Welcome to Dr. Warrick's podcast channel. Warrick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love. Hi, my name is Dr. Warrick Bishop and welcome to my podcast and videocast station. Today I would like to talk about NAFLD and NASH. Well, what are NAFLD and NASH? Well, NAFLD is the abbreviation we use for non-alcoholic fatty. liver disease now that's a pretty um it's a bit of a mouthful uh non-alcoholic fatty liver disease really defines problems with the liver with fat accumulation within the liver that is not driven by alcohol consumption which up until recent years has been the most common cause for fat accumulation within the liver well what's nash nash is non-alcoholic steato hepatitis steato hepatitis and that means fatty liver inflammation so nash is non-alcoholic steato hepatitis nash now the reason i wanted to talk about both of these is because what's happened in recent years is the prevalence of fatty liver has now become most linked to NAFLD, which can progress to NASH. Now, fatty liver from alcoholism, fatty liver from NAFLD can both progress to inflammatory processes, leading to a condition called cirrhosis. And you may have heard of cirrhosis, which is when the liver scars up and... Now, if that occurs with an alcoholic, it's called alcoholic liver disease and it's a disaster. And really the only way you can get around it is by consideration of liver transplantation. Well, in the last couple of decades, the prevalence of fatty liver with its origin from alcohol has now been surpassed by fatty liver. of non-alcoholic origin now what causes or drives non-alcoholic fatty liver disease well the main associations are really obesity so obesity and particularly morbid obesity are closely linked with the development of non-alcoholic fatty liver disease and if that continues for long enough then non-alcoholic fatty liver disease can progress to NASH, the non-alcoholic steatohepatitis, or the inflammation being driven within the liver. Now, morbid obesity is the single biggest driver, and unfortunately that's increasing in our community, and therefore the incidence of NAFLD, non-alcoholic fatty liver disease, is also increasing. Type 2 diabetes with increased weight is also a driver and really sitting under that are the things that are likely to cause fat accumulation in the liver. One of them is insulin resistance, which comes from being obese or type 2 diabetes or pre-diabetes syndromes. With the development of insulin resistance is a shift in the release of free fatty acids and some of the... Free fats that are generated within the liver, leading to the liver cells actually accumulating and holding on to fat within them. You can imagine if the cells are sitting side by side and they start to accumulate fat, then there's a distortion in the architecture. These cells, which should be neatly lined up, become bulgy and swell and really don't sit properly. And you can imagine that the architectural change leads to... functional change and that functional change can set off a sequence of events which really put the liver on a spiraling downward course. So not only is insulin resistance central to NAFLD but one of the other sugars which we see over and over can also be linked to the development of fatty liver and that sugar is fructose. Now, you may have heard of fructose and we hear of it on the telly and on the news and on documentaries with the Americans generating high fructose level syrup or corn syrup, which is used for flavouring within some of the takeaway foods. So this high level. Corn syrup, high-level fructose can end up within takeaway foods and be really problematic. But also remember that fructose is the primary sugar within fruit. And one of the things that I think we may have to reconsider or think about differently within our community is some of the advice we give individuals about fruit being healthy. Now, please don't take this out of context. In no way am I suggesting that fruit is not healthy. It's got fibre and antioxidants and nutrients. But for someone who's carrying excess weight, for a child, for example, whose parents are overweight, then this child may well be at risk of development of fatty liver if we're not careful in the advice we give. their parents and if we give that child fructose through lots of fruit and fruit-based products whether that's fruit juice or fruit wraps or dehydrated fruit or fruit out of its normal setting we may well be overloading that child's liver with fructose and driving fatty liver Well, if we do that for long enough, this fatty liver, non-alcoholic fatty liver disease, can progress to NASH, non-alcoholic steatohepatitis, which can progress to cirrhosis, and that's a disaster. So what might people feel if they've got NAFLD? Not much, generally, because a fatty liver is something you may not feel. But you might observe someone who's got a lot of central adiposity. Central adiposity, that's the word or the description we use for fat around the tummy. Central adiposity. So someone who's really carrying a lot of fat around their tummy may well have fat around their liver and fat in their liver. So they could be at high risk. The blood tests, the liver enzymes, may well give a clue that there's some derangement of the liver enzymes and the way they're working. These same people may have a little bit of fatigue. Occasionally, they may feel some distension. But if the condition