The culprit in this disturbing connection between belly fat and dementia – as well as so many other chronic health problems – is Non-Alcoholic Fatty Liver Disease

Covid-19 has certainly raised everyone’s awareness of their health and wellbeing.  The pandemic has given us an all-too-real experience of the health problems that can emerge when a person adopts the wrong lifestyles.  I am currently seeing an increasing number of patients attending the Vitality Clinic with significant weight gain brought about by lockdown.

Amongst other problems, this affects the liver.  Here, I found that my expertise in palpating the liver, gained 40 years ago, was particularly useful.  Whilst working in tropical Africa, I developed this skill because many patients there presented with hepatomegaly (enlarged liver) due to malaria, typhoid or bilharzia.

But the pattern of hepatomegaly I currently see in the UK is related to nutrition rather than infection.  People are very stressed due to Covid-19 and the associated restrictions.  This makes them eat more of the wrong food and often drink more alcohol.  This is compounded by the fact that they also take little or no physical exercise, due to general restrictions on movement, the closure of gyms and sports clubs, and the fact that they are working from home.

My particular worry about unhealthy weight gain is focused on the accumulation of fat in the body midsection.  Visceral fat is the deposition of fat in the vital abdominal organs like the liver and pancreas.  That means that, instead of having great organ function, these organs are now turned into a place for fat storage.  This accumulation of fat results in the loss of the liver’s powerful detoxification capacity, and the pancreas’s endocrine function (producing the insulin hormone to control blood sugar) and the exocrine pancreatic function (producing digestive enzymes to break down your food.)

In other words, the pandemic can not only give you diabetes but can also put you on the path to developing other degenerative diseases, as your body loses its ability to process food and nourish your body systems.

My goal in this blog is to raise awareness of this problem – what it is, who is affected and how, and what can we do to resolve the problem.  I will discuss fatty liver as a common sequel to metabolic syndrome, covering the causes of fatty liver, the various stages of development, and the progression from simple non-alcoholic fatty liver disease (NAFLD) to liver fibrosis, cirrhosis and liver cancer.  (NAFLD is the number 1 indication for a liver transplant.) 

I also want to invite patients to seek medical help early, before serious complications arise, and to encourage more people to consider the Functional Medicine approach – find the underlying cause, including any genetic issues, and use a set of natural strategies to correct your body systems’ imbalances. 

I was very impressed when one of my patients said he was attending the clinic because “He wanted to avoid diabetes and dementia in the future.”  I think that the link between weight gain and diabetes is common knowledge, but I was interested to find out how my patient made a link between belly fat and dementia.  I asked the question, and my patient promptly quoted a ground-breaking study that concluded: “The wider your waist size is, the smaller your brain size will be.”  This is an all-too-impressive and disturbing connection between belly fat and dementia.

Less exercise, more stress, worse sleep: working from home

This 45-year-old gentleman was well, apart from minor symptoms of indigestion related to fatty food.  But he was very concerned about the result of a recent routine GP blood test, which reported abnormal liver function, borderline sugar and cholesterol.  He has a history of gluten, dairy and fatty food intolerance.  And he has a family history of early death: his father died of a heart attack at the age of 48, and his mother died with breast cancer, which metastasised to the liver, in her late 50s.

The patient admitted gaining 1.5 stone in weight during the lockdown.  He kept to a gluten-free diet of bread, pasta and oat porridge, but could not exercise enough, due to the restrictions and working from home.  Being at home made him aware more aware of his family’s tribulations on a daily basis, causing stress and distracting him from his work.  He, therefore, found himself frequently working very late, with a negative impact on his sleep.  He does not drink alcohol and is not on any medication that could cause liver damage.

On examination, his body weight had risen to 75 kg, his BMI was 28.3 (within the overweight group), waist 41.5, hip 40, WHR (waist-hip ratio) very high at 1.05 (normal is less than 0.9 in men.)  There was an indication of fat accumulation in the abdomen, including the liver and pancreas, according to the following test results.

