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The Dose Transcript for April 12, 2023

Host: Dr. Brian Goldman

STORIES FROM THIS EPISODE

BRIAN GOLDMAN: Hi, I'm Dr. Brian Goldman. Welcome to The Dose. This week, we're going to tell you about an incredibly common condition that you've probably never heard of. It's called nonalcoholic fatty liver disease. It's estimated that a quarter of Canadians are living with it, but many don't know it because it doesn't have noticeable symptoms and probably nobody's told them about it. And left undiagnosed and untreated, it can lead to serious complications, at least for some people. So this week we're asking, what do I need to know about fatty liver disease? Hi, Alnoor. Welcome to The Dose.

ALNOOR RAMJI: Hi, Brian. Thank you for the invite.

BRIAN GOLDMAN: When you talk to your new patients and you're telling them about fatty liver disease, how many of them know anything about it?

ALNOOR RAMJI: The majority of patients have some idea because as a specialist, they're actually sent to you with the context of you have fatty liver disease or there is that concern. A fatty liver disease. Though I will say that the whole concept of fatty liver disease is a new concept for them. Prior to them being referred.

BRIAN GOLDMAN: And that is the major reason why I wanted to. I've been dying to do this topic for a while and I'm really, really glad to have you on the show. But before we begin, can you give us a. Hi, my name is Tell us what you do and where you do it. Just ad lib.

ALNOOR RAMJI: My name's Alnoor Ramji a hepatologist, and I am at Vancouver, my clinical associate professor through the University of British Columbia, and I work through the St Paul's Hospital site.

BRIAN GOLDMAN: So here we go. Alnoor, what is nonalcoholic fatty liver disease?

ALNOOR RAMJI: So nonalcoholic. Fatty liver disease actually implies there's no significant alcohol in there. And and that's an important consideration because alcohol itself can cause some fat in the liver. But we are more interested in talking about the nonalcoholic fatty liver disease component, essentially, of brain. What happens is when there's fat in the liver, it causes some degree of swelling of the liver, and with time this swelling can lead to inflammation of the liver. So fat in the liver cells causes inflammation, and it's that inflammation that results in scar tissue, what we call fibrosis of the liver. And with time that causes permanent damage, essentially, which in some cases can lead to even cirrhosis or extensive scar tissue within the liver.

BRIAN GOLDMAN: And I mentioned, I emphasize, nonalcoholic fatty liver disease a couple of times now, because when I've told people that they have fatty liver, you know, and I pointed it out on an ultrasound as often as an incidental finding, the first thing they say to me is, but I don't drink alcohol. Is that is that something that that you've encountered as well?

ALNOOR RAMJI: You're absolutely right. And the majority of persons who come in, they go, how can I possibly have anything wrong with the liver? It's almost a disbelief that they have a liver disease because they don't consume any significant amount of alcohol. And, you know, we make this assumption that persons who have any liver disease may be drinking much too much or they're not telling us the truth, when in actual fact we should be listening to the patient. And it is purely nonalcoholic, as you've said, and more associated with things like diabetes or obesity and not secondary to alcohol.

BRIAN GOLDMAN: So how does this that end up in the liver?

ALNOOR RAMJI: So essentially, the liver is responsible for regulation of fat production and really moving fat around the body. And certain conditions result in excess fat being stored within the liver. And that's when you get the inflammation. So conditions such as diabetes or even obesity does result in increased storage of fat within the liver cells. And that is the primary issue with this.

BRIAN GOLDMAN: And is the liver a repository for stored fat in the same way that abdominal girth is? Is that what we're talking about?

ALNOOR RAMJI: You can think of it in a very similar manner. It's that visceral fat we worry about, and the liver is just a good marker of the amount, just visceral fat in many ways. And exactly as you point out, the abdominal gut. So when the waist circumference increases, that is a good marker that there's going to be some fat potentially within the liver itself or the BMI of the body mass index is high.

BRIAN GOLDMAN: We know that the incidence and prevalence of of Canadians who are overweight and obese is just growing by leaps and bounds. So how fast is this disease growing in Canada?

ALNOOR RAMJI: So we estimate that 25 to 30% of Canadians are actually obese and that's not overweight or obese. And as that increases and diabetes increases, we see more and more fatty liver disease. And so from the data or at least modeling data we did in 2019, we think that it's going to increase by 20 percent as we get to 2030. So if we had to put numbers to it, we said there was seven and a half million probably in 2019 going into 2030, then maybe 9.3 million, 9.5 million people with fatty liver disease.

BRIAN GOLDMAN: That's astonishing.

