All About Fatty Liver Disease

Podcast Transcript

Scott Steele: Butts and Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end. Hi again, everybody, and welcome to another episode of Butts and Guts. I'm your host, Scott Steele, the Chairman of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. Today, we're going to touch on a topic that we haven't discussed much about, and that's fatty liver disease. I'm very pleased to have our expert in town. That's Jamile Wakim-Fleming, who is the Director of the Fatty Liver Disease Program here at the Cleveland Clinic. Dr. Wakim-Fleming, thanks so much for joining us. Welcome to Butts and Guts.

Jamile Wakim-Fleming: Thank you. I want to thank you for inviting me.

Scott Steele: For those who don't know your background, can you tell us a little bit about where you're from, where'd you train and how'd it come to the point that you're here at the Cleveland Clinic?

Jamile Wakim-Fleming: I was born in Lebanon and I did medical school at the French university, St. Joseph University, in Beirut. And then I came and I did my fellowship training at University Hospitals. So even when I was there, I was familiar with the Cleveland Clinic because we, the fellows at that time, were doing combined meetings. One month the meetings or journal club or whatever discussions would happen at the Cleveland Clinic, and the next month it was at University Hospitals.

So I have been in Cleveland for all these years. After I graduated, I was recruited to the VA to run their outpatient clinic. I did that, and then I was recruited to Metro and I did that and then I left the VA and I did Metro along with the Cleveland Clinic while I was raising my kids. I've been at the Cleveland Clinic since 2002. I joined the hepatology section. It was a very small section. There were three staff and I, and have been here ever since. I love it.

Scott Steele: Well, we are very happy to have you here. Thank you so much for all the great work you've done over the years. Let's start very high level here. What is fatty liver disease?

Jamile Wakim-Fleming: When we talk about fatty liver, we talk about the presence of fat globules in the liver. There are multiple causes for fatty liver. I need to make that differentiation. The most common causes of fatty liver are either related to alcohol, which causes fatty liver, or not alcohol. When we speak of fatty liver disease, we are talking about the fatty liver that is not caused by alcohol, and so we make sure that the patients are not drinking alcohol excessively. Once in a while is okay. Otherwise, we don't call it fatty liver disease. In fact, Ludwig described this back in 1980. He described fatty liver disease as arising in the absence of significant alcohol intake. So I need to make that differentiation between the two because people get confused sometimes.

So that is what is fatty liver disease. There are fat in the cells. They end up destroying the cells, and they are not related to fat that has been developed from alcohol.

Scott Steele: What are some of the symptoms that occur with this fatty liver disease that patients may notice and you would recommend that they reach out to their provider?

Jamile Wakim-Fleming: Fatty liver disease, also I want to mention this little thing, it's a spectrum. It encompasses a spectrum of events that happen to the liver. Initially, we deposit fat in the liver. That is benign. Fat cells in the liver are not harmful to the liver. But as the situation worsens, then there will be inflammation from these fat globules and fat cells. There will be inflammation in the liver. This inflammation will lead to fibrosis or cirrhosis in the liver.

So when we see patients, we could see them along the whole spectrum. What causes it, which is different than alcohol, is the metabolic features of the patient. So patient walks to you, they either are overweight or have hyperlipidemia. Triglycerides are high. Their lipid panel is high. They have diabetes. They have heart disease. All of these features are the features of the metabolic syndrome which put the patient at risk of developing this entity, the non-alcoholic fatty liver disease that we are talking about it today.

When they come to my office, their symptoms, usually either they have any of these problems or they are on the spectrum, meaning that their primary care doctor sent them because they have abnormal liver test or somebody did a biopsy that showed inflammation, or that an image showed fat in the liver and cirrhosis, or they did some studies like a FibroScan showing advanced fibrosis. So when they come to my office, thankfully they are referred by their primary care doctor for any one of these reasons.

Scott Steele: So in general, is fatty liver disease diagnoses on the rise? And if so, what would you attribute this to?

Jamile Wakim-Fleming: Fatty liver disease in fact is on the rise. When I first joined the Cleveland Clinic 2002, we were busy dealing with hepatitis C. Fatty liver was barely talked about. In the last 15 years, we have found a cure for hepatitis C so we don't see it as much. Now, we see more of fatty liver disease.

