33% of the UK population have Non-alcoholic Fatty Liver Disease (NAFLD), and many of them don’t even know they have it.
Feeling tired even after sleeping well?
Are you bloated for no reason?
Is your skin dry and itchy?
Skinny Liver will show you how to harness the power of your liver and its 300+ functions to revolutionise your mind, body and reverse non-alcoholic fatty liver disease. The four-week programme shares the steps you can take to get your liver health back on track, with everything from exercise to healthy eating and other simple lifestyle changes – along with delicious liver-friendly recipes.
Award-winning dietitian Kristin Kirkpatrick and hepatologist Dr Ibrahim Hanouneh have created a life-changing plan that will help you achieve optimal health. Their authoritative, easy-to-follow guide is not just for your most essential organ, but for your whole body.
Kristin Kirkpatrick, MS, RD, LD, is the manager of Wellness Nutrition Services at the Cleveland Clinic Wellness Institute in Cleveland, Ohio. She is a regular guest on national television shows, including The Dr Oz Show, NBC Nightly News, and the Today Show.
Ibrahim Hanouneh, MD, Dr Hanouneh currently works with Minnesota Gastroenterology, specializing in the diagnosis and treatment of adult and paediatric digestive system and liver disorders.
FOR JAKE & BODEN—
every word I write, every breath I breathe, and every action I take is for you.
Michael F. Roizen, MD,
Professor and Chief Wellness Officer, Cleveland Clinic
This book has changed how I think. It’s made me realize how important and how easy it is to keep my liver younger so it can keep me younger.
And it has changed how I advise patients. Before 1990, most docs not specializing in liver diseases assumed that the liver was pretty resilient: if stressed by a one-night alcohol excess, it will recover, assuming it’s no longer abused with alcohol or hasn’t been attacked by a virus. The popular view was that liver diseases only affected people who abused their liver with alcohol or that the diseases were largely preventable. And after all, your liver would regenerate. If you allow me a quick diversion from medicine before 1990 to mythology, I want to quickly tell the story of Prometheus.
Prometheus gave fire to the humans. His punishment from the gods for committing such a crime: the poor fellow was chained to a rock, where a vulture would peck out his liver. Amazingly, his liver would regenerate overnight. We’re not sure how the Greeks knew of the liver’s power, though it may be because they survived injuries to the organ in battle. While the Greeks were on to something, we’re pretty certain that they didn’t have as much insight into the liver as the scientific world did in 1990—and does today. The good news is that this myth was largely right. But doctors have also needed to learn a thing or two in the last thirty years.
Up until about 1990 only 1 percent of us suffered loss of energy and vitality due to what we did to our liver with food and other lifestyle and toxin challenges. But that has changed: now 30 percent of Americans are afflicted with fatty liver disease—and with that, a lack of energy and a host of other problems. Remember Morgan Spurlock? In his film Super Size Me, he documented a month of eating nothing but fast food. The consequences? His weight and LDL cholesterol zoomed up, he felt lethargic and depressed, and, said one of his doctors, his liver turned into pâté. Now, that might not be the standard definition of nonalcoholic fatty liver disease (NAFLD), but it sure paints a vivid—and accurate—picture of a condition that afflicts a third of all Americans.
In Part 1 of this book, Kristin Kirkpatrick and Ibrahim Hanouneh summarize the full picture of liver diseases and especially fatty liver disease. NAFLD is the infusion of liver cells with fat, caused by insulin resistance, obesity, diabetes, elevated triglycerides, and poor nutrition. As they explain, as you put on weight, your body becomes insulin resistant. When that happens, you can’t use insulin efficiently to shuttle sugar into your cells for energy. Instead, sugar gets stored in your liver as fat—and soon you’ve got NAFLD. And then you are at risk for some major conditions, such as cirrhosis or liver cancer.
Making the lifestyle changes that appear in the plan in Part 2, such as the suggestions for avoiding fast food (remember Morgan!), and learning how to prepare “love your liver” foods inexpensively and quickly will help you become less insulin resistant and thin that fatty liver (and yes, you will learn why eating liver may be one of the worst choices you can make for the health of your liver!). You can continue to make your liver healthier—and lose waist and weight—by following the simple Skinny Liver Plan in Part 3. You’ll learn the basics to make and keep your liver skinny—and give you more energy every day.
Kristin Kirkpatrick with Ibrahim Hanouneh have taught me how to treasure my liver, why that is so important, and what to do to keep it young. This is great news for all of us, since what keeps your liver young keeps your brain, heart, eyes, and even sex organs functioning better. This book gives you the plan for a life filled with energy. I’m sharing this plan with my own patients. In the end—if you understand their principles and follow their plan, too—you will be well on your way to making your liver skinny and your life longer and filled with much more energy and fun.
