A couple months ago, I read an article about the fatty liver epidemic in the young. The article says that 15% of obese children and adolescents have fatty livers, and a third of children are overweight in the US: and the obesity epidemic is becoming world wide.

Now, fatty liver is not rare:

NASH (non alcoholic Steatohepatitis, or fatty liver with fibrous scarring) affects 2 to 5 percent of Americans. An additional 10 to 20 percent of Americans have fat in their liver, but no inflammation or liver damage, a condition called “fatty liver.”

Fatty liver is often is found in alcoholics, and warns one that the person might end up with fatal cirrhosis.

First we check for hepatitis.

Then we docs  usually check if the person is using a medicine that can cause the problem, stopping the medicine if the lab test is above a certain level or if the harm of the liver damage is worse than the disease treated by the medicine. After all, the liver is big and can take a lot of abuse. If stopping a medicine means dying next week from a seizure or dying next year from a heart attack, well, we figure those dangers are worse than maybe dying of liver failure in ten or twenty years.

Finally, we have to check for lupus and other auto immune diseases that can sneak up on people with only vague symptoms.

But now we are seeing more fatty liver of unknown origin, associated with obesity and diabetes. Why?

Too many calories? Lack of exercize? Our toxic water bottles causing metabolic syndrome? The increase in the wrong fats in fast foods?

The culprit seems to be metabolic syndrome. This is the tendency to put on weight that is genetic; in the past, when human diets were “feast or famine” it probably kept people alive. Nowadays, with lots of cheap easily obtained food, it leads to insulin resistance, central obesity (“apple” shape, not “pear shape”)

Illustration from Healthcarenet.

You eat too much, and your body becomes “insulin resistant”, that is it has to put out more insulin to metabolize (process for energy) the food you eat. Eventually, this wears out the pancreas cells that produce insulin, resulting in Type II diabetes.

But we also see metabolic syndrome in certain other diseases, the most common one being in Stein Leventhal syndrome of women, where they get lots of small cysts on their ovaries, high testosterone levels, infertility, obesity, and facial hair.

A couple years ago, gynecologists started treating these women with diabetic medicines such as Metformin and later the “glitazone” type medicines, with remission.

So now there are studies suggesting that these medicines, which are known to increase the body’s ability to use insulin (or lower insulin resistance) might help stop metabolic syndrome and obesity…these medicines also have been used experimentally to treat fatty liver disease from metabolic syndrome.

The ordinary treatment is diet and exercize. Doctors since the time of Hippocrates have known this. The real problem is trying to make people diet. This NEJM article compared two common diets…low carb versus high carb. The result? A 4% weight loss,  and a high drop out rate.

But of course, the important part of the picture is prevention. How do we prevent overeating?

Preach at people? Start strict vcgan diets? Vegetarianism?

Or should we take away their cars and make them walk?

As a doctor, I am fascinated by the problem, mainly because in Africa we treated malnutrition, but when I worked with Native Americans, the problem in several of the tribes was the high rates of metabolic syndrome (mainly those whose traditional way of life was replaced by food stamps and government surplus foods).  Yet other tribes, such as the Apache, who stubbornly continued in their traditional way of life, had a much lower rate of the same.

So is the problem high fat foods? Junk food? Or is it the type of fat in the modern diet?

In the last twenty years, the arguments has gone from saturated fat to omega 6 type polyunsaturated fat as the culprit. So does this mean we need to stick to olive oil and canola oil? That’s the latest scoop…

Yet I am always skeptical. Yes, the Mediterranean diet is supposed to be great, but why did all those Italian grandmothers look and act twenty years older than their American cousins? Japanese diet is better, but what about the high rate of stomach cancer and hypertension? Vegan diets are great, but the low vitamin B12 can cause problems, including dementia. In Africa, we only saw heart disease and high blood pressure in the educated who ate European diets. But the local traditional diet made one prone toward Pellagra, sigmoid volvulus, and was so low in protein that wounds took weeks to heal.

Finally, I wonder many of these population surveys took into account the starvation and tuberculosis deaths of the 1940’s? My husband’s family all lived to be 90, except for those who died of TB when they were young…

Finally, I wonder if chemicals that mimic estrogen or the widespread use of hormones (birth control pills for example) will be found to be part of the problem. Are we fat because of the bisphenol 6 in all those nice unbreakable plastic bottles?

No, I don’t have answers. If I did, I’d be thirty pounds lighter.

But the cutting edge of medicine in the future might just be revising our patient’s diets to those of the “natural food” types who seem to live forever (well, up to a healthy 90 years or so).


Nancy Reyes is a retired physician living in the rural Philippines. Her website is Finest Kind Clinic and Fishmarket, and she writes medical essays at HeyDocXangaBLog.

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