Dr. Ashlee Williams (Host): You may have fatty liver disease and not even know it. In fact, it often develops silently without obvious symptoms. But if left unchecked, it can lead to serious liver damage over time. So, what is fatty liver disease? And most importantly, what can you do to protect your liver?

Welcome to the Healthier You podcast. I'm Dr. Ashlee Williams. And today, I'm talking with Dr. Alex Jow, a board-certified gastroenterologist here at Kaiser Permanente, about fatty liver disease. What causes it? How do you know if you're at risk? And what can you do to improve your liver health? Dr. Jow, thanks so much for being here today.

Dr. Alexander Jow: Dr. Williams, my pleasure. Thank you for having me.

Host: Yes, always a treat. Okay. Let's start with the basics. What exactly is fatty liver disease and why is it becoming so common?

Dr. Alexander Jow: So, fatty liver disease is actually a condition where there is excess accumulation of fat in your liver. It's incredibly common. We see this in about one-third of adults in the US. The terminology of this disease has changed somewhat. This used to be called NAFLD or non-alcoholic fatty liver disease, and that was more kind of a diagnosis of exclusion to say this is kind of diseases of fatty liver that are not related to alcohol use.

But the terminology has changed more recently to be a little bit more expansive, and now it's called MASLD or metabolic-associated dysfunction steatotic liver disease, which is more focusing on what is the etiology of the disease, which is primarily a condition related to metabolic disease. And metabolic disease is something that we are seeing increasing within the United States. These are associated with conditions such as obesity or increased visceral fat, diabetes and insulin resistance, high cholesterol levels, and hypertension.

Host: Right. And most of the time, fatty liver disease doesn't have any symptoms. So, if it doesn't have any symptoms, how does someone know if they have it?

Dr. Alexander Jow: So, that's a great question, and I think a lot of times this is an underdiagnosed or underrecognized disease, because as you said, for the most part, people with fatty liver disease will have no symptoms. The liver actually can take a fair amount of damage and inflammation before anyone really experiences any changes.

Some symptoms that people may notice, if they have kind of more severe fatty liver disease, they may have some fatigue or malaise or just low energy levels. Sometimes as you have increased fat in your liver, there can be enlargement of your liver and that can cause stretch of the liver capsule. So, some people may describe kind of some pressure and discomfort in the abdomen around the right side of your belly near the rib cage. But again, as I said, the vast majority are going to have no symptoms unless this has progressed significantly, and we see stigmata of chronic liver disease like cirrhosis.

Host: Right. And I would just want to make a plug here. I think that's why it's so important to stay up to date on your preventative care appointment so that you can get your lab tests for screening. So, let's say you have fatty liver disease. What happens if it's left untreated?

Dr. Alexander Jow: Yeah. So, I just wanted to go back to kind of how do we even make the diagnosis, as we said, you know, there are often very few symptoms. And so, this is really where our primary care doctors are so important, because these are kind of where these diagnoses are made. Some primary care doctors, because patients have known risk factors for fatty liver disease, they may be overweight or they, as we talked about, have other metabolic disorders, diabetes or hypertension, they're going to order things like baseline liver tests.

Sometimes one of the only kind of things that we're going to see that are abnormal on your workup is that we might see mild elevations of your liver enzymes, and that may prompt further workup, such as imaging of the liver, either an ultrasound or a CT scan or an MRI, and that's where we typically will see or detect fat in the liver or steatosis. There are classic radiographic changes that will help make this diagnosis of fatty liver.

So as we discussed or as your question was, going back to that, what happens if we don't do anything about it? So, you have this diagnosis of fatty liver disease. One-third of patients with fatty liver disease may progress to have inflammation of their liver, and this is called MASH or metabolic-associated steatohepatitis. And so, one-third of those patients will see either abnormal liver enzymes. If there is a liver biopsy on pathology, we often will start seeing inflammatory changes in the liver. And if that is left untreated, one-third of those patients with inflammation in their liver may end up developing clinically significant fibrosis or scarring of the liver.

And those are the most serious kind of aspects of the disease. When we start to see fibrosis, that is where we can see significant dysfunction of the liver and potentially complications of chronic liver disease.

