Maybe you've heard of non-alcoholic liver disease (#NAFLD) or non-alcoholic steatorrhea hepatitis #NASH? Either way, liver disease unrelated to alcohol or medications is the leading cause of liver disease in the United States and the leading cause for liver transplant. It is one of the most common diagnosis I make in my own practice, often by surprise and even in children, and sadly, is the disease that I was diagnosed myself, at the young age of 42 years. If you've ever said to yourself, "I need to lose a few pounds, eat better and start exercising, and reduce some of this stress," there is good potential you are headed towards liver disease, if you're not already there. One in four adults suffer with NAFLD (Budd & Cusi, 2020).
NAFLD is the more simple diagnosis of the two in that there is inflammation in the liver, but with abrupt and significant effort, this diagnosis can be reversed. However, NASH is more specific to liver injury and this one is more progressive, carrying a pretty good risk of cirrhosis over time. Obesity, insulin resistance, and diabetes are all part of this picture.
When I was first diagnosed, I was surprised but I also appreciated that I was in one of the toughest times of my life and I had not been taking proper care of myself. Just two years prior, my husband had decided to leave our family after discovering I was pregnant with our sixth child. He was 50 years old and just not mentally prepared to endure the responsibility of yet, another child. The very same day, while my husband carried out his bags and I was tending to my grieving children, I was notified by one of my staff that one of our clients had suffered a horrifying birth event with one of our midwives. The guilt of my not being there caused me significant #trauma, so much so that I later closed my practice recognizing I just can't be everything to everyone.
My best friend suffered a loss in her practice that same year, and was aggressively pursued by bullies in every corner. While her case was dismissed with absolutely no wrong doings, and only praise was offered by the judge, she lost her practice because her license had been suspended in that time, her reputation, her home, and her marriage. She even lost contact with one of her children, because it is so very hard to parent when you are in the depths of trauma and fear. I empathized with her so greatly that never again was I able to attend a birth without significant anxiety; never again did the privilege of witnessing new life emerge feel like an honor and not like standing in front of a train.
My own birth, right in the middle of all this fun, provided its own level of trauma, including emergency surgery, anaphylaxis, severe organ damage, and medical kidnapping which was so horrid and fraudulent that child protective services became my protector and savior. Suffice it to say, I struggled to leave my home that next year, was incapable of answering the phone or really doing much of anything but collapsing into panic attack after panic attack. I had little to no support whatsoever while raising, or trying to raise, my three littles.
So as I sat on the exam table in my nurse practitioner's clinic, and she reported my labs and recommended a liver ultrasound (not saying aloud what I knew she was thinking that either I am an alcoholic or a complete hypocrite and eat bags of processed junk food daily), it seemed appropriate that more than a decade of an incredibly hostile #midwifery career and two decades of a toxic marriage, added to a few really horrific life events in a really short amount of time on top of an entire childhood of abuse and neglect, plus a few too many cans of Pepsi, well, it all made for a liver on the brink of complete exhaustion.
There was no denying I was fat; I carried it all around my middle. My body couldn't discern between abusive husbands, narcissistic boyfriends, and saber tooth tigers. My midwifery career was a continual denying of my own professional and personal risk and putting others before me no matter what. My adrenals had been dumping cortisol faster than they could manufacture my entire life so my sugar cravings were escalating and my blood sugar was no doubt, exploring great peaks and deep dives. My liver was on the front line pouring glucose into my muscles so I could escape danger, and run for safety. The thing is that I couldn't find safety, ever. I had been running so long that at this point in my life, my body had taken too much damage. My liver was exhausted. My mind was completely rewired for trauma. My nervous system was frozen. I was barely able to lick my own wounds.
It is Likely Your Doctor has Missed Your Own Liver Disease
About a third of those diagnosed with type 2 diabetes, have NAFLD (Budd & Cusi, 2020). I have not been diagnosed with diabetes, although my genetics make it highly likely I may be into the future if I am not exceedingly mindful about maintaining sufficient movement daily, making clean eating choices, sleeping regularly, and drawing healthy boundaries with regards to stress. Because I had no pathology or dis-ease other than needing to lose a few pounds, catch up on sleep, and maybe get a little therapy, there were no overt indications my liver was tanking.
