Steve recently e-mailed me to update me on his condition. He also passed along his liver test results, which I've graphed below. ALT is a liver enzyme that enters the bloodstream following liver damage such as hepatitis or NAFLD. It's below 50 units/L in a healthy person*. AST is another liver enzyme that's below 35 units/L in a healthy person*.
Steve began his new diet in November of 2008 and saw a remarkable and sustained improvement in his ALT and AST levels:
Here's how Steve described his diet change to me:I totally eliminated sugar, heavy starches, and grains. Started eating more whole, real foods, including things like grass-fed beef and pastured pork and eggs, began supplementing with good fats and omega-3 (pastured butter, coconut oil, cod liver oil). Ate more fruits and vegetables instead of refined carbs. Also completely gave up on the idea that I had to eat only "lean" meats. After my last results, the GI doc said that I wouldn't need the biopsy at all, that things were great, and that if I kept it up I "would live forever."He did experience some side effects from this diet though:
My triglycerides also went from pre-diet measures of 201 and 147 to post diet 86, 81, and 71.The liver is the body's "metabolic grand central station". It's essential for nutrient homeostasis, insulin sensitivity, detoxification, and hormone conversion, among other things. What's bad for the liver is bad for the rest of the body as well. Don't poison your liver with sugar and industrial vegetable oils.
The added bonus, of course, was that my weight went from 205 pounds to 162 pounds and my body fat percentage from 24% to 12% in the matter of five months--all without the typically excessive cardio I used to try unsuccessfully for weight loss.
* The cutoff depends on who you ask, but these numbers are commonly used.
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27 comments:
Healthy living and nutrition means healthy liver Its a no brainer...
Go "Steve"!
[This post makes me wonder how bad my liver was before I switched diets a year ago.]
Good post, Stephan. What are you doing post-PhD?
Fructose appears to be a heavy contributor to NAFLD and my guess is that the use of HFCS (which can be up to 90% fructose) may have a lot to do with the huge spike in it. Fructose consumption also boosts insulin resistance.
Congrats to "Steve" on avoiding that liver biopsy.
According to UpToDate.com, insulin resistance plays a key role in non-alcoholic steatohepatitis. Yet, in terms of therapy, they write, "There is no proven effective therapy for NASH. Attempts should be made to modify potential risk factors such as obesity, hyperlipidemia, and poor diabetic control. Weight reduction should be gradual, since rapid weight loss has been associated with worsening of liver disease."
No mention here of Steve's diet, which seems lower in carbs, and low-glycemic-index.
Steve's case is a good example of why it's important for you to do some of your own medical research and not rely solely on your physician.
-a different Steve
Thanks to Steve and Stephan for sharing this experience with NAFLD. Inspiring and useful information as always!
I am wondering what kind of foods Steve includes among the "heavy starches" he avoids. I presume potatoes, sweet potatoes, yams ...?
This relates to a more general question I have about carbohydrate levels and maintaining healthy thryoid function, something that many people seem to identify as a problem with very low carb diets. I hear various solutions proposed, such as carb cycling or keeping carbs lowish but above a certain level (e.g. 100g per day I think it is on Diana Schwarbein's regime). Off topic and a complex question of its very own I know, so please feel free to ignore it, but I'm always looking for clues that relate to this issue when I read stories of metabolic recovery like Steve's.
Another data-point to motivate: 'Fructose detox'.
Stephan-- any chance you could comment on this article:
http://raypeat.com/articles/articles/glycemia.shtml
I don't always agree with Rat Peat: but he seems to be on to something with this article (first time in years he really made me think)
After reading, it made me rethink this post (which was also posted in a different form of Dr. Eades site):
http://inhumanexperiment.blogspot.com/2009/09/eating-meat-or-going-vegan-comparing.html
What if it was polyunsaturated fats all along that were causing the increase in AGEs-- and not fructose!!! <--- WOW this is what Peat is inferring from his article. (of course you don't want to eat fructose until the cows come home!)
We don't know what the poly-unsaturated fat intake was in the vegetarian groups-- but we almost have to infer that between the vegetarian groups-- the vegans probably had the lowest poly-unsaturated intake because they had the highest fructose intake-- and still didn't end up with the highest AGEs!!!
I am with Peat in the conjecture that the body relaxes with the oxidation of sugars-- I've personally have never felt right on a 50 or less carb diet a day. As long as we space out fructose intake throughout the day-- our livers will probably be fine-- not to mention we could consume saturated fat to help us out too.
This may be part of a tipping point for me to start consuming a little more fruit-- and taper off the tubers a bit. very interesting.
And I have to say-- you were right all along-- OMEGA 6 and excess polyunsaturates are most likely the #1 dangers- even possibly over sugar <---- WOW
He even semi-covers a conjecture of mine in how carbs help conserve our mitochondria (and therefore longevity). Very interesting!
Hi Brent,
I'll be doing a postdoc studying body weight regulation and diet-induced metabolic dysfunction at the UW.
Hi Steve,
I bet I know why weight loss exacerbates fatty liver in some cases: the average American has a very high percentage of linoleic acid in his fat tissue. Liberate that without sufficient omega-3 to balance it, and it could contribute to liver damage.