Host: Great. And thanks for touching on the partnership with primary care and gastroenterology. What I really love here at Kaiser Permanente is that when we do find that those liver tests are a little abnormal, we'll normally repeat it if there's just a slight abnormality, but we try to do the entire workup before the patient even gets in to see you, which may be an ultrasound or other imaging and more lab tests to try to get to the bottom of why those liver function tests are abnormal. So, I'm really grateful for that partnership. Can you talk about what people can do to improve or maybe even reverse fatty liver disease?

Dr. Alexander Jow: Absolutely. So, you know, as we said, this is a metabolic process. And so, kind of really understanding the patients and their risk factors are really an important aspect. Diabetes is a well-known risk factor for development of fatty liver disease. In fact, about 50% or even more of patients with diabetes or type 2 diabetes will develop fatty liver disease.

So, one is kind of just identifying those risk factors. If you have diabetes, work with your primary care doctors on managing your diabetes and whether that's medical management or lifestyle changes. And then, obesity is the other kind of most major cause. Obviously, in the United States and across the world, we are seeing increased rates of obesity, and certainly that is often the first-line target in terms of how to treat fatty liver disease.

So in terms of kind of just general metrics when I have patients who have fatty liver disease, they may have steatosis on ultrasound, they have maybe mild elevation of their liver tests, the first thing I tell them is kind of work on your lifestyle, work on your diet. Losing weight is going to be kind of the most significant way to help, you know, stop progression of the disease and potentially reverse it.

So, we often see with just 3% to 5% weight loss of your body weight, we will start to see some reversal or stopping the progression of the development of the steatosis, which is the fat in the liver. If there is fibrosis, which is scarring of the liver, we often have to see kind of higher weight loss goals. So, we're kind of aiming closer to 7% to 10% of your body weight. So, I often say if you're like, say, you're 200 pounds, you know, I often say, "Let's start with losing 5%, 3% to 5%. We'll lose 10 pounds." But if you have fibrosis, we're going to be a little bit more aggressive, and we're going to try to lose something closer to 20 pounds of your weight. And so, that's usually kind of a starting point.

Host: Okay. And I love lifestyle changes and making attainable, achievable goals. So, let's say the lifestyle changes don't work, are there any medications that you recommend to treat fatty liver?

Dr. Alexander Jow: Certainly, I always try to start with focusing on lifestyle changes and weight loss through kind of working with your primary care doctor or through weight loss programs. But certainly, in our higher risk populations for people who have clinically significant fibrosis and have really exhausted kind of more of these lifestyle changes, there are certain medications that are now FDA-approved for treatment of fatty liver disease with clinically significant fibrosis.

And these can act either directly on the pathway of how fat deposits in the liver or they're medications that can help assist with weight loss, which as we talked about, really is one of the significant factors in reversing both fatty liver disease and fibrosis.

Host: Great. It's good to know that there are more options. Thank you so much, Dr. Jow, for helping us better understand fatty liver disease. Here are a few takeaways to remember.

One, fatty liver disease often develops silently, and many people don't have symptoms until the condition has progressed.

Two, risk factors include obesity, type 2 diabetes, high blood pressure, high cholesterol, insulin resistance, and a family history of liver disease.

Three, while fatty liver disease can become serious if progresses to fibrosis or cirrhosis, early diagnosis and treatment can make a significant difference. Check in with your primary care doctor.

Four, in many cases, fatty liver disease can be improved and sometimes reversed through lifestyle changes like weight loss, regular physical activities, and managing underlying chronic health conditions.

And five, a diet rich in minimally processed foods can help reduce liver fat and improve overall metabolic health.

Small changes can have a meaningful impact over time. And the earlier fatty liver disease is identified, the more opportunities there are to prevent long-term consequences. For more expert insights, visit kp.org/doctor and explore more episodes of Healthier You wherever you get your podcast. If you found this episode helpful, be sure to subscribe. And you don't want to miss what's next, so be sure to share it with others. Any other topics you'd like to discuss, please put it in the comment section. Thank you. And from all of us at Kaiser Permanente, be well.