Written by Christopher Kelly
Feb. 6, 2015
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Hello and welcome to the Nourish Balance Thrive podcast. My name is Christopher Kelly. And today, I've got something slightly different for you. No guest, just me and a slightly more technical topic, shorter and a little exercise for you to do at the end. I'm going to talk about non-alcoholic fatty liver disease which according to this paper that I'm looking at in front of me right here. It's called "Liver transplantation for nonalcoholic fatty liver disease: New challenges and new opportunities" is going to be the number one reason for a liver transplant in the United States by the 2030, so not that far out.
Quite scary prospects that for some possibly diet and lifestyle reason would be the main cause for a liver transplantation. So this is not good because obviously the prognosis for transplantation is not great. It's a complicated procedure. You might not even survive it. And the chances of you needing another one are pretty high, so obviously something to be avoided, huge problem. And first, I should make clear what exactly is nonalcoholic fatty liver disease.
Now, fatty liver disease is just the excess accumulation of fat around hepatocytes which are the cells that make up the liver. Now, when the liver has too much fat surrounding it, it starts to become dysfunctional and you might even see some of the cells die and just disintegrate. The thing that's special about nonalcoholic fatty liver disease is it's not caused by alcohol, right. As the name sort of makes clear is we know that you can cause fatty liver and cirrhosis and even liver failure by consuming too much alcohol. Most people know that, but what's becoming clear is that the same very similar pathology is happening even though the person is not really consuming very much if any alcohol at all.
And so why is this happening? And I think the answer is the excessive consumption of glucose and fructose which are the two single polymer sugars that make up common or garden table sugar, right. So refined carbohydrate, but also obviously glucose is in many other complex carbohydrates, but it's all broken down to glucose and fructose inside of your body. Now, fructose might be special in particular because it behaves differently inside our bodies than glucose does.
So let me make this clear. So when you think about converting sugar into energy, that's called the glycolytic pathway. And the glycolytic pathway is regulated by an enzyme called Fructose 6-phosphate. Now, what happens is when you have enough energy -- so imagine the citric acid cycle. It's like this traffic cycle that's spinning round and round and round. It's turning glucose and fructose into energy. It's combining with the oxygen that you breathe and you're turning that into energy.
Now, once you have enough energy, it wouldn't be beneficial to produce even more, right. So once you got enough that's enough. And so what happens is you see an elevation of citrate, so some organic acid starts to come out of the mitochondria into the cytosol and maybe even into the urine where we can measure it. And that citrate will inhibit this enzyme that's called Fructose 6-phosphate. And then that'll flip you into storage mode.
So if your glycogen stores are depleted, say you've just done a really hard work out. Then you would start storing the excess glucose and fructose as glycogen or if your glycogen stores were topped off which is the case for most people most of the time, then you would start to store that excess energy as fat. Now, that sounds like a healthy thing to do, but there are some exceptions. And the particular problem with fructose is it enters into the glycolytic pathway, as it enters into this pathway that converts sugar into energy beyond this main rate limiting step.
And so it continually forces the citric acid cycle to produce more and more energy which causes problems of excess energy. And eventually that energy will be stored as fat. Now, this is probably going to happen locally around the liver. And so it could lead to this nonalcoholic fatty liver disease. Now, that's one really good reason to not consume more than, say, 20 grams per day of fructose which is about one and a half apple. Now, obviously this is going to be different if you're an 80 pound woman than if you're a 250 pounds guy. But that's kind of just to give you an idea that probably there's enough fructose in your life at some point.
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Now, the other interesting paper that I found is called the "Banting Memorial lecture 2012: reversing the twin cycles of type II diabetes." And the thing that I found interesting about this paper is it shows this graph. And on the graph, they plot something that's on every strand of blood chemistry called ALT.
Now, ALT is an enzyme that normally should be inside of the cells that make up the liver, so inside the hepatocyte. And in the chart that they show in this paper, you can see a steady rise in ALT that leads up to the diagnosis of Type II Diabetes. And what they're proposing is that marker, ALT, can be used to predict the onset of nonalcoholic fatty liver disease, the dysfunction of the liver and then Type II Diabetes.