Indifference and neglect often do much more damage than outright dislike.
—J. K. Rowling
If I asked you to pause for a moment to think about the organs that are vital to your survival, your heart, lungs, and brain would probably come to mind. That’s as it should be, because without these organs, you simply wouldn’t be alive. But there’s a key player missing from that essential list: the liver, which is often overlooked in importance, even though it is among the hardest working organs in our body. Many of us don’t have a clue where our liver is, let alone what it does. In a way, the liver is like the late comedian Rodney Dangerfield, who frequently complained, “I don’t get no respect!” The liver generally doesn’t get the respect or attention it deserves until something goes wrong.
Yet the liver is also like the great and powerful Oz, in that it makes magic happen from behind the curtain. If you were to picture what happens in your body as a Hollywood movie, your heart and brain would be among the lead actors but the liver would be the director. It’s a silent player behind the scenes, but a powerful one that orchestrates a variety of critical body functions. Located on the right side of the upper abdomen, just below the diaphragm, the liver is one of the largest organs in the body (an adult liver weighs about 3 pounds). It performs more than three hundred tasks, including playing a role in such crucial metabolic processes as converting the nutrients in our diet into substances our body can use and store for energy and removing harmful substances from our blood.
While the liver is tough and resilient, the punishment of our modern lifestyle can wreak havoc on this precious organ—and we may not even realize it’s happening! Symptoms of liver disease may be subtle to nonexistent until the condition has reached a severe stage, by which point it may be too late to reverse it. Because mild liver dysfunction is often discovered incidentally through elevated liver enzyme levels on a blood test, and because it doesn’t cause alarming symptoms the way heart disease does, most of us don’t give a second thought to our liver’s well-being or give our liver the TLC it deserves. Many people think of liver disease as related to consuming too much alcohol—but that’s only part of the story.
The reality is, a silent health crisis is under way, one that affects 30 percent of people in the United States. You may not have heard of it, but you could be among the potential victims. The crisis relates to a condition called nonalcoholic fatty liver disease (NAFLD), which involves an accumulation of fat deposits (particularly triglycerides) in the liver tissue. Largely related to our nationwide obesity epidemic, it’s a disease that’s alarmingly on the rise; its prevalence has more than doubled since 1988. Yet, because NAFLD doesn’t produce symptoms in the early stages, it often goes undetected until it has progressed to nonalcoholic steatohepatitis (NASH), a more serious condition that results in inflammation and, potentially, irreparable liver damage.
In recent decades, we have developed a collective lifestyle that promotes the development of obesity; this has created what’s often referred to as an obesogenic environment. This shift in diet and exercise habits, in particular, has given rise to the incidence of these devastating liver diseases. The exponential rise of NAFLD has paralleled the increase in obesity in the United States—and this is not a coincidence. Both surges stem primarily from an unhealthy lifestyle—too many calories consumed from food (and often the wrong foods) and too few calories expended through exercise. The result: Too much fat in our body, too much fat in our liver, and a serious threat to our health and longevity.
It’s a dire picture, indeed, and many people are completely unaware of this looming danger.
A brief pause so we can introduce ourselves:
Kristin Kirkpatrick: In my work as manager of wellness nutrition services for the Cleveland Clinic Wellness Institute, I oversee the nutrition programs, which are focused on helping people lose weight and treating and reversing various diseases. Many of the patients who come to see me are overweight and want to lose weight and/or lower their cholesterol or blood sugar levels; often they don’t realize there’s another hidden threat lurking inside their body. During our meetings, I usually have the lab reports from their blood work: Physicians often refer patients to me because they have elevated liver enzymes (in addition to their cholesterol or blood sugar abnormalities), so that I can put them on the path to weight loss and better health. These elevated liver enzymes suggest the development of NAFLD, which indicates that their lifestyle habits (such as a poor diet and/or sedentary ways), their body weight, or an underlying health condition (such as elevated blood sugar or high blood pressure) could be putting their health in serious jeopardy. Although I never have patients coming to me, saying they need to improve their liver health, that’s where we often need to turn our focus.
Ibrahim Hanouneh, MD, a well-regarded expert on liver disorders, and I met at the Cleveland Clinic where he is an associate physician in the department of gastroenterology and hepatology. There, he sees many patients with a variety of liver diseases. Whereas a lot of patients come to me with the goals of eating healthfully and losing weight, some of them who have NAFLD also work in conjunction with a physician like Dr. Hanouneh who can address and serve their medical needs. I asked Dr. Hanouneh to be the medical expert for this book because he’s so knowledgeable about these disorders, what’s behind their alarming rise, and what needs to be done to reverse this trend. Having the advice and expertise of both a physician and a dietitian often leads to greater success in preventing and treating liver problems—sometimes two heads really are better than one! In the chapters that follow, you will read patient stories from both of our practices, so that you can gain broader insights into these liver disorders, including their causes and consequences—and see how other people have altered their diet and lifestyle habits so they can protect their liver. I’ve seen success in many of my patients—the road to change is not always easy, but it is always worth it!
