Early Signs of Fatty Liver Disease You Can’t Ignore | Dr. Yousef Elyaman

When you have fatty liver, unfortunately, too many providers, too many doctors take a look at say, oh, you have fatty liver, lose weight. They don't really talk to them about it again when really that is driving heart disease, it's driving Alzheimer's disease, it's driving cancer.

Well, welcome to the Doctor's Pharmacy. Dr. E as your patients call you, it's great to have you. Thank you. Honored to be here. Well, you know, we are both part of the Institute for Functional Medicine and trained physicians and practitioners how to think differently about disease and getting the root causes and something you've been focused on lately, which I think is really important and something I really haven't seen a really good approach to from traditional medicine is what we used to call fatty liver disease or non-alcoholic fatty liver disease. Because before there was just alcoholic fatty liver disease. Then we started eating all this sugar and crap. Then we have this epidemic of what was called non-alcoholic fatty liver disease and they just changed the name to metabolic associated liver disease because this is a metabolic nutritional problem. And the problem is in medicine, we've kind of neglected it because there were no good drugs. We like diseases with drugs. Oh, you got high cholesterol, I'll give you statin. Oh, you got high blood pressure, I'll give you a blood pressure pill. Oh, you got, you know, you know, whatever else you got, kidney failure, I got the drugs for you. But if you actually have NAFLD, which we used to call non-alcoholic fatty liver disease, are now called MAFLD, there's really no great conventional medicine approaches to it. except liver transplant when things get really bad. And so you spent a lot of time focusing on this condition. I just want to give the background a little bit about this condition because it's so prevalent. I mean, think about something that affects over a third of the population of the world. We're talking about 2 billion people with a condition that is not a benign condition, it's causing huge amounts of suffering that has actually linked to all sorts of things, obviously like type 2 diabetes, heart disease, cancers, gallstones, reflux, thyroid issues, kidney stones, depression, worse maternal and fetal outcomes, a huge increase in cardiovascular mortality, three and a half times the risk of heart failure, 1.93 times excess mortality from heart disease. This is a big problem. And traditional medicine just like, not that great at it. And I remember working with one of the top hepatologists at Cleveland Clinic, and they were desperate to have some solutions because all they could do was track the disease, follow the disease, give some people some general advice, hope it didn't progress, and then when it did, they'd need to go get a liver transplant. And here, you know, this is one of the conditions that is really underdiagnosed, underappreciated. We're gonna do a deep dive in talking about why this is important, why so many of you walking around out there have this condition, don't even know it, and why you should care about it. And more importantly, that there are very specific things that you can do from a diet and lifestyle and even a functional medicine perspective that can work to not only slow this down, but to actually reverse this really pernicious condition, which has really been neglected by the traditional medical community. But I'm glad to see there's more awareness and we're talking about it. I'm glad they changed the freaking name, because why are we talking about non-alcoholic fatty liver disease? We're talking about the truth of it, which is it's a metabolic problem caused by our diet. So, Youssef, tell me more about why has this become such an issue? Why is it something that, you know, didn't really exist that much when I was in training, except in a bunch of alcoholics. And now we're seeing 30% of the population globally having it and probably more in America.

So I think when we were practicing, we kind of closed a blind eye to it. I think it existed. We'd always, I think you remember in residency the incidental findings. I think it was kind of like the gluten thing. I remember we never wanted to diagnose anyone with celiac disease. because if we really didn't know what to do with it, we felt bad for patients. And once you actually take a look at it, you can come up with a solid plan. So the same thing with this, I think from what I remember in internal medicine residency, we just kind of ignored it. And I think that now it's becoming a little more popular partly because of the new drugs that they're developing.

Yeah.

I mean, that's the reality.

As soon as you have a drug for a condition, then that becomes something we promote, we advertise or see ads on television.

But the beauty, the amazing thing is, is that because we do functional medicine, taught by yourself and the other functional medicine founders here, but because we do functional medicine, we love that they're developing of these drugs because we understand the pathways. and we know how to modulate the pathway from a nutritional, nutraceutical kind of lifestyle point of view.

Yeah. So why do you think this is increasing? I mean, it clearly was there, obviously, when we were in training, but it's just exploded. We see 75% of the population is overweight, 42% are obese, 93.2% are metabolically unhealthy, which is essentially what this is, a metabolic associated fatty liver disease, right? So, 93% of us have some metabolic dysfunction. What's driving that?

So, one of the major things is food, right? So, food and insulin resistance is kind of at the top of the list. So, our food, there's more sugar being added to our foods. There's higher carbohydrates. But when you look a little bit deeper into it, high uric acid as well. So that comes from eating too much fructose. Fructose, yeah, so fructose.

High fructose corn syrup.

So we have high fructose corn syrup, alcoholism is on the rise. So alcohol is a toxin. So that also is going to affect the liver, along with small intestinal bacterial overgrowth. So bad bacteria in the gut, the gut can be as metabolically active as the cytochrome P450. And because of our current lifestyles, the bacteria in our gut or in our intestines are changing and they're changing for the worst. And there is an association between small intestinal bacterial overgrowth, which is one of the major causes of irritable bowel syndrome and having fatty liver disease. So, there's a- that's when you're bloated.

And you get a food baby after eating. Right bloating is because there's bacteria in your small intestine which should not be there. that then ferment the food that you eat, particularly starches and carbohydrates, that then give off all kinds of toxic metabolites that can then poison your liver. That's what you're saying, right?

Absolutely. Right, right. Yeah. What did you say, a food baby?

Food baby. Yeah, yeah. That bloating thing.

The food pregnancy. Right. Yeah. So if you, one alarming statistic, they looked at young men that were not overweight, and they found that they did something called a insulin resistance score test on them. And they found that more than half of them had insulin resistance. And these are young men in their 20s, not overweight, normal ideal weight. So I think that kind of brings us to one of the first drivers, which is this insulin resistance concept.

Now, just to kind of back up on that, stunning statistics. 50% of healthy, normal weight, 20-year-old men have pre-diabetes or some degree of insulin resistance, which is on the way to pre-diabetes. Yeah, they're blood sugar normal. And now they're measuring this by the new mass spec test from Quest, which is a really new test. So. Right. So just to back up on that, that there's a, the way we used to measure insulin resistance in the lab was a euglycemic clamp test. Super complicated, very called. And we now have a new test that is equivalent to that that sort of surpasses the tests we have been using, which are just serum insulin levels and blood sugar and A1C and a glucose tolerance test, which basically can give you a lot of information. But this new technique of measuring C-peptide, which is sort of like the initial fragment of insulin, and then insulin using a technique called mass spectrometry, through Quest, we can actually now be very, very good at predicting who has insulin resistance. And so insulin resistance seems to be the driver of fatty liver, correct?

It's the huge driver of fatty liver disease. I would say it's the number one driver, but there are eight or nine drivers. So what happens is that due to inflammation, due to toxicity, due to too much sugar, like too much of a sugar overload or a carbohydrate overload, when those receptors on our fat cells, we have these insulin receptors that are supposed to take sugar and put sugar into the cells. When they start to not work well, when they start to get resistant, there is an enzyme called hormone sensitive lipase. And what that enzyme does is it starts tearing up the fat in the fat cell. and it sends the fat to the liver and it overloads the liver. So now you have this liver that gets overloaded.

So.

The liver ends up with a whole bunch of triglycerides, which is one of the tests that we look on the lipid panel. Now, here's the interesting thing. So you could check a triglyceride level and their level would look okay. And that's because some people genetically will tear those, will decrease triglycerides in the blood, but what the triglycerides do, when you end up sending a whole bunch of triglycerides to the liver, they turn into something called VLDL.