And 75%, three quarter of the patients who have fatty liver disease, are overweight. So what drive the fatty liver disease is being overweight. About three quarter of the time, 25% of the cases are not related to weight. There are some genetic factors. There are multiple other factors, but the bulk of it is related to weight.

"We deposit fat," I tell my patients. "How did it come?" they ask me. I say, "We deposit fat in the body under the skin and we look a little bit overweight. And then fat cells go from the intestine when we absorb food and the fat and goes right into the liver. That's where fat cells deposit, in the liver."

So the last 15, 20 years has shown a parallel rise in weight and in fatty liver disease because they go hand in hand. That trend occurs in children as well as in adult. For now, it's involving about 25% for the population in the United States and worldwide, and is expected to double in the next 15 years. So this is becoming a very serious issue, and it's becoming the leading cause of end-stage liver disease, cirrhosis and transplantation, one of the leading cause along with alcohol.

Scott Steele: This is the section of the podcast we like to call Truth or Myth. Truth or Myth: fatty liver disease is the same as cirrhosis.

Jamile Wakim-Fleming: Fatty liver disease is a spectrum going from simple fat, harmful fat in the liver. When it progresses and we don't pay attention to it, we don't treat it, we don't manage it, it will lead to cirrhosis. So in a way it is, but cirrhosis is caused by other conditions, too. But fatty liver disease is one of the causes of cirrhosis. If we don't treat it and catch it early, the inflammation in the liver from fat will progress into cirrhosis.

Scott Steele: Truth or Myth: fatty liver disease is irreversible.

Jamile Wakim-Fleming: I want to say that usually it is irreversible because cirrhosis, in general, is irreversible. However, cirrhosis means there's a lot of fiber developing in the liver. If you catch it early when the amount of fiber is not expansive, and you treat the cause, you may reverse it. But overall, in general I would say it is not reversible because we rarely catch them very early.

Scott Steele: How do you treat, then, fatty liver disease? I mean, we recognize that cirrhosis is not reversible, but what about fatty liver disease? I mean, how do you treat it? How do you improve? Where do you go from there?

Jamile Wakim-Fleming: That's a very, very common question, and sometimes we are frustrated because we tell our patient to do a few things. Number one, since most of the time it is tied to obesity, we want them to lose weight. If they have diabetes, we want to treat the diabetes. If they have high blood pressure, we want to treat the high blood pressure. That vicious circle of the metabolic syndrome, we need to break it. If they have abnormal lipid profile, their cholesterol, triglycerides, LDL are elevated, we want to treat those. All of these help because all these factors, the diabetes, the blood pressure, abnormal lipid profile, maybe some endocrine disorders such as hypothyroidism, all of those contribute to deposit of fat in the liver, so we want to treat each one of these elements to break that cycle and help the fatty liver.

So that's one aspect of it. We want to treat the metabolic features of it in addition to managing the weight. People who are overweight. If they are not overweight, then you focus on these things. If they are overweight, then we need to advise them on a healthy diet, exercise, and try to manage their weight as much as they can with some help from us.

Scott Steele: We hear a lot about diets out there. There's pretty much a diet for everything. Is there a diet that can improve fatty liver disease?

Jamile Wakim-Fleming: Yeah. As far as diet, eating a healthy, low in saturated fat diet and carbohydrate is a good one. We tell them to focus on what are the healthy habits. Whatever treats your heart and cholesterol, that's what you're going to do for you as far as diet.

Sometimes they ask me specifically, "Is there anything in my diet that I could take?" I tell them coffee. I tell them if they like coffee and it doesn't cause them problems, three or four cups of dark coffee will help. The studies have shown it will decrease the fibrosis and the cirrhosis in our patients.

Scott Steele: So Truth or Myth: rapid weight loss can actually make fatty liver disease worse.

Jamile Wakim-Fleming: It depends how much. We know that you lose three to 5% of your weight, the steatosis, all this fat, will disappear. If you lose seven to 10% of the weight, you improve. With other patients, they improve the majority of the features of fatty liver that we see on the microscope. If you lose more than that and more rapidly within six months, yes. Excessive weight gain and excessive weight loss in a short period of time is going to cause fatty liver.

