Nonalcoholic Fatty Liver Disease Expert Q&A
May 13, 2022
Nonalcoholic fatty liver disease is a growing condition that is believed to affect one in four adults worldwide. That makes it one of the most prevalent liver diseases. The illness occurs when fat builds up in the liver, and it typically triggers no warning signs or symptoms in the early stages. If left undiagnosed, it may lead to inflammation, scarring of the liver, and even organ failure, which may require transplantation.
While healthy individuals can develop the disease, those who are overweight, obese, and have diabetes or high blood pressure are most at risk. Join us as our experts take your questions. That's coming up right now on At the Forefront Live.
And we want to remind our viewers that today's program is not designed to take the place of a visit with your physician. Let's start off with having each one of our guests introduce themselves. And we'll have you tell a little bit about what you do here at UChicago Medicine. And Dr. Rinella, we're going to start with you. You're at the desk today.
Great, thank you.
Thanks for being here.
Thank you. My name is Mary Rinella. I am a specialist in fatty liver disease. I am the Director of the Metabolic and Fatty Liver Clinic here at the University of Chicago. And I have an interest in other forms of liver disease as well, but fatty liver is really what I've been focusing on in the last 20 years of my career.
And Annie Guinane is a registered dietician. And you're joining us from the other side of the room. We're trying to, again, continue to keep ourselves as socially distant as we can in the studio, so you're over there. Tell us a little bit about what you do here at UChicago Medicine.
My name is Annie Guinane, and I'm a registered dietician here. And I cover the liver transplant department and also am a dietician for the Metabolic Fatty Liver Clinic with Dr. Rinella.
Great. Well, let's just start right off, and we'll remind our viewers that you can type questions in and we'll get to as many as possible over the course of the program. But let's start off with talking about non-alcoholic fatty liver disease and exactly what is it. Because I think most people, when they think of liver disease, they think of situations that involve alcohol or alcoholism, but that's not necessarily the case.
Yeah, that's right. So fatty liver disease is basically just like it sounds, an accumulation of fat in the liver, in this particular case for causes that are not related to alcohol. And that is most typically obesity or excess abdominal weight, diabetes. And then other things like hypertension or high blood pressure or abnormal cholesterol and triglycerides predispose you to accumulate fat in the liver, which is not a normal place to store fat.
So what is non-alcoholic steatohepatitis? How does that differ?
Yeah, so non-alcoholic steatohepatitis, or NASH, is what I-- how I like to describe it is sort of the progressive subtype. So within the umbrella of NAFLD, or fatty liver disease overall, this is the subcategory of people who can develop inflammation and scarring that ultimately leads to cirrhosis. And those are the patients we really want to focus on and identify.
And cirrhosis of the liver, for those folks at home that maybe don't understand what that is, that is the actual scarring. Is that right?
Yeah, so it's a progressive scarring or hardening of the liver that leads to complications of liver disease, abdominal swelling with water, veins engorged with blood. There are several side effects of that. And then also the liver function starts to become impaired, and that's where you might want to consider liver transplant.
So when the liver does scar like that, you mentioned this, the function starts to get impaired. What exactly is happening there? Why is it not working as well as it used to, maybe?
So in two ways. So if you think of the liver as a sponge that's getting more and more scar tissue around the little fibers of what you might consider a sponge, two things happen. So one is that it becomes stiff, and the blood flow that comes in isn't really able to get in nicely and sort of percolate through. And so you get backup of blood flow, and that's where you can get these veins in the esophagus and in the stomach that can cause terrible bleeding.
By the same token, when blood gets in, sometimes it can't get out because of that stiffness and that scarring. And so the water, or the serum, squeezes through the liver, and you get accumulation in the belly of water. And so those are kind of mechanical reasons.
And then the more scar tissue builds up, the less liver cells are available to do what they need to do-- metabolize drugs, produce proteins, help make components of bile and excrete bile. And so when that starts to happen, people get confused and are at risk for bleeding and so on and so forth. And so that's at that stage. Of course, we hope to identify people before that stage, and we can do that. So very asymptomatic, or low symptom disease, and it requires us as people in the community, as well as physicians, to be aware of the risk factors.