Yeah.

And they call triglyceride, triglyceride rich VLDL versus triglyceride poor. And VLDL becomes, there's another enzyme found in the lining of our blood vessel. that is called lipoprotein lipase and it turns it into the tiny dense LDL, which causes clogging of the blood vessel and heart disease, strokes and heart attacks.

Okay, this is so juicy right here, I'm just gonna unpack a little bit because basically, just to kind of put things in context, in France, there's a delicacy called foie gras, which I probably didn't pronounce right, but foie gras, whatever, and that means in French, fatty liver. Now, most people think that if you eat fat, you get fat. And that fatty liver must be coming from all the fat we eat. But what you just said was that in fact it's not true that it's actually the sugar and refined starches and carbohydrates. The flour and the sugar that we're eating in pharmacologic doses that's overloading our biology and causing that carbohydrates to turn into triglycerides which then turns into fatty liver. and then you're in this vicious cycle where the fatty liver then creates all sorts of other problems. So let's kind of unpack what happens biologically when you have a fatty liver. You get a fatty liver and so your liver is looking like a fat goose or duck liver and you don't want to serve it on toast unless you're maybe handling lector. And then you've got a process going on in that liver that's just more than the accumulation of fat. So what are the things are happening in the liver that end up causing harm. You mentioned that the type of cholesterol we get because of that fatty liver is the dangerous small dense cholesterol we talked about in the podcast. We did a whole podcast on cardiovascular risk and lipid analysis. So the small dense cholesterol particles, which by the way, everybody listening, your doctor is not measuring when you go to get your cholesterol test. Less than 1% of cholesterol tests in America are for the right cholesterol test, which is called lipoprotein protein fractionation. And it's looking at the particle size, the particle number, the VLDL numbers. And you can get all that, by the way, through functionhealth.com/mark. It's a company I co-founded to allow people to get access to the right amount of information and data. So functionhealth.com/mark, you can get the right panel so you can see what's going on. And we also measure insulin, although I assume we're gonna be measuring this insulin.

Resistance score, which is very exciting.

Right, yeah.

So what's happening in the liver? So what's happening in the liver? So we can go back to what's happening in the fat and then go right back to the liver. So number one, the fat starts to send these, the triglycerides to the liver and start overloading the liver. If the fat, when that process is overloaded, then fat, then your fat cells, which actually your fat is, I don't know if you've done a podcast on this, but your fat is like an endocrine organ. It makes things like adiponectin. When the process is bad, adiponectin levels can go down, which causes more insulin resistance and more inflammation. And then there are other hormones that can go up in the liver that can cause inflammation, like tumor necrosis factor, like leptin. So those go up and now that inflammation and worsening insulin resistance and all that fat, make its way throughout the body and they go in the liver and the liver starts to accumulate and accumulate and accumulate and it just can't keep up with it. The liver packages it and sends it back to the fat. The fat takes it up but then because of the insulin resistant, it shoots it right back to the liver and you end up with this vicious cycle. In the meantime, the liver is not supposed to be storing fat. The liver is supposed to be making all these metabolic processes. It's supposed to repackage the fat. And now when it gets overloaded and jam-packed, now the liver starts to get inflamed, it starts to rust oxidative stress, sugar starts to get worse, and it kind of creates this metabolic nightmare.

It's like a vicious cycle.

It's a vicious cycle.

And what you're saying essentially is it's both an endocrine and an immune organ. So all the hormones that regulate weight, appetite, insulin resistance like leptin, adiponectin, these are hormones that the body produces to regulate your eating behavior and your way you process sugars and regulate inflammation, like you said, tumor necrosis factor-alpha or IL-6. These are cytokines. We heard about the cytokine storm. So, with the fatty liver, you're not just getting fat in there, you're getting this cytokine kind of increase that's driving systemic inflammation throughout the body, which it can explain a lot of the things we see with the increased rate of death and heart attacks and cancers and all these things that seem to be related to inflammation.

Right. And see, and the thing is, I mean, we could just go, we could probably do a whole podcast on when you have fatty liver, all of the other imbalances, all of the other things that are thrown off in the human body. Unfortunately, too many providers, too many doctors take a look at, say, oh, you have fatty liver, lose weight, and they move on, and they don't really talk to them about it again, when really that is driving heart disease, it's driving Alzheimer's disease, it's driving cancer. The liver is supposed to be metabolizing our toxins. So now your liver is not working. It causes hormone imbalances. The liver is supposed to metabolize estrogen. So now you can't metabolize estrogen. Estrogen goes up, progesterone goes down. Women start to have- Dr. Infertility issues? Dr. Infertility is big. They start to have mood issues. They start to have, they start storing more weight. And men, men start to have that estrogen effect. It blocks their testosterone. And it's kind of this, it just, it affects everything. It affects everything.

So men basically lose hair on their bodies, they grow man boobs, they have low sex drive, they low testosterone, just from having a fatty liver.

Right, right, right. So there's- Doesn't sound like fun. No, it's not. Well, I'll tell you now that we have technology, the non-invasive, easily accessible technology to take a look at the liver, When we tell people that their liver has fat in it or there's an issue with their liver, I have not seen a more motivating driver of change. As a matter of fact, when I see liver enzymes being up, I had a patient who I talked to her about, she had elevated liver enzymes. I said, I wanna take a look at your liver. I sent her to do this test, it's called a fibrosis scan. Before she came back, she had lost, she stopped drinking alcohol and she had lost 20 pounds. Amazing. Yeah, it came back, her liver was fine. But what happened when people hear that their liver, there's a problem with their liver for some reason, it creates that motivation, which I can tell them, hey, you're going to die of a heart attack and it doesn't... Yeah.

Yeah, it's interesting. But, you know, I think what you just point to is something really important, which is that this is a condition that's so prevalent. effects at least a third of Americans that is under diagnosed and that is the biggest risk factor for having a heart attack as anything else. Right. Like the level of magnitude of the risk of having a fatty liver for death, heart attacks, cancer is extremely high. Right. You have some of the data on that? Right.

Yeah, we could put them in, we can post them in the show notes. The heart attack. Yeah, yeah, we could put them in the show notes, the percentages.

Yeah, it's really significant. And I, and when I started reading about fatty liver years ago, I was like, wow, this is in and of itself a huge problem because it's driving all these other diseases that we're treating separately, but we should actually be treating the liver.

Right. And going so unfortunately in the conventional realm, unfortunately, we look at, we try to look at the disease kind of in a vacuum, right? Okay, so you have fatty liver. So what can fatty liver do? Well, the liver can start getting inflamed. and then it can start to turn into fibrosis or hardening and then you can get cirrhosis, right? And nobody wants liver cirrhosis, right? Liver cirrhosis, most people know that liver cirrhosis is a bad thing and then you can also get liver cancer. But like you just mentioned, they have more of a chance of dying of a heart attack than of the liver cirrhosis when they have fatty liver. So I think that's what you were alluding to.

Yeah, yeah, yeah.

Yeah, so it's so, but I think the beautiful thing and I'm so fortunate are grateful that I found functional medicine because we don't look at fatty liver as a disease in itself. We say there is a process that is happening.

Part of a syndrome that's happening.

Part of a syndrome. Now, and everybody is unique on what's causing it because some people, it's insulin resistance. Some people are eating lots of the way that their body deals with fructose. They start to increase uric acid. and it's the uric acid that is driving it, where other people can have thyroid dysfunction that's causing it. And others could have an issue with, can have an issue with bad bacteria in the gut.

