How To Prevent And Reverse Fatty Liver Disease with Functional Medicine

Mark Hyman, MD

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Dr. Elizabeth Boham: We're seeing this huge rise in fatty liver, not only because of alcohol, but because of high blood sugar, high levels of insulin, toxins like glyphosate and all the other toxins you've mentioned, medications that people are taking, all are putting stress on our liver. Dr. Mark Hyman: Welcome to The Doctor's Farmacy. I'm Dr. Mark Hyman. That's Farmacy with an F, a place for conversations that matter. And if you've ever heard about this weird thing called fatty liver, you better listen up. This is not something you should ignore, and it's something that affects almost one out of every two Americans. So we are going to go deep in fatty liver today, otherwise known as foie gras in French, and we're going to talk with none other than our own Dr. Elizabeth Boham from The UltraWellness Center. She has been my colleague and friend for decades now. She's the Medical Director of The UltraWellness Center. She's one of leading physicians in the functional medicine movement, training doctors all over the world, and she's what every doctor should be. She's trained as a family doctor, she's got a fellowship in nutrition, and has also studied as an exercise physiologist and trainer. She's the real deal. Welcome back, Liz. Dr. Elizabeth Boham: Oh, Mark. It's great to be with you. Thanks for having me. Dr. Mark Hyman: Okay. So let's talk about fatty liver. First of all, what is fatty liver? Why should we care, and who has it? Dr. Elizabeth Boham: Oh my goodness. So fatty liver is when the liver cells, the cells in your liver are replaced with fat cells. So fatty liver just means that some of the cells in your liver have been replaced with fat cells, and so there's fat deposited within your liver. Why do we care? Because then that means your liver can't work as well, because it doesn't have all those liver cells doing the job that the liver does, right? So the liver really helps our body detoxify and metabolize chemicals from the environment, metabolize our own hormones, metabolize and get rid of toxins. And so, we definitely don't want to have an underfunctioning liver, that's for sure. And the prevalence of fatty liver disease is really, really high, and unfortunately, it's increasing, but about 90 million people in the US have fatty liver disease. And so, and it's increasing in this country, it's increasing worldwide, the amount of fatty liver we are seeing. Dr. Mark Hyman: So why are we seeing so much fatty liver? And people think, "Oh, it's alcohol. Alcoholics have big livers. They have liver failure, they have hepatitis," but what is the most prevalent cause by far, of fatty liver in America? Dr. Elizabeth Boham: I mean, right. So you can have alcoholic fatty liver disease. So you can get a fatty liver because of drinking too much alcohol, and we'll talk about that and what is too much, but really what we're seeing, why we're seeing such a skyrocketing of the amount of fatty liver is because of the nonalcoholic fatty liver disease, which the major reason is this drive and this increase in insulin resistance, metabolic syndrome, which is connected with everything as we always talk about, but also fatty liver disease, and it's prevalent, right? So we know with nonalcoholic fatty liver disease, there's studies saying 10 to 46% of people in the United States have it, or even six to 30% of people worldwide. So somewhere in that quarter to half of people are dealing with fatty liver disease, and it's increasing, it's increasing worldwide, and we're seeing it with our children too. So as we know, how does that really impact their overall health and development, and risk of death as they get older? Significant. Dr. Mark Hyman: Yeah, that's huge. So what is the biology here? Who gets it, and I mean, we're talking about like 90 million Americans who have this problem, that's almost one out of two Americans. Dr. Elizabeth Boham: Right, right. Dr. Mark Hyman: It's something when we went to medical school was like, "What? That's not a thing," and then all of a sudden, it became a thing. It used to be, "Oh, fatty liver from alcoholics." We got that, but we never saw real problems with this when I was in medical school, and now it's 90 million Americans, and maybe one out of two Americans overall have some level of dysfunction of the liver. Dr. Elizabeth Boham: Right. So what happens first is that the fat cells replace the liver cells, and that's called fatty liver or steatosis, and then what can happen over time, if there's inflammation with that fat deposition in the liver, that's called fibrosis. So that's fatty liver with inflammation, and if that continues to progress, we can get scar tissue in the liver, and that is called cirrhosis, which, that's the non-reversible stage. So fatty liver, the great news is it's very reversible, even the fibrosis when there's inflammation is reversible. Once it becomes cirrhosis or scarred, then it's not reversible, and so the damage to the liver is non-reversible and definitely increases risk of cancer and lots of problems as we spoke about. So, and why somebody progresses from the fatty liver to cirrhosis really depends on your genetics, the rest of your diet, of