Fatty Liver: What You Need to Know This Summer 

1. Introduction: A Silent Epidemic

Fatty liver disease is a common diagnosis when we go for a general health check-up and accidentally discover it. According to the American Liver Foundation, fatty liver disease affects approximately 25% of Americans. A systematic review and meta-analysis with over 1.2M people reveals that Non-alcoholic fatty liver disease (NAFLD) affects approximately 30% of people worldwide and appears to be increasing.

This disease is so common that many people subjectively think it is a benign disease. In the early stages, fatty liver often has no symptoms or appears with vague symptoms, easily overlooked or confused with other common diseases. The disease progresses silently, until it causes extremely serious health consequences such as hepatitis, cirrhosis and liver cancer. Therefore, it is also called a silent epidemic.

So what is fatty liver disease? Can you get this disease? What are the symptoms of the disease and what should we do to prevent it?

2. What is Fatty Liver?

Fatty liver can be simply understood as the condition of excess fat accumulation in the liver. This condition can cause injury, inflammation and scarring, cirrhosis, even liver failure and liver cancer.

A healthy liver usually contains very little or even no fat. However, when we consume too much alcohol or foods containing excess fat, or have hyperlipidemia, lipid metabolism disorders, the body will process this excess fat by storing it in liver cells. When the amount of fat exceeds 5-10% of the liver weight, it will lead to fatty liver.

Fatty liver is divided into 2 types: alcoholic fatty liver and non-alcoholic fatty liver.

• Alcoholic fatty liver disease: When you drink too much alcohol over a long period of time, your liver cells become inflamed, scarred, fibrotic, and cancerous.
• Nonalcoholic fatty liver disease (NAFLD)
  • NAFLD causes excess fat to build up in the liver, but does little or no damage to liver cells. The disease rarely causes serious problems or complications. However, 25% of NAFLD progress to NASH.
  • Nonalcoholic steatohepatitis (NASH) is a form of NAFLD in which you have inflammation of the liver and liver damage, in addition to fat in your liver. 11% of NASH patients will develop cirrhosis or liver failure.

3. Who Is at Risk of Fatty Liver?

• Overweight and obese people: The amount of excess fat accumulated in the liver is proportional to body weight. Therefore, obese people tend to accumulate more excess fat in the liver than people with moderate weight. The risk of fatty liver for people who are obese or overweight is about 61-94%.
• People with type 2 diabetes: A study showed that up to 70% of type 2 diabetes patients have fatty liver disease.
• Insulin resistance: insulin resistance statistically significantly increases as simple fatty liver progresses to NASH and fibrosis level increases.
• High cholesterol/triglyceride levels
• Malnutrition: When the body does not have enough nutrients, the synthesis of certain proteins will encounter many obstacles, increasing the risk of triglyceride accumulation in the liver, from which excess fat will accumulate in the liver.
• Losing too much weight in a short period of time can also cause liver cells to be damaged and accumulate excess fat. Therefore, you should apply safe weight loss methods to avoid serious health consequences.
• Side effects of drugs: Medications commonly implicated in causing fatty liver include corticosteroids, antidepressant and antipsychotic medications and, most commonly, tamoxifen.
• People who use alcohol in higher than moderate. According to the Dietary Guidelines for Americans 2020-2025:
  • Moderate alcohol consumption for men: No more than two alcoholic beverages are consumed each day.
  • Moderate alcohol consumption for women means that no more than one alcoholic beverage is consumed each day. Serving size of alcohol are:
    • Beer: 12 ounces
    • Wine: 5 ounces
    • Hard liquor: 1 to 1-1/2 ounces 

4. Patient Stories 

Ms. Hana is 34 years old. After losing her job, she fell into a state of prolonged stress, causing her to develop uncontrolled eating habits. Her favorite foods are ultra-processed foods and sugary drinks. Within 1 year, she gained nearly 10kg, from 65kg to 75kg, BMI 27.5. Recently, she often feels tired, has indigestion, heavy breathing and loss of appetite. The results of her health check showed that she had severe fatty liver on ultrasound, liver fibroScan showed signs of mild fibrosis, liver enzymes were 2 times higher than normal, cholesterol increased, triglyceride increased, waist circumference 92cm. She was advised by the doctor to lose weight and exercise at least 150 minutes/week, apply the Mediterranean diet and was monitored every month. The results were surprising, after 6 months, her weight decreased by 5kg, to 65kg, liver ultrasound showed only mild fatty liver. She continued this lifestyle and after 1 year, her weight returned to 63kg, BMI 23, normal liver enzymes and liver returned to normal on ultrasound and fibroScan.

