Naturopaths Make Better Livers

by Steven Sandberg-Lewis, ND, DHANP

A previous blogpost I wrote is entitled Insulin Resistance - Underlying Cause of Common Health Problems. It describes a very common imbalance in blood sugar, blood fat and cellular responses to insulin. Insulin resistance affects at least 25% of the population (Powell EE 2021). In addition to increasing risk for heart disease and stroke, it can also cause liver disease. Until recently this was called Non-Alcoholic Fatty Liver Disease (NAFLD) and Non-Alcoholic Steatohepatitis (NASH). Steatosis is the medical term for excessive fat within an internal organ. Steatohepatitis is a type of hepatitis that involves excess fat in the cells that make up the liver. As you might suspect, these forms of liver disease are much more common in prediabetes, diabetes and obesity since all of these are often associated with insulin resistance.

Other factors that can drive this condition include common medications (i.e. estrogen therapy, corticosteroids and calcium channel blockers), toxic exposures (i.e. benzene, toluene, styrene), small intestine bacterial overgrowth (SIBO) and various forms of bariatric surgery.

 There were at least three problems with the previous terms NAFLD and NASH:

1)    Having the word “alcoholic” in the names was considered stigmatizing even though the actual term was “non-alcoholic”

2)    The word “fatty”, although correct, was also not flattering

3)    The names did not refer to the underlying cause, which is metabolic syndrome

 The recently updated terminology is Metabolic Dysfunction Associated Steatotic Liver Disease (MASLD) and Metabolic Dysfunction Associated Steatohepatitis (MASH). Because these terms are such a mouthful, I will use their abbreviations.

With insulin resistance the liver produces and accumulates more fat. If  disease progression stops at that stage, there is rarely any serious disease. MASLD occurs when at least 5% of the weight of the liver is fat. When free radicals oxidize the fat, toxic stress for the liver cells occurs. It causes steatohepatitis - inflammation in a liver that also has an increased fat content. At this stage it is called MASH.

Diagnosis of MASLD is made when the fat changes the liver’s appearance on ultrasound, CT scan or MRI of the abdomen. Unfortunately, these changes may not be seen with these imaging studies until the liver contains 15%-30% fat, so it may not be diagnosed until later stages. With the oxidized fat in MASH there is also an increase in blood levels of ALT and AST which are also called liver enzymes or transaminases. Inflammation causes some of the liver cells to be destroyed, leaking their internal enzymes into the blood. If things progress, scar tissue (also called fibrosis) is formed which can alter the structure and function of the liver. If not diagnosed or if allowed to continue, this can lead to liver cirrhosis.

Determining the stage of various causes of liver fibrosis (i.e. MASH) starts with a formula called FIB- 4. You can figure your FIB-4 for yourself with the following information: age, platelet count, ALT and AST levels.  One on-line calculator is found at https://medicalcharthelp.com/fibrosis-4-fib-4-index-for-liver-fibrosis-calculator/ As long as the FIB 4 is less than 1.3 there is no significant fibrosis. The FIB-4 should then be recalculated every 1-2 years using updated blood tests and age.

When the FIB-4 is above 1.3 a special form of ultrasound called elastography is used to measure the stiffness of the liver. Fibrosis causes the liver tissue to become stiffer than that of a healthy liver. Advanced fibrosis causes cirrhosis and that is what we want to prevent.

Another test that can be used at this juncture is the Enhanced Liver Fibrosis score (ELF). It is a blood test measuring three unique markers of liver fibrosis. If this calculation is greater than 7.7, it is also a sign that fibrosis is advancing. If either the FIB-4 or the ELF are elevated, steps should be taken to prevent further progression of MASH. In more advanced cases, a patient may be referred to a hepatologist – the term used for physicians who specialize diagnosing and treating liver diseases.

