Please note: transcript not 100% accurate.
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00:00
So it’s just about education and reset. And this is what I’m talking about by changing the habits at home. You know, breakfast should look a little bit differently. Your packaged lunch could be better. Your snack time could be a little bit healthier. So sugar, to answer your question, is certainly one of the problems in addition to having other ultra-processed foods combined with just not being active enough.
00:27
This is Dr. Meenal and welcome to Uncover Your Eyes, where we uncover reality. As a mom and eye doctor, I wanna know it all. The liver is the largest solid organ of the body. It performs hundreds of vital functions for us daily. We commonly hear the term fatty liver disease being tossed around much more, and definitely amongst the younger demographic more and more.
00:57
Here to give us more insight on fatty liver disease is Dr. Supriya Joshi. Dr. Joshi completed her residency in internal medicine, gastroenterology, and has a fellowship in hepatology. She works at some of the busiest hospitals in Ontario, the Credit Valley Hospital and Trillium Health Partners. She has been a guest expert on CBC Marketplace and is continuously educating healthcare professionals on liver disease and the negative impact
01:27
poor diet and lifestyle on metabolic health. Thank you Dr. Joshi for being on today. I really appreciate your time. Well, thank you so much for having me. What an honor to be here and talk about one of my favorite topics to you and your audience. So thank you for having me. Tell me, like, I don’t know a lot about the liver, but what is the liver? What does it do for us? Oh, I’m so glad you asked that question because if you can believe it or not, it was often thought just to be an empty filler in the empty abdomen as a support structure.
01:56
But interestingly, even way before that, there was a realization that the liver was important for one’s life force and soul. So I think there was some idea that a sick liver affected how you were as a human being. But we now know way more than that. And in fact, what’s commonly out there, which is correct, the liver is a large organ or abdomen connected to our digestive tract, and it filters and detoxifies the blood. That’s one of its main functions. I think that’s pretty well known.
02:24
What’s not as well known is the liver produces many proteins and digestive factors such as bile, which is important in us absorbing and digesting our fats, our healthy fats. That’s important. And it’s also to be recognized that it stores your energy in the form of glycogen. So the liver plays a very important role in our body’s balance of healthy macronutrients. So whatever we feed our body…
02:54
will almost certainly get metabolized by the liver and then manufactured into something useful for our body. So I think those are the three main functions. And we need our livers. It’s a vital organ. If you don’t have it, you’re not really going to survive unless you get a new liver, which obviously is quite a difficult thing to get. Wow. I hear the term fatty liver always being tossed around, right? And I see it in the younger demographic. I see people even coming into our practices writing it as one of their conditions now,
03:24
questionable fatty liver disease. I don’t think they even understand it. That term is being tossed around so much. First, I want to address the fact that I feel I hear that it’s been renamed and it’s not called fatty liver disease anymore. Is that true? Yes. I’m so glad that you know that. So the name fatty liver was given because the liver looked like it had fat in it on imaging, like an ultrasound. And when a person had a liver biopsy, it actually was lipid.
03:52
or fat. And that’s kind of how that name carried on for decades. But as we now are being aware, that word fat or fatty is very stigmatizing. It just makes people assume we have to be overweight, have obesity. So it was not really very humanistic term. So it has been renamed to be metabolic dysfunction associated steatotic liver disease. So it’s a very long name, which we health professionals call Masl, M-A-S-L-D, for the presence of fat in the liver.
04:21
And it was decided upon because it more correctly gives the connotation for what’s underlying it, it’s metabolic dysfunction. That’s what leads to fatty liver. And you can be any body shape and size and you can still have significant metabolic liver disease. So that’s why it’s been renamed. But it’s also important to understand that fat in the liver is not supposed to be there. And when it’s there, it means there’s some process going on that’s not healthy.
04:48
And it can be there for a variety of reasons. So not just from metabolic issues. It can also be there as a result of regular alcohol consumption. It can be there because a medication someone is on, so certain prescribed medications can cause it. It can be a side effect of certain medications like cholesterol medication, Tamoxifen for breast cancer, very common ones that I see. It can also be there to indicate someone has another disease, such as celiac disease or hepatitis C.