While “detox” diets and other plans are very popular these days, this essential organ is at the root of these purification efforts. With so many people unaware of the threats to this organ, which detoxifies the body naturally, we knew that we had to write this book—to raise awareness of this emerging risk to bodies, minds, lives, and longevity and to give you the tools you need to safeguard your liver’s health and help it function optimally. Given how important your liver is to your health, well-being, and survival, it’s critical to pay attention to these mounting threats right now—before your liver launches a rebellion. You have the power, the wherewithal, and the opportunity to protect your liver, starting now.
In Part 1, you’ll discover what a healthy liver does and how your lifestyle could be taking a toll on your liver health, as well as the scope of these newly recognized liver problems and the factors that contribute to NAFLD and NASH. You’ll also learn about how to take smart precautions to protect yourself from other liver disorders, such as hepatitis, drug-induced liver damage, and alcohol-related liver disease. Part 2 broadly addresses the prescriptive principles for maintaining good liver health (including improving your dietary and exercise habits, managing your weight more effectively, getting enough sleep and getting a grip on stress, and avoiding toxic exposures) and preventing or reversing liver problems through lifestyle modifications. And in Part 3, you’ll find an action plan that will allow you to put these healthy liver principles into action with a lifestyle makeover. Think of this as a fresh chance to give your liver and your body a second shot at better health.
Consider this: If a trustworthy agent offered you a free, comprehensive, gimmick- and loophole-free insurance policy that would likely protect your health today, tomorrow, and for the foreseeable future, would you take it? If a friend gave you a no-strings-attached present of a nonstop airplane ticket to a happy, healthy place you’ve always wanted to visit, would you accept it? It would be foolish not to say “Yes!” to both propositions, right? With this book, we want to give you the gift of good health—a full understanding of the reasons your liver is so important, vital information you (and many other people) aren’t aware of, and concrete steps to help you be the healthiest you can be. Along the way, you’ll likely lose weight (if you have extra pounds to shed), have more energy, and make major strides in preventing other life-threatening diseases, such as type 2 diabetes, heart disease, and more. It’s an opportunity that’s yours for the taking!
NOT LONG AGO, Marie, a 45-year-old mother of two, went to her primary care physician for an annual checkup. She reported being in good health and didn’t take any medications on a regular basis, but a blood test revealed that her liver enzymes and triglyceride level were elevated and her HDL (the “good”) cholesterol level was low. When her health history was examined further, it became clear that Marie had gained 15 pounds in the previous six months and her body mass index (BMI) was now in the obese category (above 30). This wasn’t entirely surprising because Marie had been laid off from her consulting job, was feeling slightly depressed, and she had fallen into a habit of eating poorly and being sedentary over the previous months.
After an ultrasound revealed the presence of fatty deposits on her liver, Marie was shocked to learn that she had a liver disease. Her first question was: “Is a fatty liver bad?” (Yes, it is.) Her second question: “Is it reversible?” (Yes, it is.) That was all Marie needed to hear to feel motivated to start a diet and exercise program, which would reduce fat on her liver and improve her liver enzyme levels.
It’s ironic: Some people go to great lengths to “detoxify” their body with cleanses, juice fasts, supercharged smoothies, raw food diets, special teas, and other unproven interventions. They swallow various herbs and supplements in an effort to purify their body from the inside out. They try to sweat out toxins in saunas, steam rooms, sweat lodges, and the like. When they do this, they feel that they’re being proactive about removing impurities from their body. Well, here’s a newsflash: These measures are of dubious benefit because the liver detoxifies the body naturally and automatically, just as a self-cleaning oven does. The key is to keep it in good working order.
Despite people’s pervasive interest in ridding the body of toxins, many of us generally don’t do much for our liver in terms of everyday care. That’s a serious mistake, given everything that our liver does for us. On a daily basis, the two lobes of the shiny, smooth, saddle-shaped organ—which are separated by a band of connective tissue that anchors the liver to the abdominal cavity—perform an astonishing array of functions as part of its 24/7 job description. For starters, the liver serves as a highly complex chemical plant, inspection station, garbage disposal, and filtration system, all rolled into one. The liver filters out 1.4 liters of blood per minute. It converts ammonia, a toxic waste product that’s formed from processing dietary protein and nitrogen-containing compounds in the body, into urea so it can be excreted by the kidneys. The liver metabolizes drugs and alcohol and gets rid of the by-products that result from the breakdown of these substances. It removes bad bacteria and debris from the bloodstream, and it breaks down worn out or damaged blood cells.
