The Best Diet to Reverse Fatty Liver Disease with Dr. Yousef Elyaman

Mark Hyman, MD

Full Transcript

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Dr. Mark Hyman: Welcome to The Doctor's Pharmacy. I'm Dr. Mark Hyam. I'm so excited to have our next guest up, which is Yousef Elyaman, who's specialized in understanding a condition that is affecting over a third of the world's population and probably more than that in America called fatty liver disease.

Dr. Mark Hyman: But now it has a new name. We'll get into that in the show, but it's an epidemic that's driving huge amounts of disease suffering. And we'd get into the details on the podcast of how this problem now affects over a third of us and why it's so prevalent, mostly related to our diet, to our gut, to environmental toxins. We talk about a traditional way of treating it, which is nothing. Basically there's very few options from an additional medical care point of view.

Dr. Mark Hyman: And we also talk about how to diagnose it. What are the things that you can do based on your traditional lab tests, based on maybe an upgraded lab panel, even ultrasound diagnostics that can help you decide if you need to do something about this because fatty liver is a dangerous condition that drives heart disease, cancer, dementia, infertility, you name it, and it's invisible. It's symptomless and it makes people really sick, but it's not something that your doctor is generally talking about or thinking about with you because there's no quick fix drug to give. We do talk about some promising medications that might be on the horizon, but we also talk about how to approach this through a functional medicine lens using diet and lifestyle, what you should be eating, how you should exercise, what supplements can be helpful. And we dive deep into the science of what's happening when you get fatty liver disease.

Dr. Mark Hyman: So I want you to make sure you tune into this episode and, enjoy it. Well, welcome, to The Doctor's Pharmacy, doctor e as your patients call you. It's great to have you.

Dr. Yousef Elyaman: Thank you. Honored to be here.

Dr. Mark Hyman: Well, you know, we we are both part of the Institute For Functional Medicine and train physicians and practitioners how to think differently about disease and getting root causes. And it's something you've been focused on lately, which I think is really important and something I really haven't seen a really good approach to from traditional medicine is what we used to call fatty liver disease or non alcoholic fatty liver disease. Because before there was just alcoholic fatty liver disease, then we started eating all this sugar and crap. Then we have this epidemic of what was called non alcoholic fatty liver disease, and they just changed the name to metabolic associated liver disease because this is a metabolic nutritional problem. And the problem is in medicine, we've kinda neglected it because there were no good drugs.

Dr. Mark Hyman: We like diseases with drugs. Oh, you got high cholesterol. I'll give you a stat. No. You got high blood pressure.

Dr. Mark Hyman: I'll give you a blood pressure pill. Oh, you got, you know, you know, whatever else you got, kidney failure, I got the drugs for you. But if you actually have NAFLD, which we used to call nonalcohol fat nonalcoholic fatty liver disease are now called Mafaldy. There's really no great conventional medicine approaches to it except liver transplant when things get really bad. And so you spent a lot of time focusing on this condition.

Dr. Mark Hyman: I just wanna give the background a little bit about this condition because it's so it's, it's so prevalent. I mean, think about something that affects over a third of the population of the world. We're talking about 2,000,000,000 people with a condition that is not a benign condition. It's causing huge amounts of suffering that as actually linked to all sorts of things, obviously, like type 2 diabetes, heart disease, cancers, gallstones, reflux, thyroid issues, kidney stones, depression, worst maternal and fetal outcomes, a huge increase in cardiovascular mortality, 3 and a half times the risk of heart failure, 1.93 times excess mortality from heart disease. This is a big problem, and traditional medicine just, like, not that great at it.

Dr. Mark Hyman: And I remember working, with one of the top hepatologists at Cleveland Clinic, and they were desperate to have some solutions because all they could do was track the disease, follow the disease, give some people some general advice, hope it didn't progress. And then when it did, they need to go get a liver transplant. And and here, you know, this is one of the conditions that is really underdiagnosed, underappreciated. We're gonna do a deep dive and talking about why this is important. Why somebody you're walking around out there have this condition, don't even know it, and why you should care about it.

Dr. Mark Hyman: And more importantly, that there are very specific things that you can do from a diet and lifestyle and even a functional medicine perspective that can work to not only slow this down, but to actually reverse this really pernicious condition, which has really been neglected by the traditional medical community. But I'm glad to see there's more awareness and we're talking about it. I'm glad they changed the fricking name because why are we talking about nonalcoholic fatty liver disease? You're talking about the truth of it, which is it's a metabolic problem caused by our diet. So, Yousaf, tell me more about why why, has this become such an issue?

Dr. Mark Hyman: Why is this something that, you know, didn't really exist that much when I was in training except been a bunch of alcoholics. And now we're seeing, you know, 30% of the population globally having it and probably more in America.

Dr. Yousef Elyaman: I so I think, there I think when we were practicing, we kind of closed the a blind eye to it. I think it existed. We'd always I I think you remember in residency the incidental findings. I think it was kinda like the gluten thing. I remember we never wanted to diagnose anyone with celiac disease because because if if, we really didn't know what to do with it, we felt bad for patients.

Dr. Yousef Elyaman: And once you actually take a look at it, you can kind of you can you can come up with a a solid plan. So the same thing with this, I think, from what from what I remember in internal medicine residency, we just kind of ignored it. And and I think that now it's becoming a little more popular partly because of the new drugs that they're developing.

Dr. Mark Hyman: Yeah. Right? I

Dr. Yousef Elyaman: mean, that's it.

Dr. Mark Hyman: The reality. As soon as as soon as you have a drug for a condition, then that becomes something we promote, we advertise, we see ads on television, but everybody gets excited. Right?

Dr. Yousef Elyaman: The amazing thing is is that because we do functional medicine, taught by yourself and the other the other functional medicine founders here. But because we do functional medicine, we love the their developing of these drugs because we understand the pathways. And and we know how to modulate the pathway in a from a nutritional, nutraceutical kind of lifestyle point of view. Yeah.

Dr. Mark Hyman: Yeah. So, what why do you think this is increasing? I mean, it's clearly was there, obviously, when we were in training, but but it's just exploded. You know, we see 75% of the population is overweight, 42% are obese, 93.2% are metabolically unhealthy, which is essentially what this is, a metabolic associated fatty liver disease. Right?

Dr. Mark Hyman: So if 93% of us are have some metabolic dysfunction, What's driving that?

Dr. Yousef Elyaman: So one of the major things is food. Right? So food and, insulin resistance is kind of at the top of the list. So our our food there there's more, sugar being added to our foods. There's higher carbohydrates.

Dr. Yousef Elyaman: But when you when you look a little bit deeper into it, high uric acid as well. So that that comes from eating too much fructose.

Dr. Mark Hyman: Fructose which is like high fructose corn syrup in all our foods that processed food.

Dr. Yousef Elyaman: High fructose corn corn syrup, alcohol alcohol and is alcoholism is on the rise. So alcohol is a toxin, so that also affects is going to affect the liver, along along with, small intestinal bacterial overgrowth. So bad bacteria in the in the gut. The gut can be as metabolically active as the cytochrome p 450. Yeah.

Dr. Yousef Elyaman: And and because of our current lifestyles, the the bacteria in our gut or in our intestines are changing, and they're changing for the worst. Yeah. And there is an association between, small intestinal bacterial overgrowth, which is one of the major causes of irritable bowel syndrome and having fatty liver disease. So there's a

Dr. Mark Hyman: That's when you're bloated and you get a food baby after eating. That bloating is because there's bacteria in your small intestine, which should not be there, that then ferment the food that you eat, particularly starches and carbohydrates, that then give off all kinds of toxic metabolites

Dr. Yousef Elyaman: Right.

Dr. Mark Hyman: That can then poison your liver. That's what you're saying. Right? Absolutely.

Dr. Yousef Elyaman: Right. Right. Yeah. Yeah. You can what did you say?

Dr. Yousef Elyaman: A food baby?

Dr. Mark Hyman: Food baby. You know, I guess Yeah. Yeah. That bloating thing that people get. Crazy.

Dr. Yousef Elyaman: Right. Yeah. So so, if if you one alarming statistic, they they looked at young men that were not overweight, and they found that they they did something called a, a insulin resistance score test on them. And they found that more than half of them had insulin resistance. And these are non these are young men in their twenties, not overweight Yeah.

Dr. Yousef Elyaman: Normal ideal weight. So so so I I think that kinda brings us to the one of the first drivers, which is this insulin resistance concept.

Dr. Mark Hyman: Now just to to kinda back up on that, that's a stunning statistics. 50% of healthy normal weight 20 year old men have prediabetes or some degree of

Dr. Yousef Elyaman: Insulin resistance.

Dr. Mark Hyman: Insulin resistance, which is on the way to prediabetes.

Dr. Yousef Elyaman: Yeah. Their blood sugar are normal.

Dr. Mark Hyman: And now they're measuring this by the new mass spec test from Quest which is a really new test. So Right. So just to back up on that, that there's a the way we used to measure insulin resistance in the lab was a euglycemic clamp test. Super complicated, very difficult. And we now, you know, have a new test that is equivalent to that, that sort of surpasses the test we have been using, which are just serum insulin levels and blood sugar and a one c and a glucose tolerance test, which basically can give you a lot of information.

Dr. Mark Hyman: But this but this new technique of measuring c peptide, which is sort of like the initial fragment of insulin and then insulin using a technique called mass spectrometry through Quest, we can actually now be very, very good at predicting who has insulin resistance. And so insulin resistance seems to be the driver of fatty liver. Correct?

Dr. Yousef Elyaman: It it it it's the huge driver of fatty liver disease. It's, it's I would say it's the number one driver, but there are 8 or 9 drivers. But I I so so what happens is is that due to inflammation, due to toxicity, due to too much sugar, like too much of a sugar overload or a carbohydrate overload, when those receptors on our fat cells, we have these insulin receptors that are supposed to take sugar and put sugar into put sugar into the cells. Yeah. When they start to not work well, when they start to get resistant, there is an enzyme called hormone sensitive lipase.

Dr. Mark Hyman: Yeah.

Dr. Yousef Elyaman: And what that enzyme does is it starts tearing up the fat in the fat cell, and it sends the fat to the liver, and it overloads the liver. So now you have this liver that gets overloaded. So the they they they they end the liver ends up with a with a whole bunch of triglycerides, which is one of the one of the tests that we look on the lipid panel. Yeah. Now here's the interesting thing.

Dr. Yousef Elyaman: So you could check a triglyceride level and their level would look okay, and that's because some people genetically will tear the will decrease triglycerides in the blood. But

Dr. Mark Hyman: Decrease it in the in the liver.

Dr. Yousef Elyaman: What the triglycerides do when when when you end up sending a whole bunch of triglycerides to the liver, they turn into something called VLDL. Yeah. And they

Dr. Mark Hyman: Very low density lipoprotein.

Dr. Yousef Elyaman: Triglyceride rich VLDL. Yeah. Versus triglyceride poor. And VLDL becomes there's another enzyme found in the lining of our blood vessel that is that is called lipoprotein lipase. Yeah.

Dr. Yousef Elyaman: And it turns it into the tiny dense LDL Yeah. Yeah. Which causes clogging of the blood vessel and heart disease, strokes, and heart attacks.

Dr. Mark Hyman: Okay. I'm gonna I'm this is so juicy right here. I'm just gonna unpack a little bit because basically, you know, just to kinda put things in context. In France, there's a delicacy called foie gras Oh, yeah. Which I probably didn't pronounce right, but foie gras or whatever.

Dr. Mark Hyman: And that means in French, fatty liver.

Dr. Yousef Elyaman: Yep.

Dr. Mark Hyman: Now most people think that if you eat fat, you get fat. And that fatty liver must be coming from all the fat we eat. But what you just said was that, in fact, it's not true that it's actually the sugar and refined starches and carbohydrates, the flour and the sugar that we're eating in pharmacologic doses that's overloading our biology and causing that carbohydrates to turn into triglycerides, which then turns into fatty liver.

Dr. Yousef Elyaman: Yes.

Dr. Mark Hyman: And and then you're in this vicious cycle where the fatty liver then creates all sorts of other problems. So let's kinda unpack what happens biologically when you have a fatty liver. You get a fatty liver and so your your your your liver is like looking like a bad goose or duck liver. Right. And, you don't wanna serve it on toast unless you're maybe Hannibal Lecter.

Dr. Mark Hyman: And and then and then, you know, you've got a process going on in that liver that's just more than the accumulation of fat. So what are the things are happening in the liver that end up causing harm? You mentioned that the type of cholesterol we get because of that fatty liver is the dangerous small, dense cholesterol we talked about in the podcast. We do a whole podcast on on cardiovascular risk and lipid analysis. So the small, dense cholesterol particles, which by the way, everybody listening, your doctor is not measuring when you go to get your cholesterol test.

Dr. Mark Hyman: Less than 1% of cholesterol test in America are for the right cholesterol test, which is called lipoprotein fractionation. And it's looking at the particle size, the particle number, the VLDL numbers, and you can get all that, by the way, through function health, dot dotcom/forward/mark. It's a company I cofounded to allow people to get access to the right amount of information and data. So so function health dot com slash mark, you can get the right panels so you can see what's going on. And we also measure insulin, although, assume we're gonna be measuring this insulin resistance score, which is very exciting.

Dr. Yousef Elyaman: Right. Yeah.

Dr. Mark Hyman: What's happening in the liver?

Dr. Yousef Elyaman: So what's happening in the liver? So so we can go back to what's happening in the fats and then go back right back to the liver. So number 1, the fat starts to send these the triglycerides to the liver and start overloading the liver. If the fat if that when that process is overloaded, then then fat then your fat cells, which actually your fat is I don't know if you've done a podcast on this, but your fat is like an endocrine organ. It makes things like adiponectin.

Dr. Yousef Elyaman: Your what when when the process is bad, adiponectin levels can go down, which causes more insulin resistance and more inflammation. And then there are other there there there are other hormones that can go up in the liver that can cause inflammation, like tumor necrosis factor, like, like leptin, like so those go up. And now that inflammation and worsening insulin resistance and all that fat make its way throughout the body, and they go in the liver. And the liver starts to accumulate and accumulate and accumulate, and it just can't keep up with it. The liver packages it and sends it back to the fat.

Dr. Yousef Elyaman: The fat takes it up, but then because of the insulin resistant, it shoots it right back to the liver, and you end up with this vicious cycle. In the meantime, the liver is not supposed to be storing fat. The liver is supposed to be making all these metabolic processes. It's supposed to repackage the fat. And now when it gets overloaded and jam packed, now the liver starts to get inflamed.

Dr. Yousef Elyaman: It starts to rust, oxidative stress. Sugar starts to get worse, and it kinda creates this this this metabolic nightmare.

Dr. Mark Hyman: It's like a vicious cycle.

Dr. Yousef Elyaman: It's a vicious cycle.

Dr. Mark Hyman: And and what you're saying essentially is it's both an endocrine and an immune organ. So all the hormones that regulate weight, appetite, insulin resistance, like leptin, adiponectin, these are hormones that the body produces to regulate your your your eating behavior and your your way you process sugars and and regulate inflammation to, like like you said, tumor necrosis factor alpha or IL 6. And these are, these are cytokines. We heard about the cytokine storm. So with the fatty liver, you're not just getting fat in there.

Dr. Mark Hyman: You're getting this cytokine kind of increase that's driving systemic inflammation throughout the body, which it can explain a lot of things we see with the increased rate rate of death and heart attacks and cancers and all these things that seem to be related to inflammation.

Dr. Yousef Elyaman: Right. And see and and the thing is, I mean, we could just go we could probably do a whole podcast on when you have fatty liver, all of the other imbalances or all of the other things that are thrown off in the human body. Unfortunately, too many providers, too many doctors take a look at say, oh, you have fatty liver, lose weight, and they move and and and they don't really talk to them about it again Yeah. When, really, that is driving heart disease. It's driving Alzheimer's disease.

Dr. Yousef Elyaman: It's driving cancer. Yeah. The liver is supposed to be metabolizing our our toxins. Yeah. So now you you now your liver is not working.

Dr. Yousef Elyaman: It causes hormone imbalances. The liver's supposed to metabolize estrogen. So now you can't metabolize estrogen. Estrogen goes up. Progesterone goes down.

Dr. Yousef Elyaman: Women start to have

Dr. Mark Hyman: Infertility issues?

Dr. Yousef Elyaman: Infertility is big. They start to they start to have, mood issues. They start to have they start storing more weight. Like, they, and men men start to get start to have, that that estrogen effect. It blocks their testosterone, and it's kind of this it it just it affects everything.

Dr. Mark Hyman: It affects everything. So men men basically lose hair on their bodies. They grow man boobs. They have low sex drive. They low testosterone Right.

Dr. Mark Hyman: Just from having a fatty liver. Right? Yeah. Right. Right.

Dr. Yousef Elyaman: So so so there sound like fun. No. It's it's not. Well well, I'll tell you. Now that we have technology, the noninvasive, easily accessible technology to take a look at the liver, When we tell people that their liver is has fat in it or there's an issue with their liver, I have not seen a a a more motivating driver of change.

Dr. Yousef Elyaman: As a matter of fact, when I see liver enzymes being up, I I had I had a patient who who I talked to her about. She had elevated liver enzymes. I said, I wanna take a look at your liver. I sent her to do this test. It's called a FibroScan.

Dr. Yousef Elyaman: Before she came back, she had lost she stopped drinking alcohol, and she had lost £20.

Dr. Mark Hyman: And Amazing. Yeah.

Dr. Yousef Elyaman: It came back. Her liver was fine. But but what happened when people hear that their liver there's a problem with their liver for some reason, it creates the it creates that motivation Yeah. Which I can tell them, hey. You're gonna die of a heart attack, and it doesn't

Dr. Mark Hyman: yeah. Yeah. It's interesting. But, you know, I I think, you know, what you just point to is something really important, which is that this is a condition that's so prevalent, affects at least a third of Americans, that is underdiagnosed, and that is a biggest risk factor for having a heart attack as anything else. Right?

Dr. Mark Hyman: Like, the the the level of magnitude of the risk of having a fatty liver for death, heart attacks, cancer is extremely high.

Dr. Yousef Elyaman: Right. Do you

Dr. Mark Hyman: have some of the data on that? Right.

Dr. Yousef Elyaman: Yeah. We could put them in we can post them in the the heart attack. Yeah. Yeah. We could put them in the in the show notes.

Dr. Yousef Elyaman: Yeah. The percentages. Yeah.

Dr. Mark Hyman: It's Yeah. Yeah. It's really significant. And I and then when I started reading about fatty liver years ago, I was like, wow. This is in and of itself a huge problem because it's driving all these other diseases that we're treating separately, but we should actually be treating the liver.

Dr. Yousef Elyaman: In the conventional realm, unfortunately, we look at we look try to look at the disease kind of, in in a vacuum. Right? Okay. So you have fatty liver. So what can fatty liver do?

Dr. Yousef Elyaman: Well, the liver can start getting inflamed, and then it can start to turn into fibrosis or hardening, and then you can get cirrhosis. Right? And nobody wants liver cirrhosis. Right? Liver every most people know that liver cirrhosis is a bad thing, and then you can also get liver cancer.

Dr. Yousef Elyaman: But like you just mentioned, they have more of a chance of dying of a heart attack than of the liver cirrhosis Yeah. When they have fatty liver. So I think that's what you were alluding to.

Dr. Mark Hyman: Yeah. Yeah. Yeah.

Dr. Yousef Elyaman: Yeah. So it's so so but but I think I think the beautiful thing and I'm so I'm so fortunate, or grateful to that I found functional medicine because we don't look at fatty liver as a disease in itself. We say, there is a process that has happened. Part of

Dr. Mark Hyman: a syndrome that's happened.

Dr. Yousef Elyaman: Part part of a syndrome. Now and and everybody is unique on what's causing it because some people, it's insulin resistance. Some people are eating lots of, the way that their body deals with fructose. They start to increase uric acid, and it's the uric acid that is driving it. Where other people can have, thyroid dysfunction that's causing it.

Dr. Yousef Elyaman: And others could have an issue with, can have an issue with bad bacteria in the gut. Yeah. So so other people have a iron overload that is causing it. Yeah. And others were exposed to different toxins.

