The liver is a 3-pound, rubbery organ that sits on the right side of your abdomen, below the diaphragm and above the stomach, and it’s very good at multitasking.

It filters blood; manufactures proteins, including those that help clot the blood; detoxifies chemicals and drugs; stores and regulates cellular fuel; produces the bile that helps digest fat; metabolizes and stores several nutrients, like iron and vitamin D; and helps respond to and destroy viruses and other germs. In other words, the liver is crucial to your health and wellbeing. But a lot of our livers aren’t doing very well.

An astounding one out of every three Americans—more than 80 million people—have a fatty liver: Their liver cells are filled with excess fat, in the form of triglycerides. Most people with fatty liver have a relatively innocuous form that doctors call nonalcoholic fatty liver (NAFL), but about 20 to 25 percent have a more active form of the disease called nonalcoholic steatohepatitis (NASH). Together, they are called nonalcoholic fatty liver disease (NAFLD).

High-risk NASH

In NASH, fat-engorged liver cells weaken, balloon, and die in greater numbers than normal, leaving the liver inflamed and scarred (a condition called fibrosis). NASH increases your risk of colon cancer and death from a heart attack, heart failure, or stroke. It doubles the risk of liver cancer, and it can lead to cirrhosis, or extensive and life-threatening scarring of the liver. NASH is the fastest-growing cause of cirrhosisrelated liver transplants.

And the situation is only getting worse. Research shows that by the end of this decade, more than 100 million Americans will develop NAFLD, with the number of deaths from NAFLD expected to double. Here is perhaps the most daunting statistic of all: Nine out of 10 people who have NAFLD don’t know they have the problem, because it doesn’t usually cause symptoms.

Risk factors

Here’s how to determine if you’re at risk for NAFLD and what to do about it.

You’re more likely to have NAFLD if you are overweight or obese, have high blood pressure, and/or have type 2 diabetes. If you have all three of those risk factors, the odds are 75 percent that you have NASH.

If you have any or all of the three main risk factors for NAFLD, talk to your primary care physician about monitoring the health of your liver. An easy way to do that is with a measurement called Fibrosis-4, or FIB4. This uses two blood tests: a liver panel, which measures liver enzymes, and a platelet count, which is part of a standard blood test called a complete blood count (CBC) test. A formula using two liver enzymes, platelet count, and your age produces a measurement that correlates to the amount of fibrosis in the liver. (Your doctor can find a FIB4 calculator at page/clinical-calculators/fib-4.)

If your score is 1.3 or lower, there is a low probability that you have liver scarring. If your score is between 1.4 and 2.5, you may want to see a hepatologist for additional testing to determine your risk of cirrhosis, such as a special ultrasound test of your liver called Fibroscan.

If your score is 2.6 or higher, there is a high probability that you have significant scarring. You should see a liver specialist (hepatologist) to determine your treatment options, with the goal of preventing cirrhosis or diagnosing cirrhosis that may already be present.

The FIB-4 test should be repeated every year. An increasing score is a strong indication that the condition of your liver is worsening and treatment is needed.

Weight loss

The first and most important lifestyle treatment is decreasing fat in the liver—in other words, losing weight. But you don’t have to lose a lot of weight: Losing just 5 to 10 percent of your total body weight will generate dramatic improvement in your risk for NAFLD. For example, if you weigh 200 pounds, losing 10 pounds is significant.

Don’t try to lose it all at once. First, stop weight gain, and then start to lose weight at a reasonable, achievable pace of about one pound per month. The best way to lose weight is also the simplest:

  • Generate a mildly negative caloric balance so you burn more calories than you consume.
  • Limit your intake of refined carbohydrates (such as white flour and white sugar) and other processed foods, and favor whole foods, such as lean meat, fish, low-fat dairy products, fruits, vegetables, beans, whole grains, nuts, and seeds.
  • Limit your consumption of high-fructose corn syrup, a sweetener that has been linked to liver inflammation and fibrosis.
  • Increase your intake of omega-3 fatty acids, which are found in fatty fish such as salmon and sardines.
  • Drink more coffee, which may protect against fibrosis.

Improve fitness

Any type of aerobic exercise is good for reducing the level of triglycerides in the liver. Walk, bicycle, swim, dance, or do any activity that makes your heart beat faster for 30 minutes at least five days a week. Pick an aerobic exercise you like and will do regularly. For many people, that’s walking.

Regular resistance exercise and/or high-intensity intermittent training are also effective. Talk to your doctor before starting an exercise program.

Sleep better

Scientific findings show that lack of sleep is linked to insulin resistance and stress, both of which lead to more fat in the liver.

To improve your sleep, follow the principles of good sleep hygiene:

  • Go to bed and wake up at the same time every day. If you need to change your sleep time, do it gradually.
  • Follow a nightly routine. Give yourself 30 minutes before bed to wind down.
  • Avoid blue light from televisions and computers 30 to 60 minutes before bed.
  • Use your bed only for sleep and sex.
  • Keep your bedroom dark, quiet, and cool.

Medical treatments

There are several medications for NASH in clinical trials—such as obeticholic acid, which reduces inflammation and balances blood sugar—but none have yet been approved by the U.S. Food and Drug Administration.

In the interim, some physicians treat NASH with off-label (not FDA approved) medications. They include the diabetes drug pioglitazone (Actos), which improves insulin resistance, and the weight loss drug semaglutide (Ozempic). There is also evidence that highdose vitamin E (800 international units daily)—a prescriptive dose that should be used only with the approval and supervision of a physician— may help control NASH. The American Association for the Study of Liver Disease recommends both pioglitazone and vitamin E for most people with proven NASH. Bariatric surgery for weight loss is also an important consideration for people with obesity. In one study, NASH was completely resolved in 84 percent of those who had the surgery. However, 10 to 20 percent of those who undergo bariatric surgery suffer from complications, such as abdominal hernia, nausea, heartburn, gallstones, and nutritional deficiencies.

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