continues from Nathal to Nash to cirrhosis, then we see all the hallmarks of liver failure. And that can be things like itch, red palms. We can see bleeding problems. And as it progresses to end stages, even jaundice, which is just, it's a disaster and really unable to be easily managed at all. There are a couple of advice or recommendations for people who may be developing NAFLD. And first and foremost is keep the weight down. You've got to keep the weight down because if you're overweight and you're driving insulin resistance, then you will drive fat accumulation within the liver full stop. Keeping the fructose down together with keeping carbohydrates down, and of course fructose is a carbohydrate, is absolutely critical. So you just got to do that stuff. It's really, really important. In fact, relatively recently, I had a patient who weighed in at somewhere around... 150 to 160 odd kilograms. We had been working for many years to try and get his weight down through dietary intervention. It just wasn't working. I had been tracking various other parameters, including his liver function. with blood tests and they started to go off i did ultrasound his liver for the very reason that i was concerned about non-alcoholic fatty liver disease and sure enough demonstrated features of not just early stages but progressive stages within fatty liver disease and a real concern that he may progress to nash the non-alcoholic steatohepatitis which is really the inflammatory process of non-alcoholic fatty liver disease and the the first step down the irretrievable road of cirrhosis. Well, this patient, with that information, I came back to him and said, my friend, we have to do something. If we don't get your weight down, you will die from a consequence of your liver eventually packing up and failing, let alone the other implications of carrying extra weight, which will be... development of diabetes. It will be worsening osteoarthritic issues. It will include obstructive sleep apnea. And of course, it's going to impact your lipid profile and some of the other parameters that we're looking after, including blood pressure. And although it's uncommon for me to do it for this gentleman, I recommend that he may seek a consultation or consider exploring bariatric surgery, which is the word we use. for surgery for weight reduction. I haven't seen the patient since his surgery but I have had a couple of letters, correspondence from the surgeon who undertook the procedure because he did elect to proceed with it and to date as far as I can recall he's lost somewhere in the order of 35 kilograms of weight and there's no question that this will have a positive impact on his liver function. and his general sense of well-being into the future. We can use a drug called ezetimibe, which I often combine with cholesterol-lowering agents, the statins, to lower cholesterol. But ezetimibe happens to have a role through the receptor that it operates through, the NCP1N receptor 2. Now, I can't remember the exact detail of that receptor, but take my word for it. It works through a particular receptor. which modifies development of non-alcoholic fatty liver disease. So if I do have a patient who has that insulin resistance, carrying too much weight, and they've got cholesterol levels, I have a low threshold for using ezetimibe in that case. Interestingly, I came across a paper just the other day which reassures us that in the setting of non-alcoholic fatty liver disease, that the statins are not detrimental to progression of the condition, and in fact, may be slightly protective. So, I've given you a big long spiel about NAFLD, non-alcoholic fatty liver disease. I've explained how that can, if it's not reversed early, progress. It can progress to... non-alcoholic steatohepatitis which is the inflammatory scarring process within the liver which can progress to cirrhosis which is really where the liver its architecture is mucked up the cells are damaged they're scarring and it just doesn't work properly and that without transplantation can be fatal and it's a disaster it's almost impossible to treat So what can you do? Well, please don't go so far down the road of carrying too much weight that this could be a problem. Be aware if the weight is building up, seek help. It is a complication of obesity that people are not aware of, not paying attention to, but it will kill more and more people. I strongly suggest that if you are carrying extra weight, that you explore whether it is excessive by speaking with your GP or your local specialist and putting in place appropriate remedies. Well, I hope you found this discussion about NAFLD and NASH interesting and informative. I hope it's given you some... insight into the importance of keeping a close eye to your weight it really flags fructose as a bit of a concern so do keep an eye out for that if you've got any queries or questions do drop us a line on info at drWarrickbishop.online and please if you've got any ideas for future podcasts i'd love to hear again drop us a note at info at drWarrickbishop.com no no no dot Until next time, of course, I wish you the very best. Live as well as possible for as long as possible. And bye for now. You have been listening to another podcast from Dr. Warrick. Visit his website at drWarrickbishop.com for the latest news on heart disease. If you love this podcast, feel free to leave us a review.