Dr. Yousef Elyaman: Yeah. And it's probably a combination of of

Dr. Mark Hyman: of Yeah.

Dr. Mark Hyman: I mean, I think this is

Dr. Mark Hyman: really important when you just I just wanna pause there because from a traditional medicine point of view, it's like, okay. You know, we do a blood test. We do a fibrous fiber scan or MRI. We look at your liver, we do a biopsy. Okay.

Dr. Mark Hyman: You have fatty liver disease, but the why is very much neglected. And, and, and there is some understanding that it's due to a high refined carbohydrate diet, but these other, and yes, people understand hemochromatosis and iron overload, but the fact that, you know, the microbiomes involved in environmental toxins are involved, that it may be thyroid dysfunction, that there's a whole list of causes. And that's really where functional medicine is different than traditional medicine. It's root cause medicine that is ruthless around investigating the causes of a condition so that you can treat that person as an individual rather than treating everybody who's got this condition the same. Right.

Dr. Mark Hyman: If someone, there was a thing I read about years ago, was a scientific paper about a guy who had liver failure, but he, he, he, he was golfer and, and, and, you know, usually golfers, I'm not a golfer, but apparently they have to clean their balls and use this ball cleaning thing on the golf course to get the dirt off, but he used to lick the balls to clean them. But there's pesticides all over the golf course. So he was getting he was getting toxic pesticide load in his liver and caused him to have liver failure. So, so we had to think about all the root causes and that's where functional medicine helps us to navigate. And then the gut role plays a huge thing too.

Dr. Mark Hyman: And we don't really think about addressing the gut, but we know, we know that how, how big a role the gut plays in, in, in affecting our metabolic health and our, our, our load of toxins. And I mean, in medical school, we used to treat liver failure with which resulted, you know, in, in the inability to metabolize toxins from the gut by which caused basically delirium, something called hepatic encephalopathy. We treated with the antibiotic and lacked and a laxative. So basically to sterilize the gut, get rid of the bacteria that were poisoning the body, which is which is interesting. We don't because now we understand the microbiome has a huge role in mental health, but that was something we learned and it it didn't really kinda connect with us in terms of a a thing about the microbiome in medical school.

Dr. Yousef Elyaman: Right. It's a pre it's a prebiotic. Lactulose is a prebiotic. Yeah. So you're feeding the good bacteria.

Dr. Yousef Elyaman: Yeah. So we're like we were manipulating the microbiome, and we thought we were just making them poop. Yeah. Right? But it was and and it was amazing.

Dr. Yousef Elyaman: It would take them out of that

Dr. Mark Hyman: Yeah. Yeah.

Dr. Yousef Elyaman: Hepatic encephalopathy. They Yeah.

Dr. Mark Hyman: So so, basically, what's going on in the liver is is you've got a a number of different things that that are happening in our society, which is nowhere load of toxins, which is obviously our diet, which, you know, other, factors that you mentioned, the the gut microbiome changing dramatically, all driving this epidemic of of fatty liver disease. And and, and now there's sort of an interest in in kind of addressing this more directly in the medical field. We renamed the disease from nonalcoholic fatty liver disease to metabolic associated fatty liver disease.

Dr. Yousef Elyaman: And, actually, it changed that. So they first went to metabolic associated liver disease, then they changed it again because, they they they

Dr. Mark Hyman: That's me.

Dr. Yousef Elyaman: They're they're yeah. Whoever they are, the the big panels. Actually, multiple panels got together and they talked to patients. But I think we should talk about that story a little bit. Right?

Dr. Yousef Elyaman: So nonalcoholic fatty liver disease was basically your naming condition by saying what it was not. Yep. It's not alcoholic.

Dr. Mark Hyman: Right.

Dr. Yousef Elyaman: Like, it was kinda weird anyway. Even though that it was called nonalcoholic fatty liver disease, they people associated with alcohol. Right. They because alcohol was in the name.

Dr. Mark Hyman: And then they They

Dr. Yousef Elyaman: have to explain it to their family. Right. Right. Right. I'm telling you it's nonalcoholic.

Dr. Mark Hyman: Right. Right. Right.

Dr. Yousef Elyaman: So that you had that negative. And then the fatty had a stigma. So they changed it to metabolic associated or, metabolic dysfunction associated fatty liver disease. But then they changed it again because they're, like, fatty is stigmatizing. So we don't we want fat out of it.

Dr. Yousef Elyaman: So now it's metabolic dysfunction associated sta staatic sta staatic, which means fat, liver disease. So the no. Staatic liver disease. So now you took everything out that anybody could understand.

Dr. Mark Hyman: So you put a medical term in which means fat, which is steatosis, which means fatty.

Dr. Yousef Elyaman: Right. Right. But now they don't get shamed.

Dr. Mark Hyman: Now it's in Latin, so it's okay.

Dr. Yousef Elyaman: Yeah. That's fancy. That's fancy.

Dr. Mark Hyman: Whatever. So so that's the problem in, you know, in medicine, we call it the naming and blaming game. We name the disease and we blame the name for the problem. Well, I know why you have that abnormal liver function.

Dr. Yousef Elyaman: Now it's called mazel.

Dr. Mark Hyman: Mazel. Mazel. Okay. Then there's okay. Forget about what it was called.

Dr. Mark Hyman: We we know this is a bad thing. We know it's increasing and we know that traditional medicine, you know, doesn't have a great approach. So let's I wanna walk through how traditional medicine approaches this and then how we're gonna approach this with a a new perspective of root cause medicine and functional medicine, and then how how we go about looking at the diagnostic, tools we have to assess it and what are the therapeutic goals. So just sort of high level, what what if you want to see a traditional hepatologist, you have fatty liver, what are they gonna tell you? What are they gonna tell you to do?

Dr. Yousef Elyaman: Okay. So you go to a traditional hep hepatologist. They take

Dr. Mark Hyman: It's a liver specialist.

Dr. Yousef Elyaman: A liver specialist. They they they see the patient. They tell the patient you have fatty liver disease. Go ahead and try to lose weight. Right?

Dr. Yousef Elyaman: They may give them vitamin e. Probably, you're gonna give them the wrong kind of vitamin e because we know that there's different forms of vitamin e. And then and then if if you're lucky, many will say no. Don't stay away from vitamin e. And then they see if you're bad enough to be enrolled in a study.

Dr. Yousef Elyaman: And if you and if if you are, then they'll put you on a drug. Right? If not

Dr. Mark Hyman: Because there's no FDA approved drugs for family delivery.

Dr. Yousef Elyaman: There is one now. We just in in in March, we have one called ResMedirom, and, we could we should probably unpackage that later, like,

Dr. Mark Hyman: because there's some come back to that. Yeah. Yeah.

Dr. Yousef Elyaman: But yes. So there's finally one drug. It costs only $4,000 a month.

Dr. Mark Hyman: Is that it?

Dr. Yousef Elyaman: Yeah. That's it. And it can cause, all kinds of side effects as well. Great. But that

Dr. Mark Hyman: being that being Sounds like fun.

Dr. Yousef Elyaman: That being said, it's it's all about getting them. Okay. We have a disease. We named it. Right?

Dr. Yousef Elyaman: We need to tame it with a particular drug.

Dr. Mark Hyman: So But up until March, before that, what would they be telling you?

Dr. Yousef Elyaman: They would some would say, take ask your doctor if he would prescribe semaglutide for you.

Dr. Mark Hyman: Ozempic?

Dr. Yousef Elyaman: Ozempic. That's that's currently what they're what they'll tell you.

Dr. Mark Hyman: Weight loss. Because when you lose weight, fatty liver gets better.

Dr. Yousef Elyaman: Right. Right. So what what would we do? We would take a look at the FibroScan. And I I I do wanna talk about this FibroScan because this is there the FibroScan because this is extremely

Dr. Mark Hyman: But but it's back to the traditional medicine. Like, are they are they thinking that, you know, this is really diet related? Are they thinking that we should cut back on carbohydrates and starches and sugars?

Dr. Yousef Elyaman: No particular diet.

Dr. Mark Hyman: Do they really talk about a keto diet or anything like that to help?

Dr. Yousef Elyaman: Traditional medicine is like lose weight.

Dr. Mark Hyman: Lose weight. Just just lose weight. Eat eat less, exercise more, come back in 3 months. And if it doesn't work, we'll put you on drugs, except oops. There's no drug for this.

Dr. Yousef Elyaman: Yes. Yes. Unfortunately, we don't. So semaglutide.

Dr. Mark Hyman: So okay. I was gonna pick. Alright?

Dr. Yousef Elyaman: Yeah.

Dr. Mark Hyman: And then and then Yeah.

Dr. Yousef Elyaman: So and that's it. And then they just kinda leave you there. Yeah. And they and most of them are not getting a FibroScan. Most of them don't know how bad it is.

Dr. Yousef Elyaman: They don't know if they're they have fibrosis, which is hardening or not. And they and they just, they just kind of wait till things get really

Dr. Mark Hyman: And they and they might if you're diabetic, which is associate a lot with diabetes. Right? Because it's sort of the same condition, but earlier on, you know, they might give you metformin or they'll give you the Ozempic or maybe some of the the

Dr. Yousef Elyaman: Although metformin hasn't been found to decrease fatty liver disease. It's it's kind of but but they may give you that. They definitely will say you have a high risk of of, heart disease, so make sure you're on a statin drug. So they will put you on a statin drug. And and and the the problem is it's a double edged sword.

Dr. Yousef Elyaman: The statin drug can cause liver toxicity

Dr. Mark Hyman: Yeah.

Dr. Yousef Elyaman: But also it can change the way the the the lipid metabolism. So you know you may be hurting the liver, but you may be helping the heart. Right. Right?

Dr. Mark Hyman: So you're one of those. And then and then if you're overweight enough, they'll say, why don't you have bariatric surgery? There you go. Bypass. So Yeah.

Dr. Mark Hyman: Clearly, you know, traditional medicine has has not developed a good approach to this yet. Right. And and let's talk about the diagnosis part because now there's some interesting new diagnostic tests. You just have to do a liver biopsy. It was an invasive procedure.

Dr. Mark Hyman: It's risky. You kinda nobody wants to get a liver biopsy. It was expensive. Now there's some blood work you can do and some ultrasound technology that you can use to really diagnose what's going on. So talk to talk to us about how people can find out.

Dr. Mark Hyman: I I don't know. I have had a liver disease. What do I do?

Dr. Yousef Elyaman: I think the best thing to do is get a FibroScan. A FibroScan is ultrasound technology, and it will come when they stay it's it's very quick. It's noninvasive, and they give you two numbers. Something called a cap score and a fibrosis score. The cap score tells you what percentage of your liver is fat, and the fibrosis score is how much hardening there is in your liver.

Dr. Yousef Elyaman: Yeah. The beautiful thing about that is before, we had no idea how bad it was. And now I can give them a number. I could say around 35% of your liver is fat right now. I can put them on some sort of a plan, and I can retouch

Dr. Mark Hyman: it. Yeah.

Dr. Yousef Elyaman: And I can see it get better. Yeah. And that is that that is profound versus, oh, yeah. You still have fatty liver disease. Oh, the ultrasound Yeah.

Dr. Yousef Elyaman: Yeah. Fatty liver disease. Or the ultrasound show you don't have fatty liver disease, but they do have fatty liver disease because ultrasound isn't sensitive enough to pick it up. Right. Right.

Dr. Yousef Elyaman: So so that And

Dr. Mark Hyman: and just to changer. And to just to to be clear, the first step is your liver gets fatty, and then it gets inflamed, and then it gets scarred.

Dr. Yousef Elyaman: Mhmm.

Dr. Mark Hyman: And then you have cirrhosis, and then you need a liver transplant. Right. Right.

Dr. Yousef Elyaman: Right. Right. But some people go right from fatty without the inflamed. They go from right from fatty to scarred. Yeah.

Dr. Yousef Elyaman: So some people do skip that step. Yeah. You you think everything is good and then they end up So so

Dr. Mark Hyman: but not everybody's gonna get a FibroScan. So are there blood tests that will clue you into maybe you need 1.

Dr. Yousef Elyaman: Right? There are. There are. So, this we talked about so the the problem if they have high triglycerides, there or if they have insulin resistance or if they have high blood sugar. So if they have any of those things, they there's a high probability that they have fatty liver.

Dr. Yousef Elyaman: That So

Dr. Mark Hyman: if you have a high blood sugar

Dr. Yousef Elyaman: Mhmm. If you

Dr. Mark Hyman: have, high triglycerides Mhmm. Low HDL,

Dr. Yousef Elyaman: and

Dr. Mark Hyman: Mhmm. Maybe a high hemoglobin a one c, like, over 5 point whatever, 5, 7? Yeah. It's 4. 4.

Dr. Mark Hyman: Yeah. So as all those numbers, and these are things you can get on a regular blood panel.

Dr. Yousef Elyaman: Yes.

Dr. Mark Hyman: The lipo protein fractionation is more more predictive.

Dr. Yousef Elyaman: Yes.

Dr. Mark Hyman: And that's a better test. Yes. And we do that with a function health panel. So you go to function health dot com. You can, you know, get all these diagnostic tests for 4.99 for membership and do it twice a year and track stuff over time.

Dr. Mark Hyman: And and if you if you track these numbers, you can see that your risk and maybe you have not only just that, you'll have elevated liver function test. Right? So you might have been

Dr. Yousef Elyaman: Small density LDL. So the problem with triglycerides is some people have a high amount of what's called it's an enzyme called hepatic lipase. So it takes it lowers their serum triglyceride levels, but they have high small density LDL. So small density LDL, when that's elevated, that tiny, tiny bad cholesterol that you check on that panel that you do Yeah. You have your people do.

Dr. Yousef Elyaman: That that is that that not only can predict it, but because some people have it high, but they don't have fatty liver. But if you have fatty liver disease and you see that number go down, the chances that they actually have a a some sort of a reversal of fatty liver disease are very high. Yes. That's what that's what I'll use as a marker.

Dr. Mark Hyman: So you track your small LDL particles.

Dr. Yousef Elyaman: You track it as it's getting better, their fatty liver disease is getting better. Yeah. That's been that's been proven too.

Dr. Mark Hyman: And yeah. And and I encourage you to go back and listen to the podcast I did, on on cholesterol and cardiovascular. It's got to talk about all these diagnostic markers that are not used in traditional medicine that should be, including this lipoprotein fractionation. So these are tests are super inexpensive, should be easy to do, but, but they don't tell the full story. So there's a newer kind of interpolation of a number of different biomarkers that are used.

Dr. Mark Hyman: Basically your ALT, AST, liver function, plus platelets, plus your age, and you get something called what?

Dr. Yousef Elyaman: A fib 4.

Dr. Mark Hyman: A fib 4 score. So this fib 4 score you can get through Quest. I don't know if LabCorp does it.

Dr. Yousef Elyaman: Yeah.

Dr. Mark Hyman: And you get this score that gives you a sense of, gee, I might be having fatty liver disease. Right?

Dr. Yousef Elyaman: Right. And anybody so the like you said, they're they're look they're looking at platelets and they're looking at AST and ALT, which are found those things are found in regular blood work the doctor does. So if they didn't

Dr. Mark Hyman: The CBC and the chem panel, it's like, basically, your annual checkup will have that.

Dr. Yousef Elyaman: Checkup stuff. Now if they didn't add the the the fib score to it, the fib 4, there's fib 4 calculators. You put the you put the numbers in the calculator, and it'll give you the fib 4. Now here's the thing about the fib 4. It really the the young under 30 age 35 and older than age 65, it's not as accurate.

Dr. Yousef Elyaman: But what is it really telling us? It's telling us a it's a predictor for hardening of the liver. Your liver could be jam packed. You could your liver could be the human feugras. Right?

Dr. Mark Hyman: Yeah.

Dr. Yousef Elyaman: But if if if it's not picking if you don't have fibrosis

Dr. Mark Hyman: Yeah.

Dr. Yousef Elyaman: It's not gonna show anything.

Dr. Mark Hyman: I see. So you go this is only in the later stages that you're gonna see this test be elevated. Right? So Right. You might see the clues with the high triglycerides, high insulin, high glucose, even see small particles of LDL, but you might not see the fib 4 score up until you're already down the road a bit.

Dr. Yousef Elyaman: Right. And and I just pointing out those levels, the ALT and a, AST. So the those are called liver function tests. They're really enzymes that the liver has in them. The the the data is showing that the number those numbers are supposed to be lower.

Dr. Yousef Elyaman: Yeah. So ALT The reference ranges that we have. Less. Yep. It's supposed to be less than 30.

Dr. Yousef Elyaman: Yeah. Less than 20.

Dr. Mark Hyman: Right? And the reference ranges in the lab are, like, 40 or 50. Right?

Dr. Yousef Elyaman: Right. They're up there. The other thing is so so what are they looking at? Why would that FIB 4 why why would a fit why would they be looking at platelets? Well, it turns out that the liver makes a hormone called thrombopoietin.

Dr. Yousef Elyaman: And if you get hardening of the liver, it can't make thrombopoietin.

Dr. Mark Hyman: Oh, so you get it.

Dr. Yousef Elyaman: So now your now your plate levels start to go down.

Dr. Mark Hyman: Oh, interesting.

Dr. Yousef Elyaman: But drinking alcohol poisons the bone marrow Mhmm. And that lowers your platelets. So if they're actively drinking alcohol, it could falsely elevate it. But it also can cause liver disease too. So it's it's kind of a

Dr. Mark Hyman: So so, basically, the the the regular blood test you can get can tell you a lot. We're gonna put all this in the show notes. You have to remember, you can get the function health panel at functionhealth.comforward/mark that gives you all of that, except it doesn't calculate the fib 4 score, but you can do it because all the data is there. Right. But there's another test that they do if this fib 4 score is elevated called an ELF test.

Dr. Mark Hyman: So can you talk about the ELF test? Because it's a little more advanced and and what it is and what it means and who should be doing it.

Dr. Yousef Elyaman: Right. So the the the ELF test is also a, a marker of fibrosis. So what they do there's, 3 different what what we call biomarkers or 3 different lab levels that can indicate that the liver is getting hard or getting that fibrosis, and you can end up with a score there. And it's much more accurate. It's maybe 80 to 90% versus around 45%.

Dr. Mark Hyman: Because because the first big four just in is sort of interpolating from existing biomarkers. It is. It's actually looking for compounds or molecules that are elevated when there's a fatty liver or liver fibrosis. Right?

Dr. Yousef Elyaman: Right. It's gonna miss more

Dr. Mark Hyman: Like hyaluronic acid, type 3, pro collagen peptides, tissue inhibitor matrix

Dr. Yousef Elyaman: Yes.

Dr. Mark Hyman: Metalloproteinase. These are all kind of big fancy medical words. But Yes. The things you can get on a blood test that are not your typical blood test. So you've got your doctor will have to ask for this.

Dr. Mark Hyman: Right. Or or if you have a fib 4 score that's high, you can go say, I want this. Right.

Dr. Yousef Elyaman: And this is where we I think this is where the podcast today changes the world. Right? Be aware be aware that you could have fatty liver. See if you can get a FibroScan if because they're popping up places are popping up, left and right. And if you do has to order that.

Dr. Yousef Elyaman: You're you're they'd yes. Or you can go there are certain places that are trying to study medication where you just go get it for free. There's, like, research centers. Yeah. So look for a a FibroScan near you near near you.

Dr. Yousef Elyaman: Maybe even pay. This may be worth paying self pay for, but once you see that you have that fatty liver disease, reverse it before that fib 4 is high, before the ELF is high, before the fibrosis. This is where this is where I think if we can catch this thing early, we can we can make a significant impact on on the health of the planet.

Dr. Mark Hyman: And so the ELF what you're thinking is the ELF test essentially, this this other test that Yeah. Is is really just picking up scarring. Right. Not necessarily just fatty liver.

Dr. Yousef Elyaman: And as a primary care doctor, when I see somebody with an elevated ELF, then then because because they it will see the fib 4 high, and that could just be a false positive. I'll check an ELF. I'll check a FibroScan. And if I see a high fibrosis in them, they're gonna be I'm gonna be co managing them with a hepatologist. I'm gonna be more aggressive, but that's where it needs to go in the specialist.

