Fatty liver disease is caused by excess fat in your liver. The medical term is hepatic steatosis. Your liver normally contains some fat, but when greater than 10% of the weight of the liver is fat, it's called fatty liver. There are two main types: nonalcoholic fatty liver disease (NAFLD) and alcoholic fatty liver disease, also called alcoholic steatohepatitis.1
NAFLD may be suspected if a blood test shows higher levels of liver enzymes than expected. While the disease is found more frequently in adults, researchers are finding NAFLD is a growing concern in the pediatric community, which triggered at least one intervention study weaning participants off sugar to reduce obesity and Type 2 diabetes.2
Chief of gastroenterology, hepatology and nutrition at University of Southern California and Children's Hospital of Los Angeles (CHLA), Dr. Rohit Kohli, commented,3 "Fatty liver disease is ripping through the Latino community like a silent tsunami and especially affecting children."
While research demonstrates 25% in the U.S. have fatty liver disease,4 in the Latino community the rate is much higher. One study in Dallas, Texas5 examined 2,287 subjects from a multi-ethnic population and found 45% of Hispanics suffered from fatty liver disease. The ethnic differences in the frequency of disease in this study mirrors those in past studies for NAFLD-related cirrhosis.
Key Facts About Fatty Liver Disease
NAFLD is the type not related to heavy alcohol use and in this category there are two types: simple fatty liver, in which your liver has additional fat but little to no inflammation or damage, and nonalcoholic steatohepatitis (NASH), in which you suffer from inflammation and damage in the liver cells, as well as excess fat in your liver.
NASH may cause fibrosis or scarring of the liver and lead to cirrhosis or liver cancer. Researchers have not been able to point to a single cause of NAFLD, but they do know it occurs more commonly in those who have specific risk factors, including:6,7
Metabolic disorders, including metabolic syndrome
High levels of fats in the blood
Middle-aged or older
High blood pressure
Rapid weight loss
Infections, such as hepatitis C
Exposure to some toxins
NAFLD affects nearly 25% globally.8 However, as the rates of obesity and Type 2 diabetes rise, so do the rates of NAFLD. NAFLD is usually a silent disease, meaning most are unaware of the condition and have few or no symptoms. When symptoms are present, individuals may feel greater fatigue or have discomfort in the upper right-hand side of the abdomen.
It is important to distinguish between simple fatty liver disease and NASH since those with NASH experience damage to their liver cells, which increases the risk of progression to fibrosis, cirrhosis and liver cancer. According to Harvard Health Publishing,9 NASH cirrhosis is expected to top the reasons for liver transplants.
Sugar Passed in Breast Milk Predisposes Infants to Obesity
A new study10 is being led by Michael Goran, Ph.D., director of the diabetes and obesity program at Children's Hospital Los Angeles. Last year, he discovered high fructose corn syrup (HFCS) sweetened beverages were passed through breast milk, potentially predisposing infants to fatty liver and obesity.11
Six weeks after giving birth, 41 participating women were randomized into two groups. One group consumed a readily available HFCS sweetened beverage and the other group consumed an artificially-sweetened control beverage. At each testing session, the mothers expressed milk every hour for six consecutive hours.
The researchers then measured the concentration of fructose, glucose and lactose in the breast milk. Changes were significant only for measurements of fructose, with comparisons showing HFCS beverages increased breast milk fructose at hour two, three, four and five hours after consumption. It is important to note breast milk normally does not contain fructose.12 Goran commented:13
"Lactose is the main source of carbohydrate energy and breast milk is very beneficial, but it's possible that you can lose some of that beneficial effect depending on maternal diet and how that may affect the composition of breast milk.
Other studies have shown that fructose and artificial sweeteners are particularly damaging during critical periods of growth and development in children. We are beginning to see that any amount of fructose in breast milk is risky."
Dr. Robert Lustig, professor in the division of endocrinology at the University of California, is a pioneer in decoding sugar metabolism. He was among the first to bring attention to the fact that processed fructose is far worse for your metabolic system than other sugars. Fructose is broken down like alcohol in your body,14 triggering liver damage and causing mitochondrial and metabolic dysfunction.
This damage is very similar to that caused by ethanol and other toxins. Fructose also triggers severe metabolic dysfunction as it is readily metabolized into fat, far more so than other sugars. Researchers are finding exposure before birth may increase an infant's risk of obesity leading to a higher risk of Type 2 diabetes and NAFLD.15
Gene Variant Increases Risk of Fatty Liver Disease
Before 2006, few knew children could develop NAFLD. Dr. Jeffrey Schwimmer, professor of pediatrics at the University of California San Diego, reviewed 742 autopsies of children and teenagers who had died from traumatic injury. He found an incidence of 13% with fatty liver disease, and 38% in those who were obese.16
The researchers concluded NAFLD was the most common liver abnormality in children aged 2 to 19. They suggested the identified risk factors should be considered in the development of protocols to screen children and adolescents who are at risk.
