NAFDL fatty liver and NASH (non-alcoholic)

Liver disease can have many causes, but when there is no cause for liver disease, it's known as NASH, non-alcoholic steatohepatitis or non-alcoholic fatty liver. The liver is a major source of detoxification in the body, and when it is overloaded, it will begin to develop fatty deposits, a sign that it is under stress. When alcohol abuse, drug toxicity and infection have been ruled out, what then could be the cause of liver disease?

NASH is a growing disease in Western culture. People with NASH often have co-morbidities, including problems managing blood sugar, high cholesterol, particularly triglycerides, and obesity. It is diagnosed by imaging studies, most commonly ultrasound of the liver, revealing hypertrophy and fatty masses on the liver. Liver function studies using blood tests are often elevated, indicating that the liver is struggling to keep up with demand and is inflamed. In some cases, a liver biopsy is required to rule out other causes of hepatic steatosis.

Symptoms of NASH are often subtle or non-existent, including fatigue, pain in the right upper abdomen or fullness in the right upper abdomen. Severe cases can result in abdominal swelling, red palms and jaundice or yellowing of the eyes and skin. The good news is that the liver is very regenerative and can begin to heal itself if the insult is removed and support is provided. Ideally, you want to start working to reverse NASH right away, the longer the liver is inflamed increases the risk of liver cirrhosis. Cirrhosis is a process where more permanent scarring begins to develop on the liver, rendering it unable to function. Fortunately, only 20% of people with unmanaged NASH will develop cirrhosis.

Traditionally, NASH patients are encouraged to manage NASH comorbidities through diet and exercise to maintain a healthy body weight, improve blood glucose levels and correct cholesterol abnormalities. This is often difficult to do without direction. Naturopathic doctors use a plethora of modalities to support liver function to treat NASH, from dietary alterations to supplementation to IV therapies. While each person is an individual and we treat each patient uniquely, the following are often staples in a treatment plan for NASH.

BOWEL TREATMENT

The gut-liver axis model has been instrumental in explaining the etiopathogenesis of hepatic steatosis (NAFLD) and steatohepatitis (NASH). The discovery of a key role for altered intestinal permeability (IP) in this pathophysiological framework has closed the link between antigenic/toxic substances in the intestinal lumen and systemic and hepatic inflammation in NAFLD and obesity, the metabolic syndrome. Recent evidence from the literature shows how IP can be modulated by several non-pharmacological and pharmacological agents and be the target of future preventive and curative treatment of NAFLD and NASH.

BALANCE BLOOD SUGAR LEVELS

Insulin resistance is present in almost everyone with NASH. Insulin is needed to transport glucose, energy, into the body's cells. Insulin resistance is a condition when the body's cells become resistant to insulin, making it difficult to bring glucose into the cells for energy. It has been found that insulin resistance can increase the supply of free fatty acids to the liver, thus increasing fat accumulation in the liver. (2) While the exact mechanism of the link between inefficient insulin use and NASH is not fully understood, what naturopathic medicine does know is how to balance blood sugar levels and improve insulin sensitivity.

Intermittent fasting is a diet that directly affects your body's ability to use glucose as an energy source. The idea behind intermittent fasting - fasting 14 to 16 hours a day, including nights - is that during this period of caloric restriction, your body will use fatty acids in the body to produce energy. As a result, fewer fatty acids are transported to the liver. Not only does the intermittent fasting dose encourage the use of fatty acids in the body, it also encourages calorie restriction. Overeating and lack of exercise are a recipe for excessive fatty acids being deposited on the liver.

Intermittent fasting has also been shown to improve insulin sensitivity, making it a favorable addition to the dietary recommendations for type II diabetics. The World Journal of Diabetes published a study on the effect of intermittent fasting on health markers in people with type II diabetes. The results of the pilot study were that it was a well-tolerated and generally safe intervention (3).

We've been taught to have breakfast every morning and eat every two hours to improve our metabolism, however, recent research is beginning to show otherwise. Intermittent fasting is not for everyone and needs to be modified to suit each individual person according to work schedule, family meal times, etc. The idea is to reduce calories overall and encourage the body to use its own fatty acid storage for energy, this can be achieved by other means too, but diet is the first place to start.

