Sep 21, 2021

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Scot: Not only does body fat impact how we look and feel about ourselves, excess body fat has been associated with a lot of diseases that can significantly impact our health. And one of the organs, I didn't even know this, that's particularly susceptible to becoming damaged by excess body fat is the liver. And today on "Who Cares About Men's Health, what to know and what to do if you've been diagnosed with fatty liver disease.

Got a big crew here today. This is going to be a lot of fun. The MD to my BS, it's emergency room physician Dr. Troy Madsen.

Troy: Hey, Scot.

Scot: All right. And we also have Dr. Susan Pohl, who is in family medicine. And she's also very passionate about wellness for disease prevention. So you're in the exact right place. Welcome, Dr. Pohl.

Dr. Pohl: Thank you. Good to be here.

Scot: And the star of this week's show . . . What do you think of that, Listener Brett? You're the star. You're the reason we're all here today.

Brett: Oh, I'm so excited. Thank you.

Scot: Yeah. So Brett wrote an email to us that I'll get to here in a second. But essentially, he was diagnosed with fatty liver disease during his last physical. So first thing, Brett, when your provider told you that, what was your reaction, being told that you had a fat liver? That kind of doesn't sound like a fun thing to be told.

Brett: It was a little scary because, "Do I need a liver transplant? Am I going to die soon? Or is this just because I am overweight?" That's the question.

Scot: We talk about the core four on this podcast, which is to be healthy today and in the future, you should watch your activity, your nutrition, your sleep, your emotional health, and then you've also got to know that plus one more, which is your genetics. I have a feeling we're going to be delving into a lot of those today.

So here is the email. "I've been listening for a while and thought I'd ask a question after my last physical. Diagnosed with fatty liver disease, but my physician didn't explain it too well. And I've been searching for more answers on what it is, why I should worry about it, and what I should do to treat it. I've Googled a lot of stuff, but I'm unsure what to do. My doctor recommended I avoid fatty, greasy, fried foods. But I wasn't sure if I should consult a dietitian or do anything else."

So that is Brett's condition. I want to ask you, when you searched on the web, what did you find about fatty liver disease? I'm kind of curious what's out there.

Brett: I found actually a couple of previous interviews that The Scope did for fatty liver disease. And I found pretty much the . . . Healthline, I think there was an article for it, and basically it said, "Take it seriously and lose weight," is the main thing, which is good, but easier said than done also.

Scot: So is the concern, actually, how to accomplish what it suggested to do? Or did you really truly find that you didn't find a lot of information that explained what this condition was, why you should be concerned, that sort of thing?

Brett: A bit of both. I wasn't really sure how I got it. Am I drinking too much soda? Am I eating the wrong foods? And then should I be exercising differently? These are things . . . Then what's the long-term prognosis? I was really scared that, "Am I going to need a liver transplant in 10,15 years? Or is this more like something that will eventually kill me when I'm 90 and that's okay?"

Troy: I'm curious, Brett, how did your healthcare provider diagnose you with fatty liver disease?

Brett: Well, there were a couple of ways. First, the blood work said that that indicated it. But then there . . . he sent me downstairs in his clinic. They had this thing called a FibroScan. It was essentially an ultrasound that looked at my liver and found the tissue was consistent with that diagnosis.

Troy: Okay, interesting. Obviously, we're all kind of spread out everywhere recording, so I haven't met you in person. But if you wouldn't mind sharing with us a little bit more about your health. Do you consider yourself overweight? Do you exercise, or did this come as a surprise to you to hear, "Wow, I've got a fatty liver and this doesn't make any sense"? I'm just a little curious about kind of where things came from there.

Brett: Effects of weight gain were definitely not a surprise to me. I've been a stay-at-home dad for the past three years, and it's been a more sedentary lifestyle than it was when I was working. I do work out, especially in the past year and a half, four to six days a week. Mostly a lot of cardio, but also weightlifting and things like that. I do it at night because as a stay-at-home dad, I don't have a lot of time in the day to run to the gym, and there's no daycare there.

So I've gained probably 25 to 30 pounds over these past three years. I've not been happy with it, but I've also thought that some of that could be from not just diet but also exercise. My body mass index is about 32 right now. So it's in the obese range, but it's on the lower range.

Going back to the episode a few weeks ago, when you had Scott on, the listener, I believe that was his name, I'm bit more average in my eating and exercise, average American, than he is. So growing up liking the normal food groups, which includes some of the fattier and sweeter foods. But also, I like to cook. I like to make meals that are healthy. I also have kids who are picky eaters, so sometimes I have to sacrifice good food for what they will actually eat. So it's a balancing act always.