Routine blood tests showed abnormal liver function with high liver enzymes – ALT at 73 (normal under 40) and gamma GT at 99 (normal under 40); blood sugar was borderline at 6.2 (normal is less than 6), but haemoglobin A1 C reflects that blood sugar control over the last three months was 5.9 (normal is under 5.5), high fasting insulin level at 21 (normal is under 5), fasting total cholesterol was high at 5.5, slightly low HDL (the good guy) at 1.2, but high LDL (the bad guy) at 3.5, triglyceride was significantly high at 3.3 (normal is under 1.7.)

Further evaluation with an abdominal ultrasound scan confirmed fatty liver but otherwise unremarkable.  (We will return to his story later).

What is fatty liver?

The condition happens when fat builds up in the liver.  This initially takes place without any symptoms such as pain or jaundice.  It starts to cause significant changes when the liver fat content exceeds 5% of its weight.  The condition affects 30% of the population, but 10% of children in the UK have mild NAFLD.  Let me emphasise – mild fatty liver does not give any symptoms at the early stages.

The condition is more reported among obese and overweight people.  It is commonly related to insulin resistance, raised blood sugar, high blood pressure, chronic kidney disease and Type II diabetes.

The condition progresses from simple inflammation of liver cells to liver damage and scarring.  With extensive scarring, it progresses to fibrosis, and later, the more serious liver cirrhosis.  The latter stages can be associated with high mortality.  Liver cirrhosis can be complicated by liver failure or eventually progress to liver cancer.

Having a fatty liver would also imply having fatty muscles, which can also interfere with insulin signalling, with a negative impact on muscle function.

Symptoms can include fatigue, fluctuations in energy, particularly feeling sleepy after a meal, a significant energy dip in the afternoon, Gynecomastia (swollen breast tissue in men), pain or discomfort on the right upper quadrant of the abdomen, ankle oedema, and in the later stages, jaundice (yellow decolouration) and confusion.

What could cause YOUR fatty liver?

Fatty liver is a condition common among people who drink too much alcohol, resulting in AFLD, alcoholic fatty liver disease.  But it is more common in people consuming a diet high in sugar and refined carbohydrates (bread, rice and pasta), resulting in non-alcoholic fatty liver disease (NAFLD.)

Refined carbohydrates (also known as empty calories) are broken down into sugar, their health-damaging effect being due to fact that they contain high energy, but lack the fibre required to slow down sugar absorption, and lack the nutrients necessary to process sugar.

Excess sugar and refined carbs in food and drink can easily be converted into a certain type of fat known as triglyceride (TG.)  This shows up as raised blood TG and is deposited in the liver, other organs and in adipose (fat) tissue.  High triglyceride (like high cholesterol) is a serious risk factor for vascular disease, and it is due to high carbohydrate, not high fat, consumption.

High fructose corn syrup (HFCS) is another story.  This is the sweetest and the cheapest sugar in the world.  It is a fructose manufactured from corn, heavily used to sweeten fizzy and non-fizzy drinks.  Unfortunately ubiquitous, it causes the worst form of insulin resistance, more even than sugar does.  Interestingly, it does not raise blood sugar or stimulate insulin secretion; it goes directly to the liver to trigger a process known as lipogenesis (fat making.)  This means the liver converts HFCS into fat to be deposited in the liver, which eventually results in fatty liver.

Fructose in fruit and vegetables does not cause a problem if consumed in moderation.  The liver can process a certain amount of fructose every day, but exceeding the limit triggers lipogenesis and can contribute to fatty liver.

Avoiding sugar altogether and moving to the world of sweeteners, such as aspartame, is not a good idea either.  This is because sweeteners interfere with your gut microbiome, resulting in the worst type of insulin resistance.

Research has confirmed that only 16% of fatty liver is related to dietary fat, that 26% is due to fructose related lipogenesis, but that most is due to sugar and refined carbohydrates.

Are YOU at risk of fatty liver?