course, the microbiome probably has this huge impact. It's not really all understood, but it's so fascinating, some of the research looking at that as well, so it's... Dr. Mark Hyman: Yeah. Well, that's right, Liz. I mean, the microbiome is such a key part because it drives inflammation, and fatty liver is an inflammatory disease of the liver, and the microbiome can release toxins and can cause leaky gut, and can cause all sorts of problems, but it seems a little prevalent fatty liver is really because of our high starch sugar diet. I mean, the average American eats about a pound of sugar and flour every single day. 152 pounds of sugar, 133 pounds of flour a year, that's an enormous amount of flour and sugar every single day, and what that does is it drives the pathology of fatty liver. Dr. Mark Hyman: And when you think of fatty liver, people are like, "Oh, if I eat fat, I'm going to get a fatty liver." Well, it's actually not true. It's the opposite. Fat actually can heal a fatty liver, which is a ketogenic diet, or even high levels of MCT oil, but with fatty liver, the real cause is the carbohydrates and the sugar. So it's the starch and the sugar that drive insulin that lead to fatty liver, and cause high triglycerides, and cause low HDL, and cause inflammation, and more insulin resistance, and you end up in this vicious cycle. And the problem is, from a nutritional point of view, we're good at diagnosing it, but not great at... Well, we're not even that good at [inaudible 00:07:03]. We know how to diagnose it, but we're not really skilled at treating it or reversing it, which is kind of stunning because like, "Oh, I'll just take these drugs or have better control of your blood sugar, or let's lose weight," that's another one. "I'll just lose weight, and it'll get better." Dr. Mark Hyman: Well, that's an easy thing to say to people, it's a hard thing to get people to do. And a lot of people who have fatty liver are pre-diabetic, insulin resistant, or diabetic. And again, 88% of Americans are metabolically unhealthy, which means that 88% of Americans are at risk for fatty liver, because they have some degree of metabolic dysfunction, and that metabolic dysfunction is caused by sugar, and starch, and processed foods, and it's driving the insulin resistance that causes the metabolic dysfunction, which is defined as high blood sugar, high cholesterol, high blood pressure. Dr. Mark Hyman: So, this is such a common issue, and then when you add on alcohol on top of that, and you add on medication on top of that, let's say people are taking Tylenol, which is damaging to the liver, you end up with not a very fun environment for the liver, and on top of that, you have all the environmental toxins that we're all exposed to, pesticides, in our household, cleaning products, in our skin care products, in our food and our water, we're constantly inundated with compounds that are putting a stress on our liver and making it work harder to detoxify. So you add all that together and then you go, "Wow, we're in a big problem." So why is fatty liver a problem? I mean, so my liver is a little fatty, who cares? Why is it an issue for people? Why do we care to fix it? Other than the fact that you can get cirrhosis and die from liver failure. Dr. Elizabeth Boham: Right. So- Dr. Mark Hyman: That's not a [inaudible 00:08:39]. Dr. Elizabeth Boham: Other than that. Dr. Mark Hyman: But that's a late-stage thing. The other problems are not late-stage and they happen to a lot of people, and they're they're unrecognized as related to fatty liver. Dr. Elizabeth Boham: Right. I mean, they can happen quickly. Fatty liver can develop quickly. They know that within two weeks of heavy drinking, having one and a half to two ounces of hard alcohol every day for two weeks, you can start to see signs of fatty liver, which is, that it can develop very quickly. What's great to also understand within a lot of this research is that it can resolve quickly. So when somebody has fatty liver because of alcohol and you take them off of alcohol, that you can see resolution of fatty liver within four to six weeks. So, it can progress unfortunately, quickly if we're not taking care of ourselves, and then it also regresses when we start to make some shifts. Dr. Elizabeth Boham: And as you were mentioning, we're seeing this huge rise in fatty liver, not only because of alcohol, but because of how high blood sugar, high levels of insulin, toxins like glyphosate, and all the other toxins you mentioned, medications that people are taking, all are putting stress on our liver and making it so that our liver can't do what it needs to do to detoxify. So it becomes this vicious cycle of we're we're inundated with toxins that are impacting our liver, but then the liver can't work as well, and so then we can't get rid of the toxins that we're inundated with. So it becomes a vicious cycle of having issues with our detoxification system in our body, and as we've spoken about before, the liver is such a critical organ within the body's natural ability to detoxify and handle all the toxins we're exposed to. Maybe we weren't put together to handle all of these toxins, unfortunately, that we're exposed to, but we do have this ability to handle toxins, and we want to take care of our body so we can