ALNOOR RAMJI: It's incredible. And when you actually look at complications related to this, we also estimate that the proportion of patients have cirrhosis or extensive damage on the liver would more or less double from 2019 through to 2030 increased by 95%. So probably in the range of 100,000 persons in 2019, going out to almost 200,000 persons in 2013.

BRIAN GOLDMAN: So I want to start digging a little bit more into the causes of of fatty liver disease. You started to mention fat causing swelling and causing inflammation. But from what I've read, that doesn't happen to everybody. It only happens to a fairly small minority. Have I got that right?

ALNOOR RAMJI: Correct. So fatty liver disease is associated with different conditions. And when you think of diabetes, almost 60% of patients who have diabetes can have fatty liver disease. And particularly when you look at diabetics, they have 18 times the higher risk factor of developing more advanced liver disease than the non diabetic. Okay. So diabetes is probably the strongest signal we have. And then the other one, as we've touched on, is obesity. And there's a large proportion of patients of obesity who will also develop fatty liver disease. And obviously if you have both of them, that's where the majority of burden of disease really occurs. I will also mention that there are some persons who we would consider lean normal body weight, and they, even if they're not diabetic, can develop fatty liver disease. So it's one of those disease states. I think we frankly just don't understand well enough. It's it's very heterogenous. There's probably a genetic predisposition to it because that's a number of patients who are normal weight, who don't have diabetes and yet have fatty liver disease. And Brian, as you pointed out, sometimes just gone to the ultrasound and sent in for that ultrasound showing fatty liver disease without any specific risk factors. So I think we're just starting to understand so much of this condition.

BRIAN GOLDMAN: Can fatty liver cause symptoms, just just the increase in stored fat?

ALNOOR RAMJI: You know, if you look at the books, probably not. But what I've heard from patients is that some persons will have a sense of hopelessness where the liver is and the liver is under the right breast or under the right rib cage area. They complain of a vague sensation almost, or even they call it a presence. It's not going to be sharp pain. It doesn't keep them from doing things or activities in any way whatsoever. But they'll be watching TV or something. But they'll, you know, when it's quiet and they'll feel this nagging sensation or a presence there is the best that I've heard it described as or even bloating or just a vague discomfort is all I've heard that people can really assess with fatty liver. But otherwise from that, really there's no other symptoms, which is the concern, right? So you have a disease which is very prevalent, which can cause significant issues and at the same time there is no is a symptom. You know, if you had a simple rash on your arm or something said, well, this is really a fatal liver disease, that would be easy. We could find everybody. But this is very hidden, which is my concern.

BRIAN GOLDMAN: And I think it's the concern of people listening to this as well. So how are most people diagnosed with fatty liver disease?

ALNOOR RAMJI: The majority of times it's when persons get routine lab work, which I would encourage that in a person. See the primary care physician that once a year make sure your liver enzymes are different. Numbers are added to the blood panel. So if those are elevated one, you have to exclude various causes of liver disease. And then you look at potential risk factors like the diabetes, obesity. And then the other part is, is an ultrasound and more often not admittedly, that's done for other reasons. You know, people have vague pelvic pain or have known discomfort in other places and they get an ultrasound which shows fatty liver. So so that's usually the routine way of coming into care, I'd say, if we were trying to be proactive, which is where we should be, we should probably think of those persons who are at higher risk and try and find a screening this person's. And that would include doing the lab work and the markers of biomarkers, we can call them to try and evaluate how much damage there is in the liver, which can easily be done at the primary care level. You don't need a specialist and then if you see signals of that, then importantly they can be linked to care.

BRIAN GOLDMAN: So if you identify somebody with fatty liver disease and of course you're going to be seeing them as part of your your consulting practice. What's going to be the. The trigger for getting them to do something about it, assuming that you can do something about having fatty liver disease.

ALNOOR RAMJI: So what is the acceptance of fatty liver disease? And it may sound quite bland when I say that, but the truth of the matter is a lot of people come in and you say you've got fatty liver disease, and it's many of the time it's not commonly understood that fatty liver disease even exists. Right? So it's, you know, moved about. And so people have to accept that they may then have fatty liver disease, that it can cause significant issues. And then you talk about modifying risk factors. So optimizing control of the diabetes, for example, really helps. And then you look at lifestyle aspects. So particularly diet and exercise to some degree as well, I think.

BRIAN GOLDMAN: We know that it is very you know, it's it's often very difficult to motivate people to lose weight to to modify their risk factors for cardiovascular disease, for diabetes. Do you find that telling them that they have fatty liver disease is a significant motivator that gets them to address those lifestyle issues?