A study released in 200817 by a group of researchers from the University of Texas demonstrated a gene variant called PNPLA3 could increase the risk of fatty liver disease. Nearly 50% of Latinos have at least one copy of this high-risk gene, and 25% have two copies according to Goran.18
Goran then undertook another study, eventually demonstrating children as young as 8 who had two copies of PNPLA3 and who consumed high amounts of sugar had 2.36 times as much fat in their livers as children without the gene.19 In the clinical trial20 currently underway, his team first tests participating children for the gene and then uses an MRI to measure liver fat percentage.
The sugar consumption of the child is measured and cataloged and then a dietitian educates the family on the impact of sugar. The team does another MRI four months later to measure liver fat and assess the impact of the intervention.
Goran's research and past studies21 have demonstrated early exposure to sugar and fructose likely contribute to obesity, diabetes and fatty liver disease as fructose enhances the body's capacity to store fat.
Excess Fructose Triggers Obesity and Fatty Liver Disease
Results of a meta-review in Mayo Clinic Proceedings22 confirmed that not all calories are equal. The dogmatic belief that a calorie is a calorie has driven the weight loss industry and contributed to an ever-worsening history of health in the Western world.
Unfortunately, it continues to be a concept taught in schools, even though we now know it's false. The source of the calories does indeed have a significant impact on your health and weight. In the review, the researchers evaluated how different calories affected health. As reported by Time Magazine:23
"What they found was that the added sugars were significantly more harmful. Fructose was linked to worsening insulin levels and worsening glucose tolerance, which is a driver for prediabetes. It caused harmful fat storage — visceral fat on the abdomen — and promoted several markers for poor health like inflammation and high blood pressure.
'We clearly showed that sugar is the principal driver of diabetes,' says lead study author James J. DiNicolantonio, a cardiovascular research scientist at Saint Luke's Mid America Heart Institute. 'A sugar calorie is much more harmful.'"
Another more recent study published in 201724 found fructose promotes complications in glucose metabolism and alters lipid profiles associated with an inflammatory response. The researchers found this implied a systemic picture of insulin resistance.
Choline Deficiency Also Plays a Key Role in Fatty Liver Disease
Choline is a compound in living tissue and is important in the synthesis and transportation of lipids (fats). It was discovered in 186225 and officially recognized as an essential nutrient in 1998.26
Several studies27,28 have linked higher intake of choline to a range of benefits and, in fact, it appears to be a key factor in preventing the development of fatty liver disease. By enhancing secretion of very low density lipoproteins (VLDL)29 in your liver, required to safely transport fat out, choline may protect your liver health.
Epigenetic mechanisms30 of choline also explain how it helps maintain healthy liver function. Dietary choline is an important modifier of DNA and modulates expression of many of the pathways involved in liver function.
Chris Masterjohn, who has a Ph.D. in nutritional sciences,31 proposes choline deficiency is a significant trigger of NAFLD and believes the rise in NAFLD is largely the result of rejecting liver and egg yolks in the diet:
"More specifically, I currently believe that dietary fat, whether saturated or unsaturated, and anything that the liver likes to turn into fat, like fructose and ethanol, will promote the accumulation of fat as long as we don't get enough choline."
In a 2010 article,32 Masterjohn reviews the medical literature supporting this view. The link between choline and fatty liver initially emerged from research into Type 1 diabetes. Studies in the 1930s demonstrated lecithin found egg yolk (containing high amounts of choline) could cure fatty liver disease in Type 1 diabetic dogs. They later found choline alone provided the same benefit.
More Ways to Support Your Liver Health
Hints to additional ways of supporting your liver health may be found in the commonly identified risk factors for NAFLD. In addition to reducing or eliminating processed fructose from your diet and including foods with choline, other modifiable factors that can have a significant impact on the development of NAFLD include:33,34
- Maintaining a healthy weight — Managing a healthy weight requires more than monitoring your calorie intake and energy expenditure. For a full explanation of one of the master keys to healthy eating, see "My Updated Nutrition Plan — Your Guide to Optimal Health."
- Exercising regularly — Regular movement and exercise benefits your body by improving insulin sensitivity, supporting your metabolism and mitochondrial health, helping to manage weight and blood pressure, toning muscle and improving your balance. Exercise also improves your sleep quality, mood and mental health. There is a long list of benefits — including reducing your risk of NAFLD.
- Limiting medications — Limit any medications to those necessary and follow dosing recommendations. Some medications increase your risk of NAFLD and other health conditions. Reduce those risks by making lifestyle changes to minimize your dependence on medications.
- Managing high blood pressure — High blood pressure increases your risk of cardiovascular disease, dementia and NAFLD. There are several natural methods of reducing high blood pressure while working with your physician to wean off medication.
- Reducing insulin resistance — Insulin resistance may lead to metabolic syndrome, prediabetes and Type 2 diabetes, all precursors to NAFLD. For an overview of insulin resistance and how to reduce your risk of metabolic disease, see my previous article, "Research Proves Causation — Sugar Consumption Increases Risk for Chronic Disease."
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