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Liver Disease—What You Need to Know About this Common Problem of Diabetes

Developing non-alcoholic fatty liver disease, or NAFLD, occurs in people with obesity and type 2 diabetes, and can be reversed with weight loss.

With James H. Tabibian, MD, PhD, Kenneth Cusi, MD, and Dimitrios A. Koutoukidis, PhD, RD

Of all the known complications of type 2 diabetes, hearing "You have fatty liver disease," likely comes as a shocking, unpleasant surprise, and no one that is expected or familiar. About one in three people in the United States has the condition. Another common cause of chronic liver disease is obesity.1

Having this form of chronic liver disease is often discovered by chance, perhaps when blood tests find elevated levels of liver enzymes.1 And the diagnosis is not uncommon, says James H. Tabibian, MD, PhD, assistant professor of medicine with a specialty in gastroenterology at the University of California/Davis, who says he is frequently having to give many patients this news.

Fatty liver disease is a common complication that occur with increased weight gain that will worsen if you do nothing. Type 2 diabetes and obesity are 2 main causes of fatty liver disease. Image: 123rf

Liver Disease Commonly Occurs if You Have Type 2 Diabetes or Obesity

Medically, the formal name for this condition involving the liver is: nonalcoholic fatty liver disease, or NAFLD.

Chronic fatty liver disease occurs because of a buildup of excess lipids in liver cells that arises for reasons other than consuming too much alcohol, which causes a different form of liver disease. While the liver normally contains some fat, when fat accumulates to more than 5-10% of the liver's weight, the disorder is termed chronic fatty liver disease.1

The reaction of patients, Dr. Tabibian tells EndocrineWeb, varies greatly. "For some, the diagnosis sounds esoteric and bizarre and they may blow it off as something of little consequence," perhaps ditching doctor's appointments that are important to monitor any changes in severity of NAFLD over time, he says.

"Others want to grab the bull by the horns," he says, and make the critical lifestyle changes necessary to forestall progression of the disease. "Unless weight loss is achieved, this [condition] worsens gradually over time," he says. "So anything you can do to prevent the disease from advancing is strongly urged, and the sooner the better."

Fortunately, receiving a diagnosis of non-alcoholic fatty liver disease is not so dire, says Dr. Tabibian. One of the best steps you can take is heed your doctors suggestion of a referral to attend an organized, structured weight loss program. 2 That was the bottom-line conclusion from a study reported by a team of researchers from the United Kingdom (UK) who evaluated results of 22 previously published studies, an approach known as a systematic review of the literature and meta-analysis.2

To accompany the study, Dr. Tabibian, with coauthors Elizabeth S. Aby, MD and Jihane Benhammou, MD, wrote a patient information page to spell out other actions that anyone who is newly diagnosed with fatty liver can take.3

Why Losing Weight Takes Center Stage is Addressing Liver Disease

The UK researchers considered the treatments of more than 2,500 men and women with NFALD, who were on average 45 years old. The question: Can weight loss help improve non-alcoholic fatty liver disease?

The researchers looked at weight loss and also at certain biomarkers, or indications of fatty liver, such as levels of a liver enzyme known as ALT (alanine aminotransferase). What they found is that in people who did not attempt to lose weight or tried with a standard weight loss diet were not very successful but those who participated in a more intensive program showed greater weight change and with it, improvement in their liver status.2

In fact, individuals who attended a structured or formal weight management program lost about 8 pounds more, over about 6 months, than those who didn’t try or relied on their own to lose weight.2 When people lost weight, they showed a marked improvement in liver tests, such as ALT, and other parameters of liver health.

Exactly how the weight loss improves liver health is not known for sure, the researchers say. It could be that by improving control of blood sugar levels and reducing problems of insulin resistance may explain the positive changes in liver function, says study leader Dimitrios A. Koutoukidis, PhD, RD, a researcher at the University of Oxford. This is important since about half of those with type 2 diabetes have NFALD, as shown from results of other research.4

What Do You Need to Know if You Have Non-Alcoholic Fatty Liver Disease

If your doctor diagnoses you with NAFLD, don’t ignore it. It's very important to accept the urgency of reversing fatty liver disease, so it doesn’t progress to the most severe form known as NASH (non-alcoholic steatohepatitis), and up to 25% of those with NASH may have cirrhosis or scarring of the liver.1

Fatty liver disease progresses but can be reversed with weight loss.Attending a formal weight loss program assures the best outcomes in someone with fatty liver disease, related to type 2 diabetes and overweight. Image: 123rf

As this liver condition progresses, you may also experience other symptoms such as trouble concentrating, increased forgetfulness, confusion and greater daytime sleepiness.3

At present, there is no specific drug available to treat available fatty liver disease, the best and only way to lessen your risks is to adopt lifestyle changes that include weight loss: the same recommendations as you’ve likely heard about or considered to management your diabetes and/or body weight.

Six Strategies to Improve Liver Disease

Dr. Tabibian and his colleagues share several key points that will not only help you improve your liver status but will similarly benefit you if you have type 2 diabetes and/or a body mass index of 25 kg/m2 or higher, 3 as follows:

  • Just by losing 10% of your current body weight will be enough to reduce liver fat and lessen the harmful inflammation. If you’ve tried diet and exercise but this approach hasn’t been enough to help you get to that goal, consider discussing weight loss medications or even weight loss surgery.
  • Adjust your meals to more closely reflect the Mediterranean diet, an approach to eating that is features mostly unprocessed (Fresh or frozen) vegetables and fruits, and limits fats to olive oil and nuts.  
  • Avoid foods and drinks high in fructose, such as artificially sweetened sodas, juices and desserts, might go a long way in lowering the level of liver fat. Better yet, don’t drink your calories.
  • Exercising is strongly recommended—Build up to at least 150 minutes a week—or aim for 10,000 to 15,000 steps a day, based on your doctor's advice.
  • Limiting alcohol (to 1 drink daily for women, and 2 at most for men) is suggested. Ask your doctor what limit is best for you.
  • To further protect the liver, ask your doctor about your need for hepatitis A and B vaccinations, if you are not already immune.

Endorsing the Benefits of Weight Loss to Improve Overall and Liver Health 

Putting into place a plan to lower your body weight is highest on the list of healthy strategies needed to tackle fatty liver disease and overweight, agrees Kenneth Cusi, MD, FACE, FACP, chief of the division of endocrinology, diabetes and metabolism at the University of Florida, Gainesville, who was not involved in the study.

"It really boils down to losing at least 7% of [your starting] weight to reduce the inflammation," he says. And if there is scarring, meaning the NFALD has progressed, ''you probably need to lose closer to 10% of your initial weight."

In general, the research results have shown that enrolling in structured weight loss programs that include repeat visits and ongoing reinforcement work best for meaningful weight management, says Dr. Cusi. Why these programs work in individuals with fatty liver disease in helping to recover liver health is sparse; still, any weight loss will be a great good step toward improving many aspects of your health.

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