Hi Lisa,
I've heard about that anecdotally, but I haven't come across anything solid to back it up yet. I'm willing to be enlightened if anyone has the data.
Hi Aaron,
Fructose is only one factor in AGE formation. Circulating fructose is generally very low compared to glucose. It goes straight from the digestive tract to the liver via the hepatic portal vein. The body keeps it out of circulation as much as possible (and turns it into fat ASAP) because of its glycation potential. It also raises serum uric acid when you eat fructose: uric acid is an anti-glycation agent and one of the main water-soluble antioxidants in serum.
The point is that glucose glycates as much, if not more than fructose, because there's generally a lot more of it around.
I read Peat's article. He's correct that the glycemic index isn't worth much. He's also correct that simply making the pancreas work is not behind insulin resistance. But he totally ignores the large body of evidence that fructose causes long-term insulin resistance, and starch doesn't. In fact, he barely mentions fructose.
If sugar is as harmless as he says, that implies that the diseases of civilization that Price and others saw were entirely due to white flour and/or micronutrient deficiency. Many of these cultures were not eating significant PUFA and they still got sick. The Tokelauans, for example, were at 3% PUFA when their diabetes skyrocketed following the introduction of sugar and white flour.
There is definitely an interplay between sugar and PUFA though. The combination of the two is the worst. Feeding rodents one or the other isn't as bad as combining them, and that's probably true for humans as well.
Aaron,
The other point is that humans don't absorb big fructose loads efficiently. It sits in the small intestine and gets fermented by bacteria, leading to nasty digestive consequences. You can observe this by measuring breath hydrogen, a product of bacterial metabolism. 25g fructose is enough to cause malabsorption in about 50% of people. That's two apples (eaten at once) or one can of soda.
This is fascinating - and the science is excellent
I generally tell my patients - eat nothing with a barcode, if it wasn't around 10,000 years ago, we probably shouldn't eat it
For the most part, the body is excellent at recycling and making do. Yet the rubbish of the twenty first century is finally felling millions of years of evolution
Hopefully we are seeing the tide turn
Hi Stephen,
You touched upon a very-unreported and undiagnosed problem of fructose malabsorption. Any chance you could do a post on that too?
It seems so important that people know that our agriculturally-centered medical officials are recommending "natural" foods for us which damage our gut function at levels even as low as TWO APPLES a day.
Up to 40% of those of European ancestry have fructose malabsorption, according to Wikipedia. Perhaps any amount of fructose is too much!
"25g fructose is enough to cause malabsorption in about 50% of people. That's two apples (eaten at once) or one can of soda."
An apple has roughly 12 grams of sugar. Isn't half of this glucose? Wouldn't there only be 12 grams of fructose in 2 apples? I believe Pepsi has 40grams of sugar per can in the form of HFCS. Isn't the Pepsi far worse than 2 apples?
Hi Gunther,
I did post on it briefly a while back in my maldigestion series. I think it's important to note that you have to eat the two apples at the same time to get the 25g fructose. If you had one at lunch and one at dinner, you'd have absorbed the first one by the time the second one hit your small intestine.
Hi Mark,
According to NutritionData, one medium apple contains about 12g fructose (including the portion that comes from sucrose), 19g total sugar. Apples are unusual because they don't have a 1:1 fructose:glucose ratio like most other fruit.
http://www.nutritiondata.com/facts/fruits-and-fruit-juices/1809/2
stephen
I have to thank you for the term nerd safari, it describes very well so much of the time I've wasted in the lab during my PhD. I enjoy very much going on safari.
"one medium apple contains about 12g fructose (including the portion that comes from sucrose), 19g total sugar. Apples are unusual because they don't have a 1:1 fructose:glucose ratio like most other fruit."
I guess that explains why I find apples nauseatingly sweet.
Thanks, Stephan.
I'm a bit confused though - wouldn't the Pepsi still be a more fattening food to consume? Might there be something else in the apple that allows the body to digest it properly? The Pepsi is 100% empty calories. Is an apple a fair comparison?
This is purely anecdotal evidence, but I have never met a person who consumes a lot of fruit and is fat. Alternatively, I never see obese people eating much fruit. (They occasionally binge on it to diet, but I only see thin people buying fruit at the grocery store.)
Hi Mark,
The short answer is I don't know. Fruit is natural, but is it natural for humans to eat a lot of fruit all the time?
It's possible that there's a difference between getting sugar from white crystals and getting it from fruit, but my guess is that there isn't. Fruit isn't that nutritious in terms of micronutrients. It's probably just a matter of quantity of sugar. Those thin people you see buying fruit in the grocery store aren't going to eat 7 bananas a day, whereas someone drinking soda might drink 3 cans in a day (equivalent amount of sugar).
"According to UpToDate.com, insulin resistance plays a key role in non-alcoholic steatohepatitis. Yet, in terms of therapy, they write, "There is no proven effective therapy for NASH. Attempts should be made to modify potential risk factors such as obesity, hyperlipidemia, and poor diabetic control. Weight reduction should be gradual, since rapid weight loss has been associated with worsening of liver disease."