Mr. Mikel, 65 years old, has been diagnosed with type 2 diabetes for 3 years and is being treated carefully with medication. He does not drink alcohol regularly. For the past year, he has had high blood pressure and was prescribed additional blood pressure medication. 6 months ago, during a health check, the doctor discovered that he had a mild fatty liver on ultrasound, blood tests showed increased cholesterol, increased triglycerides, decreased HDL and increased LDL, liver enzymes within normal limits. He was explained that fatty liver is a common condition in patients with type 2 diabetes, but he was very worried because he understood that fatty liver would eventually lead to hepatitis, cirrhosis and liver cancer. However, after being carefully advised by the doctor that, the fatty liver condition could be reversed if he complied with the treatment with medication for underlying diseases such as diabetes, high blood pressure, dyslipidemia, and changed to a healthy lifestyle such as exercise, healthy eating, and completely quitting alcohol, he agreed and applied. After 6 months, the next health check-up showed that the liver had returned to normal on ultrasound, and the blood lipid index had returned to normal.

5. Signs, Symptoms of Fatty Liver 

Fatty liver disease often has few symptoms, especially in the early stages. If there are any, they may be symptoms of unexplained fatigue or poor digestion. As the disease progresses, the liver has scarring or cirrhosis, and the following symptoms will appear:

• Yellow, dark urine, white stools
• Itching, hives, allergies, fatigue
• Jaundice, yellow eyes
• Nausea, vomiting
• Loss of appetite
• Swollen legs, abdominal ascites, enlarged spleen, subcutaneous varicose veins, gastrointestinal bleeding, red spots on the palms of the hands, etc.

6. Diagnosis

1. Blood test: This is a commonly used method to diagnose fatty liver. The evaluation results are based on the following indicators:

• ALT (Alanine transaminase): 20-40UI/L
• AST (Aspartate transaminase): 20-40UI/L
• ALP (alkaline phosphorus – APL): 35-115UI/L
• GGT (Gamma-glutamyltransferase): 3-60UI/L
• Blood lipids (Cholesterol, HDL, LDL, triglycerides)

If the indicators exceed the above ranges, it is very likely that the liver is having problems, including fatty liver.

2. Imaging: 

Imaging is also one of the common and effective ways to diagnose fatty liver. Some imaging techniques include:

• Ultrasound: It is a non-invasive imaging technique that uses sound waves to create images of the liver and other organs in the abdomen. Ultrasound can help identify the presence and severity of fatty liver, as well as assess for other liver conditions.

• Fibroscan: FibroScan uses transient elastography, which is an ultrasound-based modality, an enhanced form of ultrasound. FibroScan is used to monitor the reversal of fatty liver disease.

• CT scan: CT is capable of detecting and quantifying moderate to severe steatosis but is inaccurate at diagnosing mild steatosis and involves the use of radiation.

• MRI proton-density fat fraction is currently the most accurate and precise imaging biomarker to quantify liver steatosis, but its cost is still high.

3. Liver biopsy: 

This is the gold standard for diagnosing fatty liver but must be performed by a specialist. This is a technique for diagnosing liver damage by removing a piece of liver tissue from the body and bringing it to the laboratory for examination and evaluation under a microscope.

7. Reversing Fatty Liver: What Works

The good news is that fatty liver is reversible if we act early. If the disease has progressed to cirrhosis, it is irreversible. At this point, only a liver transplant can save the patient’s life. If the disease has progressed to liver cancer, it is also irreversible.

In 2023, Steatotic liver disease is the new name for fatty liver disease; and Metabolic dysfunction-associated steatotic liver disease (MASLD) is the new name for nonalcoholic fatty liver disease (NAFLD), emphasizing the role of metabolic disorders in fatty liver.

Therefore, fatty liver reversal methods are closely related to building a healthy metabolic pathway for the body.

1. The most effective method to reverse fatty liver is weight loss. When losing weight, patients can reduce fat, inflammation and even scarring in the liver. The goal is to lose 7 to 10% of body weight per year to reverse liver cell damage. Note that rapid weight loss is not recommended because it will cause many complications.

