Online Health Chat with Arthur McCullough, MD, and Bobby Zervos, DO

Friday, January 20, 2017 | Noon


Fatty liver disease is an excess buildup of fat in the liver, specifically, more than five percent to 10 percent of the liver’s total weight. The condition develops when the body either creates too much fat or cannot metabolize fat quickly enough. This can occur as a result of alcoholism or heavy drinking or, less commonly, due to other risk factors such as obesity, diabetes or metabolic syndrome.

Initially, fatty liver often has no symptoms. This can be problematic as, for some, prolonged excess buildup of fat in the liver can lead to inflammation, progressing to cirrhosis (scarring of the liver), which can have increasingly harmful health implications. There is not one specific treatment for fatty liver disease, but lifestyle changes are often recommended. These include diet modifications to promote weight loss, regular exercise and elimination of alcohol.

Because treatment directly targets risk factors and underlying causes, high risk groups should be carefully surveyed and made aware of prevention strategies. Maintaining a healthy weight, eating a healthy diet and limiting alcohol consumption are all considered appropriate measures of prevention.

At Cleveland Clinic, our hepatology team has substantial experience and expertise in the full scope of liver diseases. Using a multidisciplinary approach, all specialists are united in one setting to create individualized treatment plans best for each patient. Additionally, our liver transplant program is an essential component of comprehensive care, bringing together medical and surgical experts to provide a seamless transplant process when deemed the most appropriate treatment. Liver specialists at Cleveland Clinic are well versed in the evolving research and treatment options for fatty liver and other liver diseases.

About the Speakers

Arthur McCullough, MD, currently serves as staff physician in the Department of Gastroenterology and Hepatology within Cleveland Clinic’s Digestive Disease and Surgery Institute. Dr. McCullough also holds a staff position in the Department of Pathobiology and Transplantation Center at Cleveland Clinic. After attending medical school at SUNY Health Science Center at University Hospital of Syracuse, NY, Dr. McCullough completed his internship and residency at Cleveland Clinic followed by a fellowship at Mayo Clinic in Rochester, MN. Well-established in both research and innovation, Dr. McCullough is a leader in several novel studies in the field of hepatology, fatty liver disease in particular. His specialty interests include nonalcoholic fatty liver disease, metabolic syndrome, biliary disorders, end stage liver disease and liver transplantation.

Bobby Zervos, DO, is a transplant hepatologist in the Department of Gastroenterology at Cleveland Clinic Florida. He is board-certified in internal medicine, gastroenterology and transplant hepatology. Dr. Zervos specializes in the diagnosis and treatment of liver disease, including liver transplantation. His specialty interests include cirrhosis, hepatic encephalopathy, ascites, hepatitis B and C, hepatocellular carcinoma, alpha-1-antitrypsin, cholangiocarcinoma, drug hepatitis, fatty liver disease, nonalcoholic steatohepatitis, primary biliary cirrhosis, primary sclerosing cholangitis, carcinoid, autoimmune hepatitis, portal hypertension and Budd-Chiari syndrome.

Let’s chat about Fatty Liver Disease

Fatty Liver Facts

Pacemaker: Is fatty liver disease hereditary? How does a patient control weight gain caused by medication for high blood pressure and osteoarthritis, among other health conditions?

Arthur_McCullough,_MD: Fatty liver disease runs in families about 30 percent of the time, but we don't know what gene is involved. As to weight gain, you should ask your primary care doctor if there is an alternative medicine that won't cause weight gain. Otherwise, you should make an appointment with a nutritionist.

Granny2017: What symptoms or tests would indicate fatty liver disease?

Arthur_McCullough,_MD: Often, the initial symptom is right, upper quadrant abdominal pain or abnormal liver tests. It is diagnosed upon routine screening. Many patients, however, have no symptoms at all.

Joekie: What are the symptoms of a fatty liver? I had elevated liver enzymes in 2012: AST-115, ALTt-98. After several months, they returned to normal with no change in diet and/or alcoholic consumption, one to two bottles of beer a day. Several years later, I had an elevated bilirubin for several months. What are your thoughts?

Bobby_Zervos,_DO: There are no specific symptoms that can be attributed to only fatty liver disease. It sounds like you should be followed with routine labs and one or two clinic visits per year with a hepatologist with comprehensive lab tests and perhaps a liver biopsy if your enzymes remain elevated.

Yudishg: What exactly is fatty liver disease?

