Our fat livers

By WIN-SON YING

In last week’s article, we discussed the two different types of fatty liver – alcoholic fatty liver, and non-alcoholic fatty liver, as well as the risk factors that increase an individual’s chances of getting the condition. This week, we look at how common fatty liver is and explore the different approaches used in the management of this condition.

ALCOHOLIC liver disease, which is due to excessive alcohol consumption, includes alcoholic fatty liver, alcoholic hepatitis, and cirrhosis. The number of people dying from alcoholic cirrhosis (characterised by scarring of the liver) is usually used as an indicator of the prevalence of alcoholic liver disease in a population.

In the UK, death rates from alcoholic cirrhosis have shot up drastically – an 88% increase between 1974 and 1994. The highest increase was recorded in young men aged 35 to 44. Every year, seven out of 100,000 individuals in the UK die of alcoholic cirrhosis.

Essential phospholipids (EPL), which is isolated from soy bean, has been found to have protective, curative and regenerative effects on the membranes of liver cell. Basically, EPLs are incorporated into the cell membrane of damaged liver cells, replacing the lost phospholipids in the structure of the cell membrane.

In this part of the world, studies have been more focused on the other type of fatty liver – fatty liver which is non-alcohol induced.

Non-alcoholic fatty liver disease (NAFLD) is probably the most common liver disorder worldwide and has emerged as the most frequent cause of abnormal liver enzymes within the US. In our region, the Asia-Pacific Working Party for the study of NAFLD (APWP-NAFLD) has discovered that the incidence of the major risk factors for NAFLD is increasing dramatically in the Asia-Pacific region.

These risk factors include type 2 diabetes, obesity, glucose intolerance, as well as abnormal levels of lipids and cholesterol in the blood. Surveys show that the percentage of people with NAFLD in the general population across Asia varies from 5% to 40%.

Japan in the late 80s had a NAFLD prevalence of around 9 to 14%. This figure has increased to 30% over the last two decades due to lifestyle changes, which sees more obese and diabetic individuals in the Japanese population.

In our own country, 17 out of every 100 individuals are diagnosed with NAFLD. The chances of being diagnosed with NAFLD are even greater for individuals with concomitant risk factors such as diabetes, obesity, and unfavourable levels of cholesterol.

In a recent study carried out by the University Malaya Medical Centre (UMMC) on patients with fatty liver, it was found that 84% of them had the more severe form of fatty liver known as non-alcoholic steatohepatitis (NASH), and 11% of them had already developed cirrhosis.

The close association between risk factors such as obesity and diabetes with fatty liver was also shown in that same study, with more than half of the patients (59%) found to be either diabetic or have impaired glucose tolerance, and 77% of them found to be obese.

Lifestyle modification

Diet control and increased physical activity play an important role in the management of fatty liver. Lifestyle-mediated weight loss by reducing calorie intake and increasing activity is generally recommended to reduce liver fat content. Aerobic exercise reduces weight by preferentially decreasing visceral obesity while maintaining muscle mass.

Weight loss, diet and exercise have all been shown to improve liver enzymes, which in most instances are the first signs which warn you that something is not too right about your liver.

If you have fatty liver and find yourself gulping down a few pints of beer every night, it may be wise to give up alcohol. Your fatty liver is most probably alcohol-induced. The foundation of therapy for alcoholic liver disease is abstinence, which remains the cornerstone of treatment for this disease till today.

Treatments

The treatment of NAFLD patients usually focuses on the management of associated conditions such as obesity, diabetes mellitus, and high lipid levels.

Two classes of anti-diabetic drugs commonly used to correct insulin resistance are the biguanides (eg metformin) and thiazolidinediones (eg rosiglitazone and pioglitazone). The latter generally work by redistributing fat away from sites where it is not supposed to accumulate, in particular the liver.

Bariatric surgery is carried out only in cases where the patient is severely obese and fails to respond to lifestyle measures. The basic idea of this procedure is to reduce the size of the stomach in order to reduce the amount of food a person consumes.

Nutritional support such as essential phospholipids (EPL), which are isolated from soy beans, has also been studied in the management of fatty liver. During the reign of Emperor Sheng Nung (2838 BC), the soy bean plant was one of the five “holy cereals” and considered essential for human life.

In modern science, EPL administration is found to have protective, curative and regenerative effects on the membranes of liver cells.

Basically, EPLs are incorporated into the cell membrane of damaged liver cells, replacing the lost phospholipids in the structure of the cell membrane.

Some of the beneficial effects of EPL include:

·Formation and regeneration of the cell membrane, which helps maintain the structure and function of the cells

·As a component of bile, which aids in the digestion of fat

·Increases cholesterol solubility, which decreases the risk of stroke

·Antioxidant protection

The effects of EPLs have been found to be more pronounced the earlier they are given. Other nutritional support which contains silymarin (extracted from milk thistle) and betaine are also widely used.

Expected rise in Malaysia

The majority of fatty liver patients in Malaysia have concomittant conditions such as obesity and diabetes. With the prevalence of diabetes increasing globally, the number of fatty liver cases in Malaysia will also be expected to increase. The knowledge that more and more of us are indulging in sedentary lifestyles is not comforting either.

The prevalence of NAFLD in obese people has been reported to be as high as 80% in this region, which translates to eight NAFLD cases out of every 10 obese individuals.

A multimodal treatment plan which targets the underlying risk factors for fatty liver may be the best option to manage this condition.

To quote Paracelsus (1493-1541), “…because the liver is a source of many diseases, and is a noble organ that serves many organs, almost all of them: so it suffers, it is not a small suffering, but a great and manifold one”.

It is time for us to take our liver seriously and the onus is on us to keep it healthy.

References:

1. Amarapurkar, D.N. et al. 2007 “How common is non-alcoholic fatty liver disease in the Asia-Pacific region and are there local differences?”, Journal of Gastroenterology and Hepatology; 22: 788 – 793.

2. Chan, H.L.Y. et al 2007 “How should we manage patients with NAFLD in 2007?”, Journal of Gastroenterology and Hepatology; 22: 801 - 808.

3. E. Kuntz and H.D.Kuntz. Hepatology: Principles and Practice, 2nd Edition. Springer 2006, Germany.

4. Living in Britain - the 2001 General Household Survey. Department of Health. Cited in: http://www.netdoctor.co.uk/diseases/facts/alcliver.htm

5. Malik, A. et al 2007 “Non-alcoholic fatty liver disease in Malaysia: A demographic, anthropometric, metabolic and histological study”, Journal of Digestive Diseases; 8: 58-64.

6. Palekar, N.A. et al 2006 “Clinical model for distinguishing nonalcoholic steatohepatitis from simple steatosis in patients with nonalcoholic fatty liver disease”, Liver Int; 26: 151-156.

7. Preiss, D., Sattar, N. 2008 “Non-alcoholic fatty liver disease: an overview of prevalence, diagnosis, pathogenesis and treatment considerations”, Clinical Science; 115: 141-150.

This article is courtesy of sanofi-aventis.