2. Exercise more than 200 minutes per week.

3. Apply a Mediterranean or anti-inflammatory diet emphasis on whole foods, healthy fats, and antioxidants. helps reduce fat accumulation in the liver, combat oxidative stress and inflammation. Fiber and healthy fats can improve insulin sensitivity, which is often impaired in people with NAFLD. 

4. Avoid alcohol and sugary beverages. 

5. Good control of underlying diseases such as diabetes, high blood pressure, dyslipidemia, and high cholesterol is also effective in improving fatty liver condition.

8. Medical Treatment for Fatty Liver

Previously, there was no specific drug for fatty liver disease. However, since March 14, 2024, the US Food and Drug Administration (FDA) has approved the first drug to treat moderate to severe noncirrhotic non-alcoholic steatohepatitis (NASH). That is the drug Rezdiffra, researched and developed by Madrigal Pharmaceuticals (USA). It has been clinically tested for more than 900 people with non-alcoholic steatohepatitis.

Liver biopsy results after 12 months showed that the rate of resolution of some symptoms or improvement of liver scarring in people taking Rezdiffra was higher than those taking placebo. This is considered a promising new step forward in the treatment of fatty liver.

9. Summer Tips for Liver Health

Why you need to take better care of your liver in the summer.

The hot summer will make you sweat more, leading to dehydration. Your liver depends on water to filter toxins and metabolize nutrients, so dehydration will slow down this function of the liver, leading to the accumulation of toxins in the body, making you feel tired easily. In addition, too high temperatures can easily lead to oxidative stress and inflammation of liver cells. In addition, parties with unhealthy foods, alcoholic beverages, and sugary drinks also increase the risk of harm to your liver, especially those who already have fatty liver disease.

Therefore, to keep your liver healthy in the summer, you can apply the following tips:

• Stay hydrated.
• Choose grilled foods over fried.
• Pack fresh fruits and vegetables on outings.
• Limit drinking too much alcoholic beverages.

However, summer is also the season for outdoor sports such as hiking, swimming, and biking. Take advantage of these activities to lose weight while exercising, immerse yourself in nature, breathe fresh air, and get exposed to sunlight to get more vitamin D.

10. When to See a Doctor

When you have high risk factors for fatty liver, you need to see your doctor for checking up. If you have:

• Metabolic syndrome
• Type 2 diabetes
• High cholesterol
• Overweight, obesity, abdominal obesity (waist circumference over 90cm for men, over 80cm for women)
• Unexplained fatigue or abnormal liver tests

11. Final Takeaway

Fatty liver is very common. The condition progresses silently and has a bad outcome if it leads to scarring or cirrhosis, and in the worst case, liver cancer. However, early detection and lifestyle changes can protect your liver—and your life.

You may not know you have fatty liver without a general health check-up, so setting up a routine of checkups and gradual habit shifting are the key for controlling this condition. .

References: 

1. https://liverfoundation.org/about-your-liver/facts-about-liver-disease/fatty-liver-disease/
2. 1 Le MH, Le DM, Baez TC, Wu Y, Ito T, Lee EY, Lee K, Stave CD, Henry L, Barnett SD, Cheung R, Nguyen MH. Global incidence of non-alcoholic fatty liver disease: A systematic review and meta-analysis of 63 studies and 1,201,807 persons. J Hepatol. 2023 Aug;79(2):287-295. doi: 10.1016/j.jhep.2023.03.040. Epub 2023 Apr 9. PMID: 37040843. 
3. NAFLD is one of the most common causes of liver disease in the U.S. About 24% of U.S. adults are estimated to have it. Cleveland Clinic estimates that about 20-30% of adults in the U.S. have excess fat in their liver.
4.  LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-. Nonalcoholic Fatty Liver. [Updated 2019 May 4]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK547860/
5. Younossi ZM, Golabi P, Price JK, Owrangi S, Gundu-Rao N, Satchi R, Paik JM. The Global Epidemiology of Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis Among Patients With Type 2 Diabetes. Clin Gastroenterol Hepatol. 2024 Oct;22(10):1999-2010.e8. doi: 10.1016/j.cgh.2024.03.006. Epub 2024 Mar 21. PMID: 38521116. 
6. Cetin EG, Demir N, Sen I. The Relationship between Insulin Resistance and Liver Damage in non-alcoholic Fatty Liver Patients. Sisli Etfal Hastan Tip Bul. 2020 Dec 11;54(4):411-415. doi: 10.14744/SEMB.2018.83604. PMID: 33364879; PMCID: PMC7751232.