We just had a little fact up on the screen, one of our did you knows, and it talked about kidney-- there it is again. So kidney disease and how there's a high prevalence among patients with NASH. And what's going on there?
Yeah, so there is definitely a high association between chronic kidney disease and NASH, and that's for two main reasons. One is its very close association with diabetes, and the other is the inflammatory state that's produced by having NASH or non-alcoholic fatty liver disease in general. So those two factors are probably the most important things driving kidney dysfunction in this population.
And it's not terribly unusual because I know we've had guests on the program before talking about various organ transplants. Once you have one organ that is starting to fail, particularly something as important as the liver, you do have damage or impact to other organs. So that's-- I'm assuming that's kind of what we're seeing there.
Yeah, that's right. So you do end up with a good amount of simultaneous liver kidney transplants in people with fatty liver disease that are transplanted for fatty liver disease or NASH.
I did promise viewers that we would take questions, and we have our first one. This is from Brenda, and she's asking what can be done with-- and I believe-- anion gap? Am I pronouncing that correctly? Anion gap?
Anion gap. Blood levels at 10.0, which is low.
I'm not sure I understand the question exactly with respect to that because that would imply that there's acidosis, and that would not typically be an opening feature of NASH. But certainly could be seen in the end stages. So if that's kind of how we're-- I'm not sure what the question is getting at. Maybe a little more detail would be helpful.
Yeah, she's just saying what can be done with that, so maybe--
It just depends on the cause and-- right. So if it's an infection or kidney failure, so on and so forth.
Talk to your physician. So what are some of the symptoms that we can see here? Because in the intro, we talked a little bit about the fact that oftentimes there aren't symptoms until significant damage is done.
Yeah, that's part of the problem, I think, is that people feel pretty well until things are quite bad. And so about 60% of people will experience pain or discomfort in the right upper quadrant from the stretch of the capsule of the liver as it fills with fat, but that's really not a reliable symptom. And I would actually say that sometimes that happens after somebody already knows they have fatty liver disease. So I'm not convinced that that's a major factor.
Some people will have itching, but that's more typical of more severe disease. But generally, it's a fairly asymptomatic condition, and that's why understanding what the risk factors are and discussing them with your physician is really the most proactive thing to do.
You know, I think we tell patients oftentimes that they need to do a periodic physical, which I think is always a good idea. Are there ages that people need to really start being concerned about this? Or, you know, we also talked about high blood pressure. Sometimes diabetes can be an issue, obesity.
All of those things I would imagine you probably need to kind of consider and think about when you're talking about it with your physician, as well.
Correct. So it can happen at all ages, and that's one of the more frightening things about it is that the prevalence of obesity in children is really growing quite a bit. And that is something that's going to build over time, and we start to see increased levels of obesity in our country, which is happening and it's been happening over the last two decades. So that is an important risk factor.
So anyone can get it. Obesity is the most common. Not everybody has obesity. And by that I really mean sort of the accumulation of belly weight. It's really not as much, sort of, the pear shape accumulation of body weight. It's really the apple shape that are at the highest risk.
And then, really, diabetes is an important driver. So if we look at the US population as a whole, about 25% have fatty liver disease, and then a fraction of those, about 20% of those, have NASH. And then 6%, 7% will have cirrhosis overall, or 5%, 6% nationally.
But if you look at the breakdown, say, in a diabetic population, instead of having 25% of the total having fatty liver disease, about 75% have fatty liver disease. And 50% of those have NASH and scarring. So if I could pick one risk factor, it would be diabetes, type two diabetes.
And that's when you probably should maybe ask your physician if you can be screened?
Yes, absolutely. I think one of the biggest limitations in the field, really, is the lack of awareness with primary care docs because it's something that historically, I think, was underappreciated with respect to its risk for the development of liver failure. So I think that even physicians are not as abreast as they could be as to the risk factors involved.
You know, Dr. Rinella, I always tell guests to make sure that they mute their phones, and that was me. That was actually my laptop that was ringing, not my phone. Yeah. I had the phone muted, but I'll do better.
More questions from viewers. We've actually had a few come in. Peg is asking, can fatty liver disease be reversed?
