Modern Metabolic Health with Dr. Lindsay Ogle, MD

Fatty Liver Disease: The Hidden Epidemic

• Lindsay Ogle, MD • Episode 5

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We break down metabolic-associated steatotic liver disease, why it’s so often missed, and how to catch it early with the right labs and imaging. We explain simple steps to lower risk, the medications with the best evidence, and when to see a specialist.

• What MASLD is and how it progresses 
• Why incidental imaging findings matter 
• ALT, AST, platelets and what they mean 
• Using FIB-4 to estimate fibrosis risk 
• How common MASLD is in adults and people with type 2 diabetes 
• Evidence-based treatments, from GLP-1s to bariatric surgery 
• Lifestyle targets including 5–10% weight loss 
• When to ask for GI or hepatology referral

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Speaker:

Welcome to the Modern Metabolic Health Podcast with your host, Dr. Lindsay Ogle, Board Certified Family Medicine and Obesity Medicine Physician. Here we learn how we can treat and prevent modern metabolic conditions such as diabetes, PCOS, fatty liver disease, metabolic syndrome, sleep apnea, and more. We focus on optimizing lifestyle while utilizing safe and effective medical treatments. Please remember that while I am a physician, I am not your physician. Everything discussed here is provided as general medical knowledge and not direct medical advice. Please talk to your doctor about what is best for you. One of the most overlooked medical conditions is metabolic associated steatatotic liver disease. Now, if you've never heard of that, don't be surprised because this is a new term for what used to be called non-alcoholic fatty liver disease and is often shortened to fatty liver disease. But metabolic associated steatatotic liver disease or massled, which is what I'll say moving forward, is extremely common and again very often overlooked. As a practicing primary care provider and board-certified obesity medicine physician, I see this condition all of the time. And many times it has gone undiagnosed by other providers, or patients know they have the medical condition, they have mastled, but they don't understand what it is or what its implications may be long term. So today we're going to talk about this very important medical condition. So you know if you need to be screened for it, what to look for if you do have this diagnosis, and how you can treat it and even reverse it to prevent complications. So to start with the definition, massold is an kind of an umbrella term for multiple conditions and a spectrum of a disease, really. So it starts with the fatty infiltration, or we call it the steatosis of the liver, and it just has to be 5% that is seen on imaging. So this often occurs if somebody gets imaging for another reason. If somebody's having belly pain and they get an ultrasound or a CT or an MRI, if that image incidentally sees batty liver and that's noted in the documentation, then that's enough for the diagnosis of massold because it has at least 5% of the liver is that fatty tissue. So this is sometimes how it's diagnosed, just incidentally on imaging, and it can be easily overlooked when, especially when you're looking for something else. Especially if you went to the emergency room for this imaging, they're ruling out the acute, urgent, bad things. And mastold is a chronic condition that they often leave for the primary care provider to manage. And they're very busy and may not be able to see that full report. So it's good to know you have access to your lab. So take a look at that imaging, and if you see a note of fatty liver, definitely bring that up with your doctor. So that's the beginning of that spectrum of disease, the fatty liver disease or the steatosis. Then we see inflammation and fibrosis, the scarring of the liver after chronic inflammation, it can lead to that scarring. Which at this time in the middle of the disease course, it's reversible. And this is when we really need to pay attention and intervene before we get to the later stages, which is cirrhosis, and is almost always irreversible at that time, and can also lead to other complications like liver cancer can develop in patients who have cirrhosis and massold. Not everybody who has that initial fatty liver, you know, noted on imaging is going to progress to develop to cirrhosis. It's about 4% of patients. We don't right now know exactly who those patients will be, so we need to intervene with everybody to prevent the progression to cirrhosis and liver cancer. Another way this is diagnosed is this is with routine labs. And this is what I also commonly see overlooked. If somebody has a slightly elevated liver enzyme, the ALT enzyme is typically what we're looking for for mastold, and sometimes even if it's in the normal range, you can still have mastold. But I sometimes see patients have a little bit elevated enzyme and they're told, oh, don't worry about it, we'll watch it over time, repeat next year. But if this is something again, we need to intervene on as soon as possible. So if you're looking at your labs and you see alanine aminotransferase ALT for men above 29 or for women above 19, you should ask your doctor if they think you may have mastold or fatty liver disease and if there is additional testing that should be done. The other liver enzyme, the aspartate aminotransferase