#302 - Confronting a metabolic epidemic: understanding liver health and how to prevent, diagnose, and manage liver disease | Julia Wattacheril, M.D., M.P.H.

1. Target ALT/AST Under 30

Aim for AST and ALT levels under 30 for optimal liver health, rather than just within the lab’s ’normal’ range (often 40-50). Persistent elevations in the 50s and 60s (1.5-2x upper limit) warrant investigation.

2. Don’t Trust Basic Ultrasound

Do not rely on a plain old ultrasound to rule out hepatic steatosis, as it generally only detects fat levels above 30%. Consider more sensitive imaging like MRI-PDFF or vibration-controlled transient elastography for accurate diagnosis.

3. Aminotransferases Poor Early Marker

Do not rely solely on aminotransferases (AST/ALT) as an early indicator of liver injury, especially from alcohol or steatosis, as they only elevate with significant derangement. Consider bedside imaging like vibration-controlled transient elastography for earlier detection of hepatic steatosis.

4. Utilize Advanced Liver Imaging

For accurate liver assessment, consider advanced imaging like Vibration-Controlled Transient Elastography (VCTE/FibroScan) or MRI with elastography. These methods provide both a fat score and a scar (stiffness) score, which are crucial for diagnosis and monitoring.

5. High Liver Fat Predicts Diabetes

If you have a high liver fat score (CAP score) but normal scarring, recognize this as a strong predictor for developing diabetes. Lifestyle changes can normalize fat scores within 6 weeks to 6 months and significantly reduce diabetes risk.

6. Liver Fat Is Modifiable

Understand that liver fat (steatosis) is highly modifiable through lifestyle changes like reducing alcohol intake and achieving modest weight loss. Significant improvement in fat scores can be seen within weeks to months.

7. Focus on Health Fundamentals

Focus on the foundational pillars of good health: consistent exercise, adequate sleep, and balanced nutrition. These are the most important tools for improving overall metabolic health, including liver function.

8. Increase Resistance Training

Incorporate resistance training into your exercise routine, especially for women and as you age, to build muscle mass. Combine aerobic and resistance activities to improve metabolic health and combat sarcopenia.

9. Coffee Benefits Liver Health

Consider consuming up to three cups of black coffee daily for potential liver benefits, including anti-fibrotic and good metabolic effects. This is supported by multiple studies and included in some guidelines, though it’s not a prescription.

10. Avoid Processed Foods First

Instead of focusing on eliminating single nutrients like fructose, prioritize avoiding processed foods for dietary improvement. This is a more implementable and less distressing strategy for most people.

11. Detect Early Insulin Resistance

Monitor for early insulin resistance using metrics like HOMA-IR or glucose tolerance tests to identify the window for intervention before overt hyperglycemia. This allows for proactive management of metabolic health.

12. Screen Liver Disease Risk Factors

Screen for liver disease risk by evaluating metabolic health (BMI, metabolic syndrome, cardiometabolic factors), lifestyle habits (exercise, nutrition), and calculating FIB-4 scores for individuals over 50, especially if male or diabetic. These factors indicate a need for secondary testing.

13. Understand Standard Drink Sizes

Learn and adhere to standard drink definitions (1.5 oz liquor, 5 oz wine, 12 oz beer) to accurately quantify alcohol intake. Many people unknowingly consume more than a ‘standard’ drink.

14. Rest Before Liver Blood Test

Be aware that intense exercise can elevate AST and ALT levels; consider drawing blood on a rest day or after more than 24 hours of no exercise for a more accurate liver enzyme assessment. This helps avoid misinterpretation of results.

15. Investigate Atypical Liver Fat

If a patient has high hepatic fat but lacks typical metabolic risk factors or elevated circulating triglycerides, clinicians should investigate rarer causes like genomic familial hyperlipidemia or export problems. This helps identify specific, non-standard conditions.

16. Hepatitis B Cancer Screening

Screen for liver cancer in individuals with chronic, untreated hepatitis B, regardless of their degree of scar tissue or cirrhosis. This is crucial due to its unique oncologic potential, even without advanced fibrosis.

17. Cirrhosis Needs Monitoring, Not Doom

Understand that a cirrhosis diagnosis (stage four scarring) is not a death sentence or automatic transplant indication, but rather a call for increased monitoring. Early cirrhosis can even be reversible, offering hope for intervention.

18. Recognize Mixed Liver Disease

Be aware that metabolic dysfunction and even moderate alcohol use can combine to impact steatohepatitic pathways. Many individuals may have a mixed form of liver disease, requiring a comprehensive assessment of both factors.

19. Assess Holistic Health Risks

When evaluating health, consider the leading risks to overall mortality and quality of life, not just liver-specific issues. For early-stage MAFLD, cardiovascular and cancer risks often outweigh immediate liver risks.

20. Empower with Measurable Health Data

Empower patients by providing clear, measurable health information, such as scan results showing modifiable fat scores. Frame this data as an opportunity to change risk (e.g., for diabetes) and partner with them on sustainable lifestyle modifications.

21. Early Liver Disease is Reversible

Understand that early-stage liver disease is highly treatable and reversible with intervention. Seek diagnosis and address it proactively, as there’s no reason to remain unaware of its presence.

22. Beware Supplement Liver Injury

Be cautious with supplement use, as contaminated or unknown supplements can cause liver injury. Quantify exactly what’s in any supplement you take and be aware of potential risks.

23. Discuss Vitamin E Supplement Risks

Before taking vitamin E supplements, discuss potential downsides with a clinician, including increased all-cause mortality, cardiovascular risk, and prostate cancer risk, especially at higher doses or in certain populations. This ensures informed decision-making.

24. Test for Choline Deficiency

If there’s suspicion of choline deficiency, especially in individuals post-bypass surgery or with malnutrition-related steatotic liver disease, consider specific assays to measure choline levels. This helps identify and address a specific nutritional cause.

25. Don’t Assume NAFLD Instantly

When an imaging abnormality suggests hepatic steatosis, avoid a knee-jerk diagnosis of NAFLD/MASLD. Always consider alcohol as the primary differential and evaluate for rarer biochemical causes before concluding it’s purely metabolic.

26. Negative Tests Not Full Guarantee

Understand that a battery of negative tests does not guarantee future health or absence of underlying issues. Maintain humility and consider ongoing monitoring, especially for complex conditions like liver disease.

27. Comprehensive Proactive Liver Check

For proactive liver health, assess metabolic risks (BMI, metabolic syndrome factors), lifestyle habits (recreational drugs, exercise, nutrition), and current medications. This comprehensive approach helps identify potential risk factors beyond alcohol.

28. Address Patient Misinformation

For clinicians, use patient misinformation as an opportunity to educate and improve communication about health topics. This helps bridge knowledge gaps and better inform patients.

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