If you're familiar with the Adverse Events of Childhood study then you may also be familiar with the impact of childhood trauma and its ability to turn on genes related to chronic dis-ease. This may be part of your own domino effect, as it is mine. While I could certainly improve my diet and exercise regimen, overall my body composition does not reflect someone with a sedentary lifestyle. My subcutaneous body fat percentage is 21.6% and my muscle mass is high. Trauma in my childhood lead to long-term elevated levels of cortisol, which leads to insulin resistance enhanced by my epigenetic tendency towards type 2 diabetes, and ultimately, here I am navigating liver disease. My real risk though is cardiovascular disease. While a liver transplant is a serious threat, most people with NAFLD die as a result of #cardiovascular disease, followed much less commonly by liver cancer.
The reality is that the reason I diagnose so many with liver disease in my practice is because I obtain a pretty extensive, but not expensive, wellness panel if not at every wellness visit, then at least every third year. In conventional medicine, one must have signs or symptoms of disease before they can go looking so that even the specialists miss this diagnosis quite frequently. My concern though, as a functional and integrative wellness clinician, is assuring your body is in a state of wellness, so we can halt that progress before overt symptoms demand attention. These simple tests are when I discover NAFLD, that otherwise, without proper monitoring, progresses towards NASH. Not being restricted in my practice by third party payers allows me to investigate based on my individual client's history and presentation combined with my own experience and expertise. I can not imagine practicing any other way.
Another side of this coin is not a lot of clinicians really consider NASH when evaluating clients (Budd & Cusi, 2020). They are fairly unaware of how to confirm diagnosis and they aren't aware of how they might treat it, because more often, clinicians think of NASH as an inevitable consequence of poor lifestyle choices and obesity so they simply adjust their expectations. It just isn't alarming to them, but one need not be obese or have diabetes, or even metabolic disease to have NAFLD or NASH. Granted, insulin resistance, type 2 diabetes, and metabolic syndrome are all very much associated with NAFLD and NASH, as are elevated lipids and elevated blood pressure associated with heart disease, but one does not require the other.
Diagnosing Liver Disease
When I meet with clients for their annual wellness exam, especially at their first primary care visit, I like to obtain a complete metabolic panel. This allows me to evaluate basic chemistry in the body, including basic labs that reflect the health of the liver. If these are elevated, I like to order an ultrasound to evaluate for fat in the liver, called #steatosis. Ultrasound can miss this though, especially in those with more abdominal adiposity. MRIs can better measure liver fat, but these are exceedingly expensive, so only really used in these cases for research purposes. If individuals drink alcohol regularly, this is going to impact there liver as well. More than five drinks a week for a man, and four for a woman, raises high suspicion for alcoholism, but when numbers are reaching 21 drinks a week for a man and 14 drinks for a woman (for which most underestimate) then liver disease is a real concern.
Depending on results of the ultrasound, whether there is concern for liver injury or more simple inflammation determines whether one has NAFLD or the more progressive, NASH. If I am concerned that the latter may be present, then we will evaluate for type 2 diabetes and metabolic syndrome, which is already part of our wellness panel such as the complete blood count, liver enzymes, albumin, alkaline phophatase, gamma-glutamyl transferase, total bilirubin, and PT/INR (Smith, et al., 2019). I'll also order additional diagnostic panels or plasma markers if initial findings lean into the potential for liver disease, such as, viral hepatitis serologies, FIB-4 and NFS, including ferritin, transferrin saturation, autoimmune (ANA), anti-smooth muscle antibodies, ceruloplasmin, alpha-1 antitrypsin deficiency and other potential pathologic causes of liver disease (Budd & Cusi, 2020 & Smith, et al., 2019). We will also want to assure we don't have an underlying issue such as diabetes or elevated cholesterol as well, so labs for those will also be gathered. If they are more high risk, then referral may be indicated to obtain a liver biopsy.