Dr. Yousef Elyaman: But like you said, with the amount of the percentage of the world that has fatty liver disease, we don't have enough hepatologists. We Yeah. But but but

Dr. Mark Hyman: but I'm just gonna push back on you.

Dr. Mark Hyman: So because even if you you send them to a hepatologist, what are they going to tell them?

Dr. Yousef Elyaman: No. They're gonna hold they'll hold their hand as they need a transplant.

Dr. Mark Hyman: Well, that's exactly right. I mean, that's exactly right. And that that's the conversation I had with the amazing man who's the chief of hepatology at Cleveland Clinic.

Dr. Yousef Elyaman: Right.

Dr. Mark Hyman: We just don't have a

Dr. Mark Hyman: lot to offer them. Could you help us? And Right. How do we start to get these patients to change their lifestyle and behavior? So so basically, bottom line is there's some great diagnostics on your regular blood panel.

Dr. Yousef Elyaman: Right.

Dr. Mark Hyman: We'll put those in the show notes. There's some newer tests that you can get on blood work, blood work that can help. There's a great ultrasound that's not very expensive, non invasive, and has no risk

Dr. Yousef Elyaman: Right. That

Dr. Mark Hyman: you can get to see what's going on. If if you have, potential elevations in any of these numbers or you're overweight, you're at risk, even if you're not overweight, it may, maybe

Dr. Yousef Elyaman: you could

Dr. Mark Hyman: be not overweight and be what we call a skinny fat person where you're metabolically obese, normal weight because you eat crap and you're not, you don't gain weight, but you have fat on the inside.

Dr. Yousef Elyaman: Right.

Dr. Mark Hyman: But then you do all these great diagnostics and then what? Because there's no real treatment for in traditional medicine. So from a functional medicine perspective, how do you see this epidemic? What what can be done about it in a practical way to help people reverse it? We now know sort of how we can get it diagnosed.

Dr. Mark Hyman: Right.

Dr. Yousef Elyaman: How

Dr. Mark Hyman: how do we start to think about it differently from a functional medicine?

Dr. Yousef Elyaman: Right. And this is where conventional medicine and functional medicine is gonna be different. Conventional medicine says just lose fat. Right? They studied it.

Dr. Yousef Elyaman: They looked at whether low carb was helpful, high protein, whether a keto diet and believe it or not, if you go on a keto keto diet and you lose weight, it will reverse this even though you're eating fat. Like you mentioned early on, what what what we're looking for is what is it that that regardless of whether they lose weight or not, what will reverse this? Right? Right. So so Mediterranean food plan.

Dr. Yousef Elyaman: There is data that show that the Mediterranean food plan, which which we Was

Dr. Mark Hyman: that pizza and pasta?

Dr. Yousef Elyaman: Yes. Yes. No. No. No.

Dr. Yousef Elyaman: No. So it's it's, it's it's a heart healthy food plan that where they took a look at the healthy foods that people that lived in the Mediterranean high in olive oil, high in vegetables, high in those foods, And they found the significant benefits, benefit with mood, benefit with with metabolic disease, but also independent of weight loss. If you go on a meta a modified meta metabolic food plan, you will you will end up see seeing an improvement. And and IFM, the Institute For Functional Medicine has one that they call them cardiometabolic food plan, and that's what I give all of my patients. Say, let's start here, the cardiometabolic food plan.

Dr. Yousef Elyaman: Also, you could have food allergies that is pushing this. For example, gluten. Right? The you could some people have fatty liver disease because they're eating a food that is bothering them and inflaming them. And you get them off the gluten or get them off the dairy or whatnot.

Dr. Yousef Elyaman: And

Dr. Mark Hyman: because anything that causes inflammation will cause insulin resistance. So it's kind of the mechanism is well known there.

Dr. Yousef Elyaman: Right. Decreasing fried foods, because fried foods have something and glycosylation end products, which, when when you fry fry foods, sugar with other molecules at high temperatures, it causes what's these toxins, these n glycosylation end products, and they will cause inflammation, what we something called oxidative stress, which is rusting Yeah. Which worsens the condition. So decreasing those is is is extremely important. And also Sugar, sugar,

Dr. Mark Hyman: fry foods.

Dr. Yousef Elyaman: So I think I think everybody talks about the glucose, but we're not talking about the fructose piece. Right? Fructose, if you look at high fructose corn syrup or just regular table sugar, it has sucrose and it has fructose. Fructose pushes the body to make uric acid. And and uric acid tells the body store fat.

Dr. Yousef Elyaman: Mhmm. So it slows your metabolism. It tells people to store fat, and it and it worsens fatty liver disease. And and, I believe you did a podcast on this.

Dr. Mark Hyman: Richard Johnson. Yeah. People should go back and listen now. We'll put the show notes on that. Because uric acid is a is a consequence of really eating a poor diet, particularly one that's high in high fructose corn syrup.

Dr. Yousef Elyaman: And back to optimal levels. So so according to doctor Johnson, and this is what I go by, 5 you want your uric acid level less than 5.5. Right. Right? Whereas whereas the the labs is about 7.

Dr. Yousef Elyaman: 8. Yeah. 7, 8, something like that. And and when they see that uric acid high, there are supplements that you can give them, and there's also there's also, dietary changes that you can give them.

Dr. Mark Hyman: Cherry extract for that, which is great for gout and high uric acid and high dose of cherry.

Dr. Yousef Elyaman: Cherry, dark cherry extract, vitamin c, quercetin, maybe some green tea. Those things all can help lower it. So if you have somebody that

Dr. Mark Hyman: stop drinking the 2 liter bottle of Coca Cola with 75% fructose and drink everything.

Dr. Yousef Elyaman: Fun in that. So so so if you have no absolutely. Sodas are going to really drive it. So you're you can you'd follow that glucose and insulin resistance score. If your sugar is already high when it's fasting, that's your main.

Dr. Yousef Elyaman: You gotta work. That there's some work. If you just have insulin resistance, that's still a problem. So with insulin resistance, there's things like Berberine that can help. There's things like with alpha lipoic acid, n Acetylcysteine that can help.

Dr. Yousef Elyaman: So so work so, yes, Mediterranean and food plan, exercise, whether it's resistant training or cardio cardiovascular training, both independent of weight loss will reverse fatty liver disease. So you don't you can look you can you can exercise and you can stay the same exact weight and you can still have that fat start

Dr. Mark Hyman: to improve. Makes you more insulin sensitive. Makes you more I mean, this is it reminds me of an interesting study I I read years ago where they did bariatric surgery. And basically when you do bariatric surgery, you can reverse diabetes in like 2 weeks and reverse the fatty liver in a very short time. And yet they're still severely obese.

Dr. Mark Hyman: Like someone can still be £400, maybe they lost £25, but there's still £375 and diabetes goes away like that and fatty liver will improve because you're changing the food.

Dr. Yousef Elyaman: And changing metabolism. At one point, the heaviest man in the world actually had had his his blood sugar was normal, and it was because of such a high adiponectin level. So so so there there is the genetic factor, but there's also the metabolism and the way that the body, decreased sitting, of course, increasing steps, things like that. So we get them exercising. And I think I think the most important thing, and you've mentioned this a couple of times, is that we gotta we we we we really wanna be careful of the catastrophic black and black and white thinking.

Dr. Yousef Elyaman: Like, oh, if you don't lose weight, that's it. Because there are so many things that you can do besides that. We meet people where they're at, and you don't not everybody's going to be able to do that. You can go on a medicine like semaglutide or like you said Ozempic, and it could end up losing their muscle. And then what is it gonna do?

Dr. Yousef Elyaman: We see all kinds of side effects with that with with that medicine.

Dr. Mark Hyman: Resistant when you lose muscle. Yeah. It was interesting. So so just getting back to the diet part because I think there's a lot of ways to skin a cat. You mentioned just a Mediterranean diet, which essentially is fruits and vegetables, protein, nuts and seeds, olive oil, healthy food, real food.

Dr. Mark Hyman: Not pizza and pasta.

Dr. Yousef Elyaman: Right. Cut cut out the fried foods.

Dr. Mark Hyman: Yeah. Cut out the fried foods. And and so that's good. But but do you need to be more aggressive sometimes in terms of cutting out, more starches, like cutting out grains or beans or fruit? Like, because if you mentioned fructose, you're like, oh, fructose is bad.

Dr. Mark Hyman: Does that mean fruit is bad? Because that's where fructose is found.

Dr. Yousef Elyaman: So fructose is bad when it's in high amounts in a way that it wasn't found in nature. So in the form of a juice, not so good for you. In the form of a fruit, the fruit actually has the antidote in it. So when you get it as a balanced thing, it's not

Dr. Mark Hyman: the antidote.

Dr. Yousef Elyaman: The fiber is the antidote, plus it has all the different colors of the fruits and vegetables have what what they're

Dr. Mark Hyman: called. Acids.

Dr. Yousef Elyaman: Yeah. Phytonutrients. And the phytonutrients actually will counteract and decrease uric acid. So but but I think I think it all depends. If somebody is is in the beginning, they're excited, they're ready, they're ready to do whatever it takes.

Dr. Yousef Elyaman: Yes. You cut the sugar, you increase the, you increase the healthy foods. But meeting people where they're at, we got we have to be careful of the all or none thinking because what'll happen is they'll say, oh, shoot. I ate too much sugar, so screw it. I'm just gonna eat the candy bar.

Dr. Yousef Elyaman: Right? And I'm not gonna do this anymore. And that's why no. No. No.

Dr. Yousef Elyaman: Why don't we focus on what you should be eating or what you wanna be eating? Why don't you, okay, have maybe 2 servings of vegetables with that Snickers bar. Right? So might I just say Snickers, I don't know. But You can say whatever you want.

Dr. Yousef Elyaman: Okay.

Dr. Mark Hyman: But wow. So so, given that you're trying to meet people where they are and help them, not be overwhelmed and make the simple small steps that you can see that could make a big difference. But if you had a perfectly compliant patient and you wanted to create the fastest results to reverse fatty liver, what would you do? Would you put them on a ketogenic diet? Would you put them on a paleo diet?

Dr. Mark Hyman: Would you put them on a vegan diet? What would you do?

Dr. Yousef Elyaman: Mediterranean. That would be the Mediterranean the cardiometabolic food plan.

Dr. Mark Hyman: So even even with even with, option of really reducing

Dr. Yousef Elyaman: The carbs. The carbs even more? Reducing the carbs even more is logical, but now we have to look at the research we have available. And the research did show all of those diets that you mentioned are food I like calling them food plans, but all of them will help with fatty liver. But the one that has been shown that reduces that that that that will decrease fatty liver, but also but independent of weight loss is the Mediterranean.

Dr. Yousef Elyaman: And that's why I think that should be the but do I have people that go low carb and keto and it works? Absolutely. So, no, that all in intuitively, yeah, you cut the sugar, insulin resistance improves. But I think the the the the focus on Mediterranean is is you're you're focusing on healthy fats, which is something that you're a proponent of. Right?

Dr. Yousef Elyaman: You're also focusing on the fruits and vegetables. Those colors are their medicines. They're medicines. So to tell them to just eat a bunch of steak and forget about the phytonutrients

Dr. Mark Hyman: Phytochemicals is key. Because those are some of the phytochemicals actually are active as support for liver detoxification and inflammation. You know, what it once did I read years ago was, was, my mice, a mouse study and they gave mice alcohol, and then they watch what happened and develop fatty liver. And then they, they gave them alcohol plus high relatively high amounts of MCT oil, which is medium change triglycerides, and it comes from coconut oil and other places. But it's it seemed to actually reverse it.

Dr. Mark Hyman: Can you explain that?

Dr. Yousef Elyaman: Yeah. So so if you if you increase, what what does MCT oil become? Ketobutyrate? Ketobutyrate?

Dr. Mark Hyman: Yeah. It increases. Yes. It's metabolized and absorbed differently than traditional fats. So it's absorbed directly into the body.

Dr. Mark Hyman: It doesn't have to go through

Dr. Yousef Elyaman: the Right. Right. So and you can use that as a fuel, which increases your efficiency, which the of of your receptors and decreases insulin resistance. I know that I know that, omegas are fish oils. One of the things that fish oils does is is it yeah.

Dr. Yousef Elyaman: So healthy fats, if you give people healthy fats, phosphatidylcholine helps as well. It blocks some of those triglycerides from going back into the liver, so it kind of stops the liver from getting overloaded as fast. So I wonder if the MCT oil works by that mechanism.

Dr. Mark Hyman: Yeah. It was

Dr. Mark Hyman: it was fascinating. I was like, wow.

Dr. Mark Hyman: You can even, like, be drinking it like a fish and and take the m c 2 l, and it would not it would mitigate the the damage to your liver, which I thought was interesting.

Dr. Yousef Elyaman: Right. But but I do work as a in a at at the guest house, which is substance abuse and trauma center. So we're not, like, proponents of drinking like

Dr. Mark Hyman: a fish. Of course. Of course. I'm not saying drink and

Dr. Mark Hyman: take them

Dr. Mark Hyman: to all and chew your bone. I'm not saying that. Just just to be clear. So just to back up a little bit on my what you're talking about. Diet's key.

Dr. Mark Hyman: So cutting out Yeah. The free fructose and high fructose corn syrup. Just get rid of that a 100% from your diet, number 1. Number 2, increase a diet that's high in phytochemicals, high in fiber, high in good fats

Dr. Yousef Elyaman: Yes.

Dr. Mark Hyman: That, you know, nuts and seeds, lots of fruits and vegetables, clean protein, you know, some whole grains, beans can be fine. Right?

Dr. Yousef Elyaman: Alcohol. Stop the alcohol.

Dr. Mark Hyman: Stop the alcohol. Yeah. Stop the sugar. Stop the Tylenol.

Dr. Yousef Elyaman: Stop the Tylenol.

Dr. Mark Hyman: Because Tylenol, liver poison. And and then you talked about exercise being really instrumental. So that's clear. And I think everybody understands that. And you mentioned a bunch of supplements.

Dr. Yousef Elyaman: Oh, yeah.

Dr. Mark Hyman: So I wanna kind of go down that rabbit hole with you because I find that that using things that help support liver function can be extremely effective and it's actually in the published medical literature. In fact, one of the things we use for liver failure when people overdose with Tylenol, when they come into the emergency room is something called mucormist. Now, I'm in I thought that was a drug because that's what I learned in medical school but it's actually an acetylcysteine or a supplement that gets turned into glutathione.

Dr. Yousef Elyaman: Right.

Dr. Mark Hyman: And that rescues the liver from catastrophic liver failure and it's just a supplement. Right. Now the FDA is trying to, like, take it off the market because it works so well, but Yeah. It it's it's something you can take to boost your levels of glutathione Yes. Which is the body's main repair antioxidant, anti inflammatory system.

Dr. Yousef Elyaman: Right.

Dr. Mark Hyman: So you mentioned that. What other supplements are in your top, you know, 5 or 6 supplement?

Dr. Yousef Elyaman: So I'd like to I'd like to just elaborate a little bit on them. Right? So the that that n a c, N Acetylcysteine, increases glutathione. Glutathione is an anti rusting agent. Right?

Dr. Yousef Elyaman: We check a level in the blood called GGT. GGT tells me that you've been using up a bunch of glutathione and you have rust happening.

Dr. Mark Hyman: If it's elevated?

Dr. Yousef Elyaman: If it's elevated. So if they have elevated if they have an elevated liver enzyme or if the the ALT, AST, or elevated GGT, I am going to be giving them I'm gonna wanna give them the N Acetyl Cysteine. The other thing is is if they have an elevated GGT, that is a independent risk factor for fibrosis. So if you have high GGT, there's a high chance that you have fibrosis as well. And and the the the the the supplement that has been found to help is coq10.

Dr. Yousef Elyaman: Yeah. And I give the ubiquinol form, the unrusted form. Yeah. So I don't know I don't know if if you I know there's debates back and forth as does it matter if it's ubiquinol or ubiquinone? But there is data that supports giving ubiquinol with a high GGT can lower that GGT.

Dr. Mark Hyman: And and GGT can also be a a clue of environmental toxic load too, not just fatty liver. So Right. We're talking about other causes besides just diet.

Dr. Yousef Elyaman: Right. The triad, elevated liver enzymes higher than the optimal level. Right? High uric acid plus high GGT. If you have those the and and and they're not they're they're not moving, they're not budging, you have toxic overload.

Dr. Yousef Elyaman: They need to read your book on your your your detox book.

Dr. Mark Hyman: Yeah. I mean, and that and that's something that people can can learn how to do. And I think it can remove some of the environmental toxins that can be loading the liver and just reduce your exposure. I mean, I was reading the other day that that the average American has 22 pounds of food additives every year.

Dr. Yousef Elyaman: Yeah. What's that doing? It has to go through the liver. Right?

Dr. Mark Hyman: Yeah. It's not great.

Dr. Yousef Elyaman: So so you so there's already there's a couple of supplements. Right? There's research that showed that vitamin e was helpful. Now here's here's the challenge with vitamin e. The vitamin e that is normally pushed at the store at the supermarket is called d alpha tocopherol.

Dr. Yousef Elyaman: It is synthetic. Right? It's it's not the way it's found in nature. In nature, there's 8 forms of vitamin e, alpha, beta, delta, gamma, tocopherol, alpha, beta, delta, gamma, tocotrienol. And if you start hitting the body with just one type and the synthetic form,

Dr. Mark Hyman: what It becomes more oxidized.

Dr. Yousef Elyaman: Well, the more oxidized, and it may be stopping the other forms from getting in. Yeah. So you're creating a vitamin e deficiency by giving them vitamin e. Yeah.

Dr. Mark Hyman: So what you get at your, like, local drugstore is probably not the right form.

Dr. Yousef Elyaman: So I switched to

Dr. Mark Hyman: link we're gonna link to the right forms that contain multiple forms of mixed mixed tocotrienols, which we call.

Dr. Yousef Elyaman: The research that showed improvement in fatty liver actually showed the mixed. Yeah. Right? There is a supplement called phosphatidylcholine. Yeah.

Dr. Yousef Elyaman: And that stops some of the bad fats from getting into the liver and choline helps process fat. So phosphatidylcholine, I've been impressed with it. I've I've seen I've seen it work really well decreasing that fat.

Dr. Mark Hyman: It also detoxifies, you know, cell cell membranes. I actually recently did a test. I, I, we're here at the annual international conference for functional medicine and I gave a little presentation yesterday and I shared my own case history of my illness when I was 36 and chronic fatigue and being overloaded with mercury and mold toxins and everything. And I actually did this test, recently that's from Germany that looks at your cell membrane levels of toxins. And I had, you know, mold toxins, pesticides, you know, plastics, heavy metal, I mean, you name it.

Dr. Mark Hyman: I had it and I, and I did a course of intravenous phosphatidylcholine over the course of 10 weeks, twice a week, about, 10 grams a time. So it's like 2,000 grams, which is a kilo basically over time. And that, and I redid my test and I was shocked to see that the levels of the toxins dropped dramatically almost to normal by repopulating my cell membranes with a better, newer form of the fat. So all our cell membranes are made of a phospholcholine and it helps to, you know, detoxify our liver. So I I think that this phospholcholine can be helpful in many ways and I think you can take it orally, you can do it intravenously.

Dr. Mark Hyman: I wanna back up a little bit if you were talking about these tests, you know, uric acid Yeah. GGT

Dr. Yousef Elyaman: Yeah.

Dr. Mark Hyman: And all these other lipoprotein fractionations. Typically, when you go to the doctor for annual checkup, they're not checking uric acid, they're not checking GGT, they're not checking insulin, they're not checking lipoprotein fractionation.

Dr. Yousef Elyaman: Right.