Now, this is cool because you can go and look at your blood chemistry right now and see what your ALT is. On the paper, I'm looking at the diagram and I'll link to this in the show notes, what they found is 18 months prior to the diagnosis ALT was around 25 international units per liter. That's ui/l is what it would say on your blood chemistry.
And then at the diagnosis there've been quite a steady rise and eventually that had gone up to between 30 and 35 point, so quite a significant increase. Now, of course the first thing I did when I saw this was I was like, "Okay. So what was mine in 2011 when I wasn't doing very well?" And the answer is I was up at 46. So just to reiterate those numbers, to restate those numbers, the type II diabetics were diagnosed with ALT at 33 points and mine was 46.
So I'm pretty sure that was a problem. And I know that in like really severe cases of liver damage you might see something much, much higher than that like maybe 300 points, so really, really severe. Now, that's the point that your doctor is going to say, "Hey, this is a real disease. You need to go and see a specialist. There's a real problem here," right. So the doctor is not going to and didn't in my case pick up that I had mildly elevated ALT. He just didn't say anything about it and that's probably because it fell within the range that's on his lab report.
There was this star next to it, this is fine. I don't need to look at this again. Next please. And so yeah, you can go and have a look at this now and see what yours is. Now, the way that these enzymes work is they should be inside the cell. And there's another enzyme called AST that should be inside the cells of muscle and heart and liver. And the reason they would be measured on a blood chemistry in the first place is because something has happened to that cell. So if that cell is compromised in any way and it breaks down and dies then it dumps the contents out into the blood, into the plasma where it can be detected on the blood chemistry.
So some cell turnover is obviously completely normal. And so you're almost going to see some level of ALT on your blood chemistry. But if you see elevations of either AST or ALT, then I think it indicates a problem. So with AST, I said that came from muscle cells, heart cells, all types of cells. And so if you do a really hard work out, the AST rise temporarily in response to that really hard work out. But if you test it again, say, three weeks later you wouldn't see that. It'd be gone.
It's not something that stays high forever. It's quite an acute phase reactant. Now, ALT is really, really interesting in that it comes specifically from hepatocytes, so from the liver. So when you see an elevation of ALT, you know that the liver cell has been compromised in some way and dumped its contents out. And when you see elevation of that you know there's some kind of pathology going on inside the liver.
So obviously it's super-duper important for nonalcoholic fatty liver disease and it might be able to tell you something about where you're at now and whether or not you're maybe consuming too much glucose and fructose. Now, to go back to where I was in 2011, ALT 46 points, clearly in the danger zone. I was consuming massive amounts of carbohydrates. Now, I was also doing tons and tons of exercise to balance that energy intake.
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So I wasn't getting fat. I was still 3% body fat, but at the same time those liver enzymes were clearly telling me that something was wrong. I just didn't know to look. I just didn't have that knowledge at that time. And so I was eating tons of fructose. We live in California and we have amazing fruit here. We have peaches the size of your head that just are so sweet that they would make most people cringe. That it's like so sugary.
And I'm pretty sure that was what was going on for me at that point. I've consumed tons and tons of these sugary sports gels and other sugar drinks on my bike. And then I afterwards, I always backload with tons more carbohydrate and this I think is the end result. So the exercise for you then is to go and dig up your old blood chemistry and have a look at these numbers. Are your ALT and your AST in the low 20s? Because they can be mildly elevated and your doctor is not going to say anything to you. They're not going to ask why.
And so that's the difference between you and me and your doctor is you're going to be asking why, right. So maybe if the doctor did see this they might try and write you a prescription like say metformin for example, something that's going to help regulate your blood glucose and maybe lead to less metabolic dysfunction like fatty liver disease. But they're not going to be asking why. They're not going to be asking you questions about your diet and your lifestyle that might be leading to these types of problems.
So yeah, just to kind of quite a niche thing, but I think it's quite interesting and hopefully you do too. Please do let me know if you think this is useful. And also email me chris@nourishbalancethrive.com if you've got any questions. I'd be more than happy to answer those.
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