05:16
So when we see someone who’s referred to someone like in my practice with, they have a fatty appearing liver, there’s definitely a workup that has to be done before we diagnose somebody with the more common form like you’ve addressed, metabolic dysfunction of the liver. How are you diagnosing it? How do people, healthcare professionals know, what are the risks, sorry, the signs or the symptoms of who needs to be worked up and how do you work them up? Excellent question because it’s often found coincidentally.
05:46
there’s often no signs or symptoms. It’s not like the patient goes to the healthcare provider and says, hi, I have fatty liver problems. That does not happen. That conversation is not there. It’s most often I have abdominal discomfort, I’m having bloating, or on routine blood work, the liver enzymes are elevated, and then the doctor would appropriately do an abdominal ultrasound, and the liver fat is found. But it may not always be brought up in conversation because that doctor is trying to address their primary concern, what led to the ultrasound.
06:14
whether it’s the pain, the discomfort, the abnormal liver tests. And our healthcare system is so constrained and so, and not given enough time. So I really feel badly for primary care physicians because they have a lot on their plate to manage for the 10 or 15 minutes. So to then carry on the conversation about, oh, by the way, Eddie, you have a fatty liver and this is what you should do about it. That doesn’t always come up. So part of it is just how it’s found. There’s no signs or symptoms mostly. That says sometimes it’s a right-sided ache or abnormal liver test.
06:44
But once that is found, I think the healthcare provider that is aware that this is a significant finding will then carry on the next step, which is finding out why is there fat in your liver for all the reasons I just mentioned above, are you drinking alcohol? Is it a medication side effect? Do you have other condition? And some physicians feel more comfortable referring that on to specialists like myself, or some do a little bit more workup on their own.
07:12
But eventually at some point, if that does end up in my lap, my job is to make sure I’ve ruled out all the other causes. I then wanna know, has this person developed any liver damage from this fat in their liver? Is it causing liver inflammation? Is that leading to liver fibrosis or damage? And if so, how bad is it? Because I wanna be able to give this patient some indication, do you have no liver damage yet you have a lot of fatty liver?
07:40
or are you on your way to developing liver cirrhosis? And that is very impactful because that gives indication on their own mortality, the amount of sickness that they could have from other potential issues related to it. And we can figure that part out on degree of liver damage and degree of liver fat by a blood test called the FIB-4, which is a calculated test that any physician can do.
08:05
And secondly is a non-invasive scan called a fibroscan. That’s mostly what we use in North America and around the world in fact. Liver biopsy is now rarely done to diagnose it just because of the safety issues, the burden of disease, which I’m sure we’ll talk about how prevalent this problem is. We can’t go around doing liver biopsies and everybody because it’s painful and there’s potential risks of bleeding and even death. So we have to use our tests wisely with blood work.
08:31
a FIB-4 test, which is a calculated thing based on blood work and age and certain markers in the blood work, and a non-invasive fiber scan. So once I know that information, then I can have a conversation with our patient and say, listen, this is where you’re at, and these are the next steps. Wow, that was great. That was loaded. So that’s great. Okay. Can we go back to the metabolic? So, you know, you listed the reasons, alcohol, you know, meds, metabolic issues. So can we touch on that? What does that mean?
09:00
Absolutely. So part of falls into that category. Oh, yeah. So it’s become very complicated. So before a year ago, I would just tell someone, you have fatty liver, do this. And it could be from any of these causes. Now with the new definitions, it has been categorized. Okay. So you can diagnose somebody with mazzled metabolic liver disease if they have presence of fat in the liver on imaging, in addition to one of these other following criteria.
09:27
which includes elevated BMI of over 25 for non Asians, over 23 for Asians, and that means overweight or obesity. It can also be high triglycerides in the blood. Okay. It could be presence of prediabetic or diabetic state on medications. So, I mean, this is obviously…
09:50
think it’s more prevalent than we think or we know. So like how prevalent is, and I’m going to call it fatty liver disease because it’s easy for me to say. I’m totally good with that. But how many people have this? Like is this walking around? Is it one in three? Like how many? Pretty good guess actually. So in North America, it’s about 25 to 40% is the estimate of prevalence in adults and 15% of adolescents.
10:20
have fatty liver. And it’s projected to only increase by 2030 and even 2040. So if the problem of the disease is increasing, so is the problems that people who are gonna have the fibrosis and cirrhosis. And as we know, the only real treatment for end-stage liver disease is liver transplantation. So there is going to be a huge wake up call and tsunami effect, I think in healthcare, when we look at the number of people.
