Fatty Liver Reversal: Medical Doctor resorts to health blogger

First off, I don't make a big distinction -- as I see elsewhere so often -- between so-called NAFLD (non-alcoholic fatty-liver disease), i.e., fatty livers caused by hyper-carbohydrate diets -- what most people consume -- and fatty livers caused by alcohol. Most likely, it's the high levels of fructose in the diet that causes fatty liver in the former, just like excessive and chronic alcohol consumption causes it in alcoholics. And as concerns fructose, I don't mean from fruit. Roughly half of the sugar you ingest from all sources is fructose. Table sugar (from cane or beet) is precisely 50/50 fructose and glucose and in corn syrup, it's 55-60% fructose. It's the enormous quantities of sugar-laden drinks -- including fruit juice -- that people consume that's causing this epidemic of fatty livers, even in children, now.

It seems to me that there's pretty good reason to speculate that it's drinks that are the culprit, both sugary drinks and alcohol. The thing about them both is that they are extremely energy dense for volume, so they don't fill you up, and they're typically downed rapidly, often without any fat or bulk to slow absorption, so the fructose, as does the alcohol, goes straight to your liver in a cascade and has to be dealt with quickly. Fructose is unique as a sugar in this way.

For a great primer on fructose and alcohol metabolism, see physicist Robert McLeod's entry that I've linked to before.

The conclusions we can draw from this body of research are that one can safely ingest glucose regularly with the aim of not saturating the liver's glycogen storage capacity. The maximum reasonable glucose intake level will vary significantly from person to person depending on general activity level and overall health based on how insulin resistant they are. Where one gets into trouble is when you overfill your liver by eating too many calories, with a significant fraction of glucose calories, or significant fructose intake (likely in the form of sugar or corn syrup). This is likely to lead insulin resistance and liver dysfunction.

There's other reasons I've come to conclude that fructose is the culprit. The best way to find out would be to isolate variables. After all, if you have test subjects down a lot of soda pop, the sugar is 50/50 (or up to 60/40 fructose, as noted above), so it would be hard to definitively tell what caused any changes noted. But here's what you could do: give test subjects the same number of sweet drink calories, only sweeten one group with 100% glucose and the other with 100% fructose and see if there's any difference after a period of time. Well, you've guessed the punch line: not only is there a difference, there's a HUGE difference.

Dr. Stephan Guyenet sums it up.

The investigators divided 32 overweight men and women into two groups, and instructed each group to drink a sweetened beverage three times per day. They were told not to eat any other sugar. The drinks were designed to provide 25% of the participants' caloric intake. That might sound like a lot, but the average American actually gets about 25% of her calories from sugar! That's the average, so there are people who get a third or more of their calories from sugar. In one group, the drinks were sweetened with glucose, while in the other group they were sweetened with fructose.

After ten weeks, both groups had gained about three pounds. But they didn't gain it in the same place. The fructose group gained a disproportionate amount of visceral fat, which increased by 14%! Visceral fat is the most dangerous type; it's associated with and contributes to chronic disease, particularly metabolic syndrome, the quintessential modern metabolic disorder (see the end of the post for more information and references). You can bet their livers were fattening up too.

The good news doesn't end there. The fructose group saw a worsening of blood glucose control and insulin sensitivity. They also saw an increase in small, dense LDL particles and oxidized LDL, both factors that associate strongly with the risk of heart attack and may in fact contribute to it. Liver synthesis of fat after meals increased by 75%. If you look at table 4, it's clear that the fructose group experienced a major metabolic shift, and the glucose group didn't. Practically every parameter they measured in the fructose group changed significantly over the course of the 9 weeks. It's incredible.

I drink exactly zero sweet drinks (even artificially sweetened drinks), and haven't for a very long time. Mostly, I drink water and sparkling water. This, of course, is only partially for health reasons. The other is that I can drink more scotch. Fructose or alcohol: pick your poison. The difference, of course, is that even if you drink pretty frequently, it's doubtful that you're going to get anywhere near 25% of calories from alcohol regularly. It tends to have its own built in limiting factor for most people, even though I have found that paleo has dramatically boosted my tolerance for the stuff -- not necessarily a good thing. Anyone else had any alcohol tolerance changes after a significant time paleo?

Alright, so let's get to the point of the post, which is fatty liver reversal. Curiously enough, there's pretty much zero the medical profession will do for you, except that, if your fatty liver is the result of alcohol consumption they'll tell you to stop drinking -- moralizing, guilt-inducing people that humans seem to be. Of course, if it's all or mostly alcohol that caused the fatty liver and you're also not a sweets freak, reducing or eliminating alcohol will help.