Most treatment starts with gradual weight loss, although this does not apply to one form called lean MASH which occurs in people who do not have a waist circumference above 35 inches (female) or 40 inches (male). Rapid weight loss can intensify MASH so the loss should be tempered. Avoidance of alcohol is recommended by some, but the research is mixed. Less than 14 grams of alcohol per day (1.5 drinks) is the general rule if alcohol is consumed. High fructose corn syrup should be completely avoided.

Treatments to resolve insulin resistance are complex and involve diet, physical activity (i.e. daily walking), and avoidance of toxic exposures. Vitamin E is the only nutritional supplement recognized by the FDA for MASH, and resmetirom is the only approved prescription medication. Four other drugs are in the process of being researched.

There are many natural agents that I use to help my patients with MASH. Some examples include alpha lipoic acid (Valdecantos MP 2012, Tutunchi H 2023), N-acetyl cysteine (Dludla PV 2020), magnesium (Dibaba DT 2014), and B vitamins (Tripathi M 2022). Numerous herbs have important roles such as Silybum marianum/milk thistle (Jiang G 2022), and berberine containing herbs such as Berberis vulgaris /barberry (Kashkooli RI 2015). I find that hormonal balance, especially for the adrenal hormones, is essential for balanced blood sugar and insulin sensitivity. Treatment of small intestine bacterial overgrowth (SIBO) is also important to reduce liver stress and inflammation (Gudan A 2023).

Citations:

Powell EE et al. Non-alcoholic fatty liver disease. Lancet. 2021 Jun 5;397(10290):2212-2224. PMID: 33894145

Valdecantos MP et al. Lipoic acid improves mitochondrial function in nonalcoholic steatosis through the stimulation of sirtuin 1 and sirtuin 3. Obesity (Silver Spring). 2012 Oct;20(10):1974-83. PMID: 22327056 

Tutunchi H et al. Clinical effectiveness of α-lipoic acid, myo-inositol and propolis supplementation on metabolic profiles and liver function in obese patients with NAFLD: A randomized controlled clinical trial. Clin Nutr ESPEN 2023 Apr:54:412-420.PMID: 36963888

Dludla PC et al. N-Acetyl Cysteine Targets Hepatic Lipid Accumulation to Curb Oxidative Stress and Inflammation in NAFLD: A Comprehensive Analysis of the Literature. Antioxidants (Basel). 2020 Dec 16;9(12):1283. PMID: 33339155

Dibaba DT et al. Dietary magnesium intake and risk of metabolic syndrome: a meta-analysis  Diabet Med. 2014 Nov;31(11):1301-9. PMID: 24975384

Tripathi M et al. Vitamin B12 and folate decrease inflammation and fibrosis in NASH by preventing syntaxin 17 homocysteinylation. J Hepatol. 2022 Nov;77(5):1246-1255. PMID: 35820507

Jiang G et al. Hepatoprotective mechanism of Silybum marianum on nonalcoholic fatty liver disease based on network pharmacology and experimental verification. Bioengineered. 2022 Mar;13(3):5216-5235. PMID: 35170400 

Kashkooli RI et al. The effect of berberis vulgaris extract on transaminase activities in non-alcoholic Fatty liver disease. Hepat Mon. 2015 Feb 5;15(2):e25067. PMID: 25788958

Gudan A et al. Small Intestinal Bacterial Overgrowth and Non-Alcoholic Fatty Liver Disease: What Do We Know in 2023? Nutrients. 2023 Mar 8;15(6):1323. PMID: 36986052

Steven Sandberg-Lewis, ND, DHANP, has been in clinical practice since his 1978 graduation from NUNM. He has been a professor since 1985, teaching a variety of courses but primarily focusing on gastroenterology and GI physical medicine. He is the author of Let’s Be Real About Reflux - Getting to the Heart of Heartburn and the textbook CLINICAL GASTROENTEROLOGY. Both are available on all online bookstores such as Powell’s.

Hive Mind Medicine blog posts are for educational purposes only and are not intended as medical advice. Please consult with your health care practitioner for personalized guidance.