Q&A with Dr. John Goff About Fatty Liver Disease

Q: What is it?
A: Fatty liver disease is when there is excess fat in the liver. This fat can be associated with inflammation or can just be isolated fat in the liver. The fat associated with inflammation will eventually lead to scarring (fibrosis). When the fibrosis becomes extensive the liver is severely damaged and we call that situation cirrhosis.

Q: How common is it?
A: Up to 30% of adults in the US have fat in their livers. We call this non-alcoholic fatty liver disease (NAFLD). About 5% of adults will have fat and inflammation, which is called non-alcoholic steatohepatitis (NASH). Fat in the liver is the most common reason for a person to have abnormal liver blood tests (abnormal liver enzymes).

Q: What is the cause?
A: The cause(s) of NAFLD/NASH are not fully known and there are likely factors involved that we do not yet understand. However, we do know that insulin resistance (insulin not working as well as it should) and oxidative stress in the liver are significant factors in causing this problem.

Q: How do I know if I am at risk for NAFLD/NASH?
A: Clinical conditions that are associated with fatty liver are: diabetes, being overweight (especially increase abdominal girth or truncal obesity), high blood pressure, and elevated triglycerides (lipids) in the blood. Other conditions with a less strong association include: gout, poly cystic ovary syndrome, obstructive sleep apnea, cardiovascular disease, hypothyroidism and the use of tamoxifen.

Q: How do we diagnosis NAFLD/NASH?
A: The usual inial finding is elevated liver enzymes, but these are not specific so other tests need to be done some of which would be to exclude other causes of liver problems. An ultrasound, CT scan or MR scan of the liver can sometimes tell if there is fat in the liver. Measuring a fasting insulin and glucose level in the blood can help determine if there is good or bad fat in the liver (NAFLD vs NASH). However, the gold standard for determining exactly what is going on in the liver and determining the severity (stage) of the problem is a liver biopsy. However, now we can use FibroScan (a noninvasive device) or one of several composite blood tests on the market (FibroSure, FibroSpect, APRI, etc) to assess liver fibrosis and thus avoid a liver biopsy in many patients.

Q: What can I do about it, if I have NASH?

1. A: Exercise vigorously 30-60 minutes daily. This improves insulin resistance.
2. A: Weight loss through a diet of reduced calories, reduced intake of trans fats (unsaturated fat) with more intake of fish oil (omega 3), olives, and peanut or canola oil, and reduced carbohydrate intake (do not eat white foods) to achieve ideal body weight.
3. A: Vitamin E at about 800 IU daily since it is an antioxidant but be aware that too much vitamin E can increase heart disease and cause prostate cancer.
4. A: Lipoic acid may also be useful since it is an antioxidant and improves insulin resistance. It needs to be used with caution when taking hypoglycemic agents as it may cause low blood sugar levels.
5. A: The drug with the most data supporting it as beneficial for NASH is the oral blood sugar lowing agent pioglitazone (Actos). Unfortunately, it has many potential side-effects, which include: weight gain, worsening of congestive heart failure, osteoporosis, and recently reported, a small but definite risk for bladder cancer. However, if the NASH is severe and not responding to other measures, the risks are outweighed by the benefits of this medication.
6. A: There are some experimental agents being looked at for NASH and hopefully they will prove to be useful. These include drugs that prevent the development of fibrosis and others that will combat the metabolic abnormalities in the liver that lead to NASH.
7. A: Bariatric surgery is not indicated to treat NASH, but would be considered if there are other associated conditions.

Q: What are my chances?
A: There is an increased mortality compared to normal people in those with NASH that is due to liver disease. About 20% of patients with NASH will develop cirrhosis if not treated. The risk of developing liver cancer is quite low, but is increased over normal in those who develop cirrhosis. The goal is to normalize the liver enzyme levels by maintaining ideal body weight through the above mentioned life style changes and with medication as needed.