Scott Steele: Let's walk a little bit through it. So somebody is diagnosed or is concerned for having fatty liver disease. It's picked up in any different way. What are they going to experience when they come see you at Cleveland Clinic's Fatty Liver Program?

Jamile Wakim-Fleming: When I see them, they already been referred by their primary care doctor, thankfully, because we see many times the patient has not seen a primary care doctor until they had advanced cirrhosis, liver failure, liver cancer. We don't want to see that case. If they come in that situation, then we're going to have to treat the cirrhosis and its consequences, the cancer and et cetera, the liver failure.

But before then, when their liver tests are abnormal, usually the primary care doctor has ordered an ultrasound. The ultrasound is going to show fatty liver. And then you look at the patient. The patient has the metabolic features. They have all the features we talked about, some diabetes, lipid, a little bit of overweight and all of that.

What I tell them is... I take some blood and test because I want to make sure what is affecting their liver is only non-alcoholic fatty liver and no underlying diseases of the liver. Because you could have fatty liver and it could have alpha-1 antitrypsin, for example. You could have fatty liver and you could have hepatitis C. We want to make sure there isn't anything else affecting the liver, in addition to fatty liver, because we want to treat it.

We have treatments for hepatitis C. We treatments for a lot of things. We want to treat any other condition affecting the liver because two conditions affecting the liver, non-alcoholic fatty liver and something else, will make the progression to cirrhosis and decompensated liver disease or liver failure progress more rapidly. That is a very important point.

We want to make sure that we ruled out any other condition that affect the liver, and then I want to see if there is any damage in the liver and how much there is damage in the liver. How do I do that? There are few things we could do. Non-invasive test by doing either a FibroScan. Elastography, where we do like an ultrasound but it has a propensity to check for the stiffness of the liver. It tell us how much scarring in the liver because the scarring, the cirrhosis, is the driver of the complications of the liver disease.

So we do either ultrasound elastography, which is done in radiology, or FibroScan, which is done in our offices here. That will give me idea how much there is fat in the liver, and that'll give me an idea of how much scarring there is in the liver, advanced fibrosis or cirrhosis. That will direct me toward the other things. There are also noninvasive measures, markers such as the NFS, FIB4, APRI. There are noninvasive measures that we also could plug them, plug those numbers in the computer, and it'll give me a measure.

When I get all these results, I put it all together. I have the ultrasound. I have the FibroScan. I have these markers. And then I came up because there's not one test is going to be hundred percent diagnostic. We put all of these together and we tell the patient what we find. We either are at a reversible stage before the cirrhosis happen, or we are at an irreversible stage and now we're going to deal with the cirrhosis.

And then we decide, what is the management? Sometimes, none of these give me a good idea where the patient stands and how much damage in the liver. We go and we refer the patients for a liver biopsy. So we have several test that could help us determine the gravity of the disease and how much damage there is in the liver.

And then what do they expect? Once we do that, we talk about the diet, the exercise, or sometimes we have to be realistic. If I see somebody who's BMI is very high... and I mean BMI is really more than 35. Unlikely. And most of the patients come to my office, they know that they are a little overweight and they have tried, so I don't give them a hard time about it. I know everybody walking into the office. 30, 40 years old, they know what they have to do. We don't talk about it too much, but we give them another chance, about six months. But if their BMI, if their weight is in the high range, we know that the diet is not going to work and no matter what I do, the medication that I give is not going to work. That's where referral to surgical management or endoscopic weight reduction happen because we want to break that cycle and we don't want to get into cirrhosis.

Scott Steele: Is there any research taking place, new innovative ways to prevent or to treat this disease?

Jamile Wakim-Fleming: So we have a lot of research going on at the Cleveland Clinic, but also worldwide there are several trials, several medications that are in phase II or III trials. But none has been approved yet. That's the frustrating part of treating fatty liver, is preventing, treating all the conditions that cause the fatty liver. But I tell my patient, "Unfortunately, I do not have a medication like if you have a pneumonia, I could give you antibiotic and get rid of it." There is no such a thing now, but it will happen. Now, it's very important to deal with all the problems that get together to cause the fatty liver, and discover or diagnose early cirrhosis or advanced fibrosis because this is now when I can deal with it better and manage it. We could prevent serious complication to the patient.

