Dr Ritamarie
Nearly one in three adults worldwide has fatty liver disease. Alarming, right? That's about 30% of the global population. And among people with type 2 diabetes, the prevalence skyrockets to 60 to 86%. And here's the part that should make every practitioner stop and pay attention. In the United States, over 95% of people with fatty liver have no idea they're affected.
One large study found that only 4.4% of adults with non-alcoholic fatty liver disease were aware that they had any form of liver disease. And it doesn't just affect people with diabetes. Even in non-diabetic adults, about 40% show signs of insulin resistance, and that alone nearly doubles their risk of progressing to liver fibrosis over time. This is one of the fastest growing silent epidemics in the world. And by the time people, most people anyway, realize that their liver is in trouble, the damage is already advanced.
In today's episode, we're going to explore how fatty liver progresses to fibrosis and cirrhosis silently, and the role of insulin resistance, even in people without diabetes. We're going to look at early labs and assessments that catch it, before it's too late. Great news. And we're going to look at action steps that you can take as a practitioner, or if you're a self healer, to help you, to help clients reverse fatty liver and restore liver resilience. So let's dive in.
We'll start with why the liver matters. The liver is central to metabolism, detoxification, and hormone balance. It filters toxins, it regulates blood sugar, it stores nutrients, and it produces vital proteins. When it's overburdened or infiltrated with fat, every system in the body is affected, cardiovascular, immune, brain, and hormone signaling.
Sadly, there's a silent progression when it comes to liver disease. Fatty liver develops gradually. First comes simple fat accumulation, often triggered by high insulin and poor nutrient status. Then oxidative stress and inflammation fuel the fire, damaging hepatocytes, the cells in the liver. And this sets the stage for fibrosis, scar tissue formation, that stiffens and disables the liver.
Globally, 10 to 15% of people with fatty liver will progress to fibrosis or cirrhosis if nothing's done. And the good news is there's stuff that can be done. Because the early stages are asymptomatic, most people discover it too late. So they don't catch it in that early stage, and they continue to have damage to their liver, oftentimes irreversible, leading to the need for a liver transplant.
So what's the cause? And why is non-alcoholic fatty liver so prevalent? Insulin resistance is the main culprit and with 93% of the population metabolically unwell, that's a lot of people at risk.
But here's the critical thing that you as a practitioner need to know. Non-diabetic adults with high HOMA-IR scores or elevated fasting insulin are also at elevated risk, not just those that are already diabetic. And the good news is you can catch that early on, before it progresses to irreversible damage.
There was a cohort of over 32,000 non-diabetic people, and those with the highest insulin resistance had nearly double the risk of progressing to advanced fibrosis over an eight-year period. Changes in insulin resistance predicted fibrosis more strongly than changes in body weight. In other words, insulin sensitivity is more important than the number on the scale when it comes to fatty liver. Elevated fasting insulin, high triglycerides, or rising waist to hip ratio may be the earliest signs, even before glucose or hemoglobin A1c are abnormal.
So what are we as practitioners to do to catch it early? We need to do the basic labs, the ALT, AST, GGT, although GGT has been eliminated from a lot of the basic labs. We need to look at fasting insulin, which most conventional doctors don't do, but I encourage everybody to do.
We need to look at the lipid panel, especially the triglyceride HDL ratio, and we need to watch for the changes outside of functional ranges, even with excellent findings that are progressing. In other words, ALT, AST, they're perfectly fine. They're within the functional ranges. But year after year, they're getting closer and closer to the top level of those functional ranges, closer to the out of balance for ideal. That's something to pay attention to.
And you as a functional practitioner need to do that, because conventional medicine doctors are not doing that. They're not looking, and they're not catching it, until it goes outside of the lab ranges, which are a lot higher. And that means that liver progression has been happening, liver damage has been happening for a long time. So these are a problem, and these are something we all need to be looking at.
Then there's some advanced tools. So, I think that the HOMA-IR calculation, fasting insulin, fasting glucose, should be calculated on everyone. We also should look at C-peptide as a good indicator of pancreatic function. I have a previous episode on the liver-pancreas connection that has details about that.
Also, pro-insulin, which is rarely done, but there's some good data that suggests that we can get some good indications of the liver pancreas status when we do the pro insulin and the C-peptide. And in that episode, there's some charts that you can download and use when you're analyzing the labs.
Dr Ritamarie (06:31)
There's also imaging you can do. Ultrasound can show fatty infiltration of the liver, but fibroscan or transient elastography gives a better insight into the stiffness and fibrosis risk. Check out the practitioner guide in these notes, in the show notes or the description for details. I have a chart and a handout for you. So comparing the imaging techniques and which one you use most of the time.