Yeah, so it definitely can, and especially if it's at the earlier stages. And I think there's no one better to speak about this than Annie Guinane who's here because that's exactly why she's such a critical component of the clinic.
Yeah, let's get Annie involved. We haven't asked her any questions yet.
So yeah. So great point. And the main treatment right now for fatty liver disease is weight loss. And really we want to look for that 5% to 10% weight loss, but ideally 7% to 10% total body weight loss.
So the ways that you can do that is by following a healthy, well-balanced diet and getting in 150 minutes of exercise every week. So yeah, the main diet that we recommend is the Mediterranean diet, which really helps with all that inflammation that Dr. Rinella mentioned and gives you more fiber and good healthy fats.
Well this is a perfect segue to the next question from Anita, and Anita is asking what kind of food diet do you recommend? So you mentioned the Mediterranean diet, which is a diet we hear about a lot. My doctor actually talked to me about that as well. Tell us a little bit about the Mediterranean diet. What does that mean? What exactly is that?
Yeah, so the Mediterranean diet is really good for everyone across the board. And so that's what makes it an easy transition is if you can get your whole family on board if your doctor recommends the Mediterranean diet. So primarily it's a reduction in those high saturated fat foods and the trans fat foods, limiting your red meat and limiting sweets, and really putting the focus on lots of lean meats and fruits and vegetables and whole grains. Beans and nuts and seeds, those are great additions that have good healthy fats in them. And then tons of olive oil. So we actually recommend up to four tablespoons of olive oil in a day, which is a lot, but it's doable.
So why is olive oil so much better for you than regular cooking oils?
So olive oil has those good healthy fats. So the correlation of the healthy fats and the bad fats, there's tons of good mono and polyunsaturated fats in the olive oil. And then if you're cooking, you can also choose avocado oil, which has a higher smoke point so it won't splatter back at you the same way that the olive oil will.
Great. Mary has a question for us. And she wants to know if untreated fatty liver disease can turn to liver cancer.
Yes, it most certainly can. In fact, fatty liver is the underlying cause of the majority of the increase in liver cancer over the last several years. In fact, the incidence of liver cancer in this population has increased four-fold. So the absolute number is similar to alcohol-induced, but it's actually increased much, much faster, which is a concern.
The other thing that's particular about fatty liver disease is that you can see the occurrence of hepatocellular carcinoma even before cirrhosis, which is a bit unusual in liver disease. There are very few diseases that give us liver cancer in the absence of cirrhosis. That being said, it's much less common than once you have cirrhosis, but it is certainly reported.
Interesting. Lita asks, do breast cancer treatments contribute towards fatty liver disease?
So they can. Some of the medicines used to treat breast cancer, like tamoxifen for example, has associated with it. It causes fatty liver. It actually causes steatohepatitis, so the inflammatory type of fatty liver, and can lead to scarring in the liver. Sometimes it can be a confounding factor. So there is something to consider with that. Sometimes, though, there are risk factors for non-alcoholic fatty liver disease in a patient with breast cancer, so it's hard to tease that out sometimes.
So if you are a breast cancer patient, would you just ask your physician to keep an eye on that as well? Is that what you would suggest?
Well, not specifically. What I would say is that we should be screening patients who have diabetes or excess body weight. And if that applies to somebody with breast cancer who's on tamoxifen, then that would be appropriate. I don't think it would be evidence-based to say that everybody getting breast cancer treatment should be screened for fatty liver disease. But certainly if they have those underlying risk factors they should. And if the liver tests become abnormal, then that should be considered, of course.
And you've touched on this a couple of times, but maybe if we can be a little more specific on how it's actually detected. Are there screenings? And what do you look for when you screen for this?
Yeah, so there are a couple of things we can do. So there are non-invasive calculations that we can make just using somebody's age and their liver chemistry tests. And then the next step, usually, when you come see a specialist-- and some primary care practices have these, albeit not very many-- we assess liver stiffness. And that is basically an ultrasound-like machine that will tell us how stiff the liver is and how much fat is in it. So that can be a very useful tool.