Yeah.

So, so other people have a iron overload that is causing it.

Yeah.

And others were exposed to different toxins.

Yeah.

And it's probably a combination of, yeah.

I mean, I think this is really important. What you just, I just want pause there because from a traditional medicine point of view, it's like, okay, you know, we do a blood test, we do a fibrous, fibrous scan or MRI. We look at your liver. We do a biopsy. Hey, you have fatty liver disease. But the why is very much neglected. And, and, and there is some understanding that it's due to a high refined carbohydrate diet. But these other, and, yes, people understand hemochromatosis and iron overload, but the fact that, you know, the microbiomes involved, the environmental toxins are involved, that it may be thyroid dysfunction, that there's a whole list. of causes. And that's really where functional medicine is different than traditional medicine. It's root cause medicine that is ruthless around investigating the causes of a condition so that you can treat that person as an individual rather than treating everybody who's got this condition the same. If someone, there was a thing I read about years ago, it was a scientific paper about a guy who had liver failure but he was a golfer. And, you know, usually golfers, I'm not a golfer, but apparently they have to clean their balls and there's this ball cleaning thing on the golf course to get the dirt off, but he used to lick the balls to clean them. But there's pesticides all over the golf course. So he was getting toxic pesticide load in his liver and caused him to have liver failure. So we have to think about all the root causes and that's where functional medicine helps us to navigate. And then the gut role plays a huge role. thing too. And we don't really think about addressing the gut, but we know that how big a role the gut plays in affecting our metabolic health and our load of toxins. And, I mean, in medical school, we used to treat liver failure, which resulted in the inability to metabolize toxins from the gut, which caused basically delirium, something called hepatic encephalopathy. We treat it with the antibiotic and laxative. So basically to sterilize the gut, get rid of the bacteria that were poisoning the body, which is interesting because now we understand the microbiome has a huge role in mental health. But that was something we learned and it didn't really kind of connect with us in terms of a thing about the microbiome in medical school.

Right, right. It's a prebiotic. Lactulose is a prebiotic. So you're feeding the good bacteria. So we were like, we were manipulating the microbiome and we thought we were just making them poop.

Yeah.

Right. But it was, and it was amazing. It would take them out of that.

Yeah.

Hepatic encephalopathy.

Yeah. So, so basically what's going on in the liver is, is you've got a number of different things that, that are happening in our society, which is no, we're load of toxins, which is obviously our diet, which, you know, other factors that you mentioned, the gut microbiome changing dramatically, all driving this epidemic of fatty liver disease and, and. And now there's sort of an interest in kind of addressing this more directly in the medical field. We renamed the disease from non-alcoholic fatty liver disease to metabolic associated fatty liver disease.

And actually they changed that. So they first went to metabolic associated liver disease, then they changed it again.

Because.

They, yeah, whoever they are, the big panels, actually multiple panels got together and they talked to patients. but I think we should talk about that story a little bit, right? So non-alcoholic fatty liver disease was basically your naming condition by saying what it was not. It's not alcoholic. It was kind of weird anyway. But even though that it was called non-alcoholic fatty liver disease, people associated it with alcohol. Because alcohol was in the name. And then they have to explain it to their family. No, I'm telling you, it's non-alcoholic. So you had that negative. And then the fatty had a stigma, so they changed it to metabolic associated or a metabolic dysfunction associated fat liver disease, but then they changed it again because they're like, Fatty is stigmatizing so we don't we want fat out of it. So now it's metabolic dysfunction associated static or sta staadtic which means fat, liver disease. So no, stayatic, liver disease. So now you took everything out that anybody could understand.

You put a medical term on itosis which means fatty.

Right, right. But now they don't get shamed.

Now it's in Latin, so it's okay. Yeah, yeah, it's fancy. It's fancy. Whatever. So, that's the problem. And, you know, in medicine we call.

It the naming and blaming game.

We name the disease and we blame the name for the problem. Well, I know why you had that. Now it's called masaled. Masaled. Masaled. Okay, then there's, okay, forget about what it was called. We know this is a bad thing. We know it's increasing and we know that traditional medicine, you know, doesn't have a great approach. So, let's, I want to walk through how traditional medicine approaches this and then how we're going to approach this with a new perspective of root cause medicine and functional medicine, and then how we go about looking at the diagnostic tools we have to assess it and what are the therapeutic goals. So just sort of high level, what if you want to see a traditional hepatologist, you have fatty liver, what are.

They going to tell you? What are they going to tell you to do? Okay, so you go to a traditional hepatologist. They take- It's a liver specialist. Liver specialist. They see the patient. They tell the patient you have fatty liver disease, go ahead and try to lose weight, right? They may give them vitamin E. Probably you're gonna give them the wrong kind of vitamin E because we know that there's different forms of vitamin E. And then if you're lucky, many will say, no, don't stay away from vitamin E. And then they see if you're bad enough to be enrolled in a study. And if you are, then they'll put you on a drug, right? If not— Dr. Justin Because there's no FDA approved drugs for fatty liver disease. Dr. Justin There is one now. We just in March, we have one called Resmetrom and we should probably unpackage that later because there's information.

Yeah, yeah, yeah.

But yes, so there's finally one drug, it costs only $4,000 a month.

Is that it?

Yeah, that's it. And it can cause all kinds of side effects as well. Great. But that being, that being said, it's all about getting them, okay, we have a disease, we named it, right? We need to tame it with a particular drug.

But up until March before that, what would they be telling you?

Some would say ask your doctor if he would prescribe semiglutide for you.

Ozempic.

Ozempic. That's currently what they're-- weight loss.

Because when you lose weight, fatty liver gets better.

Right. So what would we do? We would take a look at the fibro score. Now, I do want to talk about this fibro score because this is the fibro scan because this is extremely But.

It'S back to the traditional medicine. Are they thinking that this is really diet related? Are they thinking that we should cut back on carbohydrates and starches and sugars? No particular diet. Do they really talk about a keto.

Diet or anything like that to help?

Traditional medicine is like lose weight. Lose weight. However you have to. Just lose weight, eat less, exercise more, come back in three months, and if.

It doesn't work, we'll put you on drugs.

Except, oops, there's no drug for this.

Yes, unfortunately we don't. So semaglutide. So okay, that was the big one. All right.

And then, and then, yeah.

So, and that's it. And then they just kind of leave you there.

Yeah.

And they, and most of them are not getting a fibro scan. Most of them don't know how bad it is. They don't know if they're, they have fibrosis, which is hardening or not. And they, and they just, they just kind of wait till things get really.

I mean, they might, if you're diabetic, which is associated a lot with diabetes, right? Because it's sort of the same condition, but earlier on, you know, they might give you metformin or they'll give you.

The ozempic or maybe some of the, although metformin hasn't been found to decrease fatty liver disease, it's kind of, but they may give you that. They definitely will say you have a high risk of heart disease, so make sure you're on a statin drug. So they will put you on a statin drug. And the problem is it's a double-edged sword. The statin drug can cause liver toxicity, but also it can change the way the lipid metabolism. So, you know, you may be hurting the liver, but you may be helping the heart. Right, right, right. So, kind of one of those.