Essentially, your liver—along with your lungs, your gastrointestinal tract, and your kidneys—is detoxifying your body every minute of every day, whether you’re awake or you’re asleep. No one is immune to the presence of internal (a.k.a. endogenous) toxins, such as metabolic waste products that are generated inside your body, or external (a.k.a. exogenous) toxins, such as pollutants, contaminants, pesticides, food additives, drugs, and alcohol. But having a strong, healthy liver, one that is well cared for and functions the way it should, makes the inherent detoxification process run smoothly and efficiently. If the health of the liver heads south, however, its ability to detoxify your body heads south, too, and no cleanse or juice fast or detox diet can make up for what you’ve lost with that failing organ.
Moreover, the liver is involved in all of the body’s central metabolic processes, including the metabolism of carbohydrates, protein, and fats and the conversion of these macronutrients into forms of energy the body can readily use. When it comes to metabolizing carbohydrates, the liver helps ensure that the level of sugar (or glucose) in your blood stays fairly steady: If your blood sugar level increases (after a meal, for example), the liver removes sugar from the blood and stores it as glycogen (the main source of stored fuel in your body); if your blood sugar level dips too low, the liver breaks down glycogen and releases sugar (glucose) into your blood. As far as dietary protein goes, your liver cells convert amino acids in foods into forms of energy that can be used by the body. And the liver produces bile, a yellowish-greenish-brownish substance that travels to the small intestine where it plays a role in the breakdown and absorption of fats.
Meanwhile, the liver stores fat-soluble vitamins (A, D, E, and K) and vitamin B12, as well as minerals (such as zinc, iron, magnesium, and copper), and releases them into the blood on an as-needed basis. In addition, blood-clotting factors are formed in the liver—these are crucial for preventing excessive bleeding—and the liver helps with the metabolism of sex hormones, including testosterone, estrogen, and progesterone, so that you don’t end up with abnormal levels of these hormones. As you can see, the liver is an incredibly hardworking, multitasking organ that never sleeps; it’s always on duty.
When it comes to organ function, there’s often a synergy that’s a bit like a well-choreographed dance: if one organ isn’t working properly, it can throw the others out of step, too, causing the whole enterprise to function inefficiently. This is true of the liver. For example, the liver works with the kidneys to regulate blood pressure, and it also operates in conjunction with the pancreas and gallbladder to properly digest food; if the liver becomes the weak link in this chain, the whole digestive process suffers. That’s just one example of the potential domino effect that liver dysfunction can have.
A few months ago, Robert, a 63-year-old financial planner, had been feeling tired and slightly nauseous, but he chalked it up to stress from work. One night he vomited blood, so he went to the emergency room and was admitted to the intensive care unit. An upper endoscopy revealed that he had actively bleeding varicose veins in his esophagus, a condition that usually occurs in people with liver cirrhosis. Aside from high blood pressure that was well controlled with medication, Robert, a regular exerciser, was lean and quite healthy; a light drinker, he had no prior history of liver disease or a family history of chronic liver disorders.
THE DETOX PROCESS DEMYSTIFIED
The detoxification process that occurs in the liver is far more complex than most people realize, yet it is essential to keeping your entire body functioning smoothly, efficiently, and effectively. At the most basic level, it helps to think of your liver as serving a similar purpose to a high-quality filter in your furnace: By trapping dirt, dust, and toxic particles, the filter allows clean air to be continuously circulated throughout your home, so you can maintain a healthy interior environment. In the case of the liver, here’s how this process works:
Yet, an ultrasound of the liver revealed that he had cirrhosis of the liver—which came as a complete shock to Robert—and further tests revealed the culprit: a chronic hepatitis C infection, which was also surprising because he hadn’t had a blood transfusion, hadn’t engaged in intravenous drug use, and didn’t have tattoos; plus, he was married with a monogamous relationship and his wife didn’t have hepatitis C. How he was infected with hepatitis C remains a mystery, but Robert apparently had the infection for many years (and had never been screened for it because he didn’t have symptoms or clear risk factors), which led to cumulative damage to his liver. Like many healthy people, Robert hadn’t given much thought to his liver over the years and he didn’t know that baby boomers, born between 1945 and 1965, are now known to be at higher risk of having contracted hepatitis C and should therefore be screened for the viral infection.