Troy: Yeah, for sure. Like you said, though, you are exercising regularly. You have put on some weight just in the last few years. But again, it sounds like this kind of blindsided you to hear this, like, "I've got fatty liver disease." Like you said, you're searching all over trying to get answers. What does this mean? What are the implications of this?

Brett: Yeah. I mean, I expected things like higher cholesterol and things like that. Those things I've actually seen over the past few years of physicals. But this was kind of more surprising. Moving from heart to liver was more surprising.

Scot: Dr. Pohl, let's have you jump in right here. I want to ask a question, but I also just kind of want to let you go with what it is you would want to know at this point. I think Brett's main concern is, "Is this something he needs to worry about? And what can he do about it?" That's what he wants to ultimately walk away from. But we could also learn more about this condition. So, Dr. Pohl, where do we go from here?

Dr. Pohl: Thank you so much for having me on the show. Just as a clarification, I am a family physician. So I work at University of Utah, and I'm board certified in family medicine. I'm also board certified in obesity medicine, so I treat people who are having complications from weight. I'm not a hepatologist. A hepatologist would be someone that just specializes in liver disease.

Scot: So let me jump in for a second. Is that ultimately who Brett should go see at this point, or . . .

Dr. Pohl: So one of the things to think about . . . I'm just going to start from a big 10,000-foot informational view, and I think Brett can then get some more information from his doctor.

First of all, when we think about the liver, the liver has hundreds of functions, including clotting and digestion and regulating your blood sugar. The liver itself also stores fat, and everybody has fat in their liver. So fat in the liver is normal, but when the amount goes up, that's considered abnormal.

Again, from a 10,000-foot view, the liver can become diseased. The two main classifications of liver disease are related to alcohol or non-alcoholic liver disease.

So the first thing I would want to know is how much alcohol you drink, because that in and of itself can be a toxin and is one of the most common causes that can progress liver disease. Brett, do you mind if I ask how much alcohol you drink?

Brett: I don't drink at all. The most I do is I throw some wine or something into a recipe for . . . But I don't drink any alcohol.

Dr. Pohl: Okay, so that makes it easy. We can classify this as non-alcoholic liver disease. So as we branch into the non-alcoholic liver disease, there are some interesting terms. I don't want to get too much into the weeds, but the term non-alcoholic fatty liver disease, or NAFLD, actually means that you just have more fat than is generally considered "normal."

Normal fat content would be somewhere around 5% to 10% of the liver content is fat. And so you've been diagnosed with a little bit more than that, and I don't know what your level is.

Now, excess fat in the liver, actually the body can tolerate that in a lot of people. And NAFLD, or non-alcoholic fatty liver disease, is actually incredibly common. One out of every four adults in the US is considered to have some level of NAFLD, or higher than what we consider normal fat in the liver. But only some of those patients will then progress to some level of fibrosis.

So fibrosis is where the fat is actually more inflammatory and there's starting to be a little bit of scarring in the liver. Scarring in the liver is fibrosis, and we can pick that up on scans, like the FibroScan that you talked about or MRI.

What we want to avoid is this becoming very progressive and it leading to cirrhosis and liver failure. And I think that's what you were concerned about, Brett.

So it's important that you had the FibroScan and that they did look for some fibrosis. Now, if we're starting to see some fibrosis, then we're talking about NASH, which is non-alcoholic steatohepatitis. Only a few people with fatty liver are starting to get some inflammation and fibrosis in their liver.

But the good news is that the liver is incredibly resilient. The liver is an organ that is just an incredibly resilient organ. So the fact that you've been found to have this, this is one of those things that you are in control of, and you can be the captain of your ship and help your liver recover and heal from this.

Troy: So hearing all that, Dr. Pohl, where do you think Brett falls on that? I know it's probably hard to tell without actually seeing results, but you think he kind of falls maybe in that fibrosis phase or maybe just a little bit more fat than the average person in the liver?

Dr. Pohl: Well, I would have to see the result of his FibroScan. I mean, verbally, that story that he's telling me . . . the fact that your doctor was concerned about it makes me think . . . I'm playing Sherlock here. But from that story, there was enough fibrosis that the doctor was concerned and would classify you more in the NASH.

Now, I'm not sure if that's true, so I would contact your doctor and say, "What level of fibrosis . . ." We score that with numbers. "What level of fibrosis do I have? And do I have NASH?" And so just ask your doctor, "Do I have NASH, non-alcoholic steatohepatitis?"

Brett: Non-alcoholic steatohepatitis.