handle the toxins that we are exposed to. Dr. Elizabeth Boham: And so, it's really important that we take care of our liver. And so, what's considered normal for alcohol intake? For men, it's less than 10 drinks a week, and for women, it's less than five drinks a week. And so, we know that that problems with the liver can occur when we're drinking too much. So we see problems when people are binge drinking or consuming more than 14 drinks a week for men, or more than seven drinks a week for women. So I think it's important we also talk to our patients about what is moderation with alcohol, how do we take care of our liver, both from all aspects of nutrition and lifestyle. Dr. Mark Hyman: So there was also an interesting study that came out recently looking at cancer and alcohol, and showing that there's a dramatic increase in prevalence of cancer. Even a little bit of alcohol may actually increase the risk of cancer. So it's not just fatty liver, but it was a Japanese study with 63,000 adults, where they looked at people who were drinking alcohol, and it was a concern. But that aside, besides just the overloading your liver, besides just the stress on your liver's ability to deal with all the normal toxins we have to deal with, what happens when you have a fatty liver, is it drives inflammation in the body and it's linked to heart disease, to cancer, to diabetes, to even dementia and all sorts of things that we don't think is necessarily related to a fatty liver. So fatty liver is sort of an early warning sign and clue that there's something wrong in your body and it's causing a risk, a dramatically increased risk for all these other problems. But that said, how do we know if we have fatty liver? Dr. Elizabeth Boham: One of the first ways we find out is with general blood work. So if you do a metabolic panel, comprehensive metabolic panel on a patient, and if we look at these markers like the AST and ALT, and if they're elevated, either high end of normal or elevated above the normal range, that's something we really have to be thinking about. Is this fatty liver? Should we go on and do an ultrasound of the liver to see if we are seeing some fat deposition in the liver? And so, that's one of the ways we start to see it most frequently with our patients. Dr. Mark Hyman: Mm-hmm (affirmative). Yeah, absolutely. And so, there's other tests you can use, which I've I've had personally, just because I'm sort of biohacking, I kind of like to check everything, but you can do an MRI and look at liver fat, and it should be less than 2%, and many people have very, very high liver fat. I thankfully have less than 2%. Dr. Elizabeth Boham: Good job. Dr. Mark Hyman: They're actually also doing fiber scans which look at the fibrous content, the scar tissue from the fatty liver, and they can use ultrasound scans, and those are good for measuring the degree, they can do liver biopsies. And I think what we see is, is really in functional medicine, a roadmap for healing the liver in ways that just doesn't exist within traditional medicine or conventional medicine. So talk about what are the ways that in addition to the testing we talked about, we'll look at insulin resistance, we'll look at particle size, we'll look at inflammation, we'll look at a lot of things that a traditional doctor wouldn't look at. What are the beginning things we do from a dietary lifestyle and supplement perspective to reverse fatty liver? Dr. Elizabeth Boham: I mean, one of the first things we do, is of course, we get a good detailed history from our patients and try to get a sense of what's going on for them, get an understanding of their timeline of their health, and that can help us find out what may be driving health problems in that person. So if there is concerns about fatty liver, you want to get a sense of what their toxic load has been in their lifetime. What is their weight? What is their nutrition? What are they eating, and what is their microbiome like? And so, we can really evaluate all of that and get a sense of how best to help this patient, that individual patient improve, because we know that for some people, it may be more focusing on toxic load. For somebody else, it may be focusing more on alcohol intake. For somebody else, it may be more they're eating way too many carbohydrates, refined sugars, soda, coffee drinks, muffins, and not exercising enough, and that whole metabolic syndrome process. Dr. Elizabeth Boham: So, we want to really help focus the treatment plan on that individual patient, and I think that's what's so special about functional medicine is it's really looking for that underlying root cause for that underlying patient, so that they can reach their optimal health. And we know that problems with the liver and fatty liver impact our immune system and how well we fight off infections. It impacts how we can digest food, metabolize food, it impacts our nutritional state in our body. So there's so many reasons why we really want to look deeper here. Dr. Mark Hyman: Absolutely, and I think in addition to the dietary stuff and getting rid of the environmental toxins that we can, sort of decreasing our overall toxic load, and we've talked about this in other podcasts, like the Environmental Working Group's Guide to how to reduce your exposure to