As is the case for many people, Robert’s first clue that he was suffering from a liver disorder manifested itself in another organ system—the digestive tract. That’s because the health of your liver can have a ripple effect on the well-being and functionality of other major organs in your body. Here’s a head-to-toe look at how the state of your liver can support or undermine the functionality of other major organs:
Your brain When it comes to normal brain function, the liver may in fact be the most important organ due to its ability to remove toxins from the blood. When this doesn’t happen, the brain can suffer the consequences. For example, when the liver is damaged and can’t remove or neutralize toxins (such as ammonia) from the blood, the toxins can build up in the bloodstream and travel to the brain where they damage the nervous system. This can lead to hepatic encephalopathy, a loss of brain function; the symptoms can be as simple as mild confusion, mental fogginess, or changes in thinking abilities, or as severe as mental unresponsiveness, slurred speech and movement, loss of consciousness, and possibly even coma.
Your eyes Few people think of the liver when an eye problem occurs, but in some cases, that may be the first place you should look. Several eye conditions can result from the liver’s inability to do its job. A condition called scleral icterus, which involves a yellowing of the white part of the eye, can develop if the liver becomes unable to process bilirubin (an orange-yellow pigment that is formed in the liver by the breakdown of hemoglobin and is excreted in bile). Yellowing of the eyes can also be a sign of jaundice, which occurs due to a buildup of bilirubin—and is sometimes one of the first major signs that things are not going well for your liver. Moreover, the liver helps with the metabolism and storage of vitamin A, which is critical for good vision and eye health.
Your thyroid gland This tiny, butterfly-shaped gland in the front of your neck is like command central for the metabolism, growth, and development of the human body, as well as the regulation of critical body functions. Research has found that people who have cirrhosis of the liver have a greater incidence of an enlarged thyroid and that people with hepatitis are more likely to have abnormal results on thyroid function tests. Other thyroid disorders can go hand in hand with chronic liver diseases, as well; for example, hypothyroidism (low thyroid function) is common in people who have autoimmune liver disease (which is why those who have autoimmune liver disease should get their thyroid function checked periodically).
Your heart Because the liver plays a major role in the storage and metabolism of cholesterol and triglycerides (blood fats), it helps keep the veins and arteries that flow into and out of the heart healthy. If it weren’t for the liver’s ability to break down medications, alcohol, and caffeine, your heart rhythm could become irregular. In addition, research has found that people with nonalcoholic fatty liver disease (NAFLD) are more likely to have heart disease, too, probably due to the fact that a dysfunctional liver increases the risk of metabolic syndrome (see box below).
THE TRUTH ABOUT METABOLIC SYNDROME
A fancy name for a simple concept, metabolic syndrome is a constellation of risk factors that increase a person’s risk of developing heart disease, stroke, and type 2 diabetes. These risk factors include high blood pressure, elevated fasting blood sugar, a low HDL (the “good”) cholesterol level, a high triglyceride level, and excessive belly fat (or a large waist circumference). Given the connection to heart disease and stroke, metabolic syndrome is worrisome enough but complicating matters, it also can cause NAFLD—and vice versa. In fact, some medical experts are now calling NAFLD the new face of metabolic syndrome. The two are that closely intertwined!
Your blood Your blood relies on the liver to store fat-soluble vitamin K, which is needed for proper blood clotting; plus, the liver makes key proteins that are necessary for normal blood clotting.
Your kidneys When it comes to removing toxins from the body and preparing them for excretion, the kidney and the liver really do need each other, so it’s not surprising that when the liver becomes diseased, the kidney suffers as well. People who have hepatitis C, for example, have an increased risk of developing a chronic kidney condition called glomerulopathy, which affects the parts of the kidneys where waste products are filtered from the blood, thus compromising the kidneys’ overall ability to function. Meanwhile, those with chronic liver disease are more likely to have decreased blood flow to and through the kidneys.
Your bones The liver also helps your body absorb important vitamins and minerals—including calcium, phosphorus, and vitamin D—to keep your bones healthy, strong, and happy.
As you can see from this hefty list of responsibilities, the liver plays a vital and indispensable role in your body’s ability to function. Unfortunately, through their lifestyle habits, many people place enormous amounts of pressure on their liver without considering the possibility that this vital organ could get fed up and shut down.
More often than not, we are blissfully unaware of the harm we may be doing to our liver until the damage becomes extreme and impossible to ignore. Many different hazards of modern living can take a toll on the health and functioning of your liver. When this indispensable organ can no longer remove waste products, bacteria, or toxins from your blood the way it should, or when its ability to metabolize macronutrients and convert them into usable forms of fuel for your body are compromised, your health, energy, and well-being will suffer. It’s that simple. And if fatty deposits, inflammation, and scar tissue build up on this vital organ, you can begin to experience severe symptoms, such as persistent fatigue, muscle weakness, nausea, vomiting, abdominal pain, memory loss, mental confusion, and other worrisome signs. That’s when your liver is sending out serious distress signals.