Fatty liver is high in obese people, particularly those with belly fat, those with high blood pressure, high cholesterol and triglyceride, diabetes and chronic kidney disease.  It is higher in those over 50.  The main stages of NAFLD are:

  • Simple fatty liver (steatosis) is a largely harmless build-up of fat in the liver cells, which is usually only diagnosed during tests carried out for other reasons.
  • Non-alcoholic steatohepatitis (NASH) is a more serious form of NAFLD, where the liver has become inflamed. This is estimated to affect up to 5% of the UK population.
  • Fibrosis is where persistent inflammation causes scar tissue around the liver and nearby blood vessels, but the liver is still able to function normally.
  • Cirrhosis is the most severe stage, occurring after years of inflammation, where the liver shrinks and becomes scarred and lumpy.  This damage is permanent and can lead to liver failure (where your liver stops working properly) and liver cancer.

It can take years for fibrosis or cirrhosis to develop, so it is vital to make lifestyle changes to prevent the disease from getting worse.

The patient I presented in this article has high CRP (C-reactive protein, i.e. inflammation marker) and significantly high liver enzymes.  These are suggestive of stage two fatty liver disease, NASH.  It will require more effort to influence the progression of his NAFLD.  He also had some genetic variants (MTHFD1 and PEMT), requiring an action plan.

NAFLD can be detected via an ultrasound scan, usually with high liver enzymes (ALT and GGT), and NASH via the high inflammatory marker (CRP.)

I blame the parents: genetic factors

Genetic factors may play a role in NAFLD.  Studies have reported that changes in the concentration of liver choline, methionine, folate and betaine may influence the development and progression of NAFLD.

Observational studies reported laboratory mice with no PEMT (gene) activity developed fatty liver easily.  PEMT activity is needed to make Phosphatidyl Choline (PC), which is very important for cell membrane and signalling, fat metabolism and brain health.

A PEMT genetic variant with low PC will slow down fat metabolism in the liver and the transport of fat to the various body part to be used as fuel.  This results in fat accumulation in the liver.  Other relevant gene variants, such as MTHFD1 and MTHFR.

One can investigate genetic factors by testing homocysteine and relevant genes.

Eat real, move more: your treatment strategies

Losing weight through diet or a combination of diet and exercise was found to be useful.  Visceral fat is usually burnt and lost early in the process.  It is very important here to emphasise the fact that the “eat less and exercise more” formula does not work failing in 97.3% of cases.  Please do not focus on the quantity; it is the quality of your food that makes the difference.  Therefore, it makes sense if you adopt a diet high in fibre and high in nutrient content.

The right action is to cut back on fake food (sugar and refined carbohydrates), the main culprit for fatty liver.  Replace them with real food, high in fibre and nutrients, such as fruit and vegetables, beans and legumes, nuts and seeds.  Studies have demonstrated the benefit of the Mediterranean diet in reducing liver fat and improving insulin sensitivity.

Monounsaturated fatty acids in avocado, olive oil, nuts and seeds were found to promote fat loss.  EGCG in green tea reduces liver inflammation and fat content.

There is also good evidence in medical literature to suggest the benefit of good physical activity in reducing the liver fat content.  This includes both endurance and resistance training, regardless of the exercise intensity.

More help: supplements

  • Berberine is known to have a great effect in reducing blood sugar, insulin level and cholesterol. A study showed Berberine 500mg three times daily, combined with physical activity of 150 minutes per week, reduced liver fat by 52% in a 16-week intervention.
  • Omega 3 fish oil with EPA and DHA, in sardines, salmon and herrings, is helpful in reducing liver fat content. Studies confirmed that a dose of 2 to 4g per day reduced fatty liver by 33%.
  • Probiotics were found to be effective in fatty liver due to dysbiosis (when you have more of the bad bacteria but less of the beneficial bacteria in your gut.)
  • Prebiotic: taking 10 to 15g of soluble fibre per day helped to reduce liver enzymes (surrogate of liver inflammation) and enhance insulin sensitivity.

There you have it, my friends: please do try and eat more real food – and to move more, with both cardio and resistance exercise – and please share your stories of lockdown life, limitations and lessons with me.  I am learning all the time – and it is mostly from you!  Your experiences will enrich my knowledge (I will try to respond to any questions) and will certainly help others in similar situations.  Thank you!


Non-alcoholic fatty liver disease: Dr. Robert Rountree shares

Fatty liver: what it is, and how to get rid of it

Non-alcoholic fatty liver disease

Genetic factors for fatty liver