I put a post out on social media at the end of last year asking if anyone had a topic they would like me to cover in a blog. I thought that this suggestion was an excellent one because non-alcoholic fatty liver disease (NAFLD) is frequently diagnosed, often as the result of a chance finding following a standard set of blood tests.

“Disease!? Yikes. That sounds nasty and truly unfair. I haven’t even had the pleasure of drinking my way to it via a booze-filled social life!”

It may come as quite a surprise to learn that, in the UK, a fatty liver would only be categorised as ‘non-alcohol related’ if the person drank less that 140g alcohol (men) or 70g (women) per week which equates to 17.5 units for men and less than 9 for women.

Let’s put that into perspective. The upper recommended limits for alcohol intake are 14 for both men and women in UK. So, you’d hardly need to be a hard partier to be labelled as someone with alcohol-related liver disease. A glass of wine with their evening meal a few times a week could move a woman from the ‘non-alcohol related’ to the ‘alcohol related’ category.

That said, most of us under-report our alcohol intake if asked by someone sitting behind a desk with a stethoscope round their neck.

NAFLD is a remarkably common condition, ranging from a quarter of adults in much of Europe and USA to over 50% in Mexico and Latin America. It is more common than Type 2 Diabetes and only slightly less common than high cholesterol levels.

Many people have no idea they have a fatty liver, others experience fatigue and/or discomfort in their upper right abdomen below the ribs. However, these can both be symptoms of a range of other conditions and shouldn’t be ignored.

NAFLD is often associated with insulin resistance or Type 2 Diabetes and raised triglycerides (fats in the blood). For this reason, it now has a fancy new name: Metabolic dysfunction associated FLD

Why is there excess fat in the liver?

We usually store fat in our thighs, hips or abdomen, dependent on where our genes decide it should be stored but, if there is an excess of calories or impaired metabolism, it can be stored in the liver. This is more likely to happen if someone has a level of insulin resistance, since this means that the cells will remove less glucose from the bloodstream. This extra glucose can be converted to fat and stored in the liver. Keep in mind that insulin resistance is an inflammatory state.

Another name for fatty liver is steatohepatosis. ‘Steato’ refers to fat, the ‘hepato’ bit refers to the liver and ‘osis’ simply means that something is present i.e. that fat is present in the liver.

In itself, having some extra fat in the liver can be harmless, just as having a bit more fat around our thighs or abdomen can be harmless. However, for a small percentage of people this leads to inflammation and the the ‘osis’ becomes an ‘itis’ and the condition becomes known as NASH or non-alcoholic steatohepatitis (NASH).

Roughly 20% go on to develop NASH and, if the inflammation is managed, further harm can be avoided. If not, the inflammation causes scarring of liver tissue or fibrosis. And, as we all know from scars on the outside of our bodies, scars are not functioning tissue; they don’t stretch, absorb or produce any compounds. The more scarring that occurs, the less useful liver tissue remains. At an advanced stage, this is known as cirrhosis. The liver is no longer able to carry out its vast number of vital roles which include making use of the fats, protein and carbohydrate we eat, neutralising toxins, ensuring our blood clots and performing the first step in the activation of Vitamin D we make from sunlight.

Don’t panic! If you have been diagnosed with NAFLD, be reassured that only 5% of those receiving this diagnosis go on to develop severe liver injury such as cirrhosis.

Why do people get NAFLD?

Ethnicity clearly plays a role from what we saw above. This may be due to genetics wrapped up with a good dose of other social determinants of health such as stress caused by socio-economic challenges, racism, marginalisation, trauma, environmental pollutants, gut bacteria and access to fresh food.

It is true that someone with higher fat stores is more likely to suffer from NAFLD.  That said, one paper found that between 3-30% of people with NAFLD did not fit into the ‘obese’ category. Clearly other factors are at play.

I mentioned above that it is the excess of calories that leads to additional fat storage in the liver and, of course, weight gain. However, if someone’s weight is stable, they are clearly not consuming excess calories, regardless of their body size. So, perhaps it is the journey to the higher weight which causes the fatty liver rather than the weight itself?