Arthur_McCullough,_MD: Non-alcoholic fatty liver disease affects 30 percent of the adult population. The normal liver has five percent fat, but in the presence of an unhealthy diet and diabetes and obesity, the amount of fat increases due to a combination of multiple pathways.

Jill: Are there different types of fatty liver disease?

Arthur_McCullough,_MD: Yes, there are different types. There are two main types. The most common is associated with insulin resistance and a metabolic syndrome, but there are many other forms called secondary fatty liver that can be caused by drug, many congenital diseases and surgery.

Heater6: What is nonalcoholic fatty liver disease?

Arthur_McCullough,_MD: There are many types of fatty liver disease. The most common type is related to alcohol, but nonalcoholic fatty liver disease is related to insulin resistance and a metabolic syndrome. It is defined as less than 14 drinks a week for women, and less than 21 drinks a week for men.

Jax2674: Who is likely to have NAFLD?

Arthur_McCullough,_MD: Thirty percent of the adult population in the United States has fatty liver disease. It is most common in patients with obesity, defined as a BMI greater than 30, and patients with diabetes. It is also more common in the Hispanic population, but virtually anyone, depending on their diet, can develop fatty liver disease.

Physician Decision

Leila: Should I be seeing a hepatologist regularly to monitor my nonalcoholic fatty liver disease (NAFLD) and enlarged liver?

Arthur_McCullough,_MD: You should see a hepatologist initially. Depending on the hepatologist and the severity of the disease, patients are often seen every six months.

Crazyqfarm: I am a 61-year-old female diagnosed with NAFLD ten years ago. I have been doing fine until a few months ago. My liver enzymes are up from 100 to 125. Is this something to be concerned with? I normally do not eat wheat, but have in the past year. I watch my alcohol intake, but do drink wine on weekends. Are these possibilities for the increase? I also want to go very low carbohydrate. Is this a good idea?

Bobby_Zervos,_DO: Exercise with a well-balanced diet are important. I would recommend getting connected with a hepatologist to monitor your liver tests through the course of the year.

Bucksrule: I am a 53-year-old male, and I have been taking a statin for about 15 years, and an ace inhibitor and calcium channel blocker for about 30 years. My hypertension and cholesterol are all well-controlled. Over time, however, my liver has gotten out of range. The last three years, the alt reading is 61, with the healthy range of 9 to 46. My primary care doctor is not that concerned, since all my other liver functions are normal. He believes that it is prescription driven. My family history doesn't show this, at least from what I know. Should I be concerned? Outside of losing weight, which I am (I’ve gotten under 29 BMI finally), is there anything else I should do? Should I see a hepatologist?

Bobby_Zervos,_DO: Your medical history indicates that you are at higher risk for nonalcoholic steatohepatitis. I recommend that you see a hepatologist for further evaluation.

By the Numbers

Pan: I am a 63-year-old man. I’m eating a mostly plant-based diet, and my BMI is 22. I am a former smoker and have always been a recreational drinker, eight to ten times per year. I don’t take drugs. Thirty years ago, I had a BMI of 28.2, and was diagnosed with nonalcoholic fatty liver disease. In a recent Doppler ultrasound (triplex) and fibroscan, the results were normal. In at least eight measurements, stiffness was not more than 0.93m/sec, which corresponds to te< 6kpa.My hepatologist told me it is OK, but there is still a little fat on the liver. Would you be kind enough to give me general advice for my condition, as well as what I can do to get rid of the remaining fat if it is possible?

Arthur_McCullough,_MD: You should continue your healthy lifestyle. Even normal livers have up to 5 percent fat. The small amount of fat that you have left will not affect your overall health.

Bigbuckeye: My blood work from annual physical/wellness exams (at least as far back as 2007) have shown slight elevations (random changes in both up and down values) for total bilirubin (ranging from 2.2 to 1.4), AST (ranging from 63 to 43) and ACT (ranging from 74 to 36). I have no symptoms that would indicate any type of liver disorder. My primary care physician has not shown any concern over these numbers. My first-born child had a slight case of jaundice at birth. Are these numbers just part of my genetic makeup? Should I be concerned?

Arthur_McCullough,_MD: First, this is not part of your genetic makeup. You should be evaluated for the etiology of your elevated liver function tests. It is most likely fatty liver, but other chronic liver diseases must be ruled out. You should not be concerned about the jaundice of your child. This is physiologic jaundice in infants and will cause no long-term problems in your child.

