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I’m sure that most of you reading this article will have heard of the term “fatty liver”. You may immediately relate it to an excessive consumption of alcohol and you wouldn’t be wrong. But there is another type of fatty liver that is becoming increasingly more common even in children. Non-alcoholic fatty liver disease or NAFLD has been called an “epidemic of the 21st century”. It is even on track to become the main indication for liver transplantation! This should not come as a total surprise because NAFLD is a disease that is associated with the rising prevalence of obesity and other metabolic diseases like type 2 diabetes and the metabolic syndrome.
If you find yourself carrying extra weight around your belly you will very likely be carrying fat within your abdominal cavity (known as visceral fat) and possibly within the liver itself. Visceral fat predicts the development of many chronic illnesses. Even if you are of normal weight but have an increased waist circumference you could still have visceral fat and have the same risks.
What waist circumference should I aim for?
The recommended waist circumference for men should be below 94cm and women below 80cm. (Australian and European Guidelines) The lower your waist measurement the better. Ideally our abdomen should be flat and you should not be able to pinch excess fat.
Although you may notice that your clothing size has increased it is much harder to appreciate the internal damage that is occurring as fat accumulates in the liver. It happens insidiously and doesn’t usually produce any obvious symptoms until much later in the disease process. Sometimes a fatty liver may be noticed incidentally while you are undergoing an abdominal scan for some unrelated reason, but most people are totally unaware of it. If you do experience any symptoms they will probably include fatigue, sleep disturbances or discomfort in the region of the liver. With progression of fatty liver disease abnormal liver enzymes may be noted on blood tests. Often hypertension, pre-diabetes, diabetes or abnormal cholesterol levels are present too.
So what exactly happens when fatty liver progresses and why should you be concerned?
A subset of people with fatty liver disease will go on to develop inflammation in the liver which occurs to remove the accumulated fat, (once this happens it is called non-alcoholic steatohepatitis or NASH). Fibrosis or scarring can then follow leading to liver cirrhosis, liver cancer and liver failure. If you are obese, have metabolic syndrome or are over the age of 50 and have type 2 diabetes your doctor should screen you for NAFLD with liver enzyme tests and / or an ultrasound scan because your risk of developing NASH is that much higher with a faster progression to liver-failure. People with NAFLD will have all the same risk factors for cardiovascular disease and in fact, heart disease is a common cause of death. Currently there are no approved medications to treat NAFLD although many are in the pipeline.
This all sounds very bleak but it shouldn’t… because non-alcoholic fatty liver disease is preventable and reversible!
Weight reduction when needed is the foundation of treatment and the aim should be to lose 10% or more of total body weight, but even a small to moderate weight loss of 3-5% will result in some resolution. With 7-10% weight loss 90% of cases of NASH will resolve! Weight loss should be slow and not exceed more than 1.6kg or 3 pounds /week because all the extra fat being broken down flooding the blood stream can sometimes make things worse.
The composition of the diet is also important with evidence suggesting that the best dietary pattern should promote the elimination of sugary foods and sugar sweetened beverages, a reduction in red and processed meat and saturated fat.
Fructose in sugar sweetened drinks is especially problematic but fructose in fruits is not a risk factor for fatty liver most likely due to the lower fructose content, beneficial fibre, phytonutrients and micronutrients which all promote prolonged satiety and a healthy gut microbiome.
Saturated and trans fats have been found to have a negative effect on NAFLD and NASH inducing insulin resistance, dysbiosis (altered gut microbiome) and inflammation whereas monounsaturated fats found in olive oil and omega 3 polyunsaturated fats have a preventative effect.
The most beneficial foods have been found to be complex carbohydrates, vegetables, fruits, legumes (beans, split peas, chickpeas and lentils associated with a 65% lower risk of fatty liver), whole grains, nuts, seeds, fish and olive oil.
These recommendations are present in a Mediterranean diet which also happens to be a way of eating that has been proven to be the easiest to stick to in the long term. (It is also a healthy plant-based diet and lifestyle program that has been proven to reverse heart disease in randomised controlled trials). Increased physical activity (aerobic and resistance training) and cessation of alcohol and smoking are also important measures.
Making heathy life changes is never easy and most people need help. The best results have been found when people receive ongoing support for a combination of changes that take into consideration their unique circumstances and preferences. Please speak to me about a lifestyle medicine consultation and coaching program if you feel you need extra support to build everyday lifestyle habits that will help you to reduce those centimetres around your waist and improve your long-term health.