ALNOOR RAMJI: I think it does. You know, you have to give them one the tools to understand where they are in the path we're fighting liver disease, the context that it can become extensive. And that importantly, if you do something about it, that you can actually reverse it. So I say the liver is this modest organ because and I think it's true completely because it's one of the few places where you can actually reverse damage. So I've had patients where we get decreased amount of fat in the liver potentially from other liver disease. We see decreased scar tissue in the liver. And that's phenomenal. Right. You can actually improve the quality. So, you know, taking that into consideration and I think also providing very reasonable aspects of lifestyle changes. So not being disappointed. For example, if you don't lose weight and often say no to patients, I want you to focus on necessarily weight loss, but more on healthy habits. So when we talk about diet, healthy eating, think about each and every meal and really try and push towards having more green vegetables, leaner meats like chicken and fish. Sugar is just pure evil, right? You want to take out sugar wherever you can, particularly like sugary drinks and and lower carbohydrate, which is different from no carbohydrate. And again, there'll be so many people tell you so many different things on that, but that's usually what I'll suggest and and putting that within someone's actual day and lifestyle so they can manage that as opposed to going really overboard, you know, such that they can continue a diet for the next 90 years. That's what that would be goals and get comfortable with a diet which you can be persistent with.

BRIAN GOLDMAN: You know, I wanted to to underscore something that you've been talking about, because I think it's pretty astonishing. Are you and I just wanted to confirm it. Are you saying that you can experience a reversal of your fatty liver disease without necessarily losing a lot of weight?

ALNOOR RAMJI: Yes. And most most of the time you end up losing some weight, but you can actually reverse some fatty liver disease without the pure weight loss per se. The majority of time you will. Right. It just it just is part and parcel of the whole context of lifestyle changes. But you think that they're very much in the healthy living aspect because if you some people who lose a modest amount of weight. Right. And yet you do see those improvements and it goes to the context of visceral fat improvement as well. Most of the time, Brain, you're losing weight with this as well.

BRIAN GOLDMAN: Okay, fair enough. A lot of people who are listening to us have heard about Ozempic and other drugs like it. Do they have a role to play because they can help you lose weight and they can help you address insulin resistance and type two diabetes? Do they have a role to play, in your opinion?

ALNOOR RAMJI: I think drugs are one piece of the puzzle, but not the end all and be all of this puzzle. So the first is really going to be the diet and exercise is a foundational aspect. There are no drugs which are approved for the use of fatty liver disease. The GOP agonist receptor, as you point out,the Ozempic or similar. They help with weight loss and they are being studied in fatty liver disease. Early phase data has shown that there is an improvement in the fat component and inflammatory component, but we have not seen the improvement of scar tissue yet and we need longer term studies. So at this stage we're not using it for purely fatty liver. But you know, if patients have issues with diabetes where we use it more often or obesity that we're considering to use it, and I think there will be drugs in the future. It's being evaluated by FDA, but we're not there yet.

BRIAN GOLDMAN: So let's let's go to the other side of this. What happens to patients if fatty liver disease goes completely untreated?

ALNOOR RAMJI: So with time, as we talked, you know, you get the fat globules within the liver, which causes inflammation. And whenever there's inflammation, you get scar tissue and you go from, you know, no scar tissue to minimal to moderate scar tissue to quite extensive scar tissue, which in actual fact can take even two decades. So it does potentially take quite a long time to develop extensive scar tissue, which is cirrhosis of the liver. And you'll hear cirrhosis of the liver and people immediately jump back on that context of alcohol again. But this is the nonalcoholic fatty liver disease causing cirrhosis. And and when you get cirrhosis of the liver, that increases the risk of liver cancer and aspects of liver failure and then potential towards transplant. Right? So so that's the that's the end part of the liver disease.

BRIAN GOLDMAN: So you've got patients in your office. What kinds of conversations do you have with them? How much do you raise the specter of these awful complications, which which I'm sure anybody would want to avoid when you're giving them your best pitch to modify their lifestyle factors?

ALNOOR RAMJI: I think you want to be realistic, right? You want to give them the truth about where they are and if they really need to worry significantly or not. And I'm not saying person shouldn't be concerned about it, but more so, can they do something to change it? Are we talking about minimal to no damage on the liver, which is the majority majority of patients I will see in my office? Right. So, you know, they have time to change a lifestyle. You know, they may not even progressed to this advanced liver disease by any means, but you want to give them, again, the conversation tool about how to modify that. And then in those patients who have more moderate damage of the liver. Those are the persons we're seeing more frequently and really pushing them with lifestyle changes, optimization of their diabetes. So, you know, I think you don't want people walking out with fear, but rather a realistic thought about where they are and how to do things so that they don't end up going to advanced liver disease.