Among the reasons liver disorders are so often overlooked is that they’re often silent in the early stages. Traditionally, liver disease has been linked to alcohol abuse and recreational drug use, which has led to a stigma associated with liver disease. People are often hesitant to see a liver doctor (a hepatologist) or even to believe they might have a liver disease because they’re afraid they’ll be labeled as a substance abuser. That’s certainly not true these days: In the last decade, there has been a dramatic turning of the tide as nonalcoholic fatty liver disease (NAFLD)—which is linked to obesity, diabetes, high blood pressure, and cholesterol abnormalities—has become the leading cause of liver disease in the United States. Yet the public is largely unaware of this connection.
Another blind spot in people’s perception of liver disease: There isn’t a clear correlation between a person’s behavior (aside from drinking to excess) and his or her liver function. By contrast, unhealthy lifestyle habits—such as overeating and getting too little physical activity—can have obvious effects on your waistline and certain aspects of your health. When you consistently eat too much and exercise too little, there’s no mystery as to why you can’t fit into your favorite jeans. If you start carrying too much weight on your frame, it wouldn’t be shocking if you developed joint aches and pains or back problems. If you smoke like a chimney, you know you’re at risk for developing a chronic cough. Similarly, most people realize that a lifetime of crummy eating and poor exercise habits, smoking and drinking to excess, can lead to clogged arteries, which can, in turn, cause chest pain, a heart attack, or a stroke (depending on the location of the blockage).
Disruption of normal liver function doesn’t typically induce such red-alert symptoms; in fact, you may experience no symptoms at all, which may cause you to conduct your life as though it’s business as usual, without giving your liver a second thought. So, while we’re all busy thinking about the health and well-being of our brain, our guts, and our heart, the liver is like Cinderella, the poor, neglected stepdaughter who does much of the heavy lifting but doesn’t get the care or attention she needs and deserves.
The reality is, a neglected or diseased liver can bring catastrophic consequences. The liver is so essential to your overall health that you could survive for only a day or two if it were to stop functioning completely. Instead of exhibiting a smooth texture and a robust color, a diseased liver resembles a misshapen, rotting piece of meat, with bumpy nodules, gristly patches, and scar tissue—it’s not a pretty picture! Meanwhile, a fatty liver contains deposits of fat that can cause liver enlargement. If this condition progresses, it can lead to liver fibrosis, where scar tissue forms and further injury occurs to the liver cells. From here, the condition can progress to cirrhosis, which is marked by scar tissue that makes the liver hard and unable to function properly.
Appearances aside, once liver disease crosses a certain threshold, it reaches a point of no return; for severe cirrhosis of the liver, there aren’t any treatment options other than having a liver transplant, an extremely complicated prospect for several reasons. It’s a situation that adds tremendous angst and anguish to the misery of living with cirrhosis of the liver (whether it’s from alcohol abuse, NAFLD, nonalcoholic steatohepatitis, or another disorder), which happens to be the third leading cause of death among adults between the ages of forty-five and sixty-five in the United States. (For more on liver transplants, see box.) In the meantime, people with chronic liver disease or cirrhosis are likely to suffer from relentless fatigue, weakness, bruising easily, nausea or abdominal pain, abnormal bowel function, difficulty with blood pressure regulation, problems with peripheral muscle strength (which can lead to falls), memory, confusion, and thinking challenges, and other unpleasant symptoms from head to toe. In short, their quality of life takes a serious downturn.
But some liver conditions can’t be reversed, including liver cancer, cirrhosis, acute liver failure, and genetic liver disorders, all of which can be remedied only with a complete liver transplant or a partial transplant from a living donor. With a living donor transplant, part of a donor’s liver is removed and implanted to replace a patient’s diseased liver; after the surgery, the donor’s liver regenerates back to its full, natural size, while the new, partial liver that was inserted into the patient grows to a normal size. It’s the human equivalent of a lizard’s ability to grow back its tail after losing it or having it amputated—nothing short of amazing! Still, it’s best to take whatever precautions you can to safeguard the health and integrity of your liver so that you don’t have to consider the possibility of going down the transplantation or regeneration path.
The good news is, if they’re caught early enough, certain liver diseases—such as NAFLD, alcoholic fatty liver disease (AFLD), and hepatitis A, B, and C—can be reversed with the proper interventions. The liver is the only organ that can regenerate itself: If 25 percent of your liver is healthy and unscarred, the liver can rebuild itself using its own cells and replace the tissue that was lost to disease until the organ returns to its original size. Once cell proliferation is completed, the new cells undergo restructuring with the formation of new blood vessels so as to supply the new cells with sufficient blood flow and nutrients to ensure their vitality.
