Non-Alcoholic Fatty Liver Disease

When people put on weight, the most damaging weight is the weight that accumulates both inside and around your internal organs. That excess fat stops the organs from functioning as they should. The most serious problem is non-alcoholic fatty liver disease, which exists for most overweight people, but is not yet diagnosed as a medical problem. It's painless and invisible, but damaging your long term health.

Edited video of Dr. Noakes' Testimony is available from the Noakes Foundation.

The following is my commentary, a reconstruction, written from my own notes, and may not be entirely as accurate as I (or Dr Noakes) would like.

NAFLD in Healthy People

From Video 24 (First half)

A study of "healthy" people in South Africa, testing for NAFLD (Nonalcoholic Fatty Liver Disease) using a test called Gamma-Glutamytransferase.

Although deemed healthy, 50% of this population are obese. To understand the data, fasting glucose of 5 mmol/l is normal, 6.2 mmol/l is pre diabetic and 6.6 mmol/l is considered diabetic. None of these people have been diagnosed as diabetic, but clearly some of them are, and there is a huge pool of future diabetes in this population.

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When doctors are presented with blood test results like most of these people have, they read it like this: triglycerides are too high, HDL cholesterol is OK, LDL cholesterol is marginal, HbA1c is a little high (An indicator of pre-diabetes). Doctors are expected to apply a standard protocol, they will recommend a low-fat and low cholesterol diet. Many would recommend a statin. Nonalcoholic fatty liver disease and insulin resistance would not be recognised or discussed. Dr Noakes considers this to be a medical diagnosis failure.

Noakes says that people with fasting glucose above 5.5 mmol/l should be reducing the carbohydrate in their diet. This will help reduce the insulin overload, and reduce the number of small dense LDL particles produced. Metabolic syndrome is evident in more than half this population, another indication the a LCHF diet should be recommended.

Pre-diabetes exists widely but it's not seen. When type two diabetes is diagnosed, the diet and treatment recommended ensures that the diabetes gets progressively worse over time. The protocol monitors glucose levels. The correct target is the insulin level. The treatment should aim at reducing insulin use to zero or as close to zero as possible. Careful attention to diet can do that.

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From Video 26 (First half)

Quite likely 70% of these people already have significant insulin resistance, but we never look for that.

The South African Diabetes Association asks three questions:
How healthy am I eating?
How much am I exercising
What medications do I need?

For the people above, these questions are irrelevant. We've known since the 1980's that the problem is excess insulin, not excess glucose. The remedy for excess insulin is in a different diet, not in exercise and medication. That means the South African Diabetes Association, doesn't yet understand what a "healthy diet" for diabetics might be.

From Video 21

Being obese on it's own is not a health problem. However obesity has a cause, the hormone system that regulates your body, the homeostat is damaged. The signals that regulate your eating and exercise and sleeping don't function well. The system is broken.

The CAUSE of this broken homeostat may be argued about, and that argument is largely unhelpful. Dr Tim Noakes thinks it's caused by carbohydrate intolerance, which gives rise to insulin resistance. So there is a chain of events. We eat excessive carbohydrate for twenty or more years, and at first the body adapts by producing large quantities of insulin to keep blood sugars regulated. You can eat what you like and there appears to be no health or weight problems. Eventually the body tries to protect itself from this dietary abuse. You might name that protection carbohydrate intolerance based on the dietary cause, or call it insulin resistance based on the bio-chemical cause. We usually use the term insulin resistance or IR.

Insulin Resistance is a systematic reaction to excess insulin in the vascular system for a long time. The vascular system becomes damaged, throughout the body, it reaches the smallest capillaries in all your organs, and we see the effect directly in diabetes, where circulation is damaged in the limbs, in the eyes and in the heart.

Study: Hepatic Steatosis and Insulin Resistance, But Not Steatohepatitis, Promote Atherogenic Dyslipidemia in NAFLD.

NAFLD - is nonalcoholic fatty liver disease.
Hepatic - refers to the liver.
Atherogenic Dyslipidemia - refers to elevated levels of triglycerides (TG) and small-dense low-density lipoprotein and low levels of high-density lipoprotein cholesterol (HDL-C).
Steatosis - is fat accumulation in liver. This is not painful and may go unnoticed for a long period of time. In severe cases, the liver can increase to over three times its normal size.
Steatohepatitis - is a type of fatty liver disease, characterized by inflammation of the liver with concurrent fat accumulation in liver.

Cardiovascular disease (CVD) remains the leading cause of death in patients with NAFLD. Atherogenic dyslipidemia is believed to play a critical role in the development of CVD in patients with NAFLD. Unfortunately, the standard blood tests for plasma triglycerides, HDL-C, and low-density lipoprotein cholesterol (LDL-C), often fail to provide the information needed to predict future cardiovascular risk .

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The study required a biopsy taken in hospital. It found that there is a close relationship between nonalcoholic fatty livers and both obesity and insulin resistance. Where these three characteristics are found there was a significantly higher plasma apolipoprotein B to apolipoprotein A1 ratio, and smaller LDL particle size. This is a good predictor of future heart disease.

We can expect that most people who are overweight also have excess liver fat that will at some stage reduce the function of the liver and reveal itself as disease. It's the excess carbohydrate in the diet that drives insulin and enables the storage of fatty deposits, both in the liver and around the hips and belly.

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Type two diabetes, and heart disease develop over a long period of time. The best time to act is ten years before the disease becomes obvious. Since most people are unaware of the warning signs, they get very sick first and then choose to act. Even at that late stage, adopting a better diet, such as the Banting Diet, will significantly improve one's health outcomes.

Study: Dietary carbohydrate restriction induces a unique metabolic state positively affecting Atherogenic dyslipidemia, fatty acid partitioning, and metabolic syndrome.

Abnormal homeostatic regulation precedes the onset of metabolic syndrome and cardiovascular diseases. The availability of glucose and insulin are important regulatory elements.

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Here we highlight the role of dietary input, specifically carbohydrate intake, in the mechanism of metabolic regulation causing metabolic syndrome. The key principle is that carbohydrate, directly or indirectly through the effect of insulin, controls the disposition of excess dietary nutrients.

The diagram demonstrates the advantages of the Banting Diet or a similar LCHF diet. A high-fat diet reverses all coronary risk factors more efficiently than a low-fat diet, as demonstrated in the graph.

In the past, the value of lifestyle modification has been largely ignored. The results from low-carbohydrate diet trials, have shown reduced cardiovascular risk, and reductions in inflammation.

The data suggests that some form of carbohydrate restriction is a candidate to be the preferred dietary strategy for cardiovascular health, beyond weight regulation.