Causes and Risk Factors

Jlro: I have been diagnosed with fatty liver disease. When my abdomen swells huge, I cannot breathe at all. My oxygen goes down to 88 percent to 89 percent, and my heart rate goes up to 120-150 beats per minute. I have been diagnosed with asthma also, but it seems as though the swelling of my abdomen is what makes my breathing really bad. Some asthma medicines do not work, except Combivent helps quite a bit. It seems to get worse when I am exposed to a lot of chemicals, and the liver just can't keep up with the things I am being exposed to.

Arthur_McCullough,_MD: Fatty liver does not cause bloating of the abdomen. An evaluation of small intestinal function for bacterial overgrowth and motility should be done. There is very little data to show any chemicals cause fatty liver disease outside of those used in rubber plant factories.

Baseballcheer: My primary care physician doesn't understand how I can have a fatty liver/nonalcoholic steatohepatitis (NASH) stage 2 since my triglycerides and cholesterol are normal. I have Crohn's and am on Remicade, yet my gastrointestinal doctor says it's not related to my Crohn's/Remicade use. I do not have autoimmune hepatitis. Thank you.

Arthur_McCullough,_MD: Many patients with fatty liver disease do not have high cholesterol or triglycerides. Other potential risk factors include diabetes, sleep apnea, hypothyroidism and hypertension. In fact, 15 percent of patients with fatty liver disease have no identified risk factors. In some studies, Remicade actually helps fatty liver, so your condition is not related to Crohn’s or Remicade treatment.

Granny2017: Does the removal of my gallbladder impact my risk of fatty liver disease, or vice-versa?

Arthur_McCullough,_MD: No. Removal of the gallbladder does not affect fatty liver in anyway.

Diagnosis and Treatment

Jfk: What other "numbers" are important to follow to ascertain if nonalcoholic fatty liver is progressing over time?

Arthur_McCullough,_MD: There are laboratory tests that are not typically done, one of them is a serum IgG level. More importantly, advancement in scarring of the liver can be determined by a new method called fibroscan. This can evaluate how much scar tissue you have.

Mikev39: As there does not appear to be any medication regime for fatty liver disease (correct me if I'm wrong), are there any vitamins or supplements that you recommend? How about drinking coffee?

Arthur_McCullough,_MD: Four cups of coffee a day seems to provide some benefit for fatty liver disease. You should make sure your Vitamin D level is normal. There is, in fact, specific treatment for fatty liver disease; however, a liver biopsy is required prior to treatment. These treatments include a natural form of Vitamin E and a medication called Trental.

Tanya: Please give your preferred treatment for a diagnosis of fatty liver. Would this treatment be any different for a diagnosis of autoimmune hepatitis? Thank you.

Arthur_McCullough,_MD: The treatment for fatty liver disease is very different from that of autoimmune hepatitis. The initial treatment for fatty liver disease is weight loss with a Mediterranean diet. However, if the liver tests do not normalize, a liver biopsy is usually suggested and there are specific medications that can help 50 percent of patients.

Steve: What complications can I expect from fatty liver disease?

Bobby_Zervos,_DO: There is a spectrum of fatty liver disease. It is best to follow-up with a hepatologist for assessment.

Yolo: I am confused about what a fibroscan is? Also, if you get a fibroscan, should you also get a liver biopsy?

Bobby_Zervos,_DO: A fibroscan uses vibrations at a low frequency to calculate the propagation of the created wave and its average speed, reported in kpa. The higher the kpa number, the more fibrosis within the liver.

Sliver: Are there any medicines I should avoid taking?

Bobby_Zervos,_DO: I do not recommend you take any over-the-counter herbs, shakes or supplements for liver disease without the consent of your primary health care team. They should have enough knowledge to know what prescription medications are appropriate, and if there are any questions can always seek the consultation of a hepatologist.

Diet Alterations

Chowmein: I was told I have to reduce consumption of fatty meats. However, I do not eat a lot of that. Then, I was told by my clinical nurse practitioner to eliminate all carbohydrates. Is this serious? I can reduce but not eliminate. Then, I was told about meal supplement drinks. This person was just not listening. Do you have any other suggestions?

Arthur_McCullough,_MD: It is not clear what your condition is and why these specific recommendations are being made. If you have fatty liver, the only proven diet is the Mediterranean diet, which has to be taken in quantities that will reduce your weight.

Chowmein: I was told I have fatty liver and to stop eating these items. So, I was baffled and never really pointed in any direction on what the next steps were.