And then if you're overweight enough, they'll say, why don't you have bariatric surgery? Bariatric bypass. So, clearly, you know, traditional medicine has not developed a good approach to this yet. And let's talk about the diagnosis part, because now there's some interesting new diagnostic tests. You just have to do a liver biopsy. It was an invasive procedure. It's risky. You kind of, nobody wants to get a liver biopsy. It was expensive. Now there's some blood work you can do. and some ultrasound technology that you can use to really diagnose what's going on. So talk to us about how people can find out. I don't know if I have fatty liver disease. What do I do?

I think the best thing to do is get a fibro scan. A fibro scan is ultrasound technology and it will come when they, it's very quick, it's non-invasive, and they give you two numbers, something called a CAP score and a fibrosis score. The CAP score tells you what percentage of your liver is fat, and the fibrosis score is how much hardening there is in your liver. The beautiful thing about that is before we had no idea how bad it was. And now I can give them a number. I could say around 35% of your liver is fat right now. I can put them on some sort of a plan and I can retest it. Recheck it, yeah. And I can see it get better.

Yeah.

And that is profound versus, oh yeah, you still have fatty liver disease. Oh, the ultrasounds are still showing fatty liver disease. or the ultrasound show you don't have fatty liver disease, but they do have fatty liver disease because ultrasound isn't sensitive.

Enough to pick it up. Right, right. So that is a game changer. And just to be clear, the first step is your liver gets fatty, and then it gets inflamed, and then it gets scarred, and then you have cirrhosis, and then you need a liver transplant.

Right, right, right. But some people go right from fatty without the inflamed. They go right from fatty, discard.

Yeah.

So some people do skip that step.

Yeah.

You, you think everything is good and then they end up.

So, but not everybody's going to get a fiber scan. So are there blood tests that will clue you into maybe you need one?

There are, there are. So this, we talked about, so the, the problem, if they have high triglycerides, they're, or if they have insulin resistance or if they have high blood sugar. So if they have any of those things, there's a high probability that they have fatty liver.

So, if you have a high blood sugar, if you have insulin, high triglycerides, low HDL, and maybe a high hemoglobin A1C, like over 5. Whatever, five, seven.

Yeah, four.

So, as all those numbers start to creep up, these are things you can get on a regular blood panel. The lipoprotein fractionation is more predictive and.

That'S what I was saying.

Better test. And, we do that with a Functional Health panel. So, you go to functionhealth.com, you can, get all these diagnostic tests for $499 for membership and do it twice a year and track stuff over time. And if you track these numbers, you can see that you're at risk. And maybe you have not only just that, you'll have elevated liver function tests, right?

So you might have been- Small density LDL. So the problem with triglycerides is some people have a high amount of what's called, it's an enzyme called hepatic lipase. So it takes, it lowers their serum triglyceride levels. but they have high small density LDL. So small density LDL, when that's elevated, that tiny, tiny bad cholesterol that you check on that panel that you do, that you have your people do, that not only can predict it, but because some people have it high but they don't have fatty liver. But if you have fatty liver disease and you see that number go down, the chances that they actually have some sort of a reversal of fatty liver disease are very high. that's what, that's what I'll use as a marker. You track your small LDL particles. You track it as it's getting better, their fatty liver disease is getting better.

That's been, that's been proven, too. And, yeah. And I encourage people to go back and listen to the podcast I did on, on cholesterol and cardiovascular. I talk about all these diagnostic markers that are not used in traditional medicine that should be, including this lipo protein fractionation. So these are tests are super inexpensive, super easy to do, but, but they don't tell the full story. So there's a newer kind of interpolation of a number of different biomarkers that are used, basically your ALT, AST liver function plus platelets plus your age. And, you get something called what? A FIB-4. A FIB-4 score. So, this FIB-4 score you can get through Quest, I don't know if LabCorp does it. And, you get this score that gives you a sense of, gee, I might.

Be having fatty liver disease, right?

Right.

And, anybody, so, like you said, they're looking at platelets and they're looking at AST and ALT. which are found, those things are found in regular blood work your doctor does. So if they didn't- the CBC and.

A chem panel, it's like basically your annual checkup.

Annual checkup stuff. Now, if they didn't add the FIB score to it, FIB-4, there's FIB-4 calculators. You put the numbers in the calculator and it'll give you the FIB-4. Now, here's the thing about the FIB-4. It really, the young, under 30, age 35 and older than age 65, it's not as accurate. But, what is it really telling us? It's telling us it's a predictor for hardening of the liver. Your liver could be jam-packed. Your liver could be the human figra, right? But, if it's not picking, if you don't have fibrosis, it's not going to show anything.

I see. So, this is only in the later stages that you're going to see this test be elevated, right? So, you might see the clues with the high triglycerides, high insulin, high glucose, you might see small particles of LDL, but you might not see the Fib-4 score up until you're already down the road a bit.

Right. And just pointing out those levels, the ALT and AST. So, those are called liver function tests. They're really enzymes that the liver has in them. The data is showing that the number, those numbers are supposed to be lower. So, ALT and AST are supposed to be less. Yep, it's supposed to be less than 30. Women less than 20. and the reference.

Ranges in the lab are like 40 or 50, right?

Right, they're up there. The other thing is, so what are they looking at? Why would that FIB-4, why would they be looking at platelets? Well, it turns out that the liver makes a hormone called thrombopoietin, and if you get hardening of the liver, it can't make thrombopoietin. So now your platelet levels start to go down. But drinking alcohol poisons the bone marrow and that lowers your platelets. So if they're actively drinking alcohol, it could falsely elevate it.

But it also can cause liver disease too. So it's kind of a- so basically the regular blood test you can get can tell you a lot. We're going to put all this in the show notes. You have to remember, you can get the function health panel at functionhealth.com/mark that gives you all of that except it doesn't calculate the Fib-4 score, but you can do it because all the data is there. Right. But there's another test that they do if this Fib-4 score is elevated called an ELF test. So can you talk about the ELF test? It's a little more advanced and what it is and what it means and who should be doing it.

Right, so the ELF test is also a marker of fibrosis. So what they do, there's three different, what we call biomarkers, or three different lab levels that can indicate that the liver is getting hard or getting that fibrosis. and you can end up with a score there. And, it's much more accurate. It's maybe 80 to 90% versus around 45%.

Because the first pitfall is just sort of interpolating from existing biomarkers. It is. It's actually looking for compounds or molecules that are elevated when there's a fatty liver or liver fibrosis, right? Right. It's gonna miss more. Like hyaluronic acid, pro-collagen peptides, tissue inhibitor matrix Yes. Metaproteases, these are all kind of big fancy medical words, but the things you can get on a blood test that are not your typical blood test. So, your doctor will have to ask for this or if you have a.

Fib-4 score that's high, you can go say, I want this. Right. And, this is where we, I think this is where the podcast today changes the world, right? Be aware that you could have fatty liver, see if you can get a fibro scan, if because they're popping up, places are popping up, left and right. And if you- Dr.

If your doctor has to order that.

Dr. Yes, or you can go, there are certain places that are trying to study medication where you just go get it for free. There's like research centers. So look for a fibro scan near you, maybe even pay, this may be worth paying self-pay for, but once you see that you have that fatty liver disease, reverse it before that FIB-4 is high, before the ELF is high, before the fibrosis, this is where I think if we can catch this thing early, we can make a significant impact on the health of the planet.

And so the ELF, what you're thinking is the ELF test, essentially this other test, is really just picking up scarring. Not necessarily just fatty liver.

And as a primary care doctor, when I see somebody with an elevated ELF, because they will see the Fib-4 high, and that could just be a false positive, I'll check an ELF, I'll check a fibro scan. and if I see a high fibrosis in them, they're gonna be, I'm gonna be co-managing them with a hepatologist. I'm gonna be more aggressive, but that's where it needs to go in the specialist. But like you said, with the amount of the percentage of the world that.