toxins in food, in household cleaning products, in personal care products. But there's also a lot we can do from a dietary perspective to upregulate those pathways in the liver that boost glutathione, all the Brassica family, the onions and garlic, all the spices that we can use, and even herbs that can be very helpful, like milk thistle and others, to help improve liver function. Dr. Mark Hyman: And then there's a whole bunch of nutrients that the liver needs to function, and in fact, you and I were both trained in traditional medicine and we worked in the emergency rooms, and people come in with a Tylenol overdose, we give them this drug called Mucomyst, right? Dr. Elizabeth Boham: Yup. Dr. Mark Hyman: Which is actually N-acetylcysteine, it's a supplement you can get over the counter. What it does is it boosts glutathione, and it helps the liver to regenerate glutathione, which is what's depleted often with fatty liver and Tylenol liver damage from overdose. And so, there's a lot of things you can do to glutathione. You can take glutathione, you can take N-acetylcysteine, lipoic acid, milk thistle, curcumin. And we use a lot of herbs, we use also the B vitamins, zinc, selenium, amino acids, and we do a lot of things to help the liver heal. Dr. Mark Hyman: And what's amazing is when you use this cocktail of substances, things like milk thistle, lipoic acid, N-acetylcysteine, glutathione and so forth, livers will come back, and it's striking to see the drop in liver function tests, the improvement in fatty liver content. And I encourage people to really think about one, checking to see if they have it, two, thinking about how to actually upgrade your lifestyle so that you can protect your liver, and live a liver healthy lifestyle which is a lot of what we do in functional medicine, and then make sure you're on the right supplements to help reverse the problem. Dr. Mark Hyman: So Liz, tell me more about a patient that we've had, because I think some of the patient stories are really helpful and instructive, and give us a sense of how we do things differently at The UltraWellness Center here in Massachusetts in Lenox, and what you found and what you were able to sort of help him with, and how it all worked. Dr. Elizabeth Boham: Yeah, so I had a 50 year old gentleman who came in to see me, and he was told by his primary doctor that his liver function tests, his ALT and AST were mildly elevated. And so, he came in because he was frustrated with his weight, he wanted to lose some weight. He was about 25 pounds overweight, and he just mentioned to me that his doctor had said his liver function tests were a little elevated and that they were going to be rechecking them in a few months. And so, we really got a good detailed history from him, and we got a sense of what his diet was like, and what his alcohol consumption was like, because that's one of the first things, of course, we think about with fatty liver or these elevated liver function tests is we're like, "Okay, how much alcohol is this person consuming?" Dr. Elizabeth Boham: And what was interesting to me about him was he was pretty moderate in his alcohol consumption. He was having about two glasses of wine a night. And so, for a man, that kind of almost falls within what's considered moderation. So he was not a binge drinker, he was not overusing alcohol from the criteria we were talking about earlier, but I think the amount of alcohol he was consuming, in connection with his diet, and probably his genetics, and many other things like his microbiome that we've spoken about, that altogether was really impacting these liver functions for him. Dr. Elizabeth Boham: And so, we noticed with his diet, it was not rich enough in vegetables, that's for sure, and really, that was probably the biggest thing I would say, with his diet. It was just devoid of a lot of vegetables. And you were talking about some of the things, supplements we use for helping the liver. One of the things we think a lot about is sulforaphane, which comes from your cruciferous vegetables, that helps and encourages the production of glutathione in the body. And so, one of the things we really worked on with him is making sure he got some cruciferous vegetables every day, broccoli, cauliflower, cabbage, kale, Brussels sprouts, really to help support the liver and help it heal, essentially. We also had him take a break from alcohol. We said, "Let's just pull away alcohol for a period of time, really help that liver calm down, and let it give us some time to heal." Dr. Elizabeth Boham: And as I was mentioning earlier, we really can see the liver function tests go down pretty quickly for some patients. We can see if somebody did have fatty liver, you can watch it improve within a few weeks of cleaning up the diet and decreasing alcohol intake. So especially if it's not too far progressed, we can see changes pretty darn quickly. And so, with him, we really focused on cruciferous vegetables, lots of the sulfurous vegetables like onions and garlic. We gave him turmeric, we gave him dandelion root to help his liver and gallbladder work better, lots of green leafy vegetables. We made sure he was eating enough protein. We know that protein is really important for the detoxification process in the body. We need to be eating enough