It can also be diagnosed by imaging, so ultrasound, although it's not very sensitive. So an ultrasound can be normal despite having pretty significant fat in the liver, as can CAT scans. MRI is extremely sensitive, but it's expensive and certainly shouldn't be a screening tool.
So Annie, I'm sure there will be people that will be watching this and think, gosh I don't want to get that, obviously. You mentioned the Mediterranean diet is a good idea for people who already have it, but it would also, I think, work as a preventative, right?
What are some other things?
Maintaining a healthy weight because it's important to remember as we gain weight, our liver also tends to gain weight. So it's not just about the number on the scale, it's also about what's happening on your insides, right, with the diet that you eat. So overall healthy, well-balanced diet, maintaining a healthy weight, and getting in that regular physical activity. There was actually a study that was done that found even just physical activity alone without the weight loss can help improve your fatty liver. So that's a great preventative thing you can do.
When you talk about physical activity, what specifically are you meaning? Does it have to be, like, a full-blown let's go to the gym and pump iron, or are you just talking maybe get out there and walk a few times a week?
It should be-- so moderate physical activity is kind of when you're a little short of breath, but you can still hold a conversation. So it can be split up into 30 minutes a day, you can do three 50-minute sessions a week. So however you can fit in that 150 minutes is best.
Great. So I'm kind of curious, if somebody has this, is this something that you traditionally see as a disease that's hereditary, or not so much?
It can be hereditary. Probably about 50% of the heritability. There's about 50% heritability in the disease, both with respect to the propensity to develop fat in the liver and to develop scarring in the liver. There are some genes that have been discovered recently that help explain some of the ethnic differences, racial differences that we might see in fatty liver disease and it's certainly, we've found, is a predictor of worsened disease or a higher risk of liver cancer. We're not to a point where we would be screening people or recommending people get these gene tests just as a screening maneuver, but certainly they help us as physicians, liver physicians, to risk stratify in a little bit more refined way.
We've talked a lot about racial disparities when it comes to health care and health issues on this program in the past. I'm kind of curious, you just mentioned that there may be some evidence that shows that there are some racial disparities here, or ethnic disparities. What are we seeing, and is that-- do we know if that's based on care, or what's the basis there do you think?
Yeah, that's a great question. So I wouldn't really call it, necessarily, disparity per se. I would call it more just differences largely driven by genetics. Characteristically, Caucasians are at fairly high risk, but the highest risk, really, are Hispanics, particularly those in Central Mexico and south of there. Very, very common, particularly related to just genes that have been carried through centuries essentially.
In Asia, there's also a high prevalence of the same gene called PNPLA3, which also leads them to have an increased risk as well. Those that are at lowest risk, actually, are African-Americans, which is interesting because they share some of the most important risk factors. Diabetes is very common. Obesity is also very common. But one thing that we've noted is that there's something about the distribution of body weight that really matters a lot. And so if you're somebody who tends to not carry weight in your abdomen, you're probably a little bit less risk, and that's part of those, I think, racial differences that we see in the disease.
Interesting. And you can tell just by carrying weight that has a--
It does. It's a lot.
It's hard on your body.
Wow. Very interesting. Let's talk about alcohol a little bit. Annie, I want to kind of get your thoughts on this because whenever we talk about liver, I think people think of alcohol use. And if you do have fatty liver disease, that even is a better reason, probably, not to use alcohol, I'm guessing.
Yeah. So it can be confusing because red wine is associated with the Mediterranean diet and they actually-- if you look it up, it'll recommend having red wine on a daily basis.
But I typically leave the alcohol question to the hepatologist. [LAUGHTER] It kind of comes from different places of how severe is your liver disease? What's the cause of your liver disease? But really it's important to remember that alcohol is extra calories, and so if you're trying to lose weight, you should avoid it. And when we drink alcohol, it inhibits us, or lets us loose a little bit, and we may tend to eat more and there's food associated with it. So many reasons to avoid alcohol. But yeah, I like to leave that question to the hepatologist.
Well, let's pick on the doctor for a minute then.
OK, so that's a really-- it's actually a really hard question to answer because it really depends on the person and it depends on their own genetic susceptibility and pattern of alcohol use. So it's easy to answer if somebody has advanced liver disease or cirrhosis. They shouldn't drink any alcohol. And the difficulty with that, though, is that there are a lot of people out there who actually have cirrhosis and have high degree of liver scarring but don't even know that they do.