Has fatty liver disease, we don't have enough hepatologists. We need more of them. But I'm just gonna push back on you, so because even if you send.

Them to a hepatologist, what are they going to tell them? No, they're gonna hold their hand as.

They need a transplant. Well, that's exactly right. I mean, that's exactly right. That's the conversation I had with amazing man who's the chief of hepatology at Cleveland Clinic. We just don't have a lot to offer them. Could you help us? And, how do we start to get these patients to change their lifestyle and behavior? So basically, the bottom line is there's some great diagnostics on your regular blade panel. We'll put those in the show notes. There's some newer tests that you can get on blood work that can help. There's a great ultrasound that's not very expensive, non-invasive and has no risk that you can get to see what's going on. If you have potential elevations in any of these numbers or you're overweight, you're at risk. Even if you're not overweight, maybe you could see them. Yeah, you could see them. You're not overweight and be what we call a skinny fat person where you're metabolically obese, normal weight because you eat crap and you don't gain weight but you have fat on the inside. Right. But then you do all these great diagnostics and then what? Because there's no real treatment for it in traditional medicine. So, from a functional medicine perspective, how do you see this epidemic, what can be done about it in a practical way to help people reverse it? We now know how we can get it diagnosed. How do we start to think about it differently from a functional medicine? Right.

And this is where conventional medicine and functional medicine is going to be different. Conventional medicine says just lose fat, right? They studied it. They looked at whether low carb was helpful, high protein, whether a keto diet, and believe it or not, if you go on a keto diet and you lose weight, It will reverse this, even though you're eating fat, like you mentioned early on. What we're looking for is what is it that regardless of whether they lose weight or not, what will reverse this? Right? So Mediterranean food plan. There was data that showed that the Mediterranean food plan, which we— Is that pizza and pasta? Yes, yes. No, no, no, no. So it's a heart-healthy food plan. that they took a look at the healthy foods that people that lived in the Mediterranean, high in olive oil, high in vegetables, high in those foods, and they found the significant benefits benefit with mood, benefit with metabolic disease, but also independent of weight loss. If you go on a modified metabolic food plan, you will end up seeing an improvement. And IFM, the Institute for Functional Medicine, has one. that they call the cardiometabolic food plan. And that's what I give all of my patients. Say, let's start here, the cardiometabolic food plan. Also, you could have food allergies that is pushing this. For example, gluten, right? You could eat some people have fatty liver disease because they're eating a food that is bothering them and inflaming them. And you get them off the gluten or get them off the dairy or whatnot.

And because anything that causes inflammation will cause insulin resistance.

So it's kind of the mechanism is well known there. Right, decreasing fried foods because fried foods have something, end glycosylation end products, which when you fry foods, sugar with other molecules at high temperatures, it causes what's these toxins, these end glycosylation end products, and they will cause inflammation, something called oxidative stress, which is rusting, which worsens the conditions. decreasing those is extremely important. And also- Sugar, sugar, sugar. So I think everybody talks about the glucose, but we're not talking about the fructose piece, right? Fructose, if you look at high fructose corn syrup or just regular table sugar, it has sucrose and it has fructose. Fructose pushes the body to make uric acid. And uric acid tells the body, store fat. so it slows your metabolism, it tells people to store fat and it worsens fatty liver disease. And I believe you did a podcast on this.

Richard Johnson, yeah, people should go back and listen to that. We'll put the show notes on that. The uric acid is a consequence of really eating a poor diet, particularly one that's high in high fructose corn syrup.

And back to optimal levels. So according to Dr. Johnson, and this is what I go by, You want your uric acid level less than 5.5. Whereas the lab says about 7.8. Yeah, 7.8, something like that. And when they see that uric acid high, there are supplements that you can give them. And, there's also dietary changes that can be made.

There's cherry extract for that. It was great for gout and high uric acid and high dose of cherry.

Cherry, dark cherry extract, vitamin C, quercetin, maybe some green tea. Those things all can help. lower it. So if you have somebody that has.

Dr.

So if you have no, absolutely, sodas are going to really drive it. So you're, you can, you'd follow that glucose and insulin resistance score. If your sugar is already high when it's fasting, that's your main, you gotta work that there's some work. If you just have insulin resistance, that's still a problem. so with insulin resistance, there's things like berberine that can help, there's things like with alpha lipoic acid, n-acetyl cysteine that can help. So, yes, Mediterranean food plan, exercise, whether it's resistant training or cardio, cardiovascular training, both independent of weight loss will reverse fatty liver disease. So you can exercise and you can stay the same exact weight and you can still have that fat start to reverse.

It makes you more insulin sensitive. Makes you more insulin sensitive. I mean, this reminds me of an interesting study I read years ago where they did bariatric surgery. And basically, when you do bariatric surgery, you can reverse diabetes in, like, two weeks and reverse the fatty liver in a very short time. And yet they're still severely obese. Like, someone can still be 400 pounds. Maybe they lost 25 pounds. but they're still 375 pounds and diabetes goes away like that and fatty liver will improve because you're changing the food.

And changing metabolism. At one point, the heaviest man in the world actually had his blood sugar was normal and it was because of such a high adiponectin level. So there is the genetic factor but there's also the metabolism and the way that the body decreased sitting, of course, increasing steps, things like that. So we get them exercising. And I think the most important thing, and you mentioned this a couple of times, is that we really want to be careful of the catastrophic black and white thinking. Like, oh, if you don't lose weight, that's it. Because there are so many things that you can do besides that. We meet people where they're at, and not everybody's going to be able to do that. You can go on a medicine like Suma-Glucan, glutamate or like you said, it was epic and it could end up losing their muscle. And then what is it going to do? We see all kinds of side effects with that.

It was interesting. So just getting back to the diet part, because I think there's a lot of ways to skin a cat. You mentioned just a Mediterranean diet, which essentially is fruits and vegetables, protein, nuts and seeds, olive oil, healthy food, real food, not pizza and pasta.

Cut out the fried foods.

Yeah, cut out the fried foods. and so that's good. But, but do you need to be more aggressive sometimes in terms of cutting out more starches, like cutting out grains or beans or fruit, like, because we mentioned fructose, and we're like, oh, fructose is bad. Does that mean fruit is bad?

Because that's where fructose is found. So fructose is bad when it's in high amounts in a way that it wasn't found in nature. So in the form of a juice, not so good for you. In the form of a fruit, the fruit actually has the antidote in it. So when you get it as a balanced thing, the fiber is the antidote. Plus it has all the different colors of the fruits and vegetables have what they're called. Yeah, phytonutrients. And the phytonutrients actually will counteract and decrease uric acid. So, but I think it all depends. If somebody is in the beginning, they're excited, they're ready to do whatever it takes. Yes, you cut the sugar, you increase the you increase the healthy foods. But meeting people where they're at, we have to be careful of the all or none thinking because what'll happen is they'll say, oh, shoot, I ate too much sugar, so screw it, I'm just gonna eat a candy bar. And I'm not gonna do this anymore. And that's why, no, no, no, why don't we focus on what you should be eating or what you wanna be eating? Why don't you, okay, have maybe two servings of vegetables with that Snickers bar? So, I might just say Snickers, I don't know.

