Liver Health for a Healthy Life & Concerns with COVID-19

Nonalcoholic fatty liver disease (NAFLD) or "fatty liver" is common. It affects approximately 75 to 100 million adults in the United States. That is 25% to 45% of all US adults. NAFLD or fatty liver is the leading cause of chronic liver disease. This is becoming more so prevalent because of the ongoing epidemic of obesity and metabolic syndrome.

Almost every 3rd American is affected by liver conditions nowadays. How can we explain the high rate of liver disease patients in the United States?

Approximately "25% to 45% of US adults" have Nonalcoholic fatty liver disease (NAFLD) or "fatty liver."

NAFLD is the liver (hepatic) manifestation of the metabolic syndrome. According to the Mayo Clinic, "metabolic syndrome is a cluster of conditions that occur together, increasing your risk of heart disease, stroke, and type 2 diabetes. These conditions include increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels."

What is Nonalcoholic fatty liver disease (NAFLD)?

Nonalcoholic fatty liver disease (NAFLD) is when there is a presence of at least 5% hepatic steatosis (fat) on liver biopsy without evidence of hepatocellular injury. Risk factors of NAFLD are insulin resistance, obesity, and as mentioned above, metabolic syndrome.

What is Nonalcoholic steatohepatitis (NASH)?

Nonalcoholic steatohepatitis (NASH) is a subset of NAFLD. It is more progressive and represents a more advanced form of fatty liver disease. There is a greater risk of fibrosis (scarring) and eventual cirrhosis (end-stage liver disease) that carries complications that can lead to high morbidity and mortality (death).

What do you choose to eat?

Body Mass Index (BMI)

"Current estimates suggest that approximately 68% of all US adults meet body mass index criteria for being overweight or obese."

What is the big deal of having a"fatty liver"?

Because "fatty liver" can progress from NAFLD to NASH. Then the risk of liver-specific morbidity (complications) and mortality (death) increases by a factor of 50 to 80 in patients with advanced fibrosis related to NASH. For this reason, correctly diagnosing and staging is critical for disease monitoring and prognosis.

Diagnosing NAFLD

Liver biopsy is the gold standard. However noninvasive means include ultrasound, blood testing, ultrasound elastography, and other radiographic options, like MRI studies. The early diagnosis and a sense of the severity of hepatic steatosis (fatty liver) may prompt further evaluation and more aggressive management of metabolic comorbidities; such as obesity, diabetes, etc.

It’s important to maintain a healthy weight, focus on eating a healthy diet, and exercise regularly.

Treatment of NAFLD

The US Food and Drug Administration has not yet approved any NAFLD-specific drug treatment. Nor is there any therapy for the management of NASH. There are clinical trials ongoing.

The only treatment is lifestyle interventions such as a balanced diet, weight loss, and healthy forms of regular exercise. Weight loss of at least 10% is the first goal. Studies highlight the underlying and true importance of diet in the management of fatty liver or NAFLD.

What are the first dietary and lifestyle changes recommended to someone with a liver condition such as NAFLD or "fatty liver"?

The only treatment is lifestyle interventions such as a balanced diet, weight loss, and healthy forms of regular exercise.

Nutrition so important for liver health, so what should you eat to ensure that your liver can function normally?

If you’re a liver patient, adjust your diet to meet your individual needs, and always talk to your doctor about what’s best for you.

Here are some general food tips for a healthy or healthier liver aka a "liver-healthy diet"?

• Eat a balanced diet from all food groups including grains, fruits, vegetables, meat and beans, milk, and oil.

• Eat food with lots of fiber which helps your liver such as fruits, vegetables, whole-grain breads, rice, and cereals.

• Don’t eat foods high in fat, sugar, and avoid salt.

• Avoid fried foods especially fast food.

• Avoid any raw or undercooked shellfish such as oysters and clams.

• You should avoid alcohol if your liver disease is advanced, so speak to your doctor.

• Drink lots of water to prevent dehydration.

• Note that I drink 4L+ a day of water. Recommend that to all my patients. Especially if they have constipation. Speak to your doctor about what is right for you.