Arthur_McCullough,_MD: I would reiterate the Mediterranean diet, which emphasizes vegetables and fruits, white meat, dairy products and a small amount of red meat. Regarding carbohydrates, these should be low glycemic index carbohydrates. This consists of wheat bread, not white bread, brown rice, not white rice, etc. You can look online with regard to low glycemic index carbohydrates.

Cah: I have mild fatty liver. I exercise and I’m trying to lose weight. Which milk would be better for me, whole or skim? Whole milk keeps me satisfied for a very long time, which means I'm not eating sugary snacks, but I am concerned about the saturated fats. Also, which is better for someone with a fatty liver, butter or a spread?

Bobby_Zervos,_DO: Having a well-balanced diet and moderating your consumption is the key. Continue to exercise with cardiovascular activities three to four times per week.

Interventions and Preventions

Rush2112: My husband was diagnosed with nonalcoholic steatohepatitis (NASH) stage 3, grade 3. NASH is a type of NAFLD. What that means for him has never been fully explained. Also, when he doesn't eat regularly, he gets foggy, can't make a sentence and walks like he is drunk. Is this from NASH or hepatitis? I really worry about the hepatitis? How can you tell if someone is experiencing an episode of hepatitis? Months ago, they tested his ammonia, and it was on the high side of normal so they didn't do anything. Also, he drank heavily for two years prior to diagnosis (never drank before that). Sometimes, he will get vodka because he craves the numbing. I have told him how bad this is for his liver, but he won't listen. How can I help him? Thank you.

Bobby_Zervos,_DO: It is important your husband stop drinking, as the liver biopsy indicates significant inflammation (grade 3) and the presence of significant scarring (stage 3). The episodes of confusion are worrisome for hepatitis and should be evaluated by a hepatologist.

Sarhol: Are there any ways to prevent nonalcoholic fatty liver disease?

Arthur_McCullough,_MD: Yes, prevention tactics include eating a healthy diet, exercising and avoiding smoking, which is a risk factor for advanced forms of fatty liver disease. I would also emphasize the importance of a Mediterranean diet.


That is all the time we have for questions today. Thank you, Dr. McCullough and Dr. Zervos, for taking time to educate us about fatty liver disease.

On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at

Arthur_McCullough,_MD: In closing, I would like to emphasize that fatty liver disease is not a completely benign condition. Even if your doctor does not think it is important, I would strongly recommend that you obtain the opinion of a specialist. It is not the most common cause of liver disease in the United States but continues to increase in prevalence. It will become the leading cause of liver transplantation within the next 10 years.

For appointments

To make an appointment with Arthur McCullough, MD, or any of the other specialists in Cleveland Clinic’s Mikati Center for liver diseases, please call 216.444.7000, toll-free at 800.223.2273 (extension 4700) or visit us at for more information.

To make an appointment with Bobby Zervos, DO, transplant hepatologist and gastroenterologist or any of the other specialists in the Department of Gastroenterology at Cleveland Clinic Florida, please call 877.463.2010.

For more information

The Mikati Center for liver diseases, part of the Digestive Disease and Surgery Institute, offers experienced liver specialists to accurately diagnose and offer advanced treatments for all types of liver diseases. Established in 2013, the Mikati Center was made possible by a generous philanthropic gift of the Mikati family and is dedicated to sustaining and improving the lives of those with liver diseases through advances in research, innovation and education. The center unites all of the specialists’ patients with liver disease need in one setting and helps create individualized treatment plans that are best for them. In addition to benefiting from our clinical experience, our patients also have the advantage of an active research team that continues to play a key role in developing and testing of new treatments. This means our patients have access to clinical trials, should they qualify. These research studies not only provide treatments otherwise unavailable, but they also help us expand our overall understanding of liver disease.

Cleveland Clinic Florida’s transplant center is one of the leading institutes for heart, liver and kidney transplantation in south Florida. As an extension of Cleveland Clinic in Ohio, Florida’s center brings more than 50 years of experience in transplantation surgeries to the region, which serves the southeastern United States, the Caribbean and Latin America. Led by world renowned transplant surgeons who are dually licensed in Florida and Ohio, Cleveland Clinic Florida is fully integrated with United Network for Organ Procurement (UNOS) and has one of the fastest growing transplant programs in the region.

Cleveland Clinic Health Information

Learn more about symptoms, causes, diagnostic tests and treatments for fatty liver disease.

Clinical trials

For additional information about clinical trials, visit

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