But you can say whatever you want. Okay. But wow. so. So given that you're trying to meet people where they are and help them not be overwhelmed and make the simple, small steps that you can see that could make a big difference. But if you had a perfectly compliant patient. Yes. And you wanted to create the fastest results to reverse fatty liver, what would you do? Would you put them on a ketogenic diet? Would you put them on a Paleo diet?

Would you put them on a vegan diet? What would you do? Mediterranean.

It would be the Mediterranean, the cardiometabolic food plant. So, even with option of really reducing the carbs, the carbs even more?

Reducing the carbs even more is logical, but now we have to look at the research we have available. And, the research did show all of those diets that you mentioned or food plans, I like calling them food plans, but all of them will help with fatty liver. But, the one that has been shown that reduces that will decrease fatty liver, but independent of weight loss is the Mediterranean. And that's why I think that should be the big. But do I have people that go low-carb and keto and it works? Absolutely. So no, that all intuitively, yeah, you cut the sugar, insulin resistance improves. But I think the focus on Mediterranean is you're focusing on healthy fats, which is something that you're a proponent of, right? You're also focusing on the fruits and vegetables. Those colors are they're medicines. They're medicines. So to tell them to just eat a bunch of steak and forget about the phytonutrients.

Semicoles is key because phytochemicals actually are active as support for liver detoxification and inflammation. You know, one study I read years ago was, was mice, a mouse study, and they gave mice alcohol, and then they watched what happened and developed fatty liver, and then they, they gave them alcohol plus. relatively high amounts of MCT oil, which is medium chain triglycerides and it comes from coconut oil and other places, but it seemed to actually reverse it. Can you explain that?

Yeah. So if you increase, what is MCT oil become? Ketobutyrate?

Yes, it's metabolized and absorbed differently than traditional fats. So it's absorbed directly into the body. It doesn't have to go through the gut.

Right, right. And you can use that as a fuel, which increases your efficiency of your receptors and decreases insulin resistance. I know that omegas are fish oils. One of the things that fish oils does is it, so healthy fats, if you give people healthy fats, phosphatidylcholine helps as well. It blocks some of those triglycerides from going back into the liver. So, it kind of stops the liver from getting overloaded as fast. So, I wonder if the MCT oil.

Works by that mechanism. Yeah, it was fascinating. I was like, wow, you could even be drinking a fish and take the MCT oil and it would mitigate the.

Damage to your liver, which I thought was interesting. Right, but I do work at the guest house, which is Substance Abuse and Trauma Center.

So, we're not proponents of drinking a fish. No, of course, of course not. I'm not saying drink and take MCT oil and chew your vitamin. I'm not saying that. to be clear. So just to back up a little bit about what you were talking about, diet's key. So cutting out the free fructose in high fructose corn syrup, just get rid of that 100% from your diet, number one. Number two, increase a diet that's high in phytochemicals, high in fiber, high in good fats, nuts and seeds, lots of fruits and vegetables, clean protein, some whole grains, beans can be fine, right?

Alcohol, stop the alcohol.

Stop the alcohol. stop the sugar, stop the Tylenol.

Stop the Tylenol.

Liver poison. And then you talked about exercise being really instrumental, so that's clear and I think everybody understands that. And you mentioned a bunch of supplements. So I want to kind of go down that rabbit hole with you because I find that using things that help support liver function can be extremely effective and it's actually in the published medical literature. In fact, one of the things we use for liver failure when people overdose with Tylenol, when they come into the emergency room, is something called Mucamyst. Now, I thought that was a drug because that's what I learned in medical school, but it's actually N-acetylcysteine or a supplement that gets turned into glutathione. And that rescues the liver from catastrophic liver failure and it's just a supplement. Now, the FDA is trying to take it off the market because it works so well, but it's something you can take to boost your levels of glutathione. which is the body's main repair antioxidant anti-inflammatory system. Right. So you mentioned that. What other supplements are in your top.

You know, five or six supplements? So I'd like to, I'd like to just elaborate a little bit on that, right? So that, that NAC, n-acetyl cysteine increases glutathione. Glutathione is an anti-rusting agent, right? We check a level in the blood called GGT. GGT tells me that you've been using up a bunch of glutathione and you have rust happening.

If it's elevated.

If it's elevated. So if they have elevated, if they have an elevated liver enzyme or if they, the ALT, AST or elevated GGT, I'm going to be giving them, I'm going to want to give them the n-acetylcysteine. The other thing is, is if they have an elevated GGT, that is a independent risk factor for fibrosis. So if you have high GGT, there's a high chance that you have fibrosis as well. And, and the, the, the, the the supplement that has been found to help is CoQ10. And I give the ubiquinol form, the unrusted form. So I don't know if you-- I know there's debates back and forth as does it matter if it's ubiquinol or ubiquinone? But there is data that supports giving ubiquinol with a high GGT can lower that GGT.

And there's two supplements. There can also be a clue of environmental toxic load too, not just fatty liver.

So we're talking about other causes besides just diet.

Right.

The triad. Elevated liver enzymes, higher than the optimal level, right? High uric acid plus high GGT. If you have those and they're not moving, they're not budging, you have toxic overload. They need to read your detox book.

Yeah, I mean, and that's something that people can learn how to do and I think it can remove some of the environmental toxins that can be loading the liver and just reduce their exposure. I was reading the other day that the average American has 22 pounds of food additives every year.

Yeah, which what's that doing? It has to go through the liver, right?

Yeah, it's not great.

So there's already, there's a couple of supplements, right? There's research that showed that vitamin E was helpful. Now, here's the challenge with vitamin E. The vitamin E that is normally pushed at the store, at the supermarket is called D-alpha-tocopherol. It is synthetic, right? It's not the way it's found in nature. In nature, there's eight forms of vitamin E. Alpha-beta-delta-gamma-tocopherol, alpha-beta-delta-gamma-tocotrienol. And if you start hitting the body with just one type in the synthetic form, what can we do? More oxidized. Well, more oxidized and it may be stopping the other forms from getting in. So you're creating a vitamin E deficiency.

By giving them vitamin E. Yes, what.

You get at your local drugstores.

Probably not the right form. So I switched to- We're gonna link to the right forms that contain multiple forms of mixed tocotrienols, which we call-.

The research that showed improvement in fatty liver actually showed the mixed, right? There is a supplement called phosphatidylcholine, and that stops some of the bad fats from getting into the liver and choline helps process fat. So phosphatidylcholine, I've been impressed with it. I've seen it work really well decreasing that fat.

It also detoxifies cell cell membranes. I actually recently did a test. We're here at the annual International Conference for Functional Medicine and I gave a little presentation yesterday and I shared my own case history of my illness when I was 36 and chronic fatigue and being over with mercury and mold toxins and everything. And, I actually did this test recently that's from Germany that looks at your cell membrane levels of toxins. And, I had mold toxins pesticides, plastics, heavy metals, you name it, I had it. And I did a course of intravenous phosphatocoline over the course of 10 weeks, twice a week, about 10 grams a time. So, it's like 2,000 grams, which is a kilo basically over time. And I redid my test and I was shocked to see that the levels of the toxins dropped dramatically, almost to normal, by repopulating my cell membranes with a better, newer form of the fat. So all our cell membranes are made of phospholipid choline and it helps to detoxify our liver. So I think this phospholipid choline can be helpful in many ways. And I think you can take it orally, you can do it intravenously. I want to back up a little bit because you were talking about these tests, you know, uric acid, GGT, and all these other lipoprotein fractionations. Typically, when you go to the doctor for annual checkup, they're not checking uric acid, they're not checking GGT, they're not checking insulin, they're not checking liver protein fractionation. So these are available through Quest or LabCorp. They're really easy to get and they're not that expensive. In fact, with Functional Health, sorry to harp on this, but you can get all these tests and lots more for $499 membership for twice a year testing and track your numbers over time and sort of have a health co-pilot that tells you what it means and what to do about it. It's so important to know what's going on in your body because most medicine waits till you have a serious problem and then they come in to rescue you and treat it. They don't see the subtle slow changes that you can pick up as clues in your blood work early on that you have to know because if you don't do it, like I said, 30% of Americans or more are walking around with this problem. It's invisible, it's painless, it has no symptoms that is extremely risky for a whole range of chronic diseases, including heart attacks, cancer, stroke, you know, dementia and more, infertility, whatever, and, and it's just not being diagnosed. So, so I encourage you to just get checked, you know, test, don't guess. Now, in terms of the next sort of set of supplements, we've got n-acetyl cysteine, we've got vitamin E, but the right form of mixed tocopherols. And, and I'm linked to that in the show notes of what, what would be the optimal forms to get. What else should people be thinking about?