"
Yes that figures in a world where there is no alternative to high carb low fat. :(
Anecdotally I've seen similar stories in various diabetes forums, however no matter how often this occurs in the Real World
this does not constitute "proof".
Hi Stephan,
Yes, perhaps that is true. Although I have never found fruit to cause me gain weight, rather I find I always lose weight when consuming a lot of fruit.
With respect to micronutrients, I was under the impression there were hundreds of micronutrients in fruit. (See also http://www.sciencedaily.com/releases/2009/08/090827073252.htm)
I do believe that sugar, HFCS, white flour, and excessive vegetable oil consumption are a health disaster, but I certainly see no evidence that the average obese American spends a lot of time eating oranges, etc.
Hi Mark,
Fruit is definitely more nutritious than white sugar. But it's still not very nutritious on a per-calorie basis, when compared to other whole foods.
I'm not against fruit in moderation, but I suspect that eating a lot of it may be problematic. I'm willing to have my mind changed.
The idea that sugars are good for us sounds really nutty. But maybe Ray Peat is onto something. Have you seen a picture of him§ I would love to know his age; but I do know he is at least 70.
In response to Mark's assertion that fruit consumption does not make people fat -- I have anecdotal evidence from my mom. She was not into sweets, did not eat much potatoes, rice, corn or grains. But she was pretty addicted to apples -- like 4-5 apples a day, every day.
She was diagnosed with fatty liver (not sure if it was full-on NAFLD) and was pre-diabetic in her late 50's. Last year, she stopped eating apples and was able to bring her a!c back to a normal range. Oh and she lost probably 10-15 lbs form cutting out the fruit. So yes, fruit, esp those with high proportion of fructose, can and do damage your body in a way similar to other sugars.
The wheat connection may be stronger than most people reading this might be giving it credit. Here are a couple of very interesting articles found via pubmed.
http://www.ncbi.nlm.nih.gov/pubmed/19878151
Quote: RESULTS: A total of 140 out of 350 CD [celiac disease] children had hypertransaminaemia: 133 cryptogenic disease, 7 AIH [autoimmune hepatitis]. GFD [gluten free diet] normalized only cryptogenic hepatitis. During treatment, all AIH persistently normalized clinical and biochemical parameters; after withdrawal, six patients maintained a sustained remission (follow-up range: 12-63 months), while one relapsed.
http://www.ncbi.nlm.nih.gov/pubmed/19034259
Quote:
Although the spectrum of liver abnormalities associated with celiac disease is particularly wide, two main forms of liver damage, namely cryptogenic and autoimmune, appear to be strictly related to gluten-sensitive enteropathy. The most frequent occurrence is a cryptogenic hypertransaminasemia, present in about a half of untreated celiac patients, as an expression of a mild liver impairment characterised by a histological picture of non specific reactive hepatitis (celiac hepatitis) reverting to normal after a few months of gluten withdrawal. In a few cases, a more severe liver injury leading to chronic hepatitis or liver cirrhosis is present. In these patients liver damage can still improve after a gluten-free diet institution. In addition, a close association between celiac disease and autoimmune liver disorders has been largely demonstrated. Indeed, 3%-7% of patients with primary biliary cirrhosis, 3%-6% with autoimmune hepatitis and 2-3% with primary sclerosing cholangitis are affected by celiac disease. Autoimmune liver dysfunction, found in celiac disease, does not usually improve after gluten-free-diet.
Just want to tell you, this approach (avoid gluten, highly restrict fructose and PUFA) totally works for chronic Hep C.
The virus piggy-backs on the TGA-VLDL-LDL system, and PUFAS and sugars increase both VLDL expression and LDL uptake. So an archevore or Atkins-paleo approach limits viral replication as well as reversing liver damage and correcting nutritional deficiencies typical of CHC.
The thing i don't understand is how this is a reversal story. Yes his numbers are down, and yes he lost weight. But until there is an ultrasound that is normal, or a biopsy that is normal, isn't this all just conjecture?
Sorry to play the devil's advocate. I was just recently diagnosed with mild NASH from a liver biopsy. Over the course of the last four months i have gone from 202lbs to 172lbs. And my ALT has gone from 157 down to 38, and my AST has gone from 66 to 25. Should I consider my NASH reversed? I have read my studies where NASH persists even with no elevated liver funtion tests, so wouldn't an ultrasound be in order to show there is no more fatty infiltration?
Thanks
Ian
Thanks for these Stephan. I think you and the commenters are right on the money here.
Yanos, I think if your ALT goes down AND you are burning fat, the liver will clear:
http://www.sciencedaily.com/releases/2009/01/090120074631.htm
But you could probably lower ALT on a normal diet with antioxidants, just by protecting the hepatocytes, and not clear the fat at all.
So if the ALT is lowered primarily as a consequence of a shift to fat-burning (in which case the liver can't really hold onto fat and won't), you'll be OK.
My sister is fond of scoffing frozen grapes (which are high in fructose) as though they are a packet of sweets. I note the doctor tested only her AST and ALT levels, not other liver enzymes when she presented with her suspicion of having gallstones due to back pain. Maybe he's on to something...
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