So it's hard to answer just for everybody. But I would say that we can say that there is no safe amount of alcohol that we think people can drink. That being said, if you consume light amounts of alcohol and you don't have advanced scarring in the liver, it's not likely to be causing a major problem with your liver. But again, we have to assess where you are on that spectrum to be able to give you at least a more educated or precise answer to that.
Very interesting. More questions from viewers. These have been great questions from our viewers today, so thank you very much for typing those in. I love that. This is Avette is asking, can a high CAP score on FibroScan indicate fatty liver disease among other liver diseases?
Sure. Yeah, absolutely. So a CAP score is going to pick up fat no matter what the etiology or the cause of the disease is. Generally we use a CAP score of greater than 288 to be more specific for fat in the liver, but lower degrees of a lower CAP score could also denote the presence of fat in the liver.
And of course you bring up a really good point. So things can coexist, right? So you can have autoimmune hepatitis or viral hepatitis or alcohol-related liver disease, which also causes fat to accumulate in the liver. And you can have both diseases or more than two diseases. And so it's important to know that because it's so prevalent it can occur in addition to something else. And so that's actually why we're working on renaming and changing the name of the disease is in order to be able to sort of accommodate for these overlaps.
Well and that kind of leads me in the direction of my next question because I was going to ask you, if you do have cirrhosis because of alcoholism or that sort of thing, does that oftentimes lead to the fatty liver diagnosis? Because we kind of talked about it going the other way, but--
Yeah, so cirrhosis from fatty liver disease, a lot of the time, has been called cryptogenic cirrhosis, meaning you don't know where it came from. And we're learning more and more that we know exactly where it came from and the problem is it just wasn't picked up in time. One of the difficulties about diagnosing fatty liver is the cause of cirrhosis is that once you develop cirrhosis, you may no longer see fat in the liver, and you may no longer see the characteristic inflammatory features of liver disease associated with NASH. So it's a presumptive diagnosis, but we know from following patients over time that that is what happens.
Is that just because the scarring is so heavy that it's hard to detect?
Yeah. Well, it's for a couple of reasons. One is that. And then there are other theories that perhaps the people that develop cirrhosis are ones that aren't able to manage or hold or store fat in a healthier way in the liver.
More questions from viewers. This is Alicia. She says thank you for allowing questions. Well, we appreciate you.
I'm 38 years old. I have a lot of weight gain around my abdomen. I have already had lab work and scans done that show evidence of fatty liver disease. She's tried different diets, has also been on anti-depressant, anxiety, and sleep medication for a while and wants to see a specialist in this area and wanted to know if anybody's taking patients. We're always up for that, I think.
And we do have the phone number that's been on the screen a few times. John, if you could pop that up, too, that would be great. If not, we'll have it later on in the show. There we go.
So yeah, we're happy to help in that area. But she wants to know thoughts on prescription weight loss medications to help and is just looking for any advice. She said any advice would be appreciated.
Yeah, so I mean I'd be able to give you a lot more advice if I had you in front of me for 30 minutes. But basically, yes, some weight loss medications can-- FDA-approved weight loss medications can also help fatty liver disease, as can a couple of antidiabetic medications if you have diabetes. So those are always options that can be explored. I think the most important thing when you have a diagnosis of fatty liver disease is to know where you are on that spectrum of disease, and then that sort of dictates what the best approach is going to be to treat you and to prevent progression, to cause regression, and to just make sure your life quality or length is not altered by the disease.
Annie, you definitely struck a nerve when you were talking about the Mediterranean diet earlier. We have another question there. This is from Cynthia, and she just wants to know if there's a good book, a diet book, a Mediterranean diet book out there that-- and I know what we don't want to necessarily promote specific brands or whatever-- but are there resources that people could use to find some good Mediterranean diet recipes and procedures?
Absolutely. And the Mediterranean diet is becoming more and more popular. So really, if you type into Amazon, Mediterranean diet cookbook, you'll find a whole bunch of them. There's one specific to the Crockpot, one specific to the Air Fryer, one specific-- they've got all different kinds. But really any resource, especially from, like, old Saint Pat's way, that is a great trustworthy resource for the Mediterranean diet.