We also need to look at what we call anthropometrics. So waist circumference and waist to hip ratio, they're powerful red flags, and they're easy to keep track of and easy to repeat, and they don't cost any money. So those are good ones.
So let's talk about the mechanism of progression, why it progresses from fatty liver to fibrosis to cirrhosis and even cancer. We'll dive deeply into what the mechanisms are and why it's so critical for us to catch it early.
So fatty liver, non-alcoholic fatty liver, NAFLD as it's known as, that's an accumulation of fat in the liver, but it's mainly due to insulin resistance, right? Other things can cause it, but the main culprit is insulin resistance, which we know is easy to detect early on when we know how to look for it and easy to reverse.
So when cells become resistant to insulin, the liver starts storing fat instead of breaking it down. And that leads to the first stage, which is fatty liver.
Most people with this condition have no symptoms, but they're at risk for inflammation. So that's putting them at risk, right? So as the fat builds up in the liver, it triggers this inflammation, and that's where things get dangerous. The liver becomes inflamed due to oxidative stress, meaning it's being damaged by the very fat and toxins it's trying to store. And this causes the liver cells, the hepatocytes to become injured. This leads to non-alcoholic steatohepatitis, also known as NASH, which is a more aggressive form of fatty liver disease.
With persistent inflammation and liver cell damage, the body tries to heal itself by creating scar tissue. We know all about that. The liver responds by activating hepatic stellate cells, which normally store vitamin A, but transform into myofibroblasts that lay down collagen and other extracellular matrix components to form scar tissue.
What does scar tissue in the liver do? It doesn't do any good. As it builds up, it starts to impair the liver's ability to function, and that leads to fibrosis. And at this stage, more severe symptoms are present and liver function can start to decline.
Dr Ritamarie (09:15)
So let's look at some of those symptoms so we can be aware. People might start to feel extreme fatigue. You likely see people experiencing fatigue every day in your practice, but keeping an eye out for one of the causes of underlying fibrosis of the liver.
The liver's inability to detoxify efficiently, right, leads to a buildup of toxins. And that leaves people feeling consistently tired and drained and brain foggy, cognitively impaired. So we see a lot of that too. We see a lot of brain fog and a lot of fatigue.
It can also lead to jaundice, right? The buildup of bilirubin, which is a waste product from the breakdown of the red blood cells. Build-up isn't eliminated, and people turn yellow. The eyes, the whites of the eyes, the skin, that's jaundice, right? So if you're seeing somebody, and you're like, why are their eyes, the whites of their eyes, yellow, or why does their skin look a little yellow?
It might not be the lights in your office or the lights on the camera and on Zoom, it might just be jaundice. So you want to see a compilation of symptoms. You're not just looking at one symptom.
One of the hallmark symptoms of advanced fibrosis is what's called ascites, which is fluid that builds up in the abdominal cavity.
This is due to portal hypertension, which is increased pressure in the liver's blood vessels. And that causes the abdomen to appear descended and swollen. And sometimes that fluid leaks into the spaces, and it kind of sloshes around. As the fibrosis progresses, the liver's ability to produce clotting factors becomes compromised. And so somebody may complain that they bruise easily, or they have bleeding gums. And you might right away go to talk to them about
bioflavonoids and vitamin C and rutin, which are great differential diagnoses in this case, but you've got to make sure you're putting all the pieces together.
So somebody says they're having fatigue, and they're having brain fog, and they're bruising easily, their gums are bleeding, their nose is bleeding. You have to think, you have to rule out liver and liver fibrosis.
Dr Ritamarie (11:32)
You know, when they have this increased tendency to bleeding, you may notice, or they may say that it takes a really long time for wounds to heal. They get cut, maybe they slice themselves with a knife and boom, they can't heal. They can't stop bleeding.
When we have fibrosis, we get lower levels of albumin, which is produced by the liver, and it accumulates, and it can accumulate in the legs and feet, leading to swelling, edema. And usually when we see edema, we're thinking blood pressure, we're thinking kidney, we can be thinking congestive heart failure, but don't forget to think about fibrosis of the liver, especially when their history seems to indicate that they have a lot of toxic exposure.
If they've experienced detox type symptoms before, or sluggish detox, or if you've looked at their genetics, and you see that they have a lot of slowed down detoxification pathways, all of these things are clues. And for us as health detectives and looking for root causes, we should be looking at the clues and putting them together, kind of like Sherlock Holmes.
Other symptoms as the fibrosis continues include confusion, forgetfulness, disorientation, cognitive impairment of some sort. Sometimes people do call that brain fog, but it may be beyond brain fog. This can be an indication that they may be having hepatic encephalopathy.