But what about NAFLD? Huh? How come there are seemingly zero prescriptions for dealing with it, since there are no drugs. OK, let's think of it this way. ...Do you think anyone is working on a drug to cure an alcoholic's fatty liver as he goes on drinking? That would be silly; some would say irresponsible, and the reason should be obvious. First you remove the cause, right?

So do you think that the general cause of NAFLD is that difficult to understand? Well, it sure must be. Get a load of this comment at Dr. Stephan's place where he blogged about a reader's fatty liver reversal, basically, by eliminating sugar and supplementing with fish oil.

As a physician (MD), it was encouraging to read this blog and the testimonials regarding increased ALT and in particular “fatty liver”. For two years, I have had borderline to somewhat elevated liver enzymes, especially ALT. At my most recent physical examination, my AST was 41 and my ALT was 101 (the last two years the numbers were similar, with the exception of an ALT rise from 65 in 2008). My internist told me that the next step would be a liver ultrasound and additional laboratory tests should the numbers not come down. On review of the formal medical literature, I could not find much about lowering ALT and treating a fatty liver with the exception of stopping all alcohol, losing weight, and exercising. I am 5’10” and 185 lbs. – slightly overweight, but certainly not obese, and I do not have diabetes. As with another patient’s discussion, I do not regularly exercise (as I should) because of my work schedule and two young children that take up the rest of my free time.

For a two week period, I followed much of the advice that I have read in this blog:

1) I limited alcohol intake to 1 glass or less of wine per day (before < 2 drinks per day)
2) I stopped taking Pepcid and Tylenol (metabolized by the liver)
3) I stopped drinking diet soda and drank more water, tea, and V-8 juice (was drinking 3+ Diet Cokes/day - Aspertame)
4) I increased raw vegetables (salad) and cut back on fatty red meat (no fast food)
5) I started taking 1200 mg of fish oil/day twice daily
6) I took a daily supplement called Livatone (mostly milk thistle and B vitamins) as well as a garlic pill

My repeat liver enzymes after only two weeks of this regimen were AST 20 and ALT 60 (down from 41 and 101 respectively). I would anticipate continued improvement with time.

Now Dr. Stephan (PhD biologist) is a very sharp guy and runs a great blog, but what does it say when an MD has to go Googling the blogosphere to get decent help for something that even an agitating layman like myself can figure out (well, I do plenty of Googling too)? That's pretty telling. Oh, yea, they did manage to tell him to stop alcohol (of course, sinner!), eat right (yea right), and exercise. Wow, such comprehensive advice.

And what was Dr. Stephan's advice to the guy who dramatically reversed his fatty liver in a month after having abnormal test results for seven years?

The quality of fat you eat has a very large influence on health, and especially on the liver. Excess omega-6 is damaging to the liver. This type of fat is found primarily in refined seed oils such as corn oil, soybean oil, and safflower oil... Sugar is also a primary contributor to fatty liver. Reducing your sugar intake will go a long way toward reversing it. Omega-3 fats also help reverse fatty liver if an excess of omega-6 is present. There was a clinical trial using fish oil that was quite effective. You might try taking 1/2 teaspoon of fish oil per day.

But that's not all. He did it again, with another reader. And now just recently, part 2 of that same experiment. While a picture is worth a thousand words, particularly in this case...

Fatty liver reversal 2
Fatty Liver Reversal

...do go read all about it on the links to Dr. Stephan's blog.

Now I ask you, what have us "paleo" bloggers been saying for quite a while, now, in regard to diet? Compare that to what Steve did to dramatically reverse his fatty liver condition.

I totally eliminated sugar, heavy starches, and grains. Started eating more whole, real foods, including things like grass-fed beef and pastured pork and eggs, began supplementing with good fats and omega-3 (pastured butter, coconut oil, cod liver oil). Ate more fruits and vegetables instead of refined carbs. Also completely gave up on the idea that I had to eat only "lean" meats. After my last results, the GI doc said that I wouldn't need the biopsy at all, that things were great, and that if I kept it up I "would live forever."

[...]

My triglycerides also went from pre-diet measures of 201 and 147 to post diet 86, 81, and 71.

The added bonus, of course, was that my weight went from 205 pounds to 162 pounds and my body fat percentage from 24% to 12% in the matter of five months--all without the typically excessive cardio I used to try unsuccessfully for weight loss.

The mind boggles at the general incompetence of the entrenched medical/pharmaceutical juggernaut.

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Comments

  1. Great example of ‘Physician, heal thyself’ self-experimentation with Fructose Detox.

    The Ancestral Fitness Epistemocracy (AFE) in the Blogosphere is quite a resource for self-directed healthcare.

    Awesome.

  2. Very nice post. I too have noticed my tolerance for alcohol is much higher which I think is directly attributable to my high consumption of saturated fat. I personally have found this to be true not just overall but on a specific meal to meal basis.