10:46
that are going to end up with very advanced stage liver disease. So my goal is to try to prevent anyone from getting there. And that means implement as many things as you can today because in 20 years, you don’t want this, you don’t want to be told you have liver cirrhosis because it’s a slow process. That’s the one benefit here. When you told you have this, it would be about 20% of people that will end up with progressive fibrosis over 10 to 20 years. So there’s a huge opportunity to intervene early.
11:16
So obviously these one in three people, you know, walking around like a lot of them don’t know about it. And like you said, there’s not a lot of symptoms. So how do these people know to visit their healthcare professional or to have this checked out such that they can make changes to not get to those stages? So who should be warned about this? So personally, I’m trying to make this more public awareness about it. And I think Canadian guidelines will be trickling down eventually the next year or so, I hope.
11:45
But in terms of looking at European and American guidelines, what it’s supposed is that if somebody’s over the age of 50 and has type two diabetes, they should be screened for fatty liver. Otherwise, if someone gets an ultrasound for other reasons and they’re told they have fatty liver, they should be counseled. So we’re not at a stage where we’re just doing widespread screening. I think we have to look at who has the risk factors for developing it. And I think we’ll have more criteria as we learn more. And are your…
12:13
biggest risk factors, I’m assuming from what you’re saying, being pre or diabetic and being overweight, I’m assuming those are some of the top two. Are there other risk factors? Absolutely. So I think what’s written down in terms of categories is what you’ve just said. Type 2 diabetes, high triglycerides, specifically like within the cholesterol profile, high blood pressure, and then overweight or obesity. But we also see a lot of other…
12:41
systemic conditions that are very common in patients with metabolic disease, which is also called insulin resistance. Just for your listeners to be aware, they’re all kind of the same thing. And that’s the connection. It’s underlying insulin resistance that starts. And I do believe it often begins in the liver when you get liver insulin resistance starting, which perpetuates weight gain, which perpetuates…
13:04
you know, cells not responding to insulin properly. And then that excessive energy in your bloodstream now gets converted into fat in your liver for storage and then causes disease. So that same process can lead to someone developing gout. Polycystic, people with polycystic ovarian syndrome are also at risk of developing fatty liver. Menopausal, perimenopausal women have more than double the risk of having metabolic liver disease or fatty liver disease. So we have to start looking not just at the classical people with metabolic syndrome.
13:33
but also these other systemic problems that pop up. So sleep apnea is another good example, someone with heart disease. So they probably have fatty liver, but it was there 20 years ago, just they were not aware of it. Wow. You know, I’ve also heard the link between, I want to say it’s dementia or Alzheimer’s and fatty liver. Is there a link? Absolutely. And again, it’s through insulin resistance. So they’ll call Alzheimer’s type 3 diabetes. So again, it comes down to insulin resistance.
14:02
elevated blood sugars, those ongoing spikes in blood sugar are not good for our health. In any way, it increases the risk of dementia, heart disease, stroke, kidney disease. It also affects your muscle and your muscle health. It affects your mood. It can increase anxiety. There’s a whole bunch of complications having ongoing elevations in blood sugar. How do we remedy that? Well, you have to look at how you’re living your life.
14:30
And that comes down to lifestyle and lack of education, poorly learned habits, not to blame or shame our families, but we learn our habits when we’re young. And also having to adapt cultural customs and habits to modern day. And I think that’s because in modern day, like you and I are sitting at a computer, we’re at work, we’re at a computer. When we’re done dinner, we go lie on the couch. We live in a cold country, we’re indoors a lot.
14:59
You know, so I think a lot of things that how we live has not allowed us to keep our muscles strong, keep us moving. So we have to fabricate that. And so that’s one of the things, the message that I try to teach my patients is that we have to change the habits we have and adapt and even things that we do culturally, you know, you know, I’m a South Asian, I have a lot of South Asian patients and a lot of people believe that vegetarian is super, super healthy, which I think it is healthy, but you have to do it right.
15:28
You know, you have to look at your protein intake, your fiber intake. If your whole meal is always sugar, ultra-processed food, and refined carbohydrates, that’s a recipe, and you’re not moving, that is a recipe for having insulin resistance and metabolic diseases as you age. So are all these diseases considered metabolic diseases? Yeah. Pretty much, right? And they’re all intertwined. Pretty much. And they’re all intertwined. So blanket statement.