AST is typically not as elevated in mastold and it's usually lower relatively than the ALT. AST is more sensitive for alcohol use. So if somebody has alcohol use disorder and it's affecting their liver, we usually see the AST number higher than the ALT number, but both can be elevated in either condition. So these are called liver function tests, but they're not really looking at how the liver is functioning. They're actually a measure of inflammation in the liver. So if the liver is inflamed, then it's going to leak these enzymes. One way we look at actual liver function is how well it is filtering platelets. And if we are seeing low platelets in your blood cell counts, then that tells us that there is possibly liver dysfunction, especially for seeing abnormal liver enzymes along with that. So if you're seeing low liver, low platelets, that's another reason to talk to your doctor about your liver function and see if you need additional testing. And oftentimes the first step is repeating these labs. I usually repeat in one to three months just to make sure that they are accurate. But if these numbers continue to be off, then we really need to take them seriously. One of the next steps is to do a calculation called the Fib 4. You input these numbers into the Fib 4 calculator, the AST, ALT, and platelets, and they will give you a number which will help to estimate if you are at low risk, intermediate, or high risk of complications from massold. If you're at higher risk for that fibrosis or scarring, and if you are at intermediate or high risk, you should have additional testing. I'm not gonna go into what those additional testing modalities are because it'll vary from location to location and patient dependent. But if your doctor, your primary care doctor is not comfortable with that additional testing, that's when you need a referral to a gastroenterologist, a GI specialist, or a liver specialist, a hepatologist, and they can order the appropriate testing for you. Taking a step back, let's consider how common is mastled. It is extremely common. It is estimated that one-third of American adults have mastold. And you can see why, and with something that is so prevalent, it may be surprising that more people aren't talking about it. And this just goes into again why this is so often overlooked. Because it is so common and because there's not an immediate effect of this condition, it's not until years, decades down the line when there's complications. So it's not an urgent thing that providers feel like they need to address right at that time. But for you and for your health, it's important to start addressing earlier rather than later. So one-third of American adults have mastold, but one half to two-thirds of patients with type 2 diabetes have mastold. And an estimated one-sixth of American adults with type 2 diabetes have liver fibrosis. And fibrosis and cirrhosis from mastold is now the leading cause of liver failure and why adults need a liver transplant. It has surpassed alcohol-induced liver disease. That is how common and how significant this condition is. So we've talked about what is mastold, what's the spectrum of disease, how common it is, how to diagnose it, how do we treat it. Luckily, we have some options at this time. I think that this is why sometimes this condition was ignored or you know continues to be ignored by some primary care doctors, is because historically we did not have great treatments for this condition or any treatments at all, other than advising weight loss. And now we have our GLP1 medications, which have been proven to be extremely promising in the treatment of mastold. And personally, I anticipate that this is going to be an FDA indication in the very near future. There have been studies for both trisepatide and semaglutide for mastold, and even for patients who have fibrosis and cirrhosis, seeing very promising results. Metabolic and bariatric surgery can also be extremely effective for the treatment and reversal of mastold. So that is another great option for patients who are struggling with this very common condition. Some other medications to consider is one of our older type 2 diabetes medications, PIT glitazone, has some good evidence for this indication. And our SGLT2 inhibitors, which are a newer type 2 diabetes medication, also have some evidence for mastold. In general, if we see a weight loss of 5 to 10%, we see improvements in mastold. So that's a great goal for weight loss. That 5 to 10% range, you will see improvements in your mastold. This is an episode that you are definitely gonna want to share with a loved one, family member, friend, coworker because we need to spread the awareness of this condition. It is so often overlooked, but it is so important to address as early as possible. So again, please share with others so they will know what to look for and how to manage this condition. I hope you have a beautiful week. Talk to you next week. Thank you for listening and learning how you can improve your metabolic health in this modern world. If you found this information helpful, please share with a friend, family member, or colleague. We need to do all we can to combat the dangerous misinformation that is out there. Please subscribe and write a review. This will help others find the podcast so they may also improve their metabolic health. I look forward to our conversation next week.