Dr. Mark Hyman: So these are available through Quest or LabCorp. They're really easy to get and they're not that expensive. In fact, with function health, sorry to harp on this, but you can get all these tests and lots more for, you know, 4.99 membership for twice a year testing and track your numbers over time and, and sort of have a health copilot that tells you what's, what it means and what to do about it. It's so, it's so important to know what's going on in your body because, you know, most medicine waits till you have a serious problem, and then they come in kind of to rescue and treat it. They don't see the subtle, slow changes that you can pick up as clues in your blood work early on that you, you, you have to know because if you don't do it, you know, like I said, 30% of Americans or more walking around with this problem, it's invisible, it's painless.

Dr. Mark Hyman: It has no symptoms that is extremely risky for a whole range of chronic diseases including heart attacks, cancer, stroke, you know, dementia and more infertility, whatever. And, and it's just not being diagnosed. So, so I encourage you all to just get checked, you know, test, don't guess. Now, in terms of the next sort of set of supplements, we've got N Acetylcysteine, we've got vitamin e but the right form of mixed Vitamin e. Tocopherols and, and I'm linked linked to that in the show notes of what what would be the optimal forms to get.

Dr. Mark Hyman: What else should people be thinking about?

Dr. Yousef Elyaman: CoQ10. Great.

Dr. Mark Hyman: Thank you. CoQ10 Uh-huh. In the right form, Ubiquinol.

Dr. Yousef Elyaman: If if it's an oxidative stress thing that we're working on, then you can consider things like alpha lipoic acid as well. It's a powerful antioxidant as well, and it can help lower sugar for insulin resistance. Yeah. So the so though those, I would I would we already kinda talked about the high uric acid. If your uric acid is higher than 5.5 in a postmenopausal woman or in a man or in a a a a woman that that does that, is having periods, it should be less than 4.5.

Dr. Yousef Elyaman: So if that uric acid is high, you already mentioned the the dark cherry extract. You you mentioned, we we also talked about quercetin. Quercetin helps with multiple things.

Dr. Mark Hyman: What does that do?

Dr. Yousef Elyaman: So it's a mass cell stabilizer, but it helps the body excrete uric acid.

Dr. Mark Hyman: So it's it's basically from plants. Right? Onion The red. Yep. Berries and different things.

Dr. Yousef Elyaman: Yeah. Apples.

Dr. Mark Hyman: And it turned out to be very effective in COVID. It's great for longevity. And the reason lot of research on, of course, Dan, it's in Himalayan tardere buckwheat at high levels, which is something that, we talked about in the podcast before with Jeff Bland that that is is really showing your immuno rejuvenating properties and actually reversing biological age. So I think this is a very important supplement that most people probably don't know of

Dr. Yousef Elyaman: Right.

Dr. Mark Hyman: But has many, many effects. It works on, also on AMPK, which is one of the longevity switches that regulates insulin resistance. So it has so many benefits, but in terms of fatty liver, specifically, it can help lower uric acid and help improve fatty liver.

Dr. Yousef Elyaman: And may lower iron because the the the liver starts to accumulate iron. Whether you have hemochromatosis or not, you can start accumulate iron. So that's milk thistle. So then there there's another one. Yeah.

Dr. Yousef Elyaman: Milk thistle, also helps with detox.

Dr. Mark Hyman: Mhmm. So so what what does that do?

Dr. Yousef Elyaman: So that helps with detoxification as well, but also may lower iron. Any inflammation helps with liver inflammation.

Dr. Mark Hyman: What about minerals and vitamins like Yeah. Selenium and things like that?

Dr. Yousef Elyaman: So now when we start looking at liver function, one of the tests that I like looking at is a homocysteine. Yeah. Because if your homocysteine is high, then the way that you're processing some of the b vitamins is off, which and then you get a backup a backup in detoxification, so your body can't get rid of toxins. Your body can't make neurotransmitters. It could lead to depression, anxiety, insomnia, and all of those things.

Dr. Yousef Elyaman: So I'll check that I'll check the homocysteine. If it's high, you consider checking that MTHFR gene mutation. Yeah. Which is which which, you need in order to lower homocysteine, you need the activated form, Methylfolate. Yeah.

Dr. Yousef Elyaman: So so And if you

Dr. Mark Hyman: have this weird genus enzyme, which about 35% of people don't have the proper enzyme to convert the inactive to the active folate

Dr. Yousef Elyaman: Right.

Dr. Mark Hyman: You get you get problems including, you know, bad liver, cancer, heart disease, you name it, dementia. So you can check that in a blood test. Again, it's not in your regular lab, but it is on the function panel.

Dr. Yousef Elyaman: Right. So so if that you in your panel, is homocysteine

Dr. Mark Hyman: in there? Absolutely.

Dr. Yousef Elyaman: Yeah. So what about MTHFR that

Dr. Mark Hyman: That's an option.

Dr. Yousef Elyaman: Yeah. So if you're yeah. If their homocysteine's high, check that MTHFR, and then you support them with b vitamins. You can support with them with things like taurine, omega threes again. Because omega threes, we didn't mention, but omega threes can reverse or decrease fatty liver disease as well.

Dr. Mark Hyman: Yeah. So omega threes. So Yeah. We got a cocktail here. We got N Acetylcysteine.

Dr. Mark Hyman: We got vitamin e in the right forms of mixed tocopherols. We got milk thistle, we've got ubiquinol, we've got, alpha lipoic acid.

Dr. Yousef Elyaman: Uh-huh.

Dr. Mark Hyman: That's a good cocktail. And, of course, making sure you're gonna be complex and multi mineral. Right? Right. Right.

Dr. Mark Hyman: And So

Dr. Mark Hyman: all all that is required to make all the metabolic pathways in the liver work properly.

Dr. Yousef Elyaman: Right. And then let's not forget curcumin. Yeah. Curcumin may help as well, and curcumin is good for heart health and for

Dr. Mark Hyman: So yeah. So curcumin is like a basically found in curry and turmeric. Right? You can take that as a supplement. Again, very important.

Dr. Mark Hyman: And, again, we're gonna we're gonna link in the show notes to what what products and things are the the best best in class there because there's a lot of junk out there. You don't wanna you don't wanna be doing that. Now, it seems like a pretty straightforward plan. It's diet, exercise, stop drinking

Dr. Yousef Elyaman: Yeah.

Dr. Mark Hyman: Stop taking drugs that damage your liver

Dr. Yousef Elyaman: Right.

Dr. Mark Hyman: And then be on a number of supplements that can help support Right. Optimal liver function.

Dr. Yousef Elyaman: But personalized medicine, functional medicine. Right? So you see what their imbalances, and you give them supplements based on the imbalance. Yeah. Not just and and first, the lifestyle.

Dr. Yousef Elyaman: Actually, you can give a good go at lifestyle Mediterranean food plan, omega threes, and just see what happens. Yeah. Right? Mind you, these they they've already ruled out other causes of liver disease. They've their doctors already told them no.

Dr. Yousef Elyaman: Yeah. You what you have is fatty liver disease. It's not something else. Because other liver diseases can cause turn the liver to fat. But once we know that, start with that and then refollow those things that are apt.

Dr. Yousef Elyaman: Find out what their abnormalities are and refollow them and make it more personalized.

Dr. Mark Hyman: And the beautiful thing about liver is it regenerates. Like, the you know, it's one of the few organs. If you cut your liver off and give up way half your liver, it'll grow back. Right. Right?

Dr. Mark Hyman: So if it's like a salamander, like, growing an arm, except it's one of the few organs. So you want if you actually can give a liver part of your liver to somebody else's transplant and you're still alive and have a liver Right. Grow back, which is pretty cool. So it has a lot of capacity we generate. So tell us in terms of this approach, when you have some come in Yeah.

Dr. Mark Hyman: With fatty liver, whether it's, you know, more advanced stage or a less advanced stage, what kind of results are you seeing? Can you share some cases of patients who've had this and they follow this approach and actually reversed?

Dr. Yousef Elyaman: Right. No. There there are tons of cases that follow. So they it goes anywhere from at improving their their markers, their their blood markers, and improving their, and and improving their the fat in the liver to people that had fatty liver that no longer have fatty liver. Like, it is, it's using this personalized approach.

Dr. Yousef Elyaman: It works. Yeah. We see it. And the beautiful I I tell you the most frustrating thing for me, I hated even getting into fatty liver. That's I hate it.

Dr. Yousef Elyaman: I hated talking about it. Because I tell them they have fatty liver and then tell them to lose weight, and then and then how do I know if it's getting better or not? I there I have no way of telling. And now I'm so excited that we have ways of telling

Dr. Mark Hyman: New diagnostics.

Dr. Yousef Elyaman: And and and the other scary thing. So I'll tell you about a case I had too. A lady who had fatty liver disease was told she had fatty liver disease years ago. Right? And now we have this technology.

Dr. Yousef Elyaman: She's coming and seeing us. Yeah. We do the FibroScan Yeah. And it shows high fibrosis, and we do a biopsy. She has cirrhosis.

Dr. Yousef Elyaman: Yeah. Now probably saved her life because we get her in a study. We work on a functional medicine approach. But imagine, like, this person knew years ago she had fatty liver disease, but instead of the only thing she was told is, yeah, lose weight. And and sometimes they do it without even without even thinking that they will.

Dr. Yousef Elyaman: Right? Yeah.

Dr. Mark Hyman: Yeah. So the problem with,

Dr. Mark Hyman: you know, traditional medicine is, like, we say, okay. You are, you know, diagnosed with this condition and there's here's this one drug, take this pill to fix the disease. Right? But with functional medicine, it's it's multi causal and multimodal treatment. In other words, there may be many factors, so you might have to clean up the gut if people have dysbiosis or bacterial overgrowth.

Dr. Mark Hyman: You might have to get rid of environmental toxins if they're, you know, not filtering their water, they're eating too much tuna or they're having exposure to all kinds of chemicals in their environment.

Dr. Yousef Elyaman: Right.

Dr. Mark Hyman: You might have to do a lot of things to kinda help reduce a risk. So we do multiple things, and diet exercise, supplements, other factors, reducing toxins, fixing the gut. That's the whole functional medicine approach. What, what, are you seeing in terms of the, the, the, the kind of data on this? Are there are there studies that show multimodal treatment approaches?

Dr. Mark Hyman: Because it's not how we study things in medicine. Right. Have you have you done or has anybody else done studies that look at collective interventions to actually see what kind of change we can get in this.

Dr. Yousef Elyaman: As far as I know, there is no study that does like the Bredesen protocol that that follows a multimodal approach.

Dr. Mark Hyman: Yeah. All

Dr. Yousef Elyaman: I can tell you is our clinical practice. We have 7 providers. We take insurance. We have where we we actually, the FibroScan company knows us really well. Yeah.

Dr. Yousef Elyaman: The the the the the company that is doing these, doing this research knows us really well because we send so many people to get FibroScans. We just we just open the floodgates and send them through. But we have we have probably done thousands of FibroScans because of this in the last couple of years. So we're able And you

Dr. Mark Hyman: see the changes?

Dr. Yousef Elyaman: We're able to see the changes. Yeah. But it's very different if I

Dr. Mark Hyman: People normalize, do they get

Dr. Yousef Elyaman: People normalize all the time.

Dr. Mark Hyman: Yeah. So this is the problem. And and I think I think, you know, it's like the way medicine, works and the way medical research is done is okay. Let's see if I do let's just give you vitamin e and see what happens. Right.

Dr. Mark Hyman: Or let's just give you, you know, a little exercise when after. Let's just give you milk this all and see what happens.

Dr. Yousef Elyaman: Right.

Dr. Mark Hyman: It's the wrong way to do it because you have to treat all the things. You can't just treat the one thing and you have to fix all the diff his functions. So that's really the beauty of functional medicine and then and I think if it's stunning to me that we have something that affects a third of the population

Dr. Yousef Elyaman: Right.

Dr. Mark Hyman: And nobody's doing any real research on how to actually fix this. Now there are drugs that are in development. Maybe we can spend less minutes talking about

Dr. Yousef Elyaman: Yeah.

Dr. Mark Hyman: You know, what what, on what's on the horizon, what's the future of this? And how do we start to think about it? Because, you know, it's a little scary to me. I I was at an obesity conference, was on a pediatric obesity conference. And I met this guy here who was a hepatologist, a liver specialist, and kids.

Dr. Mark Hyman: I'm like, what are you doing here? Yeah. He's like, well, you know, all these kids drinking soda all the time. At 15, they're needing liver transplants.

Dr. Yousef Elyaman: Oh, god.

Dr. Mark Hyman: Liver transplants in kids from fatty liver. So tell us what the future looks like.

Dr. Yousef Elyaman: Yeah. So the future the future looks like these drugs being developed, one drug per per, condition that have side effects, and there is a role for them. Right? But also the future looks like us unpackaging. And we could take this new drug and unpackage it as a as functional medicine providers.

Dr. Yousef Elyaman: Right? But, maybe maybe that'll be a nice end of the show or how you but it's your show and however you want. But but but what what we take all of this information and we unpackage it and we've and we use a functional medicine approach. So there are things called PPAR gamma agonists. So there's a drug there's a drug coming out that is PPAR alpha, gamma, and delta.

Dr. Yousef Elyaman: There is there's anti inflammatory there's a anti inflammatory drugs coming out. And the one that just got approved, this, this redmedirom med if you look at what this is, resmedirom, the thyroid gland the thyroid gland makes thyroid hormone. And for thyroid hormone to work, it has to bind to what's called the thyroid receptor.

Dr. Mark Hyman: Yeah.

Dr. Yousef Elyaman: There's 2 types of thyroid receptors, alpha and beta. Alpha will be in some areas of the body, beta will be in other areas. Alpha is found in the heart. One of the problems with just giving people a bunch of thyroid medicine and why we're very careful with giving thyroid medicine is because it could over excite the heart.

Dr. Mark Hyman: That's your super high heart rate and

Dr. Yousef Elyaman: Erythrophy Stroke and death. Yeah. That's why I mean, otherwise, just give people thyroid, let them lose all the weight. Right? Because it's a metabolism hormone.

Dr. Yousef Elyaman: So what what this does is that this is a beta agonist, and a beta beta is found in the liver, but not found in the heart. So it stimulates the liver. Now it does have its side effects.

Dr. Mark Hyman: Thyroid pill for your liver, basically.

Dr. Yousef Elyaman: Your liver. Just for your liver. But then what happens if you give the beta without the alpha? Is that gonna lower the effect? I mean, there's so many questions on what the long term effects are gonna be.

Dr. Mark Hyman: And how and how big of a an improvement is there?

Dr. Yousef Elyaman: There was a I can't. I need to look at it.

Dr. Mark Hyman: I mean, is

Dr. Yousef Elyaman: it is it But

Dr. Mark Hyman: there was

Dr. Yousef Elyaman: a it was enough to, like, sit to get the FDA approval, but I it it shows significant. No. You're right. You're right.

Dr. Mark Hyman: And I

Dr. Yousef Elyaman: I know the number

Dr. Mark Hyman: My guess is you compare it head to head with an aggressive lifestyle and functional medicine approach. It would it would it would outshine this drug or any future drug

Dr. Yousef Elyaman: A 100%.

Dr. Mark Hyman: By far. No. So so people are looking for the quick pick Right. Quick fix and the quick pill, but it's not coming.

Dr. Yousef Elyaman: But we as as functional medicine providers now unpackaging that unpackaging that. What we know is that when we are stressed, our body wants to hold on to fat. Right? Because our ancestors, when they were stressed, they were it was because their life was in danger. They either couldn't find food or something was trying to make them food.

Dr. Yousef Elyaman: Yep. You have to slow down your metabolism. Right? And you can't slow down if you you don't wanna turn off the thyroid. But what what happens is is that that TSH, that signals that comes from the brain still works.

Dr. Mark Hyman: Mhmm.

Dr. Yousef Elyaman: But instead of making t 3, you make reverse t 3. And reverse t 3 blocks your thyroid. And if you look at conventional doctors, they don't check reverse t 3. Right? So the the very quick pearl that I would now that that I would add to the the fatty liver disease plan is I would do a full thyroid panel.

Dr. Yousef Elyaman: I would do TSH, free t 4, reverse t 3, total t 3, and thyroid antibodies. And there is Which by

Dr. Mark Hyman: the way, your your traditional doctor doesn't test all of it. They just check a TSH and they don't look at all those thyroid antibodies. They don't look at Right. T 4, t 3. Some of them look at g 4, and they for sure don't look at reverse.

Dr. Yousef Elyaman: The rock stars. The rock stars look at t 4. But beyond that, forget it. So so so now what what happens, t 3 is the actual is the more active hormone anyway. The t 4 has to become t 3.

Dr. Yousef Elyaman: There's debate on whether t four has an effect or not. Right? So that being said, when we're looking at those ratios, we look at the t three reverse t three ratio, and and we're trying to make sure that that number is is greater than 6. If it's less than 6, we know something is happening and they're not converting. So we work on stress management.

Dr. Yousef Elyaman: There are supplements to give to lower cortisol. We can check cortisol levels, and there's a now another herb. There's an herb, ashwagandha. Ashwagandha can help convert Say

Dr. Mark Hyman: it again.

Dr. Yousef Elyaman: Yes. Okay. And there's an herb called ashwagandha, and ashwagandha can actually help convert your t 4 to t 3. Now there was a case study showing liver disease with or liver, elevated liver enzymes with ashwagandha. You have to make sure you get a clear source.

Dr. Yousef Elyaman: You have to make sure you're following those liver enzymes. And if you start one supplement and the levels go up, then but but optimizing the thyroid, that what the new $4,000 a month drug

Dr. Mark Hyman: Oh my god. Does.

Dr. Yousef Elyaman: Right? We can take that information and say, this is another piece to the puzzle. So I need to make sure I do comprehensive thyroid panel on on my patients that have fatty liver so that I can start working on, on that.

Dr. Mark Hyman: I mean, as you take that $4,000, you shave it down dramatically and give people free food for 6 months. It would cure their fatty liver disease. So but I'm working on that in Washington. Well, this is amazing. I think, you know, I I really I I really think this is an important new awareness.

Dr. Mark Hyman: And we were talking earlier before the podcast about how people people are now starting to recognize this and hearing about it. It's more than news. There's articles and newspapers about it. And I think it's a good thing because up to now, it's been sort of neglected by doctors because doctors don't like to check things they can't do anything about. Right?

Dr. Mark Hyman: If you can't do anything, but now and and and I don't think they're doing anything about means drugs. I think it means Yeah. Actually figuring out, how to deal with the the root cause of it, which is primarily lifestyle, but it's also the things you mentioned, like environmental toxins, right, you know, the good news is, you know, you you you do a lot of work to train physicians and, you know, we certainly do that at the Institute For Functional Medicine, but you have your own training course, and people can go learn about MAPDL d or whatever you wanna call it. Was it called now MASHA or

Dr. Yousef Elyaman: Mazeled.

Dr. Mark Hyman: Mazeled. Mazeled. And, and it's m m f mpessentials.com. And, it's a course for practitioners, but if you're not a practitioner, you wanna learn more about it, you can. I think everybody needs to really understand they need to get checked.

Dr. Mark Hyman: They need to get test. This is really common. It's life threatening. It progresses if you don't do anything about it. It's invisible.

Dr. Mark Hyman: It's symptomless, but the good news is there are clear strategies, particularly through a functional medicine lens of how to diagnose it and treat it effectively. So, I really wanna applaud you for bringing this to awareness for your hair. We're gonna give a talk at the Institute for Functional Medicine Conference, and I I'm excited to hear that talk. And I think everybody should be very excited to go get these lab tests and go get checks. So just quick reminder, functionhealth.com forward slash mark.

Dr. Mark Hyman: If you wanna skip the 200,000 person wait list, you can kinda learn about what's going on in your body and be empowered to to be the CEO of your own health and learn from what we have. And we'll put all again all this in the show notes. Youssef, it's been great to have you on here. Thank you so much for the work you're doing and and just making the world a better place.

Dr. Yousef Elyaman: Pleasure is mine. Thank you

Dr. Mark Hyman: so much. I don't know how you take care of your 7 kids and are part of 15 siblings, but, god bless you. Thank you. Thanks. Thanks for listening today.

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Dr. Mark Hyman: This podcast is separate from my clinical practice at the Ultra Wellness Center and my work at Cleveland Clinic and Function Health where I'm the chief medical officer. This podcast represents my opinions and my guest opinions and neither myself nor the podcast endorses the views or statements of my guests. 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.