Brett: Yeah, or N-A-S-H. You can do a lot with this. And that's the good news, is that lifestyle medicine is the way, really, to approach this. It's the best way to improve the fat distribution that you have. Everyone needs fat, but the way your body is distributing its fat is causing some issues for you.

So I'm just going to segue into some lifestyle things you can do. You mentioned things like soda and sugar. Your doctor had mentioned things like fat, and obviously excess fried foods are going to be calorically rich, and so that can lead to weight gain in general. But tell me about the sugar that you eat regularly, including sugary sodas and drinks.

Scot: They always go after the good stuff, don't they, Brett?

Brett: Yeah. Well, it's true. I think I'm a little better than average in terms of soda intake. I probably have one or two a week, maybe. My post-workout drink, because it's at night, is a cup of chocolate milk. I looked online and it says eat chicken breasts and things like that. But when I get home from the gym at 11:00, that's not exactly appetizing. So that's my main sugar intake.

I feel like I'm pretty normal on things like candy and things like that. Not a lot, but like I said, I'm also around kids, so sometimes they make me eat. "Make me." Yeah.

Troy: Dr. Pohl, do you think that for Brett it's just flat out you've got to get your BMI down and this is all going to reverse? Or maybe he continues on at a BMI of 32 but drops the sugar, and then that's the key to reversing this.

Dr. Pohl: Most people with a BMI of 32 that have fatty liver or NASH will benefit most easily from weight loss. So unless there's a profound transformation of fat to muscle, most people need weight loss.

Scot: It sounds like really it's just a matter you're decreasing your total body fat and, in turn, you're decreasing the fat in the liver, and that's really what you're trying to do here.

Dr. Pohl: Yes, exactly. And sugar does tend to be very toxic to the liver. When we get big spikes of sugar, that's very inflammatory and actually produces inflammation in the liver.

I never say no to . . . I like chocolate cake, and I never say no to those things, and an occasional soda. I mean, all those things are part of my diet. But just realize that those should be kind of the peak of your pyramid. So if you really need that piece of pumpkin pie around Thanksgiving, have that piece of pumpkin pie. I mean, that's important to you. Have that piece of pumpkin pie. But don't have rolls and pasta and pumpkin pie and a Coke and chocolate milk after your workout. That is five servings of carbohydrates that your body is going to turn into sugar.

So think about what's important to you. Just don't waste those calories on things that . . . waste those sugar grams. If you want to get really technical, talk to your doctor about monitoring the sugar and actual grams of sugar in your diet. Most people do well by keeping it under 50. A lot of people do really well if they keep it . . . Getting it under 25 would be awesome, but that's hard to do, because it hides in so many things like ketchup and salad dressing and those kind of things. So decreasing your sugar is really important.

And then there is some data that shows that increasing the good foods in your diet will also help. So the nice thing about this is it's the same diet that we talk about for heart health. So we're not talking about a different liver diet than heart health. The Mediterranean diet is what tends to promote weight loss. It tends to decrease inflammation.

I'm sure you've talked about the Mediterranean diet before, but that's a diet that's high in foods like salmon and cod and fatty fish, and then high in dark vegetables like greens and kale, and adding some nuts.

Now, the key with nuts is measure those nuts because they're very calorically dense, but nuts are a good part of your diet. And by decreasing the empty carbs and adding some of these good nutritious foods to your diet usually you can heal that liver.

Brett: I do think that's something that I haven't done too much, is doing a detailed monitoring of the food that I've eaten, looking at the . . . That's good to know the level for the sugar content to have in a day, because I haven't really tried to measure that. And I think that's a good idea to get started.

I've really struggled about how to start approaching this, whether to start cutting out 20% of my portion size of my meal or whether to just cut out certain foods entirely or whether to do certain things.

One of the questions I had to my doctor, and he was kind of saying, "Yeah, maybe, but you could try these other things," is should I look at going to a dietician to help me get started on this? Or should I start with some more basic steps?

Dr. Pohl: I think consulting with a dietitian is fine. And I think you can talk to your insurance about whether they'd pay for it. I think if you've got inflammation in the liver, they likely will, but sometimes that becomes a barrier. Sometimes insurance doesn't want to pay for that. But investing in that or accessing your insurance for that is a great tool.

One of the things to start with, though, is to start with just the easy things. I'm not getting paid by MyFitnessPal, I promise, but I'm a big fan and I recommend it all the time. Just for three days, if you enter in all the foods that you eat, it'll actually show you how many sugar grams you're eating. Just for three days, enter in all your foods and see at the end of the . . . Don't modify anything. Just enter it in and see how many sugar grams you end up with at the end of the day.