Coq10, right? Coq10 in the right form, ubiquinol. If it's an oxidative stress thing that we're working on, then you can consider things like alpha lipoic acid as well. It's a powerful antioxidant as well and it can help lower sugar for insulin resistance. We already kind of talked about the high uric acid. If your uric acid is higher than 5.5 in a post-menopausal woman or in a man, or in a woman that is having periods, it should be less than 4.5. So if that uric acid is high, you already mentioned the dark cherry extract. We also talked about quercetin. Quercetin helps with multiple things.

What does that do?

So it's a mass cell stabilizer, but it helps the body excrete uric acid.

So it's basically from plants.

Yes.

Onion, the red, yep, berries and different things.

Apples.

And it turned out to be very effective in COVID. It's great for longevity in the research of course, Dan. It's in Himalayan Tattari buckwheat at high levels, which is something that we talked about on the podcast before with Jeff Bland that is really showing immunorejuvenating properties and actually reversing biological age. So I think this is a very important supplement that most people probably don't know of. Right. But has many, many effects. It works on also on AMPK, which is one of the longevity switches that regulates insulin resistance. So, it has so many benefits. But in terms of fatty liver specifically, it can help lower uric acid and.

Help improve fatty liver. And may lower iron because the liver starts to accumulate iron. Whether you have hemochromatosis or not, you can start accumulate iron. So, that's milk thistle. So, then there's another one.

Yeah.

Milk thistle also helps detox.

So, what does that do?

That helps with detoxification as well but also may lower iron and inflammation. Helps with liver inflammation.

What about minerals and vitamins like selenium?

Now when we start looking at liver function, one of the tests that I like looking at is a homocysteine. Because if your homocysteine is high, then the way that you're processing some of the B vitamins is off, which and then you get a backup in detoxification so your body can't get rid of toxins, your body can't make neurotransmitters, it could lead to depression, anxiety, insomnia, and all of those things. I'll check the homocysteine. If it's high, you consider checking that MTHFR gene mutation, which is you need in order to lower homocysteine, you need the activated form methylfolate.

So, if you have this weird gene this enzyme, which about 35% of people don't have the proper enzyme to convert the inactive to the active folate. Right. So, you get problems including bad liver, cancer, heart disease, you name it, dementia. So, you can check that in a blood test.

Again, it's not in your regular lab, but it is on the function panel.

Right.

So, if that in your panel is homocysteine in there? Absolutely.

Yeah.

So, what about MTHFR? That's an option. Okay. So, if their homocysteine is high, check that MTHFR. and then you support them with B vitamins. You can support them with things like taurine, Omega-3s again, because Omega-3s, we didn't mention, but Omega-3s can reverse or decrease.

Fatty liver disease as well. Yeah, so Omega-3s, so we got a cocktail here. We got n-acetyl cysteine, we got vitamin E, the right forms, mixed tocopherols. We've got milk thistle, we've got ubiquinol, we've got alpha-lipoic acid. That's a good cocktail. And of course, making sure you're gonna be complex and multi-mineral, right?

Right, right.

And, so all that is required to make all the metabolic pathways in the liver work properly.

Right, and then let's not forget curcumin. Yeah, curcumin may help as well. And, curcumin is good for heart health.

And for, so yeah, so curcumin is basically found in curry and turmeric, right? You can take that as a supplement. Again, very important. And again, we're gonna link in the show notes to what products and things are the best in class there because there's a lot of junk out there. You want me to do that? Now, it seems like a pretty straightforward plan. It's diet, exercise, stop drinking, stop taking drugs that damage your liver, and then be on a number of supplements that can help support optimal liver function.

But personalized medicine, functional medicine, right? So you see what their imbalance is and you give them supplements based on the imbalance. Not just, and first the lifestyle. Actually, you can give a good go at lifestyle, Mediterranean food plan, Omega-3s, and just see what happens. Mind you, they've already ruled out other causes of liver disease. Their doctors already told them, no, yeah, what you have is fatty liver disease, it's not something else, because other liver diseases can turn the liver to fat. But once we know that, start with that and then re-follow those things that are ab, find out what their abnormalities are and re-follow them and make it more personalized.

And, the beautiful thing about liver is it regenerates. It's one of a few organs, if you cut your liver off, and give away half your liver, it'll grow back. Right, right. So if it's like a salamander or like growing an arm, except it's one of the few organs. So if you actually can give a liver part of your liver to somebody else as a transplant and you're still alive and have a liver, right, to grow back, which is pretty cool. So it has a lot of capacity to regenerate. So tell us in terms of this approach, when you have someone come in with fatty liver, whether it's, you know, more advanced stage or a less advanced stage, what kind of results are you seeing?

Can you share some cases of patients who've had this?

And they followed this approach and actually reversed.

Right, no, there are tons of cases that follow, so it goes anywhere from at least improving their markers, their blood markers, and improving their fat in the liver to people that had fatty liver that no longer have fatty liver. Like it is, using this personalized approach, it works. We see it. And the beautiful, I tell you the most frustrating thing for me, I hated even getting into fatty liver. I hated talking about it because I tell them they have fatty liver and then tell them to lose weight and then how do I know if it's getting better or not? I have no way of telling. And now I'm so excited that we have ways of telling. Dr. And the other scary thing. So I'll tell you about a case I had too. A lady who had fatty liver disease, was told she had fatty liver disease years ago, right? And now we have this technology, she's coming and seeing us. We do the fibro scan and it shows high fibrosis and we do a biopsy. She has cirrhosis. Now, probably saved her life because we get her in a study, we work on a functional medicine approach. But imagine, like this person knew years ago she had fatty liver disease, but instead of the only thing she was told is, yeah, lose weight. And sometimes they do it without even thinking that they will, right?

So the problem with, you know, traditional medicine is like we say, okay, you are, you know, diagnosed with this condition and there's, here's this one drug, take this pill to fix the disease.

Right.

But with functional medicine, it's, it's multi-causal and multimodal treatment. In other words, there may be many factors. So you might have to clean up the gut. If people have dysbiosis or bacterial overgrowth, you might have to get rid of environmental toxins. If they're, you know, not filtering their water, they're eating too much tuna or they're having exposure to all kinds of chemicals in their environment. You might have to do a lot of things to kind of help reduce the risk. So we do multiple things, diet, exercise, supplements, other factors, reducing toxins, fixing the gut. That's the whole functional medicine approach. What are you seeing in terms of the kind of data on this? Are there studies that show multimodal treatment approaches because it's not how we study things in medicine. Have you done or has anybody else done studies that look at collective interventions to actually see what kind of change we can get in this?