What does that mean? Well, due to the decline in the liver's ability to detoxify, there's a buildup of ammonia that can travel to the brain causing hepatic encephalopathy. So the symptoms, like I said, include confusion and in severe cases, it can even lead to coma.
Portal hypertension also leads to the formation of varices, so enlarged veins, not just in the legs, right? People would complain about their varicose veins in their legs, but it’s also in the esophagus and in the stomach. And these are subject to rupture and that can cause internal bleeding, which can lead to low iron and anemia-like symptoms. Also vomiting blood or blood that's passing in their stools as black, tarry stools. So we want to make sure that we're ruling this out whenever people have some of these complaints. Whenever you have a suspicion that they have the fatty liver from the insulin resistance, it may be leading to fibrosis.
As the liver function continues to decline, people might experience chronic nausea or vomiting or even loss of appetite making it difficult to maintain proper nutrition. So then they get symptoms of malnutrition. This symptom significantly impacts a person's ability to stay healthy, because their body's essential nutrient processing declines.
So we may see a lot of other symptoms, widespread symptoms in other parts of the body and in their hormones and in their gut. We may see the spider grate. We might see spider veins or angiomas that appear under the skin, those little blood-like freckles that we see as the function deteriorates. So don't dismiss those as just minor things. They could be, but they could be a sign of fibrosis, and we want to make sure that we rule it out. They're common signs of advanced liver damage.
Dr Ritamarie (14:45)
So here's the deal. As practitioners, when we understand these symptoms, and we understand the early stages of fibrosis, it's really important,so that we can help people to reverse or significantly reduce the damage, when we catch it early.
When we catch it later in the game, which is what typically happens, a lot of these changes are irreversible. So let's really pay attention and really go back to doing that really thorough history and really thorough exam, if you do it in person. Or in the virtual exam, you're asking them about a lot of these symptoms. You're asking them to look at the backs of their legs. You're asking them to look at the various parts that you may not see, because you're not in person.
So when we catch fibrosis, when we catch it in the fibrosis stage, before it progresses to cirrhosis or cancer, that's good, right? We really want to catch it when it's in the fatty liver stage, before it even progresses to fibrosis. So pay attention to those signs that we may be progressing.
The good news is that we have targeted intervention and many of these symptoms can be alleviated or prevented. If we don't intervene early enough though, we run the risk of progression to cirrhosis. And the liver is so scarred at that point that it can't regenerate. We see this a lot in alcoholics, but we see it in the non-alcoholic fatty liver disease as a progression. So we really need to look at this.
Cirrhosis leads to more in the form of portal hypertension, increased blood pressure in the liver, ascites, and various kinds of bleeding like we talked about earlier. It's the point where liver transplant may be needed, like in the later stages.
Now, the scary part is that as the cirrhosis continues, it promotes chronic inflammation, which can cause DNA damage in the liver. What happens when we have DNA damage? It can lead to uncontrolled growth of the liver cells and lead to liver cancer.
Cirrhosis is the leading cause of liver cancer, and people with cirrhosis are 20 to 25% more likely to develop liver cancer over a five year period. This progression is silent and gradual. So detection early is the key.
Once the liver reaches cirrhosis, it's much, much harder to reverse the damage. That's why as health practitioners, we need to identify fatty liver early, intervene with targeted treatment, and prevent further damage.
Dr Ritamarie (17:10)
I'm going to tell you a quick story about a patient that I had very early on. It was even in my clinic days, before I even graduated, before I was licensed. He was a neighbor who agreed to come in and do one of the many exams that I had to do to graduate. And we ran blood tests and his liver enzymes were whacked through the roof. I alerted him to this, and I told him to go and get some further testing with his doctor. Well, long story short, he went off and did that and found out that he had some hepatitis, signs of having had a hepatitis early on, which does potentially lead to fibrosis.
Anyway, I found out a few years later, after actually I'd been out and in practice, I hadn't heard from him. I mean, he was just a neighbor that came in to help me out in the clinic, and I didn't really follow up with him. But I found out through someone else that he ended up having to have a liver transplant.
I caught it early, but his doctors didn't necessarily catch it early, right? Or they didn't take it seriously early. So if you are seeing those progressive increases in ALT, AST, GGT, take it seriously and go down all the paths to rule it out.
Insulin resistance is one of the most common problems in our society. It's said that 93% of the population is metabolically unwell, which has some indication that they have early insulin resistance or full-blown insulin resistance.
So let's talk about what we can do now that we understand the progression. What can we do to reverse fatty liver, before it becomes fibrosis, and how to prevent cirrhosis and liver cancer?