Then you can start thinking about, "Oh, goodness, maybe some of those empty calories that . . . Do I really need the barbecue sauce with the sugar or can I substitute some Tabasco sauce or something else?" So there are some easy substitutes, if you start looking at that.

My suggestion for most people is start monitoring with one of those easy online apps, and MyFitnessPal is pretty easy to use. Just put your information in. You can take that information to your dietician, and then they can help you with some easy substitutions as well.

Scot: Dr. Pohl, it sounds like really the place that you recommend Brett to start is just those added sugars. That's what we're talking about, right? So monitor what you're eating for three or four days and find out what those added sugars are and see if you can get rid of some of those with something else. Is that accurate?

Dr. Pohl: Yes. Get rid of those easy, added sugars. Yes, that's a good summary.

Scot: Yeah. And I will tell you a soda, I think, has like 50 grams of added sugar. And you said you want to try to keep it at 50 grams a day?

Dr. Pohl: Yeah, exactly. So even that one soda is a lot for your day. Now, I don't like to tell people you can never have a soda, but just realize that you're spending those grams of sugar on a drink. Do you really want to do that? If we talk about it as a cost, it's an expensive cost to have all of your sugar in one can of soda.

Scot: We had an episode called "Hidden Sugar." It's really shocking where sugar hides. Like Dr. Pohl said, in barbecue sauce, in salad dressings. We talked about you think you're eating a fruit-flavored yogurt and that's healthy, but there's a lot of added sugar in that. The little packets of instant oatmeal that you get, half of that is added sugar. So it really kind of hides in very insidious ways.

You might be surprised after looking at packages and monitoring just how much added sugar you're actually getting. Even I used MyFitnessPal and I eat pretty clean, and my added sugar was higher than I ever would have expected. So I think that is good advice.

Dr. Pohl: I want to admit that I had been advising people about diet and exercise, and then I looked at my low-fat yogurt and found the exact same thing. It was 24 grams of sugar. So it was a day's supply of sugar in my low-fat, healthy yogurt.

These things that are sold to you in packages, make sure you look at those packages, because a lot of the things in the health food aisle like granola and low-fat yogurt and things that have the word "fruit" on it, fruit snacks, fruit juice, all those things, they're in the health food aisle, so we feel like, "Oh, these must be great." But check those sugar grams because they hide in these "healthy foods."

Scot: Especially low-fat food, because when you take the fat out, you've got to add something back in to make it taste good. And sugar is what they do. They add sugar back in.

Troy: Yeah, I saw something about a junior high that has their healthy foods vending machine, and they would sell applesauce in there. And the applesauce was just selling out like crazy, and they're so excited, like, "The kids are eating applesauce. Yay." Each little thing of applesauce has like 15 grams of added sugar or something ridiculous. It's amazing.

But I went through that same process with yogurt as well. I was thinking I was eating healthy. We had Thunder on here, Thunder Jalili, who talked about hidden sugars. I looked at the yogurt I was eating, same thing, just tons of added sugar. It's just amazing.

Brett: Yeah, I do try and monitor some of that, and I try and not do as many processed meals and things like that, try to make meals from scratch. Even things like pancakes and waffles, I make from scratch so I can see what exactly I'm putting in there, and not relying on a box mix or something like that. I like to make even macaroni and cheese from scratch, but sometimes my kids aren't fooled by the difference between the colors.

But that's the thing. I do like to try and control those hidden sugars after . . . I did listen to that episode, and that's one of the things I tried to control through the recipes that I've gotten. But I'm absolutely not perfect in that way, and I'm eating plenty of things I know are sugary, too, though.

Scot: I'm really trying to make this simple for any guy that's listening, and sometimes it can get really complex and it can get confusing as to "What should I really, really do?"

So I think we've established to really critically look at those sugars. You might think you're doing well, but after a three- or four-day examination, you might discover, "Not doing as well as I thought." So if you can maybe replace some of those calories with healthier choices, limited seeds and nuts and some vegetables, that's another strategy to try.

I think a lot of people don't realize how many calories are in the foods they eat. I think it's really easy to eat way too many calories. So perhaps monitoring those through MyFitnessPal will give you some insight into that.

And maybe really having two or three meetings with a nutritionist also have just a separate set of eyes on what's going on might be advantageous too.

Dr. Pohl, what do you think of that advice? Brett, do you think that's . . . is that a little bit more straightforward of a plan that you think you could follow?

Dr. Pohl: I love that summary. I think it's a great, actionable summary. Brett, what do you think you could do?