What diet is recommended if I have fatty liver disease (the build-up of fat in liver cells)?

• Limit foods that are high in calories

• Eat foods that have fiber

What diet is recommended if I have Hepatitis C (inflammation caused by the hepatitis C virus)?

• Avoid foods that have high concentrations (amounts) of iron

• Do not use iron pots and pans to cook

• Limit your salt intake and foods that contain a lot of salt

What diet is recommended if I have cirrhosis (scarring and hardening of the liver)?

1. Limit salt and foods that have a lot of salt

2. Talk to your doctor about how much protein to have

What are the most important nutritional qualities liver patients should consider when choosing foods and how can I shop for foods if I have liver disease?

Here is a great list of tips from the American Liver Foundation. See below.

10 Healthy Tips to Follow at the Supermarket

1. Pick out vegetables and fruits without high-calorie sauces or added salt & sugars

2. Choose fiber-rich whole grains

3. Pick up poultry and fish without skin prepared in a healthy way

4. Decide over lean cuts of meat instead of those high in fat

5. Eat fish at least twice a week, especially fish containing omega-3 fatty acids (e.g. salmon, trout, and herring)

6. Make sure your dairy is Fat-free (skim) or low-fat (1%)

7. Avoid foods with partially hydrogenated vegetable oils to reduce trans fat

8. Limit saturated fat and trans fat by replacing them with better fats (monounsaturated and polyunsaturated)

9. Cut back on beverages and foods with added sugars

10. Choose foods with less sodium and prepare foods with little or no salt

What about protein if I have cirrhosis?

People with liver cirrhosis can experience malnutrition which can be managed with a healthy plant-based diet based on a diverse variety of fruits and vegetables. Look for lean proteins, such as legumes, poultry, or even fish. Always avoid raw seafood if you have cirrhosis.

Prevention and management of malnutrition are essential to you if have cirrhosis. It is estimated that 50% to 90% of individuals with cirrhosis have malnutrition. For the best nutrition management, a registered dietitian should be involved.

Olivia Moss, M.S., R.D., Food and Nutrition Services, UC Davis Health, Sacramento, CA

Here are some great links to use as resources.

• VA | Eating Tips for People with Cirrhosis - Viral Hepatitis and Liver Disease

• Mayo Clinic | Cirrhosis - Diagnosis and treatment
• AASLD | Nutrition Priorities: Diet Recommendations in Liver Cirrhosis

Coronavirus and Liver disease

Are patients with chronic liver disease at greater risk of developing a more severe form of COVID-19 than other population groups and if so, why?

According to the CDC, "Adults of any age with certain underlying medical conditions are at increased risk for severe illness from the virus that causes COVID-19. Severe illness from COVID-19 is defined as hospitalization, admission to the ICU, intubation or mechanical ventilation, or death."

Furthermore, "Having chronic liver diseases, such as alcohol-related liver disease, nonalcoholic fatty liver disease, and especially cirrhosis (scarring of the liver), might increase your risk for severe illness from COVID-19."

Actions to take

• Take your medicine(s) exactly as prescribed.

• Make sure that you have at least a 30-day supply of your medicines.

• Call your healthcare provider if you have concerns about your condition or feel sick.

• If you don’t have a healthcare provider, contact your nearest community health center or health department.

Am I at risk for further liver injury or liver failure in severe COVID-19 cases?

Yes.

In one study, "Of all COVID-positive patients, 45% had mild, 21% moderate, and 6.4% had a severe liver injury. Moderate and severe liver injury was more common in patients who required ICU-level care."

How should liver disease patients support their liver health during a lockdown or social distancing?

If you are worried about your own personal risk, discuss this with your doctor.

How the COVID-19 virus behaves is still an evolving process of learning for the medical community.

What precautions should liver disease patients take during the coronavirus pandemic?

1. Wear a mask.

2. Wear a face cover.

3. Wash your hands.

4. Keep a safe distance.

Learn more here from the CDC: How to Protect Yourself & Others