Fantastic. Carmine has a question. I often feel like I see may cause liver damage on warning labels of medications. Are there any medications that people should be a little bit more aware of, particularly if they do have fatty liver disease or if they think they may have some of the other issues that could lead to it?
Yeah, so there are a couple of drugs that are associated with fatty liver disease. One is steroid use. But mostly because it causes weight gain. There are, sort of, independent reasons why it could affect some people that are on steroids could be at higher risk.
People who have atrial fibrillation, for example, are on amiodarone. I would say that's the biggest risk drug because it causes steatohepatitis, which can lead to scarring of the liver, and so that's a kind of a big red flag I think. Because some of the patients that are on that really have risk factors for fatty liver disease.
So this is a more of a comment from Jamie. You have a fan. She is a post-liver transplant recipient due to NASH and she knows Dr. Rinella and says this is a very informative session. So great.
Another question from a viewer recently diagnosed due to obesity. And as mentioned earlier, losing weight is the best practice. But if somebody who has fatty liver disease and PCOS has a hard time losing weight, besides diet and exercise, what other options are there out there for someone like her? And would a lap band help in a situation like this?
Yeah, that's a great question. So lap bands we don't do so much anymore. I think that they're not as effective. They don't lead to as durable weight loss as some of the other bariatric-type surgeries. So just to take a step back before I give you a couple of my thoughts on bariatric surgery, there are some really effective weight loss medications now that are FDA-approved. So that's something to consider.
The other is bariatric surgery. Bariatric surgery, it makes people live longer. It reduces the risk of death from heart disease and cancer. So there's no doubt if you meet criteria and you can't lose weight another way, it is probably something that you should consider. Sleeve gastrectomy is probably the least invasive but effective way to have bariatric surgery. And then there are other, more traditional Roux-en-Y, but the lap band, not so much anymore.
Yeah, that reminds me. We haven't done a show recently with our bariatric folks. And we have in the past, and they do fantastic work here at UChicago Medicine. And that's one of the neat things about this organization in general. You can even see today the team approach that we take for various diseases and conditions. We really involve a lot of folks, from dieticians to physicians, and it makes a huge difference.
And actually I'll add to that, we probably should have mentioned at the beginning that part of the Metabolic Fatty Liver Clinic is our endocrinologist, actually, Celeste Thomas, Dr. Celeste Thomas. So she is really an important part of our team that sees the patients with us and assesses them. There are some endocrine conditions besides diabetes that can be associated with fatty liver disease, and she helps us identify and manage those as well. So it's really kind of a nice team approach.
Great. We're going to take one more question from a viewer because we are technically out of time here. So let's do this one. This is from Loretha. And she asks, if diagnosed with fatty liver and your liver numbers are always normal, is that a good sign that your fatty liver is maybe not that bad?
Unfortunately not. So unfortunately, liver enzymes are not going to help you-- they shouldn't reassure you, really, that your liver isn't sick, unfortunately. In fact, some patients with diabetes and patients that are older, the liver numbers will come down even though they have very severe disease, even cirrhosis. So unfortunately that's not a good way to know.
OK. Well that was fantastic. You both were awesome. I really appreciate you being on the program.
And as several of the viewers mentioned, I think there was a lot of great information there. So thank you very much for doing that. We are out of time. A special thanks to our guests for being with us today. And a big thank you to those of you who watched and participated in the program.
Now please remember to check out our Facebook page for our schedule of programs coming up in the future. If you want to make an appointment, you can go online at uchicagomedicine.org, or give us a call on the main number 888-824-0200. I know we've had the other number up there as well. You can use that one for today's subject. Thanks again for being with us today, and I hope everyone has a great week.
Nonalcoholic fatty liver disease (NAFLD) is a growing condition that is believed to affect 1 in 4 adults worldwide, becoming one of the most prevalent liver diseases. UChicago Medicine liver disease experts Mary E. Rinella, MD, and Annie Guinane, RD, LDN, CNSC, discuss the disease and the role of diet.
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