As far as I know, there is no study that does like the Bredesen Protocol that follows a multimodal approach. All I can tell you is in our clinical practice, we have seven providers, we take insurance, we have Where we actually the FibroScan company knows us really well. The company that is doing this research knows us really well because we send so many people to get FibroScan. We just open the floodgates and send them through. But we have probably done thousands of FibroScan because of this in the last couple of years. So we're able to see the changes. We're able to see the changes. But it's very different. If they normalize, they get- People normalize all the time.

Yes, and this is the problem. And I think, you know, it's like the way medicine works and the way medical research is done is, okay, let's see a fatty acid, let's just give you vitamin E and see what happens. Or let's just give you a little exercise, let's just give you milk thistle and see what happens. It's the wrong way to do it because you have to treat all the things. You can't just treat the one thing and you have to fix all the dysfunctions. So that's really the beauty of functional medicine. And I think, It's stunning to me that we have something that affects a third of the population and nobody's doing any real research on how to actually fix this. Now, there are drugs that are in development. Maybe we can spend the last few minutes talking about what's on the horizon, what's the future of this, and how do we start to think about it? Because it's a little scary to me. I was at an obesity conference, a pediatric obesity conference. I met this guy here who was a hepatologist, a liver specialist in kids. I'm like, what are you doing here? He's like, well, you know, all these kids drinking soda all the time at 15, they're needing liver transplants.

Oh, God.

Liver transplants in kids from fatty liver. So tell us what the future looks like.

Yeah. So the future. The future looks like these drugs being developed, one drug per per condition. that have side effects and there is a role for them, right? But also the future looks like us unpackaging and we could take this new drug and unpackage it as functional medicine providers, right? But maybe that'll be a nice end of the show or however you want. But we take all of this information and we unpackage it and we use a functional medicine approach. So there are things called PPAR gamma agonists. There's a drug coming out that is PPAR alpha, gamma, and delta. There's anti-inflammatory, there's anti-inflammatory drugs coming out. And the one that just got approved, this red metronidazole, if you look at what this is, resmetrom, the thyroid gland, the thyroid gland makes thyroid hormone. And for thyroid hormone to work, It has to bind to what's called the thyroid receptor. There's two types of thyroid receptors, alpha and beta. Alpha will be in some areas of the body, beta will be in other areas. Alpha is found in the heart. One of the problems with just giving people a bunch of thyroid medicine and why we're very careful with giving thyroid medicine is because it could over excite the heart.

It's a super high heart rate and-.

Arhythmia, stroke and death, right? That's why, I mean, otherwise just give people thyroid, let them lose all the weight.

Right?

Because it's a metabolism hormone. So, what this does is that this is a beta agonist and a beta is found in the liver but not found in the heart. So, it stimulates the liver. Now, it does have its side effect. It's a thyroid pill for your liver basically. Just for your liver. Just for your liver. But then what happens if you give the beta without the alpha? Is that going to lower the effect? I mean, there's so many questions on.

What the long-term effects are going to be and how big of a an improvement is there?

There was a significant, I can't, I need to look at this. But there was a significant, it was enough to like to get the FDA approval, but I, it didn't seem like it was enough. No, you're right.

I don't know the number. I guess if you compare it head to head with an aggressive lifestyle and functional medicine approach. Yeah, by far.

It would outshine this drug or any future drug.

100% so, so we're looking for the quick pick, quick fix and the quick pill, but it's not coming.

But we as functional medicine providers now unpackages unpackaging that, unpackaging that. What we know is that when we are stressed, our body wants to hold on to fat, right? Because our ancestors, when they were stressed, it was because their life was in danger. They either couldn't find food or something was trying to make them food. You have to slow down your metabolism, right? And you can't slow down if you don't want to turn off the thyroid. But what happens is that TSH, that signal that comes from the brain still works. But instead of making T3, you make reverse T3. And reverse T3 blocks your thyroid. And if you look at conventional doctors, they don't check reverse T3, right? So, the very quick pearl that I would now that I would add to the fatty liver disease plan is I would do a full thyroid panel. I would TSH, free T4, reverse T3, total T3, and thyroid antibodies. And there is-- and by the way.

Your traditional doctor doesn't test all of them. They just check a TSH and they don't look at all those thyroid antibodies. They don't look at T4, T3, sometimes.

They look at G4, and they for sure don't look at-- the rock stars. Rock stars look at T4, but beyond that, forget it. So now what happens, T3 is the more active hormone anyway. The T4 has to become T3. There's debate on whether T4 has an effect or not. That being said, when we're looking at those ratios, we look at the T3 reverse T3 ratio, and we're trying to make sure that that number is greater than six. If it's less than six, we know something is happening and they're not converting. So we work on stress management. There are supplements to give to lower cortisol. We can check cortisol levels. And there's now another herb. There's an herb ashwagandha. Ashwagandha can help convert.

Say it again. Yes.

Okay. And there's an herb called Ashwagandha. And Ashwagandha can actually help convert your T4 to T3. Now, there was a case study showing liver disease with, or liver, elevated liver enzymes with Ashwagandha. You have to make sure you get a clear source. You have to make sure you're following those liver enzymes. And if you start one supplement and the levels go up then, but optimizing the thyroid, that what the new $4,000 a month drug does. We can take that information and say, this is another piece to the puzzle. So, I need to make sure I do comprehensive thyroid panel on my patients that have fatty liver so that I can start working on that.

I mean, honestly, you take that $4,000, you shave it down dramatically and give people free food for six months. It would cure their fatty liver disease. But, I'm working on that in Washington. this is amazing. I think, you know, I, I really, I really think this is an important new awareness. And we were talking earlier before the podcast about how people, people are now starting to recognize this and hearing about it. It's more than news. There's articles and newspapers about it. And I think it's a good thing because up to now it's been sort of neglected by doctors because doctors don't like to check things they can't do anything about. Right. If they can't do anything. But now, and, and I don't think they're doing anything about means drugs. I think it means actually figuring out how to deal with the root cause of it, which is primarily lifestyle. But it's also the things you mentioned, like environmental toxins. You know, the good news is, you know, you, you do a lot of work to train Physicians, and, you know, we certainly do that at the Institute for Functional Medicine, but you have your own training course, and people can go learn about mafold D or whatever you want to call it. What do you call now? Masher.

Mazed.

Mazed. And And, it's mfpessentials.com, and it's a course for practitioners. But, if you're not a practitioner, you want to learn more about it, you can. I think everybody needs to really understand they need to get checked, they need to get tested. This is really common. It's life-threatening, it progresses if you don't do anything about it, it's invisible, it's symptomless. But, the good news is there are clear strategies, particularly through a functional medicine lens, of how to diagnose it and treat it effectively. So, I really want to applaud you for bringing this to awareness for, you're here, I'm going to give a talk at the Institute for Functional Medicine's conference and I'm excited to hear that talk and I think everybody should be very excited to go get these lab tests and go get checked. So, just quick reminder, functionalhealth.com/mark, if you want to skip the 200,000 person wait list, you can kind of learn about what's going on in your body and be empowered to be the sea of your own health. learn from what we have. And we'll put all again all this in the show notes. Yosef, it's been great to have you on here. Thank you so much for the work you're doing and just making the world a better place.

Pleasure is mine. Thank you so much.

I don't know how you take care of your seven kids and are part of 15 siblings, but God bless you.

Thank you.

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