15:58
is sugar the culprit? It’s one of them. Yeah. Probably one of the main ones, I would say. It’s certainly one of the… Yeah, because we’re not… We’re over consuming and it’s hidden in everything. And this is part of the whole by design for manufacturing and for money and for business. I’m sure you’ve heard of the thing called the bliss point where recipes that we… Items that we buy at the store are purposely designed to taste that way.
16:23
to get that bliss point where it raises your dopamine levels, you get addicted to it, you want more of it. So when it comes down to something like sugar intake, North America is one place where people get accustomed to adding sugar to their coffee or tea. Coffee is very beneficial for reducing the risk of liver disease and liver cancer if you tolerate coffee, but adding sugar to it all of a sudden makes it not a very healthy drink. So it’s about how many spoons of sugar are you getting in a day?
16:50
And the WHO in 2015 made a statement because people don’t realize how much they’re getting. And I do believe nutritional labels are not people friendly. How do you know what does grams mean? What does that look like? So realizing that four grams of sugar is one teaspoon is one sugar cube and then understanding sugar math. So I’m not, again, my goal is not to shame anyone, but make them understand what they’re consuming and what that budget is. So for women,
17:20
They should not be having more than six teaspoons of sugar a day. That’s 24 grams. Yet, if you look at the grocery aisle and you look at a fruit yogurt, that has four and a half spoons of sugar in it. You know, one glass of juice can have, you know, six teaspoons of sugar in it. You know, a child should not have more than three teaspoons a day. Yet kids, depending on their, by breakfast time have blown that budget. If they’re getting, you know, Fruit Loops, Nutella.
17:49
and a glass of orange juice or chocolate milk. So it’s just about education and reset. And this is what I’m talking about by changing the habits at home. Breakfast should look a little bit differently. Your packaged lunch could be better. Your snack time could be a little bit healthier. So sugar, to answer your question, is certainly one of the problems in addition to having other ultra processed foods combined with just not being active enough. So how is coffee helpful?
18:16
I don’t know the answer to that. It’s a great question. It’s been said. It’s come down, yeah, coffee. So studies show that whether it’s brewed, it’s decaf, it’s instant, all has shown benefits to multiple areas of health, including liver health. So the recommendations are, they say two to four cups a day, but I think that’s a lot. I think two to three cups a day can actually reduce the incidence of liver disease by up to 50%. Wow. So coffee drinkers tend to have less incidence of liver disease, as long as they’re keeping it as a healthy form.
18:46
It’s thought to be part of the antioxidants in it. It’s one of the main things and the flavonoids from what I’ve read. But other than that, there’s other compounds in it that I don’t really understand the science of it. Wow. I’ve also heard the myth of, you know, with lifestyle changes, like you mentioned all these things, saunas. Yes. What is the science behind that or why? Well, yeah, it comes down to heat shock proteins. So a lot of the data on saunas comes from Finland. So it’s…
19:13
coming to talk about cultural habits. So they have this amazing cultural habit where almost everyone has access to a sauna. And studies show that if you can spend at least 20 minutes in a sauna at least three or four times a week, you can reduce your risk of heart disease and dementia, but over 50%. So it was quite an astounding effect. So what happens when you have heat shock proteins is that they correct the damage in our own cells replication. So our cells, as you know, are always replicating. They’re always re-brooming and changing. But it takes that one mistake.
19:43
to then become a bad cell that leads to poor health. And that poor health can manifest in different ways. Could be atherogenic heart disease, it could become a cancer. But heat shock proteins will fix that error in cell replication. And so you wanna elevate your heat shock proteins. So sauna has been one of the more main ones studied, but I think there’s also data coming out that even a steam bath, like hot yoga, anywhere where you get hot, sustained levels for 15, 20 minutes can be helpful.
20:12
And if you use the sauna or active or exposure to heat for less time, then their benefits are less as well. Wow. That’s the first I’ve heard of that. So that’s, that’s amazing. Why don’t doctors talk about this? Like, why are patients not aware of these things? So, you know, what do doctors know this or, uh, like in your experience with other healthcare professionals that you’re talking to, is it that we are not aware of these things or is it that
20:41
we keep them a secret because we want to prescribe the pill. What is your honest opinion on that? I think it’s unawareness. I went to medical school a long time ago, 25 or so years ago, and we learned science, we learned disease, and lifestyle issues were never really… Move more, eat less was kind of always the teaching point, and just tell someone to lose weight.