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Dr. Mark Hyman: Welcome to The Doctor's Pharmacy. I'm Dr. Mark Hyam. I'm so excited to have our next guest up, which is Yousef Elyaman, who's specialized in understanding a condition that is affecting over a third of the world's population and probably more than that in America called fatty liver disease.

Dr. Mark Hyman: But now it has a new name. We'll get into that in the show, but it's an epidemic that's driving huge amounts of disease suffering. And we'd get into the details on the podcast of how this problem now affects over a third of us and why it's so prevalent, mostly related to our diet, to our gut, to environmental toxins. We talk about a traditional way of treating it, which is nothing. Basically there's very few options from an additional medical care point of view.

Dr. Mark Hyman: And we also talk about how to diagnose it. What are the things that you can do based on your traditional lab tests, based on maybe an upgraded lab panel, even ultrasound diagnostics that can help you decide if you need to do something about this because fatty liver is a dangerous condition that drives heart disease, cancer, dementia, infertility, you name it, and it's invisible. It's symptomless and it makes people really sick, but it's not something that your doctor is generally talking about or thinking about with you because there's no quick fix drug to give. We do talk about some promising medications that might be on the horizon, but we also talk about how to approach this through a functional medicine lens using diet and lifestyle, what you should be eating, how you should exercise, what supplements can be helpful. And we dive deep into the science of what's happening when you get fatty liver disease.

Dr. Mark Hyman: So I want you to make sure you tune into this episode and, enjoy it. Well, welcome, to The Doctor's Pharmacy, doctor e as your patients call you. It's great to have you.

Dr. Yousef Elyaman: Thank you. Honored to be here.

Dr. Mark Hyman: Well, you know, we we are both part of the Institute For Functional Medicine and train physicians and practitioners how to think differently about disease and getting root causes. And it's something you've been focused on lately, which I think is really important and something I really haven't seen a really good approach to from traditional medicine is what we used to call fatty liver disease or non alcoholic fatty liver disease. Because before there was just alcoholic fatty liver disease, then we started eating all this sugar and crap. Then we have this epidemic of what was called non alcoholic fatty liver disease, and they just changed the name to metabolic associated liver disease because this is a metabolic nutritional problem. And the problem is in medicine, we've kinda neglected it because there were no good drugs.

Dr. Mark Hyman: We like diseases with drugs. Oh, you got high cholesterol. I'll give you a stat. No. You got high blood pressure.

Dr. Mark Hyman: I'll give you a blood pressure pill. Oh, you got, you know, you know, whatever else you got, kidney failure, I got the drugs for you. But if you actually have NAFLD, which we used to call nonalcohol fat nonalcoholic fatty liver disease are now called Mafaldy. There's really no great conventional medicine approaches to it except liver transplant when things get really bad. And so you spent a lot of time focusing on this condition.

Dr. Mark Hyman: I just wanna give the background a little bit about this condition because it's so it's, it's so prevalent. I mean, think about something that affects over a third of the population of the world. We're talking about 2,000,000,000 people with a condition that is not a benign condition. It's causing huge amounts of suffering that as actually linked to all sorts of things, obviously, like type 2 diabetes, heart disease, cancers, gallstones, reflux, thyroid issues, kidney stones, depression, worst maternal and fetal outcomes, a huge increase in cardiovascular mortality, 3 and a half times the risk of heart failure, 1.93 times excess mortality from heart disease. This is a big problem, and traditional medicine just, like, not that great at it.

Dr. Mark Hyman: And I remember working, with one of the top hepatologists at Cleveland Clinic, and they were desperate to have some solutions because all they could do was track the disease, follow the disease, give some people some general advice, hope it didn't progress. And then when it did, they need to go get a liver transplant. And and here, you know, this is one of the conditions that is really underdiagnosed, underappreciated. We're gonna do a deep dive and talking about why this is important. Why somebody you're walking around out there have this condition, don't even know it, and why you should care about it.

Dr. Mark Hyman: And more importantly, that there are very specific things that you can do from a diet and lifestyle and even a functional medicine perspective that can work to not only slow this down, but to actually reverse this really pernicious condition, which has really been neglected by the traditional medical community. But I'm glad to see there's more awareness and we're talking about it. I'm glad they changed the fricking name because why are we talking about nonalcoholic fatty liver disease? You're talking about the truth of it, which is it's a metabolic problem caused by our diet. So, Yousaf, tell me more about why why, has this become such an issue?

Dr. Mark Hyman: Why is this something that, you know, didn't really exist that much when I was in training except been a bunch of alcoholics. And now we're seeing, you know, 30% of the population globally having it and probably more in America.

Dr. Yousef Elyaman: I so I think, there I think when we were practicing, we kind of closed the a blind eye to it. I think it existed. We'd always I I think you remember in residency the incidental findings. I think it was kinda like the gluten thing. I remember we never wanted to diagnose anyone with celiac disease because because if if, we really didn't know what to do with it, we felt bad for patients.

Dr. Yousef Elyaman: And once you actually take a look at it, you can kind of you can you can come up with a a solid plan. So the same thing with this, I think, from what from what I remember in internal medicine residency, we just kind of ignored it. And and I think that now it's becoming a little more popular partly because of the new drugs that they're developing.

Dr. Mark Hyman: Yeah. Right? I

Dr. Yousef Elyaman: mean, that's it.

Dr. Mark Hyman: The reality. As soon as as soon as you have a drug for a condition, then that becomes something we promote, we advertise, we see ads on television, but everybody gets excited. Right?

Dr. Yousef Elyaman: The amazing thing is is that because we do functional medicine, taught by yourself and the other the other functional medicine founders here. But because we do functional medicine, we love the their developing of these drugs because we understand the pathways. And and we know how to modulate the pathway in a from a nutritional, nutraceutical kind of lifestyle point of view. Yeah.

Dr. Mark Hyman: Yeah. So, what why do you think this is increasing? I mean, it's clearly was there, obviously, when we were in training, but but it's just exploded. You know, we see 75% of the population is overweight, 42% are obese, 93.2% are metabolically unhealthy, which is essentially what this is, a metabolic associated fatty liver disease. Right?

Dr. Mark Hyman: So if 93% of us are have some metabolic dysfunction, What's driving that?

Dr. Yousef Elyaman: So one of the major things is food. Right? So food and, insulin resistance is kind of at the top of the list. So our our food there there's more, sugar being added to our foods. There's higher carbohydrates.

Dr. Yousef Elyaman: But when you when you look a little bit deeper into it, high uric acid as well. So that that comes from eating too much fructose.

Dr. Mark Hyman: Fructose which is like high fructose corn syrup in all our foods that processed food.

Dr. Yousef Elyaman: High fructose corn corn syrup, alcohol alcohol and is alcoholism is on the rise. So alcohol is a toxin, so that also affects is going to affect the liver, along along with, small intestinal bacterial overgrowth. So bad bacteria in the in the gut. The gut can be as metabolically active as the cytochrome p 450. Yeah.

Dr. Yousef Elyaman: And and because of our current lifestyles, the the bacteria in our gut or in our intestines are changing, and they're changing for the worst. Yeah. And there is an association between, small intestinal bacterial overgrowth, which is one of the major causes of irritable bowel syndrome and having fatty liver disease. So there's a

Dr. Mark Hyman: That's when you're bloated and you get a food baby after eating. That bloating is because there's bacteria in your small intestine, which should not be there, that then ferment the food that you eat, particularly starches and carbohydrates, that then give off all kinds of toxic metabolites

Dr. Yousef Elyaman: Right.

Dr. Mark Hyman: That can then poison your liver. That's what you're saying. Right? Absolutely.

Dr. Yousef Elyaman: Right. Right. Yeah. Yeah. You can what did you say?

Dr. Yousef Elyaman: A food baby?

Dr. Mark Hyman: Food baby. You know, I guess Yeah. Yeah. That bloating thing that people get. Crazy.

Dr. Yousef Elyaman: Right. Yeah. So so, if if you one alarming statistic, they they looked at young men that were not overweight, and they found that they they did something called a, a insulin resistance score test on them. And they found that more than half of them had insulin resistance. And these are non these are young men in their twenties, not overweight Yeah.

Dr. Yousef Elyaman: Normal ideal weight. So so so I I think that kinda brings us to the one of the first drivers, which is this insulin resistance concept.

Dr. Mark Hyman: Now just to to kinda back up on that, that's a stunning statistics. 50% of healthy normal weight 20 year old men have prediabetes or some degree of

Dr. Yousef Elyaman: Insulin resistance.

Dr. Mark Hyman: Insulin resistance, which is on the way to prediabetes.

Dr. Yousef Elyaman: Yeah. Their blood sugar are normal.

Dr. Mark Hyman: And now they're measuring this by the new mass spec test from Quest which is a really new test. So Right. So just to back up on that, that there's a the way we used to measure insulin resistance in the lab was a euglycemic clamp test. Super complicated, very difficult. And we now, you know, have a new test that is equivalent to that, that sort of surpasses the test we have been using, which are just serum insulin levels and blood sugar and a one c and a glucose tolerance test, which basically can give you a lot of information.

Dr. Mark Hyman: But this but this new technique of measuring c peptide, which is sort of like the initial fragment of insulin and then insulin using a technique called mass spectrometry through Quest, we can actually now be very, very good at predicting who has insulin resistance. And so insulin resistance seems to be the driver of fatty liver. Correct?

Dr. Yousef Elyaman: It it it it's the huge driver of fatty liver disease. It's, it's I would say it's the number one driver, but there are 8 or 9 drivers. But I I so so what happens is is that due to inflammation, due to toxicity, due to too much sugar, like too much of a sugar overload or a carbohydrate overload, when those receptors on our fat cells, we have these insulin receptors that are supposed to take sugar and put sugar into put sugar into the cells. Yeah. When they start to not work well, when they start to get resistant, there is an enzyme called hormone sensitive lipase.

Dr. Mark Hyman: Yeah.

Dr. Yousef Elyaman: And what that enzyme does is it starts tearing up the fat in the fat cell, and it sends the fat to the liver, and it overloads the liver. So now you have this liver that gets overloaded. So the they they they they end the liver ends up with a with a whole bunch of triglycerides, which is one of the one of the tests that we look on the lipid panel. Yeah. Now here's the interesting thing.

Dr. Yousef Elyaman: So you could check a triglyceride level and their level would look okay, and that's because some people genetically will tear the will decrease triglycerides in the blood. But

Dr. Mark Hyman: Decrease it in the in the liver.

Dr. Yousef Elyaman: What the triglycerides do when when when you end up sending a whole bunch of triglycerides to the liver, they turn into something called VLDL. Yeah. And they

Dr. Mark Hyman: Very low density lipoprotein.

Dr. Yousef Elyaman: Triglyceride rich VLDL. Yeah. Versus triglyceride poor. And VLDL becomes there's another enzyme found in the lining of our blood vessel that is that is called lipoprotein lipase. Yeah.

Dr. Yousef Elyaman: And it turns it into the tiny dense LDL Yeah. Yeah. Which causes clogging of the blood vessel and heart disease, strokes, and heart attacks.

Dr. Mark Hyman: Okay. I'm gonna I'm this is so juicy right here. I'm just gonna unpack a little bit because basically, you know, just to kinda put things in context. In France, there's a delicacy called foie gras Oh, yeah. Which I probably didn't pronounce right, but foie gras or whatever.

Dr. Mark Hyman: And that means in French, fatty liver.

Dr. Yousef Elyaman: Yep.

Dr. Mark Hyman: Now most people think that if you eat fat, you get fat. And that fatty liver must be coming from all the fat we eat. But what you just said was that, in fact, it's not true that it's actually the sugar and refined starches and carbohydrates, the flour and the sugar that we're eating in pharmacologic doses that's overloading our biology and causing that carbohydrates to turn into triglycerides, which then turns into fatty liver.

Dr. Yousef Elyaman: Yes.

Dr. Mark Hyman: And and then you're in this vicious cycle where the fatty liver then creates all sorts of other problems. So let's kinda unpack what happens biologically when you have a fatty liver. You get a fatty liver and so your your your your liver is like looking like a bad goose or duck liver. Right. And, you don't wanna serve it on toast unless you're maybe Hannibal Lecter.

Dr. Mark Hyman: And and then and then, you know, you've got a process going on in that liver that's just more than the accumulation of fat. So what are the things are happening in the liver that end up causing harm? You mentioned that the type of cholesterol we get because of that fatty liver is the dangerous small, dense cholesterol we talked about in the podcast. We do a whole podcast on on cardiovascular risk and lipid analysis. So the small, dense cholesterol particles, which by the way, everybody listening, your doctor is not measuring when you go to get your cholesterol test.

Dr. Mark Hyman: Less than 1% of cholesterol test in America are for the right cholesterol test, which is called lipoprotein fractionation. And it's looking at the particle size, the particle number, the VLDL numbers, and you can get all that, by the way, through function health, dot dotcom/forward/mark. It's a company I cofounded to allow people to get access to the right amount of information and data. So so function health dot com slash mark, you can get the right panels so you can see what's going on. And we also measure insulin, although, assume we're gonna be measuring this insulin resistance score, which is very exciting.

Dr. Yousef Elyaman: Right. Yeah.

Dr. Mark Hyman: What's happening in the liver?

Dr. Yousef Elyaman: So what's happening in the liver? So so we can go back to what's happening in the fats and then go back right back to the liver. So number 1, the fat starts to send these the triglycerides to the liver and start overloading the liver. If the fat if that when that process is overloaded, then then fat then your fat cells, which actually your fat is I don't know if you've done a podcast on this, but your fat is like an endocrine organ. It makes things like adiponectin.

Dr. Yousef Elyaman: Your what when when the process is bad, adiponectin levels can go down, which causes more insulin resistance and more inflammation. And then there are other there there there are other hormones that can go up in the liver that can cause inflammation, like tumor necrosis factor, like, like leptin, like so those go up. And now that inflammation and worsening insulin resistance and all that fat make its way throughout the body, and they go in the liver. And the liver starts to accumulate and accumulate and accumulate, and it just can't keep up with it. The liver packages it and sends it back to the fat.

Dr. Yousef Elyaman: The fat takes it up, but then because of the insulin resistant, it shoots it right back to the liver, and you end up with this vicious cycle. In the meantime, the liver is not supposed to be storing fat. The liver is supposed to be making all these metabolic processes. It's supposed to repackage the fat. And now when it gets overloaded and jam packed, now the liver starts to get inflamed.

Dr. Yousef Elyaman: It starts to rust, oxidative stress. Sugar starts to get worse, and it kinda creates this this this metabolic nightmare.

Dr. Mark Hyman: It's like a vicious cycle.

Dr. Yousef Elyaman: It's a vicious cycle.

Dr. Mark Hyman: And and what you're saying essentially is it's both an endocrine and an immune organ. So all the hormones that regulate weight, appetite, insulin resistance, like leptin, adiponectin, these are hormones that the body produces to regulate your your your eating behavior and your your way you process sugars and and regulate inflammation to, like like you said, tumor necrosis factor alpha or IL 6. And these are, these are cytokines. We heard about the cytokine storm. So with the fatty liver, you're not just getting fat in there.

Dr. Mark Hyman: You're getting this cytokine kind of increase that's driving systemic inflammation throughout the body, which it can explain a lot of things we see with the increased rate rate of death and heart attacks and cancers and all these things that seem to be related to inflammation.

Dr. Yousef Elyaman: Right. And see and and the thing is, I mean, we could just go we could probably do a whole podcast on when you have fatty liver, all of the other imbalances or all of the other things that are thrown off in the human body. Unfortunately, too many providers, too many doctors take a look at say, oh, you have fatty liver, lose weight, and they move and and and they don't really talk to them about it again Yeah. When, really, that is driving heart disease. It's driving Alzheimer's disease.

Dr. Yousef Elyaman: It's driving cancer. Yeah. The liver is supposed to be metabolizing our our toxins. Yeah. So now you you now your liver is not working.

Dr. Yousef Elyaman: It causes hormone imbalances. The liver's supposed to metabolize estrogen. So now you can't metabolize estrogen. Estrogen goes up. Progesterone goes down.

Dr. Yousef Elyaman: Women start to have

Dr. Mark Hyman: Infertility issues?

Dr. Yousef Elyaman: Infertility is big. They start to they start to have, mood issues. They start to have they start storing more weight. Like, they, and men men start to get start to have, that that estrogen effect. It blocks their testosterone, and it's kind of this it it just it affects everything.

Dr. Mark Hyman: It affects everything. So men men basically lose hair on their bodies. They grow man boobs. They have low sex drive. They low testosterone Right.

Dr. Mark Hyman: Just from having a fatty liver. Right? Yeah. Right. Right.

Dr. Yousef Elyaman: So so so there sound like fun. No. It's it's not. Well well, I'll tell you. Now that we have technology, the noninvasive, easily accessible technology to take a look at the liver, When we tell people that their liver is has fat in it or there's an issue with their liver, I have not seen a a a more motivating driver of change.

Dr. Yousef Elyaman: As a matter of fact, when I see liver enzymes being up, I I had I had a patient who who I talked to her about. She had elevated liver enzymes. I said, I wanna take a look at your liver. I sent her to do this test. It's called a FibroScan.

Dr. Yousef Elyaman: Before she came back, she had lost she stopped drinking alcohol, and she had lost £20.

Dr. Mark Hyman: And Amazing. Yeah.

Dr. Yousef Elyaman: It came back. Her liver was fine. But but what happened when people hear that their liver there's a problem with their liver for some reason, it creates the it creates that motivation Yeah. Which I can tell them, hey. You're gonna die of a heart attack, and it doesn't

Dr. Mark Hyman: yeah. Yeah. It's interesting. But, you know, I I think, you know, what you just point to is something really important, which is that this is a condition that's so prevalent, affects at least a third of Americans, that is underdiagnosed, and that is a biggest risk factor for having a heart attack as anything else. Right?

Dr. Mark Hyman: Like, the the the level of magnitude of the risk of having a fatty liver for death, heart attacks, cancer is extremely high.

Dr. Yousef Elyaman: Right. Do you

Dr. Mark Hyman: have some of the data on that? Right.

Dr. Yousef Elyaman: Yeah. We could put them in we can post them in the the heart attack. Yeah. Yeah. We could put them in the in the show notes.

Dr. Yousef Elyaman: Yeah. The percentages. Yeah.

Dr. Mark Hyman: It's Yeah. Yeah. It's really significant. And I and then when I started reading about fatty liver years ago, I was like, wow. This is in and of itself a huge problem because it's driving all these other diseases that we're treating separately, but we should actually be treating the liver.

Dr. Yousef Elyaman: In the conventional realm, unfortunately, we look at we look try to look at the disease kind of, in in a vacuum. Right? Okay. So you have fatty liver. So what can fatty liver do?

Dr. Yousef Elyaman: Well, the liver can start getting inflamed, and then it can start to turn into fibrosis or hardening, and then you can get cirrhosis. Right? And nobody wants liver cirrhosis. Right? Liver every most people know that liver cirrhosis is a bad thing, and then you can also get liver cancer.

Dr. Yousef Elyaman: But like you just mentioned, they have more of a chance of dying of a heart attack than of the liver cirrhosis Yeah. When they have fatty liver. So I think that's what you were alluding to.

Dr. Mark Hyman: Yeah. Yeah. Yeah.

Dr. Yousef Elyaman: Yeah. So it's so so but but I think I think the beautiful thing and I'm so I'm so fortunate, or grateful to that I found functional medicine because we don't look at fatty liver as a disease in itself. We say, there is a process that has happened. Part of

Dr. Mark Hyman: a syndrome that's happened.

Dr. Yousef Elyaman: Part part of a syndrome. Now and and everybody is unique on what's causing it because some people, it's insulin resistance. Some people are eating lots of, the way that their body deals with fructose. They start to increase uric acid, and it's the uric acid that is driving it. Where other people can have, thyroid dysfunction that's causing it.

Dr. Yousef Elyaman: And others could have an issue with, can have an issue with bad bacteria in the gut. Yeah. So so other people have a iron overload that is causing it. Yeah. And others were exposed to different toxins.