LIVER TRANSPLANTS
Within the next decade, NAFLD is predicted to become the leading cause of liver transplants in this country, and yet demand will outpace the supply of livers that are available for transplantation. Between 2004 and 2013, the number of adults awaiting a liver transplant due to NASH tripled, and yet patients with NASH are less likely to undergo a liver transplant and less likely to survive for ninety days on the waiting list than are patients with hepatitis C, alcoholic liver disease, or a combination of the latter liver diseases. This is a serious threat, indeed. Many people who have NASH eventually die from complications of portal hypertension, liver failure, and hepatocellular cancer.
Unfortunately, some liver conditions can’t be reversed, including liver cancer, cirrhosis, acute liver failure, and genetic liver disorders. For severe cirrhosis of the liver, the only treatment option is a liver transplant, an extremely complicated prospect for several reasons. For one thing, the underlying state of your health will help determine whether you’re a good candidate for a transplant so if you have other life-threatening conditions that aren’t well controlled, this may not even be a viable option for you. In addition, the cost of a liver transplant, the odds of finding a suitable match (which is based partly on the person’s blood type and size), and the recovery from this type of surgery are also tremendous challenges. It also involves a commitment to lifelong medications used post-transplant to prevent organ rejection—and unfortunately these medicines often have severely unpleasant side effects.
There is also an increased risk of kidney problems after liver transplantation. Research suggests that about 27 percent of people who have a liver transplant develop some form of kidney disease and 10 percent of these cases progress to end-stage kidney disease.
Currently, more than sixteen thousand people are on the waiting list for a liver transplant in the United States. They’re essentially engaged in a race against time, one that pits the progression of their liver disease against their chances of finding an appropriate match. For more detail on transplants, see Chapter 12.
The regeneration process can take from a couple of weeks to several years, depending on the extent of the damage. Surprisingly enough, in most cases, liver function is only partially affected during liver regeneration. It’s an incredible physiological feat and a critical healing process for people with liver diseases where partial removal of the liver is necessary because of a tumor or chemical injury (from alcohol or drugs, for example). Meanwhile, other liver conditions—such as primary biliary cholangitis, an autoimmune disease that’s marked by a slow progressive destruction of the liver’s small bile ducts, and hemochromatosis, a condition that causes your body to absorb too much iron from the food you eat—can be managed with various medications and/or lifestyle modifications.
In the chapters that follow, you’ll learn more about the latest threats to your liver, the subtle distress signals you should be alert to, and the best ways to protect the health of this vital organ. If you already have a liver disorder, don’t despair: You’ll also find out how you can set that critical wheel of disease-reversal into motion and improve the state of your current and future health. You will gain the critical tools you need to empower yourself to make liver-boosting changes to your lifestyle, changes that will enable you to better manage your weight, your liver health, your fitness, and reduce your risk of developing life-threatening diseases. These changes will certainly improve the quality of your life—and they may just save your life!
CARLY, 56, CAME to see me on her physician’s advice because she wanted to slim down and get back to her high school weight. During our initial meeting, she mentioned that her doctor had told her that she likely had fat accumulation on her liver because her liver enzymes were slightly elevated; plus, Carly had type 2 diabetes, high cholesterol, and a body mass index (BMI) of 32, which put her in the obese category. When we began discussing the possibility that she might have nonalcoholic fatty liver disease (NAFLD), naturally she was scared, partly because she had never heard of it and partly because she was (rightly) worried that it could cause adverse health events that could threaten her health and longevity.
Many people associate liver problems with excessive alcohol consumption—and that’s the end of it; their thinking stops there. Granted, they’re not entirely off base, since years of heavy drinking can lead to alcoholic liver disease, including inflammation of the liver and potential scarring (or cirrhosis) of the liver. But there are newer, more prevalent threats to our liver, particularly in the form of NAFLD, a buildup of fat deposits in the liver tissue, and nonalcoholic steatohepatitis (NASH), a more severe condition that involves fat accumulation, inflammation, and damage to the liver. These newly emerging liver diseases also stem largely from lifestyle factors, but not usually from excessive drinking; they’re more likely to result from being overweight or obese, having poor eating habits, and/or having a genetic predisposition to type 2 diabetes.
For the record, these new threats are in addition to the usual suspects such as hepatitis (A, B, C, and others), alcohol-related liver disease, and primary biliary cholangitis (PBC), a chronic disease in which the medium-size bile ducts in the liver are slowly destroyed, increasing the risk of cirrhosis. They’re also over and above the steady occurrence of genetic disorders of the liver, such as hemochromatosis (in which the body absorbs and stores too much iron, which causes liver damage) and Wilson disease (in which the body retains excess copper, which builds up in the liver, causing damage). With most of these disorders, symptoms are typically absent in the early stages, which is part of the reason they go unnoticed for so long.