Most of the time these clients have no symptoms (Budd & Cusi, 2020 & Smith et al., 2019). A high level of suspicion is warranted, especially in those who are overweight or obese, particularly with much of the weight around their waist, or those who have type 2 diabetes. Although not diagnostic, alanine aminotransferase (ALT) is usually higher than aspartate aminiotransferase (AST). In most, an ALT equal or greater than 40iu/L is a good indicator of active steatohepatitis, while increased AST above 25iu/L is more an indicator of advanced fibrosis. Normal ALT for women is <19 and <30 in men, although most commercial labs will still report abnormal plasma aminotransferases only when above 40. This cuts-off those with NAFLD prior to being diagnosed with the more advanced disease, NASH. Personally, it is my belief, that everyone with type 2 diabetes should be evaluated with these inexpensive liver enzyme tests to rule out any suggestion of liver disease, just as we like to evaluate for pre-diabetes and get serious before overt disease.
Biopsy really is the gold standard to rule out other causes of chronic liver disease and to establish diagnosis and staging of disease. Less than 1% of liver biopsies result in serious adverse events. FIB-4 and NFS assist in determining severity of disease. Be cautious though with NFS because type 2 diabetes can exaggerate these results a bit. A FIB-4 of <1.3 has a low association with advancing fibrosis but higher than 2.67 is significant. A NFS of less than -1.455 is pretty reassuring but higher than 0.676 is pretty concerning.
How is Liver Disease Managed?
This is a treatable disease and like most all chronic disease, it's about transforming your life a bit. Most clinicians aren't going to fuss with this discussion until you demonstrate signs of fibrosis or advanced disease, but let's get serious; what we all want is to live with vitality into the second half of our life, and education is empowering. I have created a program to address NALFD and NASH, because it is the current bane of my existence. I have clients who are both young and old who are participating and working to get their life habits in line with their life goals.
Keep in mind though that while my discussions online largely address liver disease from some level of abuse, whether stress, sugar, or alcohol, there are times liver disease results from alpha-antitrypsin deficiency which is an autosomal recessive genetic trait, Wilson disease, or an autoimmune response for which we can identify antinuclear antibodies. Other times it is the result of hemochromatosis, and remember diagnosis of this is when we are in overwhelming overt expression of the disease, but we can certainly lean into it prior and add that to the stress of alcohol or sugar, or even stress, on the liver and we may have damage before these underlying issues are appreciated.
Weight loss is the cornerstone of treatment (Budd & Cusi, 2020). I lost about fifty pounds after my own diagnosis, but these last ten to twenty have been much more of a challenge for me. Since diagnosis I have married, opened and closed a primary care practice, and moved to Kentucky. I am healing, but admittedly, my trauma and my mental and emotional health were my priority. More recently my attention has turned more to my physical health, and I have the goal of being fit and firm by fifty. If you want to join in this effort, I have a physical health program that might interest you, and if you're already an active client, then you might enjoy the Yoga & Mindfulness group I've created.
The Mediterranean diet is always the forerunner of diet plans and this one focuses on consumption of fresh fruits and vegetables, unprocessed cereals, nuts, fish or white meat, and olive oil. The diet also avoids simple sugars and red or processed meats. If you're over 200 pounds though, diet can be exceptionally tough because hormones are without a doubt, out of balance, which impacts cravings and much movement can create more inflammation. Weight loss medications can help you get started. If you have any interest here, let's talk. Pharmaceuticals should be used judiciously but, don't under estimate the risk of obesity. We talk more about these options in the physical health program. Vitamin E at about 800 units/d improves liver health as well, and should certainly be used in children with ALT elevations.
Of course, due to the progression of this disease and the potential for heart disease, regular visits with your primary care practitioner are important. Glucose, lipids, and blood pressure should all be monitored regularly. An #ultrasound should be repeated about every 3 to 5 years as well, in those who were originally diagnosed with NAFLD. If risk is higher, then consultation with a hepatologist may be helpful. We can do this. If you aren't aware of your liver health status, connect with me and I'll happily offer a consultation that prioritizes your health and wellness.
References
Budd, J. & Cusi, K. (2020). Nonalcoholic fatty liver disease: what does the primary care physician need to know? The American Journal of Medicine, 133, 536-543.
Smith, A., Baumgartner, K., & Bositis, C. (2019). Cirrhosis: diagnosis and management. American Family Physician, 100(12), 759-770.