Fatty liver is commonly present in patients with Prediabetes, Type 2 diabetes and Metabolic Syndrome. Often, it remains undiagnosed and untreated until it is too late. In this article, I share my approach to diagnose and treat this common medical disorder.
What is Fatty Liver?
Fatty liver means there is excess deposition of fat in your liver. In medical terms, it is called NAFLD (Non-Alcoholic Fatty Liver Disease), which simply means increased deposition of fat in your liver. Sometimes, fatty liver can lead to inflammation of the liver cells, which is called NASH (Non-Alcoholic Steato-Hepatitis). Often, you don’t have any symptoms due to this condition. However, in some cases it can lead to cirrhosis of the liver, which is a very serious disease and can be fatal.
What Causes Fatty Liver?
In most patients, fatty liver results from abnormal fat metabolism in the liver which is due to underlying insulin resistance. Obesity and in particular abdominal obesity seems to play a central role in causing fatty liver.
Insulin resistance in the fat cells leads to increased breakdown of fat. Subsequently, there is an increased level of free fatty acids in the blood stream. As a result, there is an increased entry of free fatty acids into the liver.
Inside the liver, there is a high level of insulin in these patients with insulin resistance. Now high insulin level promotes increased synthesis of fat from free fatty acids in the liver. As a result, there is an increased accumulation of fat in liver cells.
In addition, there is excessive oxidative stress in the presence of insulin resistance. It can initiate cell death and scarring inside the liver.
For this reason, in any individual with clinical features of insulin resistance syndrome and an abnormal liver function test, NASH should be on top of the list of possible diagnosis.
How to Diagnose Fatty Liver – NASH (Non-Alcoholic Steato-Hepatitis)
Ultrasound of the Liver
can detect moderate to severe fat accumulation in liver, but fails to diagnose fatty liver if fat accumulation is less than 18 %. Inaddition, ultrasound of the liver can be difficult in these patients who are often obese. Also, it cannot distinguish between simple fatty liver and NASH.
CT Scan of the Liver
In the same way, a CT scan can diagnose moderate to severe fat accumulation in the liver, but the scan can be normal in mild cases.
MR spectroscopy (Magnetic Resonance Spectroscopy)
A new technology called MR spectroscopy (Magnetic Resonance Spectroscopy) appears to be a promising imaging modality to diagnose fatty liver and NASH. But is available at only a few academic centers and is expensive.
Liver biopsy is supposedly the gold-standard method to diagnose fatty liver – NASH. But it is invasive, costly and impractical considering the vast number of patients afflicted with fatty liver. Even when liver biopsy is performed, a single core biopsy may miss the diagosis of NASH. For this reason, you have to do multiple core biopsies of the liver.
Practical Approach To Diagnose Fatty Liver – NASH (Non-Alcoholic Steato-Hepatitis)
Since 2000, we have been carefully investigating abnormal liver enzymes in patients with any 2 of the following features of Insulin Resistance Syndrome :
- Abdominal obesity.
- Triglycerides more than 150 mg/dl.
- HDL cholesterol less than 40 mg/dl in males, 50 mg/dl in females.
- Type 2 diabetes
Criteria for the Diagnosis of NASH (Non-Alcoholic Steato-Hepatitis)
In patients with Insulin Resistance Syndrome, we use the following clinical parameters to identify patients with NASH.
- Presence of at least 2 of the features of Insulin Resistance Syndrome.
- Elevated ALT (alanine aminotransferase) more than 45 U/L
- Use of alcohol limited to no more than 2 drinks (about 20 g) per day.
- Negative serology for Hepatitis A, B, and C .
- Absence of a drug known to cause liver injury.
ALT (alanine aminotransferase), AST (aspartate aminotransferase), bilirubin, and albumin are blood tests for liver function. These tests are included in most blood chemistry panels. Elevation in ALT and AST is usually the first indication of liver disease including fatty liver. In more advanced cases of liver disease, serum bilirubin is also elevated, and serum albumin goes down.
The most common causes for abnormal liver function include fatty liver, drugs, alcoholism, and hepatitis. Your physician needs to carefully look into these common causes for abnormal liver function.
Comprehensive Treatment Of Fatty Liver (NAFLD and NASH)
The treatment of NASH is often unsuccesful as physicians typically focus only on the drugs. On the other hand, I believe that treatment of NASH should be comprehensive with a focus on treating its root cause, which is insulin resistance.
I utlize my 5-step approach to treat insulin resistance in my patients with fatty liver in the same way as I use it to treat Prediabets or Type 2 diabetes (except for the section on medications.) With this approach, I have seen good results in my patients.
Scientific studies concur with my treatment approach. For example, a weight loss of more than 7% is found to be effective in the treatment of NASH.1
Please refer to Diet For Type 2 Diabetes to learn about my diet that works not only for Type 2 diabetes, but is also an effective diet for weight loss.
Dietary Supplements To Treat Fatty Liver
- Vitamin E can reduce fat deposition and inflammation in NASH. But it may not reduce fibrosis.Vitamin E dose is 800 IU per day. However, its safety for long-term use – after 6 months – is not clear.
- Omega 3 fatty acid – in a dose of more 830 mg per day – is somewhat beneficial for patients with fatty liver and NASH.
Drugs To Treat Fatty Liver
Drugs alone are somewhat effcetive to treat fatty liver – NASH. For example, in a placebo-controlled study, researchers found Actos (pioglitazone) to be somewhat effective – and safe – in treating NASH patients who also had pre-diabetes or Type 2 diabetes.2
Metformin has been studied mostly in small uncontrolled trials. In one small study, researchers noticed some beneficial effects of metformin on fatty liver disease.3
- Belfort R1, Harrison SA, Brown K, Darland C, Finch J, Hardies J, Balas B, Gastaldelli A, Tio F, Pulcini J, Berria R, Ma JZ, Dwivedi S, Havranek R, Fincke C, DeFronzo R, Bannayan GA, Schenker S, Cusi K. A placebo-controlled trial of pioglitazone in subjects with nonalcoholic steatohepatitis. N Engl J Med. 2006 Nov 30;355(22):2297-307.
- Marchesini G, Brizi M, Bianchi G, Tomassetti S, Zoli M, Melchionda N. Metformin in non-alcoholic steatohepatitis. Lancet. 2001 Sep 15;358(9285):893-4.
Excerpts from my book, “Reverse Your Type 2 diabetes Scientifically”