Dr. Yousef Elyaman: Yeah. And it's probably a combination of of

Dr. Mark Hyman: of Yeah.

Dr. Mark Hyman: I mean, I think this is

Dr. Mark Hyman: really important when you just I just wanna pause there because from a traditional medicine point of view, it's like, okay. You know, we do a blood test. We do a fibrous fiber scan or MRI. We look at your liver, we do a biopsy. Okay.

Dr. Mark Hyman: You have fatty liver disease, but the why is very much neglected. And, and, and there is some understanding that it's due to a high refined carbohydrate diet, but these other, and yes, people understand hemochromatosis and iron overload, but the fact that, you know, the microbiomes involved in environmental toxins are involved, that it may be thyroid dysfunction, that there's a whole list of causes. And that's really where functional medicine is different than traditional medicine. It's root cause medicine that is ruthless around investigating the causes of a condition so that you can treat that person as an individual rather than treating everybody who's got this condition the same. Right.

Dr. Mark Hyman: If someone, there was a thing I read about years ago, was a scientific paper about a guy who had liver failure, but he, he, he, he was golfer and, and, and, you know, usually golfers, I'm not a golfer, but apparently they have to clean their balls and use this ball cleaning thing on the golf course to get the dirt off, but he used to lick the balls to clean them. But there's pesticides all over the golf course. So he was getting he was getting toxic pesticide load in his liver and caused him to have liver failure. So, so we had to think about all the root causes and that's where functional medicine helps us to navigate. And then the gut role plays a huge thing too.

Dr. Mark Hyman: And we don't really think about addressing the gut, but we know, we know that how, how big a role the gut plays in, in, in affecting our metabolic health and our, our, our load of toxins. And I mean, in medical school, we used to treat liver failure with which resulted, you know, in, in the inability to metabolize toxins from the gut by which caused basically delirium, something called hepatic encephalopathy. We treated with the antibiotic and lacked and a laxative. So basically to sterilize the gut, get rid of the bacteria that were poisoning the body, which is which is interesting. We don't because now we understand the microbiome has a huge role in mental health, but that was something we learned and it it didn't really kinda connect with us in terms of a a thing about the microbiome in medical school.

Dr. Yousef Elyaman: Right. It's a pre it's a prebiotic. Lactulose is a prebiotic. Yeah. So you're feeding the good bacteria.

Dr. Yousef Elyaman: Yeah. So we're like we were manipulating the microbiome, and we thought we were just making them poop. Yeah. Right? But it was and and it was amazing.

Dr. Yousef Elyaman: It would take them out of that

Dr. Mark Hyman: Yeah. Yeah.

Dr. Yousef Elyaman: Hepatic encephalopathy. They Yeah.

Dr. Mark Hyman: So so, basically, what's going on in the liver is is you've got a a number of different things that that are happening in our society, which is nowhere load of toxins, which is obviously our diet, which, you know, other, factors that you mentioned, the the gut microbiome changing dramatically, all driving this epidemic of of fatty liver disease. And and, and now there's sort of an interest in in kind of addressing this more directly in the medical field. We renamed the disease from nonalcoholic fatty liver disease to metabolic associated fatty liver disease.

Dr. Yousef Elyaman: And, actually, it changed that. So they first went to metabolic associated liver disease, then they changed it again because, they they they

Dr. Mark Hyman: That's me.

Dr. Yousef Elyaman: They're they're yeah. Whoever they are, the the big panels. Actually, multiple panels got together and they talked to patients. But I think we should talk about that story a little bit. Right?

Dr. Yousef Elyaman: So nonalcoholic fatty liver disease was basically your naming condition by saying what it was not. Yep. It's not alcoholic.

Dr. Mark Hyman: Right.

Dr. Yousef Elyaman: Like, it was kinda weird anyway. Even though that it was called nonalcoholic fatty liver disease, they people associated with alcohol. Right. They because alcohol was in the name.

Dr. Mark Hyman: And then they They

Dr. Yousef Elyaman: have to explain it to their family. Right. Right. Right. I'm telling you it's nonalcoholic.

Dr. Mark Hyman: Right. Right. Right.

Dr. Yousef Elyaman: So that you had that negative. And then the fatty had a stigma. So they changed it to metabolic associated or, metabolic dysfunction associated fatty liver disease. But then they changed it again because they're, like, fatty is stigmatizing. So we don't we want fat out of it.

Dr. Yousef Elyaman: So now it's metabolic dysfunction associated sta staatic sta staatic, which means fat, liver disease. So the no. Staatic liver disease. So now you took everything out that anybody could understand.

Dr. Mark Hyman: So you put a medical term in which means fat, which is steatosis, which means fatty.

Dr. Yousef Elyaman: Right. Right. But now they don't get shamed.

Dr. Mark Hyman: Now it's in Latin, so it's okay.

Dr. Yousef Elyaman: Yeah. That's fancy. That's fancy.

Dr. Mark Hyman: Whatever. So so that's the problem in, you know, in medicine, we call it the naming and blaming game. We name the disease and we blame the name for the problem. Well, I know why you have that abnormal liver function.

Dr. Yousef Elyaman: Now it's called mazel.

Dr. Mark Hyman: Mazel. Mazel. Okay. Then there's okay. Forget about what it was called.

Dr. Mark Hyman: We we know this is a bad thing. We know it's increasing and we know that traditional medicine, you know, doesn't have a great approach. So let's I wanna walk through how traditional medicine approaches this and then how we're gonna approach this with a a new perspective of root cause medicine and functional medicine, and then how how we go about looking at the diagnostic, tools we have to assess it and what are the therapeutic goals. So just sort of high level, what what if you want to see a traditional hepatologist, you have fatty liver, what are they gonna tell you? What are they gonna tell you to do?

Dr. Yousef Elyaman: Okay. So you go to a traditional hep hepatologist. They take

Dr. Mark Hyman: It's a liver specialist.

Dr. Yousef Elyaman: A liver specialist. They they they see the patient. They tell the patient you have fatty liver disease. Go ahead and try to lose weight. Right?

Dr. Yousef Elyaman: They may give them vitamin e. Probably, you're gonna give them the wrong kind of vitamin e because we know that there's different forms of vitamin e. And then and then if if you're lucky, many will say no. Don't stay away from vitamin e. And then they see if you're bad enough to be enrolled in a study.

Dr. Yousef Elyaman: And if you and if if you are, then they'll put you on a drug. Right? If not

Dr. Mark Hyman: Because there's no FDA approved drugs for family delivery.

Dr. Yousef Elyaman: There is one now. We just in in in March, we have one called ResMedirom, and, we could we should probably unpackage that later, like,

Dr. Mark Hyman: because there's some come back to that. Yeah. Yeah.

Dr. Yousef Elyaman: But yes. So there's finally one drug. It costs only $4,000 a month.

Dr. Mark Hyman: Is that it?

Dr. Yousef Elyaman: Yeah. That's it. And it can cause, all kinds of side effects as well. Great. But that

Dr. Mark Hyman: being that being Sounds like fun.

Dr. Yousef Elyaman: That being said, it's it's all about getting them. Okay. We have a disease. We named it. Right?

Dr. Yousef Elyaman: We need to tame it with a particular drug.

Dr. Mark Hyman: So But up until March, before that, what would they be telling you?

Dr. Yousef Elyaman: They would some would say, take ask your doctor if he would prescribe semaglutide for you.

Dr. Mark Hyman: Ozempic?

Dr. Yousef Elyaman: Ozempic. That's that's currently what they're what they'll tell you.

Dr. Mark Hyman: Weight loss. Because when you lose weight, fatty liver gets better.

Dr. Yousef Elyaman: Right. Right. So what what would we do? We would take a look at the FibroScan. And I I I do wanna talk about this FibroScan because this is there the FibroScan because this is extremely

Dr. Mark Hyman: But but it's back to the traditional medicine. Like, are they are they thinking that, you know, this is really diet related? Are they thinking that we should cut back on carbohydrates and starches and sugars?

Dr. Yousef Elyaman: No particular diet.

Dr. Mark Hyman: Do they really talk about a keto diet or anything like that to help?

Dr. Yousef Elyaman: Traditional medicine is like lose weight.

Dr. Mark Hyman: Lose weight. Just just lose weight. Eat eat less, exercise more, come back in 3 months. And if it doesn't work, we'll put you on drugs, except oops. There's no drug for this.

Dr. Yousef Elyaman: Yes. Yes. Unfortunately, we don't. So semaglutide.

Dr. Mark Hyman: So okay. I was gonna pick. Alright?

Dr. Yousef Elyaman: Yeah.

Dr. Mark Hyman: And then and then Yeah.

Dr. Yousef Elyaman: So and that's it. And then they just kinda leave you there. Yeah. And they and most of them are not getting a FibroScan. Most of them don't know how bad it is.

Dr. Yousef Elyaman: They don't know if they're they have fibrosis, which is hardening or not. And they and they just, they just kind of wait till things get really

Dr. Mark Hyman: And they and they might if you're diabetic, which is associate a lot with diabetes. Right? Because it's sort of the same condition, but earlier on, you know, they might give you metformin or they'll give you the Ozempic or maybe some of the the

Dr. Yousef Elyaman: Although metformin hasn't been found to decrease fatty liver disease. It's it's kind of but but they may give you that. They definitely will say you have a high risk of of, heart disease, so make sure you're on a statin drug. So they will put you on a statin drug. And and and the the problem is it's a double edged sword.

Dr. Yousef Elyaman: The statin drug can cause liver toxicity

Dr. Mark Hyman: Yeah.

Dr. Yousef Elyaman: But also it can change the way the the the lipid metabolism. So you know you may be hurting the liver, but you may be helping the heart. Right. Right?

Dr. Mark Hyman: So you're one of those. And then and then if you're overweight enough, they'll say, why don't you have bariatric surgery? There you go. Bypass. So Yeah.

Dr. Mark Hyman: Clearly, you know, traditional medicine has has not developed a good approach to this yet. Right. And and let's talk about the diagnosis part because now there's some interesting new diagnostic tests. You just have to do a liver biopsy. It was an invasive procedure.

Dr. Mark Hyman: It's risky. You kinda nobody wants to get a liver biopsy. It was expensive. Now there's some blood work you can do and some ultrasound technology that you can use to really diagnose what's going on. So talk to talk to us about how people can find out.

Dr. Mark Hyman: I I don't know. I have had a liver disease. What do I do?

Dr. Yousef Elyaman: I think the best thing to do is get a FibroScan. A FibroScan is ultrasound technology, and it will come when they stay it's it's very quick. It's noninvasive, and they give you two numbers. Something called a cap score and a fibrosis score. The cap score tells you what percentage of your liver is fat, and the fibrosis score is how much hardening there is in your liver.

Dr. Yousef Elyaman: Yeah. The beautiful thing about that is before, we had no idea how bad it was. And now I can give them a number. I could say around 35% of your liver is fat right now. I can put them on some sort of a plan, and I can retouch

Dr. Mark Hyman: it. Yeah.

Dr. Yousef Elyaman: And I can see it get better. Yeah. And that is that that is profound versus, oh, yeah. You still have fatty liver disease. Oh, the ultrasound Yeah.

Dr. Yousef Elyaman: Yeah. Fatty liver disease. Or the ultrasound show you don't have fatty liver disease, but they do have fatty liver disease because ultrasound isn't sensitive enough to pick it up. Right. Right.

Dr. Yousef Elyaman: So so that And

Dr. Mark Hyman: and just to changer. And to just to to be clear, the first step is your liver gets fatty, and then it gets inflamed, and then it gets scarred.

Dr. Yousef Elyaman: Mhmm.

Dr. Mark Hyman: And then you have cirrhosis, and then you need a liver transplant. Right. Right.

Dr. Yousef Elyaman: Right. Right. But some people go right from fatty without the inflamed. They go from right from fatty to scarred. Yeah.

Dr. Yousef Elyaman: So some people do skip that step. Yeah. You you think everything is good and then they end up So so

Dr. Mark Hyman: but not everybody's gonna get a FibroScan. So are there blood tests that will clue you into maybe you need 1.

Dr. Yousef Elyaman: Right? There are. There are. So, this we talked about so the the problem if they have high triglycerides, there or if they have insulin resistance or if they have high blood sugar. So if they have any of those things, they there's a high probability that they have fatty liver.

Dr. Yousef Elyaman: That So

Dr. Mark Hyman: if you have a high blood sugar

Dr. Yousef Elyaman: Mhmm. If you

Dr. Mark Hyman: have, high triglycerides Mhmm. Low HDL,

Dr. Yousef Elyaman: and

Dr. Mark Hyman: Mhmm. Maybe a high hemoglobin a one c, like, over 5 point whatever, 5, 7? Yeah. It's 4. 4.

Dr. Mark Hyman: Yeah. So as all those numbers, and these are things you can get on a regular blood panel.

Dr. Yousef Elyaman: Yes.

Dr. Mark Hyman: The lipo protein fractionation is more more predictive.

Dr. Yousef Elyaman: Yes.

Dr. Mark Hyman: And that's a better test. Yes. And we do that with a function health panel. So you go to function health dot com. You can, you know, get all these diagnostic tests for 4.99 for membership and do it twice a year and track stuff over time.

Dr. Mark Hyman: And and if you if you track these numbers, you can see that your risk and maybe you have not only just that, you'll have elevated liver function test. Right? So you might have been

Dr. Yousef Elyaman: Small density LDL. So the problem with triglycerides is some people have a high amount of what's called it's an enzyme called hepatic lipase. So it takes it lowers their serum triglyceride levels, but they have high small density LDL. So small density LDL, when that's elevated, that tiny, tiny bad cholesterol that you check on that panel that you do Yeah. You have your people do.

Dr. Yousef Elyaman: That that is that that not only can predict it, but because some people have it high, but they don't have fatty liver. But if you have fatty liver disease and you see that number go down, the chances that they actually have a a some sort of a reversal of fatty liver disease are very high. Yes. That's what that's what I'll use as a marker.

Dr. Mark Hyman: So you track your small LDL particles.

Dr. Yousef Elyaman: You track it as it's getting better, their fatty liver disease is getting better. Yeah. That's been that's been proven too.

Dr. Mark Hyman: And yeah. And and I encourage you to go back and listen to the podcast I did, on on cholesterol and cardiovascular. It's got to talk about all these diagnostic markers that are not used in traditional medicine that should be, including this lipoprotein fractionation. So these are tests are super inexpensive, should be easy to do, but, but they don't tell the full story. So there's a newer kind of interpolation of a number of different biomarkers that are used.

Dr. Mark Hyman: Basically your ALT, AST, liver function, plus platelets, plus your age, and you get something called what?

Dr. Yousef Elyaman: A fib 4.

Dr. Mark Hyman: A fib 4 score. So this fib 4 score you can get through Quest. I don't know if LabCorp does it.

Dr. Yousef Elyaman: Yeah.

Dr. Mark Hyman: And you get this score that gives you a sense of, gee, I might be having fatty liver disease. Right?

Dr. Yousef Elyaman: Right. And anybody so the like you said, they're they're look they're looking at platelets and they're looking at AST and ALT, which are found those things are found in regular blood work the doctor does. So if they didn't

Dr. Mark Hyman: The CBC and the chem panel, it's like, basically, your annual checkup will have that.

Dr. Yousef Elyaman: Checkup stuff. Now if they didn't add the the the fib score to it, the fib 4, there's fib 4 calculators. You put the you put the numbers in the calculator, and it'll give you the fib 4. Now here's the thing about the fib 4. It really the the young under 30 age 35 and older than age 65, it's not as accurate.

Dr. Yousef Elyaman: But what is it really telling us? It's telling us a it's a predictor for hardening of the liver. Your liver could be jam packed. You could your liver could be the human feugras. Right?

Dr. Mark Hyman: Yeah.

Dr. Yousef Elyaman: But if if if it's not picking if you don't have fibrosis

Dr. Mark Hyman: Yeah.

Dr. Yousef Elyaman: It's not gonna show anything.

Dr. Mark Hyman: I see. So you go this is only in the later stages that you're gonna see this test be elevated. Right? So Right. You might see the clues with the high triglycerides, high insulin, high glucose, even see small particles of LDL, but you might not see the fib 4 score up until you're already down the road a bit.

Dr. Yousef Elyaman: Right. And and I just pointing out those levels, the ALT and a, AST. So the those are called liver function tests. They're really enzymes that the liver has in them. The the the data is showing that the number those numbers are supposed to be lower.

Dr. Yousef Elyaman: Yeah. So ALT The reference ranges that we have. Less. Yep. It's supposed to be less than 30.

Dr. Yousef Elyaman: Yeah. Less than 20.

Dr. Mark Hyman: Right? And the reference ranges in the lab are, like, 40 or 50. Right?

Dr. Yousef Elyaman: Right. They're up there. The other thing is so so what are they looking at? Why would that FIB 4 why why would a fit why would they be looking at platelets? Well, it turns out that the liver makes a hormone called thrombopoietin.

Dr. Yousef Elyaman: And if you get hardening of the liver, it can't make thrombopoietin.

Dr. Mark Hyman: Oh, so you get it.

Dr. Yousef Elyaman: So now your now your plate levels start to go down.

Dr. Mark Hyman: Oh, interesting.

Dr. Yousef Elyaman: But drinking alcohol poisons the bone marrow Mhmm. And that lowers your platelets. So if they're actively drinking alcohol, it could falsely elevate it. But it also can cause liver disease too. So it's it's kind of a

Dr. Mark Hyman: So so, basically, the the the regular blood test you can get can tell you a lot. We're gonna put all this in the show notes. You have to remember, you can get the function health panel at functionhealth.comforward/mark that gives you all of that, except it doesn't calculate the fib 4 score, but you can do it because all the data is there. Right. But there's another test that they do if this fib 4 score is elevated called an ELF test.

Dr. Mark Hyman: So can you talk about the ELF test? Because it's a little more advanced and and what it is and what it means and who should be doing it.

Dr. Yousef Elyaman: Right. So the the the ELF test is also a, a marker of fibrosis. So what they do there's, 3 different what what we call biomarkers or 3 different lab levels that can indicate that the liver is getting hard or getting that fibrosis, and you can end up with a score there. And it's much more accurate. It's maybe 80 to 90% versus around 45%.

Dr. Mark Hyman: Because because the first big four just in is sort of interpolating from existing biomarkers. It is. It's actually looking for compounds or molecules that are elevated when there's a fatty liver or liver fibrosis. Right?

Dr. Yousef Elyaman: Right. It's gonna miss more

Dr. Mark Hyman: Like hyaluronic acid, type 3, pro collagen peptides, tissue inhibitor matrix

Dr. Yousef Elyaman: Yes.

Dr. Mark Hyman: Metalloproteinase. These are all kind of big fancy medical words. But Yes. The things you can get on a blood test that are not your typical blood test. So you've got your doctor will have to ask for this.

Dr. Mark Hyman: Right. Or or if you have a fib 4 score that's high, you can go say, I want this. Right.

Dr. Yousef Elyaman: And this is where we I think this is where the podcast today changes the world. Right? Be aware be aware that you could have fatty liver. See if you can get a FibroScan if because they're popping up places are popping up, left and right. And if you do has to order that.

Dr. Yousef Elyaman: You're you're they'd yes. Or you can go there are certain places that are trying to study medication where you just go get it for free. There's, like, research centers. Yeah. So look for a a FibroScan near you near near you.

Dr. Yousef Elyaman: Maybe even pay. This may be worth paying self pay for, but once you see that you have that fatty liver disease, reverse it before that fib 4 is high, before the ELF is high, before the fibrosis. This is where this is where I think if we can catch this thing early, we can we can make a significant impact on on the health of the planet.

Dr. Mark Hyman: And so the ELF what you're thinking is the ELF test essentially, this this other test that Yeah. Is is really just picking up scarring. Right. Not necessarily just fatty liver.

Dr. Yousef Elyaman: And as a primary care doctor, when I see somebody with an elevated ELF, then then because because they it will see the fib 4 high, and that could just be a false positive. I'll check an ELF. I'll check a FibroScan. And if I see a high fibrosis in them, they're gonna be I'm gonna be co managing them with a hepatologist. I'm gonna be more aggressive, but that's where it needs to go in the specialist.