A common recommendation for the treatment of NAFLD is weight loss. Certainly, this will reduce the fat stores in the liver in the short-term. However, since research shows that most people regain any weight lost on a diet within 3 to 5 years, the ‘diet’ backfires. Whilst slowly regaining that weight, they are taking in excess calories and are likely to be storing some as fat in the liver. Consequently, liver fat stores may return to baseline or perhaps higher. This is YoYo dieting really showing its true colours.

So, what can I do to reduce the chances of my NAFLD progressing to a more dangerous level?

I hate to sound like a broken record but regular exercise and adopting as healthy a diet as you can are the two most effective steps you can take. Oh, and since the aim is to reduce inflammation, reducing sources of stress will be a tremendous help but that’s easier said than done, I know.

There are no specific ‘anti-inflammatory foods’, since adding one carrot a week into an otherwise veg-free diet is unlikely to touch the sides, just as a fastfood burger meal once a week is unlikely to damage a generally healthy diet. It’s the dull story of variety, plenty of colourful fruit and vegetables and more plant foods than anything else. This approach will bring you the antioxidants, fibre, minerals and vitamins that day by day may well gradually help reduce that inflammation.

Since NAFLD is associated with insulin resistance, it makes sense to consider the amount and types of carbohydrates you eat too. Foods made with highly processed grains, such as white flours, and sugary foods are going to cause blood glucose levels to rise more quickly. And, if the portions are large, the rise will be greater.  If our cells are already struggling to cope with the glucose in our blood due to insulin resistance, then opting for wholegrains and balancing out the carbohydrate foods with some protein and plenty of vegetables is a great approach.

For example, if you’re having a pasta dish, maybe serve out a smaller portion, include a little more protein and have a side salad. If having pie topped with pastry, perhaps avoid having potatoes too, just load your plate with vegetables. Beans, lentils and chickpeas all contain some carbohydrate alongside protein and fibre and the carbohydrate they contain breaks down very slowly. They tend to make us feel full more quickly and for longer and they make a great replacement for other typical starchy carbohydrates like rice, pasta and potatoes. As for snacks, if it’s in a packet it is likely to be processed and high in simple carbs. How about a piece of fruit,  some nuts and seeds, plain yoghurt with a handful of berries, olives, gherkins, sticks of veg and dips, a boiled egg, a bowl of soup …..  I’m sure you have plenty more brilliant ideas.

And, in case you missed it, regular exercise is vital, with one of its key benefits being a reduction in insulin resistance. When we exercise, our muscle cells suck up the glucose from our blood system amazingly effectively which means excellent blood glucose management.

There is some more promising news too. Firstly, there is emerging evidence that regular coffee drinkers may be protected since caffeine seems to slow the progress of liver fibrosis. Yay!

Secondly, studies have shown promise in the use of Silybin (great name) which is the active component of Silymarin (slight less amusing unless you are a sailor). This comes from milk thistle (latin name Silybum marianum – don’t snigger). I remember people talking about the benefits of milk thistle after a heavy night out years ago but the reasons why it might be helpful just weren’t known.

It seems that it has two key actions which protect the liver. It acts as an antioxidant and seems to impede certain enzymes which lead to liver fibrosis and cirrhosis.

However, it may interact with certain medications and its effective dose is unclear. So, before panic buying a year’s worth, have a chat with your local pharmacist or doctor first.

One more thing, are you a big fizzy drink guzzler? If so, check if they contain high fructose corn syrup (HFCS). This is more likely in USA than in Europe. Too much fructose can lead to oxidative stress (damage), raised triglycerides and may be harming your gut microbes and the health of your gut lining. The relatively small amount of fructose we might get from a couple of portions of fruit a day is nothing to be concerned about.

The liver is a key player in metabolising and detoxifying the random things we put in our body. It does an amazing job and can continue to do so even when the vast majority of its tissue is damaged or absent. So, it is rarely too late to reverse or to put a stop to the damage caused by the slings and arrows of our outrageous fortune or misfortune (sorry Hamlet). I hope you find the ideas above helpful, however ‘Sily’ they may sound.

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