    Drinking alcohol with a meal very heavy in fat, at least for me, allows for more alcohol consumption without the “buzz” effects than is so with a meal that is lower in fat.

    And so far, my liver seems to be doing just fine. :-)

    Michael
    Nutrition and Physical Regeneration

  3. I had a similar experience with a patient who came to me with elevated liver enzymes (I practice acupuncture and herbal medicine) and abdominal bloating. He got the same advice from his primary M.D. (cut alcohol, lose weight, exercise). I loaned him a copy of fat head and gave him my diet handout (condensed: Eat meat, natural fat, vegetables, fruits, avoid everything else). Also told him to take schizandra berry (Chinese: wu wei zi), which trials have demonstrated to lower liver enzymes. Within 3 months his enzymes were normal, abdominal bloating resolved, acid reflux resolved, total cholesterol dropped, HDL increased.

  4. Richard, I think you are confusing “corn syrup” with High Fructose Corn Syrup. The latter is, indeed, about the same glucose/fructose ratio as table sugar. (They can alter the percentages as desired.)

    Old fashioned corn syrup enzymatically breaks the corn starches into glucose. In Europe they get this glucose directly from grapes. But you know what we have a lot of on this side of the pond! A look in the sweeteners in the grocery store, or at the Karo website shows that the products are far from pure glucose, however. They just can’t stop themselves from bastardizing a decent (for sweetener) product with HFCS.

  5. Paul:

    It was just shorthand

    I get too tired of seeing “High Fructose Corn Syrup.”

    Sorry.

  6. Let’s not forget that that ethanol and fructose are metabolized quite similarly, almost as toxins, in the liver.

    Coincidence?

  7. gallier2 says:

    Bryce:
    Let’s not forget that that ethanol and fructose are metabolized quite similarly, almost as toxins, in the liver.

    Coincidence?

    No coincidence at all, alcohol is partly metabolized fructose. Where does alcohol come from? Not from fermented meat or blubber, but from carbs.

  8. I’m surprised to hear the higher alcohol tolerance on Paleo. My tolerance is way down. I assumed it went with my body weight (165 to 145).

  9. Richard, how about HFCS. I think it’s an acknowledged shorthand.

    Also, what I’ve noticed about cutting out most carbs is that if I “overindulge” in adult beverages, I experience absolutely none of the pain of the old days. I’ll still be lethargic, but no headache, no pain issues.

  10. Richard,

    This is great post as par for the course where I learn so much from your personal observations and others. Yes, truly!

    NALFD is so common — and underdiagnosed. One does not need to waste HC resources to do an abdom ultrasound or MRI or blah blah blah. If the ALT is > 12-15, then one probably has probably a fatty/calcified liver.

    This is nearly 50-70% of ALL the chronic patients that I see… Sad… b/c some of these will go to tragic liver cancer if not dealt with.

    You bring up alcohol — some people abstain. Like children and some adults. Yet they drink ‘fruit juices’. Franky at Peter’s blog once pointed out that we would never let children drink alcohol and damage their liver, but children are given fructose. Worse, as you poignantly pointed out (with Stephan’s comments), fructose is FAR WORSE. The changes in cholesterol, small dense LDL and increase in visceral fat deposition start the calcification process (scar tissue) in every tissues:
    –liver
    –gallbladder
    –THYROID (is this why hypothyroidism is rampant? endless daily non-Paleo fruit consumption)
    –pancreas (Metabolic Syndrome, diabetes Type 2)
    –brain (the stupid-fication process known as Type 3 diabetes)
    –coronary arteries and soft plaque

    But like everyone who commented and the 2 cases that Stephan brings up, NALFD is completely reversible with low carb Paleo (no grains, minimal fruit).

    Literally, I also see calcified livers reverse in ALL compliant (and even some of the not so compliant) in 1-4 mos. EASY!

    Btw, this condition is SUPER common in Asians, Phillipinos and Indo-Asians (the ‘skinny’ fat individuals). And it’s not related to alcohol.

    Our bodies are AMAZING. The recovery of any organ is within our grasp. Thank you for all the work you put in your blog and sharing your tremendous insights!! Scotch tolerance… oh my!

    -G

  11. I can’t say for sure if my alcohol *tolerance* has changed since I adopted my present high fat/low carb regime, but I don’t think so. What does seem to have changed is my appetite for alcohol: I now drink about a third less than I used to.

  12. g,

    If you have any info on hypothyroidism and fructose consumption I’d like to see it. I’m looking into the various autoimmunity endocrine disorders but no one really seems to search for causative factors.