As Carly’s story shows, most people are unaware that having unhealthy eating habits or being overweight can take a toll on their liver; moreover, most people have never even heard of these potentially life-threatening liver diseases. For the most part, research suggests that primary care physicians don’t know how to approach nonalcoholic fatty liver disease, either. In fact, many don’t even recognize NAFLD for what it is. In a recent study involving 251 patients identified with NAFLD, researchers from Baylor College of Medicine in Houston found that only 22 percent had NAFLD mentioned as a possible diagnosis in their medical charts; all the others simply had notations that their liver enzyme levels were abnormal, they were counseled about making diet and exercise changes, or they were referred to a specialist (such as a hepatologist or a gastroenterologist). The researchers’ conclusion: “Most patients in care who may have NAFLD are not being recognized and evaluated for this condition.” Compounding the problem is the reality that NAFLD can be asymptomatic even as it begins causing problems for the person who has it.
While it’s normal for the liver to contain some fat, if fat makes up more than 5 to 10 percent of the weight of your liver, you are considered to have fatty liver disease, which is often noticed by your healthcare professional incidentally when liver enzymes are abnormal on a blood test or fat accumulation on the liver is detected during an abdominal ultrasound or CT scan. NAFLD—which is usually asymptomatic but occasionally causes fatigue or malaise—has become the leading liver disorder in the United States and western Europe, and in some people it can turn into NASH if it’s not reversed. The primary differences between the two conditions is that with NAFLD, there’s only fat on the liver; with NASH, by contrast, the liver is riddled with fat and inflammation.
As noted earlier, an estimated 30 percent of the US population currently has NAFLD, including more than 6 million children. Meanwhile, approximately 6 million people in the United States are believed to have NASH, and approximately 10 percent of them are thought to have NASH-related cirrhosis. In the last two decades, the prevalence of NAFLD has more than doubled among children, teenagers, and adults, according to several national surveys by health officials. And the rise in NAFLD is parallel and directly proportional to the worldwide increase in obesity, especially abdominal obesity. The fact that obesity rates in the United States and worldwide have skyrocketed in recent decades certainly explains a good proportion of the rise in NAFLD and NASH diagnoses. Since the 1970s, obesity rates have more than doubled among adults and children, according to the National Center for Health Statistics. Among patients with severe obesity who undergo bariatric surgery, the prevalence of NAFLD can be greater than 90 percent.
Some people have questioned whether the rapid rise in the diagnosis of NAFLD stems in part from our increasing awareness of it—the fact that it’s now on doctors’ radar screens and they’re looking for it. And there may be some truth to this because epidemiological studies suggest that NAFLD and NASH are common causes of cases of liver cirrhosis that were described as “cryptogenic” (meaning, “of unknown origin”) in the past. A little more than twenty years ago, we learned that excess body fat can cause liver disease and the connections between obesity, diabetes, lipid abnormalities, and fatty liver disease became increasingly apparent.
As you’ve learned, the liver is a complex organ that wears a lot of different hats, including playing a critical role in the metabolism of dietary fats, carbohydrates, and proteins. In some ways, fats are the trickiest macronutrients for the liver to handle because it needs to metabolize, store, process, and package fat into lipoproteins that can be delivered to cells throughout the body. Although a healthy liver can handle plenty of dietary fat without a problem, the same isn’t true of an already distressed liver, which can become overburdened when the person consumes too much dietary fat. If the liver can’t handle the overload of fat that’s consumed from the diet and accumulated in the body, triglycerides (fats that are carried in the blood) can build up in specific liver cells called hepatocytes, leading to NAFLD. Over time, this unchecked fat accumulation can lead to inflammation and scarring, which progresses from fibrosis (the early stages of scarring) to cirrhosis (the late stages of scarring) of the liver. With cirrhosis, the liver cells are replaced with scar tissue, which impedes this vital organ’s ability to work properly.
Other experts contend that the real culprit behind NAFLD is insulin resistance, a condition in which glucose builds up in the blood, increasing insulin levels and triglyceride levels. As you’ve learned, high blood levels of triglycerides are an independent risk factor for NAFLD because this is the predominant type of fat that builds up in the liver. What’s more, elevated insulin levels may inhibit the breakdown of fat in cells throughout the body and stimulate the synthesis of new fatty acids from excess blood sugar. When this happens, the liver ends up with an overabundance of materials for producing fats but nowhere to send them once they’re made, so they hang around like truant teenagers and accumulate in the liver, eventually leading to fatty liver disease.