Scott Steele: Well, it looks like we have some actually things on the horizon, and to look forward to, that can treat those. For those who know this podcast, you know we always like to wind up with some quick hitters to get to know our experts better. So with that, I would ask you, what is your favorite sport?

Jamile Wakim-Fleming: My favorite sport, dancing. And swimming. Dancing and swimming.

Scott Steele: Okay, good. What's your favorite meal?

Jamile Wakim-Fleming: Ooh, salad.

Scott Steele: What is the last nonmedical book that you read?

Jamile Wakim-Fleming: Nonmedical book? Oh my goodness. I just finished a book by Mark Twain. The Prince and the Pauper? The Prince and the Pauper.

Scott Steele: And finally, tell us something... Sounds like you've made the rounds here in Cleveland. What is something you like about the city itself or the area?

Jamile Wakim-Fleming: I mean, I came to Cleveland and I've been here for over 20 years. I don't want to leave. I think other than the Cleveland Clinic... And I'm not saying this because I work at it... I love the Cleveland Clinic. I think this is a place where ideas reach the sky. That draws me in it.

When I was a resident, I liked the Cleveland Orchestra. I used to be the doctor in the Cleveland Orchestra. Volunteer to be in the audience in case an emergency happen until the ambulance came. I enjoyed that a lot. I still enjoy that. I enjoy the Museum of Art, and I enjoy traveling a little bit outside Cleveland to see what's going on in the one-hour drive here and there when I have time. I enjoy the Flats and the East 4th Street, all these nice restaurants.

Mostly, to tell you the truth, I love the lake. I love the lake. I love watching the lake. It opens my mind when I just go watch the lake and watch the fishermen catch fish and the beauty of seeing the seagulls in the winter. I would walk there over to the lake in the winter and there will maybe hundreds and hundreds of seagulls. You could see them on the ramp. It's amazing in the winter. In the fall, there's a lot of fish on the ramp. And then the summer, it's beautiful.

Scott Steele: Well, I couldn't agree with you more. That may be the most inclusive answer I've ever gotten to that question. So what is the final take-home message regarding fatty liver disease for our listeners?

Jamile Wakim-Fleming: What I want to tell my listeners, don't worry. I tell them if you lose one pound, that's all what I want a month. If you lose two, that's good. Don't worry about it. Don't stress.

First of all, learn how to manage stress. If there is any stress in your life, don't eat because you're stressed. Learn how to manage it. It's very, very important.

This past year, 2020, was a very difficult year on everybody. Lot of patients who had made a good stride in losing weight the year before, now they gained it back. About 99% of my patients have gained their weight back that they had lost in 2019. There is a lot of stresses. There were a lot of stresses affecting all of us. So I tell them, "Learn how to manage this stress. Distract yourself. Read. Walk. Climb the stairs up and down. Do whatever you want. Climb a tree." I always advise to have a primary care doctor and follow with a primary care doctor because they refer a lot of patient. They discover problems.

My other thing is I tell them, "Beware of drinking alcohol." We all want to drink. Just beware. When you eat, when you drink, just think of the calories we're ingesting and just think, I want to be healthy.

That's it. Don't think of the weight. Don't think of what's going on here and there. Just think of, I'm going to live a healthy life. What is it? We all know what is a healthy life. That's all what I want them to do. And drink coffee if you like it.

Scott Steele: Again, that's some great advice. For more information on fatty liver disease, please visit Cleveland Clinic's Health Library at clevelandclinic.org/health. That's clevelandclinic.org/health, H-E-A-L-T-H. And to speak with a specialist in the Digestive Disease and Surgery Institute, please call 216.444.7000. That's 216.444.7000.

Again, finally, remember in times like these, it's still important, extremely important, for you and your family to continue to receive medical care. Rest assured, here at the Cleveland Clinic we are taking all the necessary precautions to sterilize our facilities and protect our patients and caregivers. Dr. Wakim-Fleming, thank you so much for joining us here on Butts and Guts.

Jamile Wakim-Fleming: Thank you, Dr. Steele. Thank you very much for inviting me. Continue to take care of your health. You will get there.

Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.