  13. “Sugar: The Bitter Truth”

    It’s a 1 hour 30 minute video wherein Robert H. Lustig, MD, UCSF Professor of Pediatrics, explains in quite a bit of detail _why_ fructose causes these problems. Among other things, he explains the metabolic pathways for glucose, fructose, and alcohol.

    I cannot remember the web site I got this from or I’d give them credit — it was in a comment.

  14. Hey McLeod,

    Would love to point you that way! But I’m still getting together the foundations of that thought. I think the autoimmune damage on thyroid and other organs that is instigated by fructoserelated to mannose and mannose-binding lectins produced by our immmune system to identify and ward off pathogens. Fructose is found on the outside of microbes. When you talk about infectious diseases on your blog, I believe you are on the right track. Your father is a physician, correct? My parents too. When they learned autoimmune disease in med school half a century ago, autoimmune dz were simply known as ‘collagen’ diseases. Scar tissue and keloids are collagen and just a natural part of the healing and recovery process by the immune system at the point of entry where microbes can enter.

    DR. Ayers are briefly discussed here and in the comments…
    http://coolinginflammation.blogspot.com/2009/08/cause-of-autoimmunity-and-allergies.html

    If I find something more concrete, I’ll email. Umm… u probably have more thoughts on this than me!!

    -G

  15. Anand Srivastava says:

    I have also lost my fatty liver.
    Last year my tests had shown fatty liver along with not good Liver Function Test.

    This year after eliminating refined oil, reducing fructose drastically and supplementing with Fish oil, the fat on the liver is gone.

    The problem remains for my cholestrol levels. My HDL is still too low 31, though it increased from 26. My LDL is 100 increased from 91. VLDL has gone down from 45 to 15. Tryglicerides have remained nearly constant.

    My diet does not eliminate grains or reduce carbs substantially, so that may be a reason. But I have added a lot of saturated fats, so I was expecting a higher HDL. I guess HDL does increase slowly.

    Also I discovered that my thyroid function is low. TSH is not too high 2.0 (this means that no doctor at least in India will take my numbers seriously). The T3 is at the bottom of the range. T4 is also nearly at the bottom. That condition must have persisted for a very long time. Now to search for a cure.

    • Anand,

      You need to reduce your intake of polyunsaturated oils/fats. They are toxic to the thyroid. Do some research onlines on PUFA and Thyroid function. I would suggest you look into integrating organic virgin coconut oil into your diet. Also investigate getting your vitamin D levels tested. Get controlled sun exposure every day you can if your levels are low. Again, research these topics.

      Good luck!

  16. My alcohol tolerance is WAAY down in recent years (low carb for two years and now lacto-paleo for about a year). I can get a good buzz going on one beer, and I am not a lightweight guy (185lbs).

  17. Dave, RN says:

    Good article, although I wish people would stop ragging “fatty red meat”. The problem is not the fat or the red meat, it’s what we FEED our source of red meat. Cows do not naturally eat grains. They eat grass. Buy grass fed, no hormone, no antibiotic containing meat and then it’s good for you. Lets face it, native plains indians ate all the buffalo they could get, and yet I don’t think they were dropping dead of colon ancer and heart attacks.
    Keep up the good work with your blog. I read it daily!

  18. A liver needs to be massaged and squeezed until its clean. Liver washing service will be all the rage soon for those with the wonga and will. Get your biggest drinks ready! were going to get hammered.

  19. Steve L. says:

    As a first-time commenter I should, first of all, thank you for all the advice, recipes and inspiration. I started going mostly Paleo last spring and have dropped about 35 pounds so far. Without the inspiration provided by you, the Drs. Eades, Mark Sisson and Gary Taubes I would not have done nearly as well. As for your question about Paleo and alcohol tolerance, my experience has been the opposite of yours. But, I strongly suspect that it’s because I switched from beer to vodka and club soda (no carbs!). Maybe I should switch back and find out. Nah! All the best.

  20. Very nice post. I found some case studies on himalaya liv52.
    The herbs in Liv.52 have been selected due to their well known ayurvedic properties that are beneficial for the liver and for overall well being. Liv.52 maintains the functional efficiency of the liver. It detoxifies and protects liver cells from harmful toxins and supports the liver’s ability to regenerate itself.

    Liv52 also supports the liver’s function when challenged by toxins not just in our food, water and air, but also increased consumption of protein and prohormones.

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  5. [...] Fructose is metabolized in the liver just like alcohol, so, giving them a piece of candy, in terms of the liver, is really not much different than giving them a shot of whiskey. It astounds me that parents, grandparents and so many others are so irresponsible in this way. Look around, people. What do you see? And when you not only give candy to kids, but defend it and even get indignant at the thought of denying them, you are no better — far worse, actually — than someone who makes excuses for and enables destructive alcoholics and addicts. [...]