods are high in fructose?
The levels of fructose depend on which region you are in around the world. For example, fructose is one of the most commonly used sweeteners in the USA. Other fruits and vegetables, such as watermelon and apples, contain high levels of fructose. However, apples also have other compounds, such as pectin, which research has shown to correct fatty liver in animals.[14]
Let’s start simply.
If you were to honestly assess the number of soft drinks and sweetened foods you eat and found your daily consumption to be reasonably high, this is the first place to start.
If you don’t consume many of these foods or don’t at all, then it’s time to look a little closer at your fruit and vegetable consumption. I rarely recommend taking fructose out of people’s diets for longer than six weeks, but even four weeks should be good enough.
Alcohol is a significant consideration here as well. Mainly down to the things we mix our alcohol with, cocktails, for example.
Once the diet is under control, herbal and nutritional measures can also help.
Let’s look at two of the best ones according to the evidence.
Berberine is a constituent found in numerous different herbs around the world. Originally its use has been widespread in natural medicine for having a positive effect on the microbiome.
To give you a sense of how long Berberine has been in use, there are records of its use in traditional Chinese medicine for over three thousand years!
Berberine reduces ALT and AST levels in type-2 diabetes patients.[15]
In another study, one hundred eighty-four patients with NAFLD were given berberine and lifestyle intervention over sixteen weeks. Researchers looked at another group using lifestyle intervention on its own, and another using a drug called pioglitazone studied together simultaneously.
Berberine and lifestyle changes reduced the amount of fat in the liver and improved body weight compared to the other groups.[16]
This a great example of how dietary intervention and herbal medicine can work together. I’m sure with the rapid introduction of MAFLD or the metabolic version of fatty liver, that Berberine will become more of a cornerstone of successful treatment.
A lesser-known form of Vitamin E has significant effects on fatty liver.
I got put onto this via a lecture I attended in Nashville, TN, presented by the esteemed biochemist Barry Tan.
Aside from being one of the people I never miss at a conference, Barry Tan has donated almost three decades of his life to fat-soluble vitamins. One of which is improving vitamin e absorption and benefit.
A source of vitamin E from Annatto called delta-tocotrienols has remarkable effects on fatty liver. Over twenty-four weeks, thirty-five people used delta-tocotrienol compared to thirty-six people who used a placebo.
The results showed a significant change in favour of vitamin E compared to the placebo in not only the ALT and AST enzymes we’ve touched from your blood tests but the inflammation in the liver as well.[17]
So what’s the moral of the story here?
If you’ve been told you have “mild fatty liver”, then it’s an excellent opportunity to ask a few more questions or even get things investigated more thoroughly to find out exactly “how fatty.”
We’ve seen that there are some things you can do to reverse the process and take control of your mild fatty liver. Using a combination of the proper testing, diet and natural medicine, you don’t have to wait and see if things get worse in your next annual exam.
Hope this helps xx
References
[1] Riazi K, Azhari H, Charette JH, et al. The prevalence and incidence of NAFLD worldwide: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol. 2022;7(9):851-861. doi:10.1016/S2468-1253(22)00165-0
[2] Yip TC, Lee HW, Chan WK, Wong GL, Wong VW. Asian perspective on NAFLD-associated HCC. J Hepatol. 2022;76(3):726-734. doi:10.1016/j.jhep.2021.09.024
[3] Nielsen EM, Anderson KP, Marsden J, Zhang J, Schreiner AD. Nonalcoholic Fatty Liver Disease Underdiagnosis in Primary Care: What Are We Missing?. J Gen Intern Med. 2022;37(10):2587-2590. doi:10.1007/s11606-021-07197-3
[4] Li J, Ha A, Rui F, et al. Meta-analysis: global prevalence, trend and forecasting of non-alcoholic fatty liver disease in children and adolescents, 2000-2021. Aliment Pharmacol Ther. 2022;56(3):396-406. doi:10.1111/apt.17096
[5] Eslam M, Sanyal AJ, George J; International Consensus Panel. MAFLD: A Consensus-Driven Proposed Nomenclature for Metabolic Associated Fatty Liver Disease. Gastroenterology. 2020;158(7):1999-2014.e1. doi:10.1053/j.gastro.2019.11.312
[6] Targher G, Corey KE, Byrne CD, Roden M. The complex link between NAFLD and type 2 diabetes mellitus – mechanisms and treatments. Nat Rev Gastroenterol Hepatol. 2021;18(9):599-612. doi:10.1038/s41575-021-00448-y
[7] Li W, Kadler BK, Brindley JH, et al. The contribution of daytime sleepiness to impaired quality of life in NAFLD in an ethnically diverse population. Sci Rep. 2022;12(1):5123. Published 2022 Mar 24. doi:10.1038/s41598-022-08358-y
[8] White DL, Kanwal F, El-Serag HB. Association between nonalcoholic fatty liver disease and risk for hepatocellular cancer, based on systematic review. Clin Gastroenterol Hepatol. 2012;10(12):1342-1359.e2. doi:10.1016/j.cgh.2012.10.001
More references!
[9] Kasper P, Martin A, Lang S, et al. NAFLD and cardiovascular diseases: a clinical review. Clin Res Cardiol. 2021;110(7):921-937. doi:10.1007/s00392-020-01709-7
[10] Romero-Gómez M, Zelber-Sagi S, Trenell M. Treatment of NAFLD with diet, physical activity and exercise. J Hepatol. 2017;67(4):829-846. doi:10.1016/j.jhep.2017.05.016
[11] Vilar-Gomez E, Martinez-Perez Y, Calzadilla-Bertot L, et al. Weight Loss Through Lifestyle Modification Significantly Reduces Features of Nonalcoholic Steatohepatitis. Gastroenterology. 2015;149(2):367-e15. doi:10.1053/j.gastro.2015.04.005
[12] Ouyang X, Cirillo P, Sautin Y, et al. Fructose consumption as a risk factor for non-alcoholic fatty liver disease. J Hepatol. 2008;48(6):993-999. doi:10.1016/j.jhep.2008.02.011
[13] Vos MB, Lavine JE. Dietary fructose in nonalcoholic fatty liver disease. Hepatology. 2013;57(6):2525-2531. doi:10.1002/hep.26299
[14] Li W, Zhang K, Yang H. Pectin Alleviates High Fat (Lard) Diet-Induced Nonalcoholic Fatty Liver Disease in Mice: Possible Role of Short-Chain Fatty Acids and Gut Microbiota Regulated by Pectin. J Agric Food Chem. 2018;66(30):8015-8025. doi:10.1021/acs.jafc.8b02979
[15] Imenshahidi M, Hosseinzadeh H. Berberine and barberry (Berberis vulgaris): A clinical review. Phytother Res. 2019;33(3):504-523. doi:10.1002/ptr.6252
[16] Yan HM, Xia MF, Wang Y, et al. Efficacy of Berberine in Patients with Non-Alcoholic Fatty Liver Disease. PLoS One. 2015;10(8):e0134172. Published 2015 Aug 7. doi:10.1371/journal.pone.0134172
[17] Pervez MA, Khan DA, Slehria AUR, Ijaz A. Delta-tocotrienol supplementation improves biochemical markers of hepatocellular injury and steatosis in patients with nonalcoholic fatty liver disease: A randomized, placebo-controlled trial. Complement Ther Med. 2020;52:102494. doi:10.1016/j.ctim.2020.102494