Dr. Yousef Elyaman: But like you said, with the amount of the percentage of the world that has fatty liver disease, we don't have enough hepatologists. We Yeah. But but but

Dr. Mark Hyman: but I'm just gonna push back on you.

Dr. Mark Hyman: So because even if you you send them to a hepatologist, what are they going to tell them?

Dr. Yousef Elyaman: No. They're gonna hold they'll hold their hand as they need a transplant.

Dr. Mark Hyman: Well, that's exactly right. I mean, that's exactly right. And that that's the conversation I had with the amazing man who's the chief of hepatology at Cleveland Clinic.

Dr. Yousef Elyaman: Right.

Dr. Mark Hyman: We just don't have a

Dr. Mark Hyman: lot to offer them. Could you help us? And Right. How do we start to get these patients to change their lifestyle and behavior? So so basically, bottom line is there's some great diagnostics on your regular blood panel.

Dr. Yousef Elyaman: Right.

Dr. Mark Hyman: We'll put those in the show notes. There's some newer tests that you can get on blood work, blood work that can help. There's a great ultrasound that's not very expensive, non invasive, and has no risk

Dr. Yousef Elyaman: Right. That

Dr. Mark Hyman: you can get to see what's going on. If if you have, potential elevations in any of these numbers or you're overweight, you're at risk, even if you're not overweight, it may, maybe

Dr. Yousef Elyaman: you could

Dr. Mark Hyman: be not overweight and be what we call a skinny fat person where you're metabolically obese, normal weight because you eat crap and you're not, you don't gain weight, but you have fat on the inside.

Dr. Yousef Elyaman: Right.

Dr. Mark Hyman: But then you do all these great diagnostics and then what? Because there's no real treatment for in traditional medicine. So from a functional medicine perspective, how do you see this epidemic? What what can be done about it in a practical way to help people reverse it? We now know sort of how we can get it diagnosed.

Dr. Mark Hyman: Right.

Dr. Yousef Elyaman: How

Dr. Mark Hyman: how do we start to think about it differently from a functional medicine?

Dr. Yousef Elyaman: Right. And this is where conventional medicine and functional medicine is gonna be different. Conventional medicine says just lose fat. Right? They studied it.

Dr. Yousef Elyaman: They looked at whether low carb was helpful, high protein, whether a keto diet and believe it or not, if you go on a keto keto diet and you lose weight, it will reverse this even though you're eating fat. Like you mentioned early on, what what what we're looking for is what is it that that regardless of whether they lose weight or not, what will reverse this? Right? Right. So so Mediterranean food plan.

Dr. Yousef Elyaman: There is data that show that the Mediterranean food plan, which which we Was

Dr. Mark Hyman: that pizza and pasta?

Dr. Yousef Elyaman: Yes. Yes. No. No. No.

Dr. Yousef Elyaman: No. So it's it's, it's it's a heart healthy food plan that where they took a look at the healthy foods that people that lived in the Mediterranean high in olive oil, high in vegetables, high in those foods, And they found the significant benefits, benefit with mood, benefit with with metabolic disease, but also independent of weight loss. If you go on a meta a modified meta metabolic food plan, you will you will end up see seeing an improvement. And and IFM, the Institute For Functional Medicine has one that they call them cardiometabolic food plan, and that's what I give all of my patients. Say, let's start here, the cardiometabolic food plan.

Dr. Yousef Elyaman: Also, you could have food allergies that is pushing this. For example, gluten. Right? The you could some people have fatty liver disease because they're eating a food that is bothering them and inflaming them. And you get them off the gluten or get them off the dairy or whatnot.

Dr. Yousef Elyaman: And

Dr. Mark Hyman: because anything that causes inflammation will cause insulin resistance. So it's kind of the mechanism is well known there.

Dr. Yousef Elyaman: Right. Decreasing fried foods, because fried foods have something and glycosylation end products, which, when when you fry fry foods, sugar with other molecules at high temperatures, it causes what's these toxins, these n glycosylation end products, and they will cause inflammation, what we something called oxidative stress, which is rusting Yeah. Which worsens the condition. So decreasing those is is is extremely important. And also Sugar, sugar,

Dr. Mark Hyman: fry foods.

Dr. Yousef Elyaman: So I think I think everybody talks about the glucose, but we're not talking about the fructose piece. Right? Fructose, if you look at high fructose corn syrup or just regular table sugar, it has sucrose and it has fructose. Fructose pushes the body to make uric acid. And and uric acid tells the body store fat.

Dr. Yousef Elyaman: Mhmm. So it slows your metabolism. It tells people to store fat, and it and it worsens fatty liver disease. And and, I believe you did a podcast on this.

Dr. Mark Hyman: Richard Johnson. Yeah. People should go back and listen now. We'll put the show notes on that. Because uric acid is a is a consequence of really eating a poor diet, particularly one that's high in high fructose corn syrup.

Dr. Yousef Elyaman: And back to optimal levels. So so according to doctor Johnson, and this is what I go by, 5 you want your uric acid level less than 5.5. Right. Right? Whereas whereas the the labs is about 7.

Dr. Yousef Elyaman: 8. Yeah. 7, 8, something like that. And and when they see that uric acid high, there are supplements that you can give them, and there's also there's also, dietary changes that you can give them.

Dr. Mark Hyman: Cherry extract for that, which is great for gout and high uric acid and high dose of cherry.

Dr. Yousef Elyaman: Cherry, dark cherry extract, vitamin c, quercetin, maybe some green tea. Those things all can help lower it. So if you have somebody that

Dr. Mark Hyman: stop drinking the 2 liter bottle of Coca Cola with 75% fructose and drink everything.

Dr. Yousef Elyaman: Fun in that. So so so if you have no absolutely. Sodas are going to really drive it. So you're you can you'd follow that glucose and insulin resistance score. If your sugar is already high when it's fasting, that's your main.

Dr. Yousef Elyaman: You gotta work. That there's some work. If you just have insulin resistance, that's still a problem. So with insulin resistance, there's things like Berberine that can help. There's things like with alpha lipoic acid, n Acetylcysteine that can help.

Dr. Yousef Elyaman: So so work so, yes, Mediterranean and food plan, exercise, whether it's resistant training or cardio cardiovascular training, both independent of weight loss will reverse fatty liver disease. So you don't you can look you can you can exercise and you can stay the same exact weight and you can still have that fat start

Dr. Mark Hyman: to improve. Makes you more insulin sensitive. Makes you more I mean, this is it reminds me of an interesting study I I read years ago where they did bariatric surgery. And basically when you do bariatric surgery, you can reverse diabetes in like 2 weeks and reverse the fatty liver in a very short time. And yet they're still severely obese.

Dr. Mark Hyman: Like someone can still be £400, maybe they lost £25, but there's still £375 and diabetes goes away like that and fatty liver will improve because you're changing the food.

Dr. Yousef Elyaman: And changing metabolism. At one point, the heaviest man in the world actually had had his his blood sugar was normal, and it was because of such a high adiponectin level. So so so there there is the genetic factor, but there's also the metabolism and the way that the body, decreased sitting, of course, increasing steps, things like that. So we get them exercising. And I think I think the most important thing, and you've mentioned this a couple of times, is that we gotta we we we we really wanna be careful of the catastrophic black and black and white thinking.

Dr. Yousef Elyaman: Like, oh, if you don't lose weight, that's it. Because there are so many things that you can do besides that. We meet people where they're at, and you don't not everybody's going to be able to do that. You can go on a medicine like semaglutide or like you said Ozempic, and it could end up losing their muscle. And then what is it gonna do?

Dr. Yousef Elyaman: We see all kinds of side effects with that with with that medicine.

Dr. Mark Hyman: Resistant when you lose muscle. Yeah. It was interesting. So so just getting back to the diet part because I think there's a lot of ways to skin a cat. You mentioned just a Mediterranean diet, which essentially is fruits and vegetables, protein, nuts and seeds, olive oil, healthy food, real food.

Dr. Mark Hyman: Not pizza and pasta.

Dr. Yousef Elyaman: Right. Cut cut out the fried foods.

Dr. Mark Hyman: Yeah. Cut out the fried foods. And and so that's good. But but do you need to be more aggressive sometimes in terms of cutting out, more starches, like cutting out grains or beans or fruit? Like, because if you mentioned fructose, you're like, oh, fructose is bad.

Dr. Mark Hyman: Does that mean fruit is bad? Because that's where fructose is found.

Dr. Yousef Elyaman: So fructose is bad when it's in high amounts in a way that it wasn't found in nature. So in the form of a juice, not so good for you. In the form of a fruit, the fruit actually has the antidote in it. So when you get it as a balanced thing, it's not

Dr. Mark Hyman: the antidote.

Dr. Yousef Elyaman: The fiber is the antidote, plus it has all the different colors of the fruits and vegetables have what what they're

Dr. Mark Hyman: called. Acids.

Dr. Yousef Elyaman: Yeah. Phytonutrients. And the phytonutrients actually will counteract and decrease uric acid. So but but I think I think it all depends. If somebody is is in the beginning, they're excited, they're ready, they're ready to do whatever it takes.

Dr. Yousef Elyaman: Yes. You cut the sugar, you increase the, you increase the healthy foods. But meeting people where they're at, we got we have to be careful of the all or none thinking because what'll happen is they'll say, oh, shoot. I ate too much sugar, so screw it. I'm just gonna eat the candy bar.

Dr. Yousef Elyaman: Right? And I'm not gonna do this anymore. And that's why no. No. No.

Dr. Yousef Elyaman: Why don't we focus on what you should be eating or what you wanna be eating? Why don't you, okay, have maybe 2 servings of vegetables with that Snickers bar. Right? So might I just say Snickers, I don't know. But You can say whatever you want.

Dr. Yousef Elyaman: Okay.

Dr. Mark Hyman: But wow. So so, given that you're trying to meet people where they are and help them, not be overwhelmed and make the simple small steps that you can see that could make a big difference. But if you had a perfectly compliant patient and you wanted to create the fastest results to reverse fatty liver, what would you do? Would you put them on a ketogenic diet? Would you put them on a paleo diet?

Dr. Mark Hyman: Would you put them on a vegan diet? What would you do?

Dr. Yousef Elyaman: Mediterranean. That would be the Mediterranean the cardiometabolic food plan.

Dr. Mark Hyman: So even even with even with, option of really reducing

Dr. Yousef Elyaman: The carbs. The carbs even more? Reducing the carbs even more is logical, but now we have to look at the research we have available. And the research did show all of those diets that you mentioned are food I like calling them food plans, but all of them will help with fatty liver. But the one that has been shown that reduces that that that that will decrease fatty liver, but also but independent of weight loss is the Mediterranean.

Dr. Yousef Elyaman: And that's why I think that should be the but do I have people that go low carb and keto and it works? Absolutely. So, no, that all in intuitively, yeah, you cut the sugar, insulin resistance improves. But I think the the the the focus on Mediterranean is is you're you're focusing on healthy fats, which is something that you're a proponent of. Right?

Dr. Yousef Elyaman: You're also focusing on the fruits and vegetables. Those colors are their medicines. They're medicines. So to tell them to just eat a bunch of steak and forget about the phytonutrients

Dr. Mark Hyman: Phytochemicals is key. Because those are some of the phytochemicals actually are active as support for liver detoxification and inflammation. You know, what it once did I read years ago was, was, my mice, a mouse study and they gave mice alcohol, and then they watch what happened and develop fatty liver. And then they, they gave them alcohol plus high relatively high amounts of MCT oil, which is medium change triglycerides, and it comes from coconut oil and other places. But it's it seemed to actually reverse it.

Dr. Mark Hyman: Can you explain that?

Dr. Yousef Elyaman: Yeah. So so if you if you increase, what what does MCT oil become? Ketobutyrate? Ketobutyrate?

Dr. Mark Hyman: Yeah. It increases. Yes. It's metabolized and absorbed differently than traditional fats. So it's absorbed directly into the body.

Dr. Mark Hyman: It doesn't have to go through

Dr. Yousef Elyaman: the Right. Right. So and you can use that as a fuel, which increases your efficiency, which the of of your receptors and decreases insulin resistance. I know that I know that, omegas are fish oils. One of the things that fish oils does is is it yeah.

Dr. Yousef Elyaman: So healthy fats, if you give people healthy fats, phosphatidylcholine helps as well. It blocks some of those triglycerides from going back into the liver, so it kind of stops the liver from getting overloaded as fast. So I wonder if the MCT oil works by that mechanism.

Dr. Mark Hyman: Yeah. It was

Dr. Mark Hyman: it was fascinating. I was like, wow.

Dr. Mark Hyman: You can even, like, be drinking it like a fish and and take the m c 2 l, and it would not it would mitigate the the damage to your liver, which I thought was interesting.

Dr. Yousef Elyaman: Right. But but I do work as a in a at at the guest house, which is substance abuse and trauma center. So we're not, like, proponents of drinking like

Dr. Mark Hyman: a fish. Of course. Of course. I'm not saying drink and

Dr. Mark Hyman: take them

Dr. Mark Hyman: to all and chew your bone. I'm not saying that. Just just to be clear. So just to back up a little bit on my what you're talking about. Diet's key.

Dr. Mark Hyman: So cutting out Yeah. The free fructose and high fructose corn syrup. Just get rid of that a 100% from your diet, number 1. Number 2, increase a diet that's high in phytochemicals, high in fiber, high in good fats

Dr. Yousef Elyaman: Yes.

Dr. Mark Hyman: That, you know, nuts and seeds, lots of fruits and vegetables, clean protein, you know, some whole grains, beans can be fine. Right?

Dr. Yousef Elyaman: Alcohol. Stop the alcohol.

Dr. Mark Hyman: Stop the alcohol. Yeah. Stop the sugar. Stop the Tylenol.

Dr. Yousef Elyaman: Stop the Tylenol.

Dr. Mark Hyman: Because Tylenol, liver poison. And and then you talked about exercise being really instrumental. So that's clear. And I think everybody understands that. And you mentioned a bunch of supplements.

Dr. Yousef Elyaman: Oh, yeah.

Dr. Mark Hyman: So I wanna kind of go down that rabbit hole with you because I find that that using things that help support liver function can be extremely effective and it's actually in the published medical literature. In fact, one of the things we use for liver failure when people overdose with Tylenol, when they come into the emergency room is something called mucormist. Now, I'm in I thought that was a drug because that's what I learned in medical school but it's actually an acetylcysteine or a supplement that gets turned into glutathione.

Dr. Yousef Elyaman: Right.

Dr. Mark Hyman: And that rescues the liver from catastrophic liver failure and it's just a supplement. Right. Now the FDA is trying to, like, take it off the market because it works so well, but Yeah. It it's it's something you can take to boost your levels of glutathione Yes. Which is the body's main repair antioxidant, anti inflammatory system.

Dr. Yousef Elyaman: Right.

Dr. Mark Hyman: So you mentioned that. What other supplements are in your top, you know, 5 or 6 supplement?

Dr. Yousef Elyaman: So I'd like to I'd like to just elaborate a little bit on them. Right? So the that that n a c, N Acetylcysteine, increases glutathione. Glutathione is an anti rusting agent. Right?

Dr. Yousef Elyaman: We check a level in the blood called GGT. GGT tells me that you've been using up a bunch of glutathione and you have rust happening.

Dr. Mark Hyman: If it's elevated?

Dr. Yousef Elyaman: If it's elevated. So if they have elevated if they have an elevated liver enzyme or if the the ALT, AST, or elevated GGT, I am going to be giving them I'm gonna wanna give them the N Acetyl Cysteine. The other thing is is if they have an elevated GGT, that is a independent risk factor for fibrosis. So if you have high GGT, there's a high chance that you have fibrosis as well. And and the the the the the supplement that has been found to help is coq10.

Dr. Yousef Elyaman: Yeah. And I give the ubiquinol form, the unrusted form. Yeah. So I don't know I don't know if if you I know there's debates back and forth as does it matter if it's ubiquinol or ubiquinone? But there is data that supports giving ubiquinol with a high GGT can lower that GGT.

Dr. Mark Hyman: And and GGT can also be a a clue of environmental toxic load too, not just fatty liver. So Right. We're talking about other causes besides just diet.

Dr. Yousef Elyaman: Right. The triad, elevated liver enzymes higher than the optimal level. Right? High uric acid plus high GGT. If you have those the and and and they're not they're they're not moving, they're not budging, you have toxic overload.

Dr. Yousef Elyaman: They need to read your book on your your your detox book.

Dr. Mark Hyman: Yeah. I mean, and that and that's something that people can can learn how to do. And I think it can remove some of the environmental toxins that can be loading the liver and just reduce your exposure. I mean, I was reading the other day that that the average American has 22 pounds of food additives every year.

Dr. Yousef Elyaman: Yeah. What's that doing? It has to go through the liver. Right?

Dr. Mark Hyman: Yeah. It's not great.

Dr. Yousef Elyaman: So so you so there's already there's a couple of supplements. Right? There's research that showed that vitamin e was helpful. Now here's here's the challenge with vitamin e. The vitamin e that is normally pushed at the store at the supermarket is called d alpha tocopherol.

Dr. Yousef Elyaman: It is synthetic. Right? It's it's not the way it's found in nature. In nature, there's 8 forms of vitamin e, alpha, beta, delta, gamma, tocopherol, alpha, beta, delta, gamma, tocotrienol. And if you start hitting the body with just one type and the synthetic form,

Dr. Mark Hyman: what It becomes more oxidized.

Dr. Yousef Elyaman: Well, the more oxidized, and it may be stopping the other forms from getting in. Yeah. So you're creating a vitamin e deficiency by giving them vitamin e. Yeah.

Dr. Mark Hyman: So what you get at your, like, local drugstore is probably not the right form.

Dr. Yousef Elyaman: So I switched to

Dr. Mark Hyman: link we're gonna link to the right forms that contain multiple forms of mixed mixed tocotrienols, which we call.

Dr. Yousef Elyaman: The research that showed improvement in fatty liver actually showed the mixed. Yeah. Right? There is a supplement called phosphatidylcholine. Yeah.

Dr. Yousef Elyaman: And that stops some of the bad fats from getting into the liver and choline helps process fat. So phosphatidylcholine, I've been impressed with it. I've I've seen I've seen it work really well decreasing that fat.

Dr. Mark Hyman: It also detoxifies, you know, cell cell membranes. I actually recently did a test. I, I, we're here at the annual international conference for functional medicine and I gave a little presentation yesterday and I shared my own case history of my illness when I was 36 and chronic fatigue and being overloaded with mercury and mold toxins and everything. And I actually did this test, recently that's from Germany that looks at your cell membrane levels of toxins. And I had, you know, mold toxins, pesticides, you know, plastics, heavy metal, I mean, you name it.

Dr. Mark Hyman: I had it and I, and I did a course of intravenous phosphatidylcholine over the course of 10 weeks, twice a week, about, 10 grams a time. So it's like 2,000 grams, which is a kilo basically over time. And that, and I redid my test and I was shocked to see that the levels of the toxins dropped dramatically almost to normal by repopulating my cell membranes with a better, newer form of the fat. So all our cell membranes are made of a phospholcholine and it helps to, you know, detoxify our liver. So I I think that this phospholcholine can be helpful in many ways and I think you can take it orally, you can do it intravenously.

Dr. Mark Hyman: I wanna back up a little bit if you were talking about these tests, you know, uric acid Yeah. GGT

Dr. Yousef Elyaman: Yeah.

Dr. Mark Hyman: And all these other lipoprotein fractionations. Typically, when you go to the doctor for annual checkup, they're not checking uric acid, they're not checking GGT, they're not checking insulin, they're not checking lipoprotein fractionation.

Dr. Yousef Elyaman: Right.

Dr. Mark Hyman: So these are available through Quest or LabCorp. They're really easy to get and they're not that expensive. In fact, with function health, sorry to harp on this, but you can get all these tests and lots more for, you know, 4.99 membership for twice a year testing and track your numbers over time and, and sort of have a health copilot that tells you what's, what it means and what to do about it. It's so, it's so important to know what's going on in your body because, you know, most medicine waits till you have a serious problem, and then they come in kind of to rescue and treat it. They don't see the subtle, slow changes that you can pick up as clues in your blood work early on that you, you, you have to know because if you don't do it, you know, like I said, 30% of Americans or more walking around with this problem, it's invisible, it's painless.