protein to do that. And so, we made sure he was getting enough foods that were rich in fiber to bind toxins, things like the beans and legumes, and nuts and seeds, ground flax seed. Dr. Elizabeth Boham: And I did, I gave him some N-acetylcysteine, some NAC. I gave him some liposomal glutathione and milk thistle. We put him on a really good multi that had methylated B vitamins in it. I gave him a little bit of an extra methylated B vitamin, and really focused on those nutrient-dense foods so that he wasn't wasting his calories, because he was 25 pounds overweight and we needed to cut back on that weight, so we really needed to pull away those foods that were not nutrient-dense. So, things that people are eating way too much of that are getting into our diet that are not giving us all of the nutrients the body needs to work properly. Dr. Mark Hyman: Yeah. So incredible, so incredible. So, I feel like we see this so prevalently, it's so misdiagnosed or underdiagnosed, it's such a huge impact on your long-term risk factors for all sorts of chronic illnesses from heart disease to cancer, diabetes, and more, and it's something that traditional medicine doesn't really deal with very well. And you might've been told your liver function tests are elevated or don't worry about them, or they're not that bad, or "Whatever, we'll watch it." That is just not a good idea, and I don't think we are equipped in our traditional training with an understanding of how to actually figure out what to do for these patients with abnormal liver function tests, and I certainly was never trained. Dr. Mark Hyman: But the beautiful thing about functional medicine is that we have a way of evaluating the liver differently, we have different diagnostic tests, we have different therapy options, and we see tremendous improvements in liver function and quality of health, and it's not just about the liver. It's like when you treat what's going on with your patient, it's like everything gets better. His hormones get better, his liver gets better, he loses weight, his sex drive improves, everything gets better. The blood pressure goes down, and all of a sudden, you've got a person who's instead of going on a trajectory towards increased risk of disease and death, to actually having a more vibrant and healthy life. So it's super encouraging when you see these kinds of patients, because they're really relatively easy to diagnose and treat and yet, traditional care just doesn't cut it, for the most part. Dr. Elizabeth Boham: Yeah. I mean, within four months on the plan, his liver functions came down to totally normal. He lost 10 of those pounds, and then within a few more months, he lost another 10 pounds, and his fasting insulin came down to normal, his liver function tests, his markers of inflammation in the body improved. And then eventually, I've been seeing him for a while, so at this point, he does have one or two glasses of wine a few days a week. He does drink some alcohol at this point. As I said, he never had a problem with alcohol abuse or alcohol overuse disorder, it just was he was drinking too much for his body. And so, at this point in time, he's having a little bit of alcohol and doing okay with that, and it's not causing a bump in those liver function tests, or some problem with his weight or insulin resistance anymore. So he did really well. Dr. Mark Hyman: Well, that's so great, and I think for those listening, if you've had issues with liver function abnormalities, if you have fatty liver, if you think you have it, or if you know someone who has it, please tell them about this podcast, go listen to it, come see us at The UltraWellness Center. We take people from all over the world, we have virtual consults we do now. We can accommodate you, although we're pretty booked up, so you might have to wait a little while. But the beautiful thing is there's lots of free content, we're doing groups online too now, which will be able to help sort through your problem, even without getting an immediate appointment. Dr. Mark Hyman: And we'd love to see you, so come to visit us and also share your experiences with maybe what you've had with fatty liver. Have you struggled? What have you done? How have you fixed it? Leave a comment, we'd love to hear from you. Subscribe wherever you get your podcasts, and share this with your family and friends on social media. We'd really be excited to get this out there, because this is a big problem and everybody needs to know about it. And we'll see you next week on The Doctor's Farmacy. Speaker 1: Hi, everyone. I hope you enjoyed this week's episode. Just a reminder that this podcast is for educational purposes only. This podcast is not a substitute for professional care by a doctor or other qualified medical professional. This podcast is provided on the understanding that it does not constitute medical or other professional advice or services. If you're looking for help in your journey, seek out a qualified medical practitioner. If you're looking for a functional medicine practitioner, you can visit ifm.org and search their Find a Practitioner database. It's important that you have someone in your corner who's trained, who's a licensed healthcare practitioner, and can help you make changes, especially when it comes to your health.