NUTRACEUTICAL AND THERAPEUTIC INTERVENTIONS

Many vitamins and herbal supplements have been shown to help support liver detoxification and relieve liver stress and inflammation. The following is not an exhaustive list, but can be used in various doses and combinations to help someone with NASH.

1. First of all, we need to take care of the intestines: intestinal permeability, dysbiosis, parasites, candida and mycosis, as well as the inflammation caused by these factors.
2. SAMe- S-adenosylmethionine- A molecule naturally formed in the body, which, when completed, serves as a precursor to the amino acid cysteine, which protects against free radicals, or toxic stresses, that can enter the body, including alcohol, pesticides, environmental pollutants . (4) The liver is the first place where these free radicals are neutralized and can be submerged, making SAMe an excellent addition to liver protection.
3. NAC-n-acetyl-cysteine-A molecule that encourages the production of glutathione, the liver's most powerful endogenous detoxification support. NAC has been shown to reduce stress on the liver, as demonstrated by liver enzyme blood tests. The dose of NAC depends on the individual, however, it has been shown to be a safe and effective supplement in people with NASH. (5)
4. Vitamin E supplementation with vitamin E has been shown to improve inflammation and fatty deposits on the liver. Vitamin E is a natural antioxidant that helps neutralize the oxidative effects of toxins on the liver, protecting it from further damage and enabling healing (6).
5. Glutathione - A super-potent molecule that is vital for supporting liver detoxification and protection among many other important roles in the body. Glutathione can be supplemented orally with advantageous benefit for studies of liver function in NASH patients. (7) Oral glutathione supplementation can become expensive and may not be as well absorbed as intramuscular glutathione injection or IV glutathione injection. Both have proven advantageous in improving your liver enzyme profiles. (8)

If you're struggling to know what to do about a NASH diagnosis, consider a nutritional and functional micronutrition consultation with us.

1. Scarpellini, Emidio & Lupo, Marinella & Iegri, C. & Gasbarrini, Antonio & De santis, Adriano & Tack, Jan. (2014). Intestinal Permeability In Non-Alcoholic Fatty Liver Disease: The Gut-Liver Axis... Reviews on recent clinical trials.. 9. 10.2174/1574887109666141216104334. 
2. Journal of Clinical Endocrinology & Metabolism | Oxford Academic. OUP Academic. https://academic.oup.com/jcem/article/91/12/4753/2656230. Published December 1, 2006. Accessed January 28, 2018.
3. Arnason T, Bowen M, Mansell K. Effects of intermittent fasting on health markers in people with type 2 diabetes: A pilot study. World J Diabetes . 2017;8(4):154. doi:10.4239/wjd.v8.i4.154.
4. CS L. S-adenosyl-L-methionine: its role in the treatment of liver disorders. - PubMed - NCBI. Ncbinlmnihgov . 2018. Available at: https://www.ncbi.nlm.nih.gov/pubmed/12418503. Accessed January 28, 2018.
5. Manouchehr Khoshbaten F. N-acetylcysteine improves liver function in patients with nonalcoholic fatty liver disease. PubMed Central (PMC). 2018. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3270338/. Accessed January 28, 2018.
6. Pacana T, Sanyal A. Vitamin E and nonalcoholic fatty liver disease. Curr Opin Clin Nutr Metab Care . 2012;15(6):641-648. doi:10.1097/mco.0b013e328357f747.
7. Honda Y, Kessoku T, Sumida Y et al. Efficacy of glutathione for the treatment of nonalcoholic fatty liver disease: an open-label, single-arm, multicenter pilot study. BMC Gastroenterol . 2017;17(1). doi:10.1186/s12876-017-0652-3.
8. Dentico P, Volpe A, Buongiorno R et al [Glutathione in the treatment of chronic fatty liver disease]. Europepmcorg . 2018. Available at: http://europepmc.org/abstract/med/7569285. Accessed January 28, 2018.