21:07
And even me as a gastroenterologist, that’s my primary training, and I delivered a disaster that it was, yeah, then you just go lose weight, I’ll see you in six months. Like that was always the discharge advice. However, I soon learned that this isn’t working, you know, telling people to just lose weight. And so we have on my own, we have to learn about what else is out there, because I wanna give my patients a toolbox. This is all the things that you can do and try to improve your health. And if these strategies work for you, if it doesn’t work for you, it doesn’t, but try it.
21:35
So sauna is something I learned about. In fact, we put a sauna in our house and my husband, even 10 years ago was using it. I just thought he was lazy to do it. I thought he didn’t want to go work out. But he knew the data, you know, that the sauna can be beneficial on reducing cardiac risk and dementia. Wow, I am, I am into this sauna. It comes down to like self learning. Yes. Right. Yes. And also you get muscle recovery, get improvement with your muscle recovery after a workout.
22:03
helps it sleep. There’s lots of great benefits to having access to Sona. I mean, with our South Asian background, I think we’re, I mean, especially myself, like at risk of, you know, everything. And so, you know, if, if that is going to help, I mean, so what are top three things that you would, or I don’t want to limit it to three, whatever you want to say, you want to say to healthcare professionals out there such that they are aware of these and able to
22:32
better educate their patients and themselves. Yeah, I would say when you see somebody with fatty liver, don’t ignore it. And as many people are just told, oh, everyone has it, so no one talks about it. But Ishwarya brought up that this is actually an indicator that you are developing insulin resistance. And this is a patient who may not have elevated blood sugar and type 2 diabetes, may not yet have high blood pressure. They’re a little bit, they’ve had some weight gain, but they’re not really classifying as overweight or obesity as of yet.
23:01
But I think that education, that discussion, that conversation, oh, look, you’ve got liver fat. This could mean that you’re developing insulin resistance. And if you don’t modify these things in your lifestyle, then in time, in five, 10, 15 years, you may develop these medical problems. I think that conversation is not happening enough. I think there’s a lot of doctors who are learning this and practicing this way, but certainly the majority are not. And they don’t have time. Honestly, the way traditional medicine is.
23:31
We don’t have time to talk about all these interventions. I’ve taken it upon myself to spend this time with my patients because I’ve had no, funny enough, no prescription to write to treat fatty liver disease. As of a week ago, we now have three medications available to treat people with advanced fibrosis from liver disease. They’re not yet available in Canada with this indication, but I’m sure they’ll be coming. I’m sure you’ve heard of like Trisapatide, Simaglutide, and Resmetteron. Those are the three medications that have been shown to reverse it. But…
24:01
Even those medications cannot take the place of lifestyle modification. So when I give an education, they’ll talk to physicians. What I recommend is educate your patient on sugar and how to cut back, cutting back on refined carbohydrates and processed food. I also educate people to prioritize protein if they can. 30 grams a meal. I know it’s hard. I try and I fail, but trying is important. 30 grams of fiber a day. Again, try. But I also tell people…
24:30
not to eat late at night. Because I think we become a society where we have dinner and we sit on the couch and watch Netflix. That has to change. After your meal, go for a walk. Because even just walking after a meal can have some significant improvements in your post-meal blood sugar spike. And the reason for not eating at least three hours before bed is because when you eat in the evening, you activate those hunger hormones, such as ghrelin, which makes you more hungry the next day.
24:58
and your leptin levels in the daytime go down. So ghrelin is our hunger hormone, leptin is our hormone that tells us we’re full. And they both can be influenced by eating or not eating or eating the right foods like protein and fiber. If you eat a lot of sugar and processed foods, the leptin level drops and you don’t feel hungry, you don’t feel full and that makes you feel hungry again. And that’s kind of the science behind why.
25:25
eating processed and junk foods just lead you to have that sugar spike and crash. Sugar spike and crash. It’s an interaction between our insulin, our glucose, leptin, and ghrelin. I’m sure there’s many others as well, but these are the main players that balance that. So this is what I want doctors to have this conversation with. Educate them on nutrition. Time of eating can matter, like avoiding late night eating. Even the sequence of foods, having your fiber and your protein. If you want your carb, have it at the end.