Dr. Mark Hyman: It has no symptoms that is extremely risky for a whole range of chronic diseases including heart attacks, cancer, stroke, you know, dementia and more infertility, whatever. And, and it's just not being diagnosed. So, so I encourage you all to just get checked, you know, test, don't guess. Now, in terms of the next sort of set of supplements, we've got N Acetylcysteine, we've got vitamin e but the right form of mixed Vitamin e. Tocopherols and, and I'm linked linked to that in the show notes of what what would be the optimal forms to get.

Dr. Mark Hyman: What else should people be thinking about?

Dr. Yousef Elyaman: CoQ10. Great.

Dr. Mark Hyman: Thank you. CoQ10 Uh-huh. In the right form, Ubiquinol.

Dr. Yousef Elyaman: If if it's an oxidative stress thing that we're working on, then you can consider things like alpha lipoic acid as well. It's a powerful antioxidant as well, and it can help lower sugar for insulin resistance. Yeah. So the so though those, I would I would we already kinda talked about the high uric acid. If your uric acid is higher than 5.5 in a postmenopausal woman or in a man or in a a a a woman that that does that, is having periods, it should be less than 4.5.

Dr. Yousef Elyaman: So if that uric acid is high, you already mentioned the the dark cherry extract. You you mentioned, we we also talked about quercetin. Quercetin helps with multiple things.

Dr. Mark Hyman: What does that do?

Dr. Yousef Elyaman: So it's a mass cell stabilizer, but it helps the body excrete uric acid.

Dr. Mark Hyman: So it's it's basically from plants. Right? Onion The red. Yep. Berries and different things.

Dr. Yousef Elyaman: Yeah. Apples.

Dr. Mark Hyman: And it turned out to be very effective in COVID. It's great for longevity. And the reason lot of research on, of course, Dan, it's in Himalayan tardere buckwheat at high levels, which is something that, we talked about in the podcast before with Jeff Bland that that is is really showing your immuno rejuvenating properties and actually reversing biological age. So I think this is a very important supplement that most people probably don't know of

Dr. Yousef Elyaman: Right.

Dr. Mark Hyman: But has many, many effects. It works on, also on AMPK, which is one of the longevity switches that regulates insulin resistance. So it has so many benefits, but in terms of fatty liver, specifically, it can help lower uric acid and help improve fatty liver.

Dr. Yousef Elyaman: And may lower iron because the the the liver starts to accumulate iron. Whether you have hemochromatosis or not, you can start accumulate iron. So that's milk thistle. So then there there's another one. Yeah.

Dr. Yousef Elyaman: Milk thistle, also helps with detox.

Dr. Mark Hyman: Mhmm. So so what what does that do?

Dr. Yousef Elyaman: So that helps with detoxification as well, but also may lower iron. Any inflammation helps with liver inflammation.

Dr. Mark Hyman: What about minerals and vitamins like Yeah. Selenium and things like that?

Dr. Yousef Elyaman: So now when we start looking at liver function, one of the tests that I like looking at is a homocysteine. Yeah. Because if your homocysteine is high, then the way that you're processing some of the b vitamins is off, which and then you get a backup a backup in detoxification, so your body can't get rid of toxins. Your body can't make neurotransmitters. It could lead to depression, anxiety, insomnia, and all of those things.

Dr. Yousef Elyaman: So I'll check that I'll check the homocysteine. If it's high, you consider checking that MTHFR gene mutation. Yeah. Which is which which, you need in order to lower homocysteine, you need the activated form, Methylfolate. Yeah.

Dr. Yousef Elyaman: So so And if you

Dr. Mark Hyman: have this weird genus enzyme, which about 35% of people don't have the proper enzyme to convert the inactive to the active folate

Dr. Yousef Elyaman: Right.

Dr. Mark Hyman: You get you get problems including, you know, bad liver, cancer, heart disease, you name it, dementia. So you can check that in a blood test. Again, it's not in your regular lab, but it is on the function panel.

Dr. Yousef Elyaman: Right. So so if that you in your panel, is homocysteine

Dr. Mark Hyman: in there? Absolutely.

Dr. Yousef Elyaman: Yeah. So what about MTHFR that

Dr. Mark Hyman: That's an option.

Dr. Yousef Elyaman: Yeah. So if you're yeah. If their homocysteine's high, check that MTHFR, and then you support them with b vitamins. You can support with them with things like taurine, omega threes again. Because omega threes, we didn't mention, but omega threes can reverse or decrease fatty liver disease as well.

Dr. Mark Hyman: Yeah. So omega threes. So Yeah. We got a cocktail here. We got N Acetylcysteine.

Dr. Mark Hyman: We got vitamin e in the right forms of mixed tocopherols. We got milk thistle, we've got ubiquinol, we've got, alpha lipoic acid.

Dr. Yousef Elyaman: Uh-huh.

Dr. Mark Hyman: That's a good cocktail. And, of course, making sure you're gonna be complex and multi mineral. Right? Right. Right.

Dr. Mark Hyman: And So

Dr. Mark Hyman: all all that is required to make all the metabolic pathways in the liver work properly.

Dr. Yousef Elyaman: Right. And then let's not forget curcumin. Yeah. Curcumin may help as well, and curcumin is good for heart health and for

Dr. Mark Hyman: So yeah. So curcumin is like a basically found in curry and turmeric. Right? You can take that as a supplement. Again, very important.

Dr. Mark Hyman: And, again, we're gonna we're gonna link in the show notes to what what products and things are the the best best in class there because there's a lot of junk out there. You don't wanna you don't wanna be doing that. Now, it seems like a pretty straightforward plan. It's diet, exercise, stop drinking

Dr. Yousef Elyaman: Yeah.

Dr. Mark Hyman: Stop taking drugs that damage your liver

Dr. Yousef Elyaman: Right.

Dr. Mark Hyman: And then be on a number of supplements that can help support Right. Optimal liver function.

Dr. Yousef Elyaman: But personalized medicine, functional medicine. Right? So you see what their imbalances, and you give them supplements based on the imbalance. Yeah. Not just and and first, the lifestyle.

Dr. Yousef Elyaman: Actually, you can give a good go at lifestyle Mediterranean food plan, omega threes, and just see what happens. Yeah. Right? Mind you, these they they've already ruled out other causes of liver disease. They've their doctors already told them no.

Dr. Yousef Elyaman: Yeah. You what you have is fatty liver disease. It's not something else. Because other liver diseases can cause turn the liver to fat. But once we know that, start with that and then refollow those things that are apt.

Dr. Yousef Elyaman: Find out what their abnormalities are and refollow them and make it more personalized.

Dr. Mark Hyman: And the beautiful thing about liver is it regenerates. Like, the you know, it's one of the few organs. If you cut your liver off and give up way half your liver, it'll grow back. Right. Right?

Dr. Mark Hyman: So if it's like a salamander, like, growing an arm, except it's one of the few organs. So you want if you actually can give a liver part of your liver to somebody else's transplant and you're still alive and have a liver Right. Grow back, which is pretty cool. So it has a lot of capacity we generate. So tell us in terms of this approach, when you have some come in Yeah.

Dr. Mark Hyman: With fatty liver, whether it's, you know, more advanced stage or a less advanced stage, what kind of results are you seeing? Can you share some cases of patients who've had this and they follow this approach and actually reversed?

Dr. Yousef Elyaman: Right. No. There there are tons of cases that follow. So they it goes anywhere from at improving their their markers, their their blood markers, and improving their, and and improving their the fat in the liver to people that had fatty liver that no longer have fatty liver. Like, it is, it's using this personalized approach.

Dr. Yousef Elyaman: It works. Yeah. We see it. And the beautiful I I tell you the most frustrating thing for me, I hated even getting into fatty liver. That's I hate it.

Dr. Yousef Elyaman: I hated talking about it. Because I tell them they have fatty liver and then tell them to lose weight, and then and then how do I know if it's getting better or not? I there I have no way of telling. And now I'm so excited that we have ways of telling

Dr. Mark Hyman: New diagnostics.

Dr. Yousef Elyaman: And and and the other scary thing. So I'll tell you about a case I had too. A lady who had fatty liver disease was told she had fatty liver disease years ago. Right? And now we have this technology.

Dr. Yousef Elyaman: She's coming and seeing us. Yeah. We do the FibroScan Yeah. And it shows high fibrosis, and we do a biopsy. She has cirrhosis.

Dr. Yousef Elyaman: Yeah. Now probably saved her life because we get her in a study. We work on a functional medicine approach. But imagine, like, this person knew years ago she had fatty liver disease, but instead of the only thing she was told is, yeah, lose weight. And and sometimes they do it without even without even thinking that they will.

Dr. Yousef Elyaman: Right? Yeah.

Dr. Mark Hyman: Yeah. So the problem with,

Dr. Mark Hyman: you know, traditional medicine is, like, we say, okay. You are, you know, diagnosed with this condition and there's here's this one drug, take this pill to fix the disease. Right? But with functional medicine, it's it's multi causal and multimodal treatment. In other words, there may be many factors, so you might have to clean up the gut if people have dysbiosis or bacterial overgrowth.

Dr. Mark Hyman: You might have to get rid of environmental toxins if they're, you know, not filtering their water, they're eating too much tuna or they're having exposure to all kinds of chemicals in their environment.

Dr. Yousef Elyaman: Right.

Dr. Mark Hyman: You might have to do a lot of things to kinda help reduce a risk. So we do multiple things, and diet exercise, supplements, other factors, reducing toxins, fixing the gut. That's the whole functional medicine approach. What, what, are you seeing in terms of the, the, the, the kind of data on this? Are there are there studies that show multimodal treatment approaches?

Dr. Mark Hyman: Because it's not how we study things in medicine. Right. Have you have you done or has anybody else done studies that look at collective interventions to actually see what kind of change we can get in this.

Dr. Yousef Elyaman: As far as I know, there is no study that does like the Bredesen protocol that that follows a multimodal approach.

Dr. Mark Hyman: Yeah. All

Dr. Yousef Elyaman: I can tell you is our clinical practice. We have 7 providers. We take insurance. We have where we we actually, the FibroScan company knows us really well. Yeah.

Dr. Yousef Elyaman: The the the the the company that is doing these, doing this research knows us really well because we send so many people to get FibroScans. We just we just open the floodgates and send them through. But we have we have probably done thousands of FibroScans because of this in the last couple of years. So we're able And you

Dr. Mark Hyman: see the changes?

Dr. Yousef Elyaman: We're able to see the changes. Yeah. But it's very different if I

Dr. Mark Hyman: People normalize, do they get

Dr. Yousef Elyaman: People normalize all the time.

Dr. Mark Hyman: Yeah. So this is the problem. And and I think I think, you know, it's like the way medicine, works and the way medical research is done is okay. Let's see if I do let's just give you vitamin e and see what happens. Right.

Dr. Mark Hyman: Or let's just give you, you know, a little exercise when after. Let's just give you milk this all and see what happens.

Dr. Yousef Elyaman: Right.

Dr. Mark Hyman: It's the wrong way to do it because you have to treat all the things. You can't just treat the one thing and you have to fix all the diff his functions. So that's really the beauty of functional medicine and then and I think if it's stunning to me that we have something that affects a third of the population

Dr. Yousef Elyaman: Right.

Dr. Mark Hyman: And nobody's doing any real research on how to actually fix this. Now there are drugs that are in development. Maybe we can spend less minutes talking about

Dr. Yousef Elyaman: Yeah.

Dr. Mark Hyman: You know, what what, on what's on the horizon, what's the future of this? And how do we start to think about it? Because, you know, it's a little scary to me. I I was at an obesity conference, was on a pediatric obesity conference. And I met this guy here who was a hepatologist, a liver specialist, and kids.

Dr. Mark Hyman: I'm like, what are you doing here? Yeah. He's like, well, you know, all these kids drinking soda all the time. At 15, they're needing liver transplants.

Dr. Yousef Elyaman: Oh, god.

Dr. Mark Hyman: Liver transplants in kids from fatty liver. So tell us what the future looks like.

Dr. Yousef Elyaman: Yeah. So the future the future looks like these drugs being developed, one drug per per, condition that have side effects, and there is a role for them. Right? But also the future looks like us unpackaging. And we could take this new drug and unpackage it as a as functional medicine providers.

Dr. Yousef Elyaman: Right? But, maybe maybe that'll be a nice end of the show or how you but it's your show and however you want. But but but what what we take all of this information and we unpackage it and we've and we use a functional medicine approach. So there are things called PPAR gamma agonists. So there's a drug there's a drug coming out that is PPAR alpha, gamma, and delta.

Dr. Yousef Elyaman: There is there's anti inflammatory there's a anti inflammatory drugs coming out. And the one that just got approved, this, this redmedirom med if you look at what this is, resmedirom, the thyroid gland the thyroid gland makes thyroid hormone. And for thyroid hormone to work, it has to bind to what's called the thyroid receptor.

Dr. Mark Hyman: Yeah.

Dr. Yousef Elyaman: There's 2 types of thyroid receptors, alpha and beta. Alpha will be in some areas of the body, beta will be in other areas. Alpha is found in the heart. One of the problems with just giving people a bunch of thyroid medicine and why we're very careful with giving thyroid medicine is because it could over excite the heart.

Dr. Mark Hyman: That's your super high heart rate and

Dr. Yousef Elyaman: Erythrophy Stroke and death. Yeah. That's why I mean, otherwise, just give people thyroid, let them lose all the weight. Right? Because it's a metabolism hormone.

Dr. Yousef Elyaman: So what what this does is that this is a beta agonist, and a beta beta is found in the liver, but not found in the heart. So it stimulates the liver. Now it does have its side effects.

Dr. Mark Hyman: Thyroid pill for your liver, basically.

Dr. Yousef Elyaman: Your liver. Just for your liver. But then what happens if you give the beta without the alpha? Is that gonna lower the effect? I mean, there's so many questions on what the long term effects are gonna be.

Dr. Mark Hyman: And how and how big of a an improvement is there?

Dr. Yousef Elyaman: There was a I can't. I need to look at it.

Dr. Mark Hyman: I mean, is

Dr. Yousef Elyaman: it is it But

Dr. Mark Hyman: there was

Dr. Yousef Elyaman: a it was enough to, like, sit to get the FDA approval, but I it it shows significant. No. You're right. You're right.

Dr. Mark Hyman: And I

Dr. Yousef Elyaman: I know the number

Dr. Mark Hyman: My guess is you compare it head to head with an aggressive lifestyle and functional medicine approach. It would it would it would outshine this drug or any future drug

Dr. Yousef Elyaman: A 100%.

Dr. Mark Hyman: By far. No. So so people are looking for the quick pick Right. Quick fix and the quick pill, but it's not coming.

Dr. Yousef Elyaman: But we as as functional medicine providers now unpackaging that unpackaging that. What we know is that when we are stressed, our body wants to hold on to fat. Right? Because our ancestors, when they were stressed, they were it was because their life was in danger. They either couldn't find food or something was trying to make them food.

Dr. Yousef Elyaman: Yep. You have to slow down your metabolism. Right? And you can't slow down if you you don't wanna turn off the thyroid. But what what happens is is that that TSH, that signals that comes from the brain still works.

Dr. Mark Hyman: Mhmm.

Dr. Yousef Elyaman: But instead of making t 3, you make reverse t 3. And reverse t 3 blocks your thyroid. And if you look at conventional doctors, they don't check reverse t 3. Right? So the the very quick pearl that I would now that that I would add to the the fatty liver disease plan is I would do a full thyroid panel.

Dr. Yousef Elyaman: I would do TSH, free t 4, reverse t 3, total t 3, and thyroid antibodies. And there is Which by

Dr. Mark Hyman: the way, your your traditional doctor doesn't test all of it. They just check a TSH and they don't look at all those thyroid antibodies. They don't look at Right. T 4, t 3. Some of them look at g 4, and they for sure don't look at reverse.

Dr. Yousef Elyaman: The rock stars. The rock stars look at t 4. But beyond that, forget it. So so so now what what happens, t 3 is the actual is the more active hormone anyway. The t 4 has to become t 3.

Dr. Yousef Elyaman: There's debate on whether t four has an effect or not. Right? So that being said, when we're looking at those ratios, we look at the t three reverse t three ratio, and and we're trying to make sure that that number is is greater than 6. If it's less than 6, we know something is happening and they're not converting. So we work on stress management.

Dr. Yousef Elyaman: There are supplements to give to lower cortisol. We can check cortisol levels, and there's a now another herb. There's an herb, ashwagandha. Ashwagandha can help convert Say

Dr. Mark Hyman: it again.

Dr. Yousef Elyaman: Yes. Okay. And there's an herb called ashwagandha, and ashwagandha can actually help convert your t 4 to t 3. Now there was a case study showing liver disease with or liver, elevated liver enzymes with ashwagandha. You have to make sure you get a clear source.

Dr. Yousef Elyaman: You have to make sure you're following those liver enzymes. And if you start one supplement and the levels go up, then but but optimizing the thyroid, that what the new $4,000 a month drug

Dr. Mark Hyman: Oh my god. Does.

Dr. Yousef Elyaman: Right? We can take that information and say, this is another piece to the puzzle. So I need to make sure I do comprehensive thyroid panel on on my patients that have fatty liver so that I can start working on, on that.

Dr. Mark Hyman: I mean, as you take that $4,000, you shave it down dramatically and give people free food for 6 months. It would cure their fatty liver disease. So but I'm working on that in Washington. Well, this is amazing. I think, you know, I I really I I really think this is an important new awareness.

Dr. Mark Hyman: And we were talking earlier before the podcast about how people people are now starting to recognize this and hearing about it. It's more than news. There's articles and newspapers about it. And I think it's a good thing because up to now, it's been sort of neglected by doctors because doctors don't like to check things they can't do anything about. Right?

Dr. Mark Hyman: If you can't do anything, but now and and and I don't think they're doing anything about means drugs. I think it means Yeah. Actually figuring out, how to deal with the the root cause of it, which is primarily lifestyle, but it's also the things you mentioned, like environmental toxins, right, you know, the good news is, you know, you you you do a lot of work to train physicians and, you know, we certainly do that at the Institute For Functional Medicine, but you have your own training course, and people can go learn about MAPDL d or whatever you wanna call it. Was it called now MASHA or

Dr. Yousef Elyaman: Mazeled.

Dr. Mark Hyman: Mazeled. Mazeled. And, and it's m m f mpessentials.com. And, it's a course for practitioners, but if you're not a practitioner, you wanna learn more about it, you can. I think everybody needs to really understand they need to get checked.

Dr. Mark Hyman: They need to get test. This is really common. It's life threatening. It progresses if you don't do anything about it. It's invisible.

Dr. Mark Hyman: It's symptomless, but the good news is there are clear strategies, particularly through a functional medicine lens of how to diagnose it and treat it effectively. So, I really wanna applaud you for bringing this to awareness for your hair. We're gonna give a talk at the Institute for Functional Medicine Conference, and I I'm excited to hear that talk. And I think everybody should be very excited to go get these lab tests and go get checks. So just quick reminder, functionhealth.com forward slash mark.

Dr. Mark Hyman: If you wanna skip the 200,000 person wait list, you can kinda learn about what's going on in your body and be empowered to to be the CEO of your own health and learn from what we have. And we'll put all again all this in the show notes. Youssef, it's been great to have you on here. Thank you so much for the work you're doing and and just making the world a better place.

Dr. Yousef Elyaman: Pleasure is mine. Thank you

Dr. Mark Hyman: so much. I don't know how you take care of your 7 kids and are part of 15 siblings, but, god bless you. Thank you. Thanks. Thanks for listening today.

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Dr. Mark Hyman: This podcast is separate from my clinical practice at the Ultra Wellness Center and my work at Cleveland Clinic and Function Health where I'm the chief medical officer. This podcast represents my opinions and my guest opinions and neither myself nor the podcast endorses the views or statements of my guests. 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.

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