Brett: Yeah, that sounds like a very good idea to start monitoring, start there. It's the easiest thing to do for me personally, and it gives me some data to go to the nutritionist and see what to move forward from there.

Dr. Pohl: And the biggest thing is also just talk to your doctor about it and just find out what your level of fibrosis is and what kind of weight loss plan you should be on.

The caution I want to give you at the very end is that dramatic weight loss, which would be something more in the line of two to four pounds a week, we would recommend . . . If you're going for dramatic weight loss quickly, that can actually worsen fatty liver because of the stress that you're putting your body under. So slow and steady weight loss, something in about the range of one to two pounds per week, is kind of that sweet spot of sort of detoxifying your body.

Troy: And how long do you think Brett should give it before he really goes back to his doctor and says, "Hey, I'd really like you to take a look at my liver again and see where things are"? I mean, are we talking a few months, six months, a year?

Dr. Pohl: Well, talk to your doctor about what level of fibrosis you have. And then the goal would be if you're starting to see some changes on the scale, and you've made some changes consistently for at least three months, then go talk to your doctor about whether you should be rescanned and see whether that level of fibrosis is less. Three to six months.

It's interesting to see . . . the studies show that even small amounts of weight loss, like 5 to 10 pounds, which is only a couple of percentage points, can actually make big changes on the inflammatory properties of the liver.

So set a goal of a certain amount of weight loss. But if you've had some success with 5 or 10 pounds, definitely talk to your doctor about if it's time to look.

Scot: I hear Troy's voice in my head right now, Brett. So I'm going to share some additional thoughts here. And I'd like to get both Troy and Dr. Pohl's thoughts on this.

So it doesn't have to be all at once. Don't expect you're going to change overnight what you eat, or you're going to go from one person to another. It doesn't have to be radical changes. You don't have to all of a sudden go to eating chicken breasts and a plateful of vegetables. The nutrition can still be good. Just start making some minor changes.

Is there one thing that you could do in the first week? Maybe that's to eliminate one soda, or maybe that's to eat an extra serving of vegetables. Give yourself a little bit of time, I think, to go through this process.

I think a lot of times we think, "Oh, I've got to eat healthy now." And then that comes with a lot of baggage of what it is you're going to eat, and sometimes then you get miserable and it's not sustainable.

Troy always says just make those little, small changes one at a time.

Troy: Yeah, that's the key too. I think you have to give yourself credit for what you're doing as well. You're exercising a lot. I think that's great. You're doing more exercise, far more, than the average person does. So you really need to give yourself credit there.

Dr. Pohl has given some great advice just in terms of maybe dropping some sugars here and there. I'm sure you'll start to see that weight loss. Again, one pound a week sounds like that's the goal. And as you see that, again, give yourself credit for it. Say, "Hey, I'm making progress. This is where I need to go." It's not a dramatic change. It's going to be something over several weeks and months.

Scot: And that weight fluctuates from week to week, right? So if all of a sudden you gain a pound, don't worry about that. Sometimes it's just the time of day you've weighed yourself on that scale. Dr. Pohl, a half-pound would be fine, right? This is a long-term game right now. He's got time.

Dr. Pohl: Oh, yeah. In fact, if there's no weight loss, but you're making those dietary changes . . . Like I said, if you're exercising and making dietary changes and you're weight-neutral, that's fine. But I just don't want you to go for dramatic weight loss because that can be harmful as well.

Brett: Well, thank you so much. I really appreciate you doing this and for giving me all the congratulations for actually caring about my health. I'll take all the praise I can get, and hopefully I don't die from this soon. No, just kidding. This was very reassuring. Thank you.

Scot: Brett, thank you very much. Appreciate having you on the show. Hope you have a great rest of your day.

Brett: Thank you.

Scot: Awesome. Dr. Pohl, thank you as always. I appreciate your time.

Dr. Pohl: Thank you for inviting me. It's so much fun to talk about health and helping people become more healthy and reach their fitness goals and their health goals.

Scot: Hey, it's me, Scot. You made it to the end. Good for you. That must make you a super fan. Just wanted to throw this out there. If you found this podcast helpful, or if you've enjoyed "Who Cares About Men's Health" episodes, and you know somebody else that could get benefit out of it, please let them know. That's the way we can grow the show.

We'd also love to hear from you at any time. Listener Brett reached out to us so we could answer his question. You can email us at hello@thescoperadio.com. You can also go to our Facebook page. It's facebook.com/whocaresmenshealth. And you can also call and leave a message on our listener line at 601-55SCOPE.

Would love to hear from you. Love it if you'd recommend the show to somebody. Thanks for listening, and thanks for caring about men's health.


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