BRIAN GOLDMAN: So you mentioned you've said sugar is pure evil, and I'm going to remember that that's a memorable line. What are the other major principles of the diet? Are we talking about the Mediterranean diet?

ALNOOR RAMJI: Yeah. So that's one that's probably being touted the most is the Mediterranean diet. There's not enough data to say any single diet will improve. That entire Mediterranean diet has a good amount of data and essentially just weight loss overall whichever diet using. At the same time, I think you want to put into patients perspective and we talk about, you know, cultural sensitivity in the even in the context of of diets, because I live in Vancouver again on the Pacific Rim, people not really revolve around the Mediterranean diet. If we're from Asia, for example, and there's a high carbohydrate content in that diet. So it's allowing persons to eat what they enjoy, but maybe just having less amounts of that. So it's the quantity or the calories of food that you're getting, but also the quality. And that's what I really like to emphasize, the quality of foods. So in looking back at those green veggies and the leaner meats, which is very much part of the Mediterranean diet, as you know. Right. And then trying to talk about, okay, you know, you can have some carbohydrates because some people, again, you don't have to get overboard and have no carbohydrates, but some carbohydrates is fine and really go back down on the sugar. So Mediterranean diet mostly. And then interestingly, coffee coffee's good for the liver. So two cups of coffee apparently helps your liver, your fatty liver disease. We don't understand how or why.

BRIAN GOLDMAN: Oh, that's interesting. Well, I'm a coffee drinker, so you've made my day to close off what needs to be done to raise more awareness about fatty liver disease, in your opinion?

ALNOOR RAMJI: So I think exactly what you're doing. So, you know, this has been such a silent disease. Persons don't know about it. It's given no recognition. I feel at all when you're looking at a disease that affects 25% of the population and, you know, you walk in to somewhere, you think about your family. One in four persons may have it. Why have you not heard of this? People? Yeah, but diabetes and high blood pressure, heart attacks and all that. Why? I've not heard about it. So it's education and it's education. I think to primary care is to say what the person's at risk and how to evaluate them and link them to care. But more importantly is really education to the public. For them to take responsibility in this context and go to their primary care and say, could I have this? Should I be tested? How do I do something about it? And then it goes a long way to have advocacy groups, policy aspects, right? You know, the you know, the ministry says, okay, we need a policy around fatty liver disease or even if it's obesity or diabetes, another associated features about it. How are we going to grapple with that looking into the future? Because 2030, we don't have significant issues within the health care system if persons continue to develop fatty liver disease and its complications.

BRIAN GOLDMAN: Dr. Alnoor Ramji, thank you so much for talking about nonalcoholic fatty liver disease and really making it incredibly clear and for such a passionate pitch for more awareness of this important condition. Thank you so much.

ALNOOR RAMJI: It's my pleasure. Thank you for having me on.

BRIAN GOLDMAN: Dr. Alnoor Ramji is a hepatologist and a clinical associate professor at the University of British Columbia. Here's your dose of smart advice. Nonalcoholic fatty liver disease causes excess fat to build up inside your liver. An estimated one in four Canadians has it left untreated? The stored fat can trigger inflammation. Cirrhosis or. Barring liver failure that in some cases can lead to liver transplantation and even liver cancer. This condition is not caused by alcohol use. It occurs in people who are overweight or obese and especially if they have type two diabetes. It can also happen to people who are lean. People with untreated diabetes are more likely to end up with cirrhosis. Fatty liver has been called a silent disease, but some patients complain of a feeling of fullness on the right side of the abdomen, just under the rib cage and they can also get bloating. Your doctor can diagnose and monitor fatty liver with periodic blood tests and an ultrasound of the liver. Treatments include weight loss, lowering cholesterol and triglycerides, and especially getting diabetes under control. Most doctors recommend the Mediterranean diet. That means fruits and vegetables, whole grains, seafood, nuts, legumes, olive oil, fish, poultry, eggs, cheese and. Other dairy products. Avoiding excess carbs and especially refined sugars are critical to success. Patients who follow this advice often achieve less inflammation in the liver and reversal of the disease as seen on an ultrasound. Although alcohol doesn't cause fatty liver, any consumption can make fatty liver disease worse. If you have topics you'd like discussed or questions answered, our email address is the dose at cbc.ca. If you like this episode, please give us a rating and review wherever you listen. This edition of The Dose was produced by Isabelle Gallant, our senior producer. This week is Geoff Goodes, The Dose wanting to be better informed about your health. If you're looking for medical advice, see your health care provider. I'm Dr. Brian Goldman. Until your next dose.

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What do I need to know about fatty liver disease?- Transcript

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