25:54
Because again, it stabilizes that blood sugar. And just prioritizing or emphasizing the importance of physical movement. So I tell everybody, walk after meals if you can, at least the American Heart Association, and I believe this as well, at least 150 minutes a week of exercise. And there should also be purposeful strength training, because after age 30, we all start to lose our muscle mass. And as you lose our muscle mass, we become less insulin sensitive. And that’s also partly why
26:24
we have these issues of metabolic diseases, we’re aging because we’re having less muscle mass to help soak up that glucose to keep our level steady. So as we’re all living longer, we wanna be healthy older people and aging well, prioritizing our muscle health is super important. And I advise people to minimize alcohol. And I think most people in North America are vitamin D deficient as well. And there’s a role for vitamin D.
26:53
I recommend magnesium viscoseint as well because it can help activate the vitamin D, but it can also help rest this leg, help people possibly have a better sleep, and helps them have a good poop in the morning. That makes people quite happy. Top that. Yeah. Oh, so I think that’s the GI part of me. Interplay is still with everything. Everything’s connected. It’s all connected. You mentioned the aging factor. I think at the beginning you said women are more likely to have it after age 50 than men who are-
27:22
younger, when they’re younger, are more likely to have it. So does menopause play a role in this? Is that why it’s so hormonally? Yes, I believe so. So under age 50, it’s more metabolic or fatty liver disease more common in men than women, but then it shifts. So after age 50, there’s a peak with women becoming more prevalent than men with diagnosis. And we know that category women are
27:51
is related to insulin resistance. And that’s probably one mechanism how this may play out. So for my perimenopausal menopausal women, I really emphasize all of what I just talked about, you know, and also to talk to their doctor about menopausal placement therapy, because it’s available. And we now know women were given a huge injustice with being told that hormone therapy was was all evil and all bad. And we know that it’s not. Because if you’re not getting good quality sleep,
28:21
that’s going to affect your metabolic health. If you’re insulin resistant, that’s going to affect your heart health, your brain health as you’re aging. So I think we owe women that extra conversation to say, this could be menopause related as well. So obviously do what you can with lifestyle effort, but also consider.
28:44
menopause replacement therapy if it’s a good fit for you. Wow. What a connection, eh? Like, I don’t know if everyone would add that all up. Menopause, metabolic conditions, everything’s linked. Sugar’s the culprit. It’s one of them. I just want to make another video. It’s one of them. And the processed food. Yeah, oh, I did a whole expose with Tim Horton’s Double Doubles years ago. Wow. Yeah, yeah, because I realized I would actually interview every patient, so what do you have for breakfast? And they go, oh yeah, I have a coffee. I’m like, what do you put in your coffee?
29:12
And I realized, some people go to Tim Horton’s for their coffee and they order a double double. I’m like, what did you think that’s in that? And I actually went on and calculated the sugar content. It is not two spoons of sugar. It is way more. And I feel, so I did a whole thing on it. And CBC did an episode on that as well. And it’s just mind-boggling that most people don’t know that. It’s two pumps of sugar, which is not equivalent.
29:37
To the spoons of people that are accustomed to. Yeah, but listen, I do believe sugar is a big problem because it’s everywhere, right? All the Instagrammable drinks and all of that, all that nonsense. Thank you so much, Dr. Joshi. This was amazing and very inspiring and insightful. So thank you for your time. Can you tell us where our listeners can find you? Well, I’m glad it was helpful. I hope it was. Thank you for having me. I’m not very tech savvy, you know, but I do have my Instagram and TikTok page. I’m @LiverHealthMD
30:06
And hopefully soon I will be making a landing page and starting launching some master classes. So people want to learn more about very liver-specific related issues. I’ll be able to give information and do some Q&A for that. So hopefully we’ll get that going soon. That’s great. Thank you so much. Thank you, listeners and viewers, for tuning in. If you want to catch more episodes of Uncover Your Eyes, make sure to Follow or Subscribe on your favorite podcast platform and on YouTube.
30:35
To learn more about me, follow me on Instagram @Dr.MeenalAgarwal Until next time, keep those eyes uncovered!