Fatty Liver: The Essentials

Weight Loss


I’ve previously discussed how dietary fat does not cause fatty liver. But I believe that this bears repeating and expanding, as SO many people diagnosed with the condition are still being told “There’s nothing we can do about it” or “Cut your dietary fat” or “There will be a new medication coming out to treat it soon” or other ineffective, even harmful, advice. And fatty liver is everywhere, affecting up to one-third of Americans, 65% of overweight people, 90% of obese people, now the #1 most common form of liver disease.

Contrary to the uncertainties of many doctors, the evidence is quite clear: Fatty liver parallels the development of insulin resistance, high blood sugar, pre-diabetes, type 2 diabetes, visceral fat accumulation, obesity. In other words, it is yet another facet of the man-made epidemics of overweight and type 2 diabetes. If you can reverse insulin resistance and type 2 diabetes, you can reverse fatty liver.

The condition is typically without symptoms and identified via screening labs such as AST, ALT, or GGT that are increased, common markers of liver status. Or it might be noted incidentally during an abdominal ultrasound, CT scan, or MRI performed for other reasons, noted as fatty tissue infiltration or fibrosis (fibrous tissue deposition). Screening for this condition can be especially important, as even early phases of the condition before fibrosis or damage are incurred still represent a risk factor for liver cancer development. And it is indeed important that you reverse this condition, as it substantially raises your risk for type 2 diabetes (diabetes is often diagnosed concurrently with fatty liver), liver cancer and other cancers, heart disease, and dementia.

There is indeed good evidence on how to reverse fatty liver, so why do so many doctors claim that there is nothing you can do about it? What they are really saying is that there are no prescription drugs or medical procedures that reverse fatty liver and prevent its progression to cirrhosis, portal hypertension, then liver failure necessitating liver transplant. That is true—but it does NOT mean that there are not NUTRITIONAL solutions that are impressively effective, reversing fatty liver within weeks. But you already know that the majority of doctors are rank amateurs in nutrition, frighteningly ignorant of what is achievable with nutrition.

Problem: If allowed to progress to the point in which liver damage has occurred and fibrous tissue has infiltrated the liver in response, liver damage becomes irreversible. This can be detected via imaging such as ultrasound, CT scan, MRI, or liver biopsy. This is not a good place to be, as it can lead to something called portal hypertension, accumulation of grotesque quantities of fluid in the abdomen (ascites), breathlessness, and, eventually, liver failure (although there is a high likelihood that you will die of heart disease before the liver fails). The key is therefore take steps to reverse fatty liver either as soon as it is identified or, even better, before it even begins.

It really helps to understand the main processes driving fatty liver:

  • De novo lipogenesis
  • Insulin resistance
  • Dysbiosis and SIBO

The relatively recently discovered process of liver de novo lipogenesis refers to the liver’s ability to convert carbohydrates such as sucrose, fructose, or the sugars that result from digestion of amylopectin A of grains into triglycerides. (Triglycerides are fats.) Some of the triglycerides are released into the bloodstream and blood triglyceride levels will therefore be increased. (I define “increased” as 60 mg/dl or greater.) Some triglycerides, however, remain in the liver and accumulate where, over time, they damage liver tissue. Blood markers for fatty liver, such as increased AST and ALT, are therefore typically accompanied by high triglyceride levels above 60 mg/dl.

Insulin resistance, i.e., impaired responsiveness to blood insulin, occurs in the liver that increases liver triglyceride production. Combine carb consumption with insulin resistance and the liver becomes a high-powered triglyceride factory. This situation is made even worse by the inflammatory contribution of visceral abdominal fat, nearly always present to excess when insulin resistance is a factor.

Most recently, it has become clear that many, if not most, people with fatty liver also have small intestinal bacterial overgrowth, SIBO. A flood of bacterial byproducts, such as bacterial lipopolysaccharide, empties into the portal circulation that drains to the liver, making the liver the direct recipient of a huge flood of inflammatory factors, igniting liver inflammation and damage. It is not clear whether SIBO is a cause or a consequence of fatty liver, but addressing SIBO is part of the necessary process to reverse fatty liver, as well as the other many health consequences of SIBO.

Then how to reverse fatty liver? Address and correct the main processes that created the situation in the first place. It means:

  1. Avoid foods that fuel de novo lipogenesis, i.e., sugars and carbohydrates that includes, of course, wheat and grains. We already know that this reverses fatty liver within weeks. I have personally witnessed reversal countless times with normalization of AST/ALT/GGT, as well as imaging measures.
  2. Reverse insulin resistance—This is the basis for the strategies in the Wheat Belly and Undoctored programs. For the most complete version of the programs that incorporate all these strategies, consider following the program detailed in my new Revised & Expanded Edition of Wheat Belly. Managing vitamin D status, thyroid status, and magnesium status, for example, all contribute to reversing insulin resistance, factors all disrupted by modern life.
  3. Cultivate healthy bowel flora—Such steps include assessing your breath hydrogen level to determine whether small intestinal bacterial overgrowth, SIBO is present (it likely is), then taking steps to eradicate the flood of ascending microorganisms that allow this situation to emerge. (A full prescriptive program for eradication of SIBO without the doctor is available in my Undoctored Inner Circle.)

It means that conventional medical “solutions” for the issues surrounding fatty liver do nothing to reverse the condition. Injecting insulin or taking other diabetes drugs to control blood sugar does not reverse fatty liver. “Everything in moderation” or “Move more, eat less” does not reverse fatty liver. Taking a statin cholesterol drug or fibrate drug to reduce triglycerides does not reverse fatty liver. Taking a non-steroidal anti-inflammatory drug to reduce inflammation does not reduce fatty liver. Sadly, following the advice of your primary care doctor or gastroenterologist does not reverse fatty liver.

The good news: You have profound control over fatty liver, including the ability to reverse it within weeks using tools and strategies that you can employ on your own with results that far exceed anything the doctor could achieve.


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