The liver has tremendous capacity for regeneration. And with the right interventions early on, fatty infiltration and early fibrosis can be reversed. So let's look at some key strategies.
First and foremost, diet. Dietary guidance is critical. Food first is one of my mottos, like food is your medicine. So emphasize with these people, whole foods, plant-strong diet, rich in antioxidants and phytonutrients, and low glycemic.
So keeping the insulin under control.
Encourage cruciferous vegetables, leafy greens, sulfur rich foods, assuming they handle them well. And if they don't, then you have to go figure out why. It's usually something that you can look at the gut microbiome and all that to reverse.
So we want to look at those. We want to look at bitters to support detox pathways. I think the bitters are such an important piece to help with stomach acid and the secretions in the digestive tract. And almost everybody I talk to, I talk to them about bitters.
You want to make sure they get enough choline, and you can get that from flax and sunflower seeds, the lecithin part, soy, soy lecithin, Brussels sprouts and other foods, right? And that helps to export fat out of the liver. You want to reduce refined carbohydrates and alcohol and processed fats that lead to fat deposition in the liver.
So what are some of the lifestyle interventions? It's a lot of the stuff we standardly look at as foundations. But a lot of us forget about these when we're dealing with a complex case. Go back to your basics, go back to your foundations.
Daily movement helps improve insulin sensitivity. Even short post meal walks reduce liver fat. Post meal walks. Go out and have your people walk for 10, 20 minutes after a meal. That can make a huge difference.
Strategic intermittent fasting or time restricted eating. So work with them. If they're premenopausal, you want to work with them for the right timing in the month, but intermittent fasting can be so super helpful to help to balance the insulin levels and the fat in the liver.
Of course, stress reduction. I think sympathetic overload is one of the leading causes of conditions that we see all the time. It's getting people down off the fence, getting people to get their cortisol levels down. And in some cases, people already got their cortisol levels down, but if they're too far down, then they can't respond to stress. So teaching them some of the major techniques like meditation and yoga and heart math and tapping and all these things to help them bring their stress levels under control.
And in some cases, they're going to need to have some interventions, right? Some PTSD type interventions, trauma healing interventions, because so many people have stored trauma that increases the stress, which increases the cortisol, which increases the blood pressure and the blood sugar, which increases fatty liver.
Dr Ritamarie (21:47)
Let's look at some of the supplementation that can be helpful when it's appropriate. Again, we don't just jump right into supplementation. We want to get the basics covered. A lot of times people, when you jump into supplementation, they think, I'm good. I don't have to do the food part, because I'm doing all the supplementation.
So things like antioxidants, vitamin C, vitamin E, NAC, those can be helpful, appropriately used. And you need to study this. If you're not sure when it's appropriate, study it. We go through a lot of that very detailed in our functional nutrition certification program.
Other things that sensitize people to insulin like berberine and inositol can be useful. Liver support like milk thistle, artichoke, dandelion, and other things like that. Barberry, hawthorne, things like that. A lot of support. So go in and check those things out.
And then you want to monitor progress, right? You want to look at and repeat, I would say at least every three months, you're doing some of the basic tests like AST, ALT, fasting insulin, and the lipid ratios and seeing if they're responding after three or four months. And are you on the right track, right? So all of that stuff. You want to look at easy stuff that they can be measuring all the time, which would be a decrease in their waist circumference and improvement in their waist to hip and waist to height ratio.
How's their energy? I do symptom surveys and ask them to record how's their energy, how's their brain fog, how's their cognition.
So here's the thing, we as functional practitioners are the future of healthcare. We are committed to putting the care back into healthcare, and that means going beyond symptom suppression and addressing the root causes of imbalance.
Fatty liver doesn't happen overnight. It's a slow burn fueled by insulin resistance, toxins, and nutrient imbalances. So what do we do? The encouraging news is that with root cause strategies, as we've talked about here, and as you hopefully have in your toolbox, and we teach our practitioners in our nutritional endocrinology practitioner training program, that when you have those tools in your toolbox, it's highly reversible.
You just need to know how to be that detective that catches those signs early and knows how to intervene.
As practitioners, when we learn to identify the early signals and intervene with food, lifestyle, and functional insights, we can save our clients from ever reaching the point of fibrosis and cirrhosis.
I've dedicated my life to empowering people to take charge of their health and to mentoring practitioners who want to make a real difference. And the Lord knows we need it. If you're already ready to take your practice to the next level, visit us at INEmethod.com.
And if you want to explore fatty liver and insulin resistance in more depth, head over to the show notes. We have links and references and other trainings that you can listen to and other episodes of the podcast.
So together, let's continue the movement to reinvent healthcare. And until next time, shine on.
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