Is fatty liver really a minor problem? Is it really not a big deal? The answer is no. Studies have shown that fatty liver is not a “good” disease, and it is no less harmful than viral hepatitis, which is regarded as a “flooding beast”! But unfortunately, for a long time, fatty liver has not received the attention it deserves, and the diagnosis and treatment of fatty liver is not standardized. Although fatty liver is “loud” and its “scale” is no less than that of cardiovascular diseases, people’s awareness and attention to fatty liver is surprisingly shallow. The reasons for this are mainly related to the fact that fatty liver is not painful and people are not sufficiently aware of the dangers of fatty liver. In order to raise the public’s awareness of fatty liver, stimulate the “worry awareness” of fatty liver patients, and minimize the harm of fatty liver to human health, we invite experts in the field of fatty liver research in China to introduce 9 new ideas about the diagnosis and treatment of fatty liver, which we hope will be helpful to you. Fact 1: Fatty liver is a disease, not a sub-health. Fatty liver is a metabolic stress liver disease, a chronic inflammation in the body, a common cause of chronic hepatitis, and a manifestation of metabolic syndrome in the liver, not a “subclinical state”. Fatty liver, which usually indicates an imbalance in the body’s energy metabolism, is therefore not only a disease of the liver, but also part of a systemic disease. As research continues, there has been a major shift in the medical community to determine the nature of fatty liver, which is likely to be a non-benign disease! Some experts even predict that in the next 20 years, fatty liver will become the leading cause of chronic liver disease and liver failure! Fact 2: The outcome of treating fatty liver is very different from not treating it. Anyone who has a fatty liver should intervene early. Fatty liver is a large group of diseases caused by various causes with fatty deposits in the liver as the main manifestation. Primary causes include obesity, diabetes/abnormal glucose tolerance, hyperlipidemia, hypertension, etc. Secondary factors include alcohol, drugs, malnutrition, lipodystrophy and acute pregnancy fatty liver. Alcoholic fatty liver is closely related to liver inflammation, liver fibrosis, cirrhosis and liver cancer. About 40% of alcoholic fatty liver is combined with alcoholic hepatitis, and the 5-year survival rate of patients with alcoholic hepatitis is less than 50% if they do not quit drinking or reduce the amount of alcohol consumed in time. Since fatty liver is an important part of the metabolic syndrome, patients with fatty liver are prone to hyperlipidemia, diabetes and hypertension, and have a significantly higher probability of coronary heart disease and stroke (stroke) within 10 years. Fact 3: Fatty liver is not exclusive to fat people, but can also be caused by excessive weight loss. Not all people who get fatty liver are fat. It is worth noting that losing weight too fast and too hard, or having large weight fluctuations over a period of time, can also easily trigger fatty liver. This is mainly because weight loss is actually a fat mobilization process, fat mobilization too fast and too hard, more than the body’s metabolic capacity, fat will “run” everywhere, running to the liver, heart and other places, more harmful. By the same token, for patients with obese fatty liver, although weight loss is a proven treatment, it must be measured, that is, there must be a reasonable goal. Currently, a weight loss of 10% in six months is considered appropriate. A weight loss of more than 5 kg per month will lead to abnormal liver function and increase the risk of gallstone disease. In addition, alcohol, medication or drug abuse can also lead to the development of fatty liver. Studies have shown that dozens of drugs may be associated with fatty liver, such as long-term high-dose use of adrenal glucocorticoids, tetracycline, synthetic estrogens, nifedipine, sodium valproate, amiodarone, and some lipid-regulating drugs. Fact 4: The presence or absence of normal liver function and clinical symptoms do not correlate significantly with the severity of the disease. The determination of the severity of fatty liver disease should be based on a global concept, focusing not only on the lesions of the liver, but also on the progress of other metabolic syndromes that accompany it. Studies have shown that the clinical symptoms of fatty liver are non-specific and most patients may have no conscious symptoms, while some patients may show symptoms such as malaise, distension in the liver area or other symptoms accompanying the metabolic syndrome. Most patients with simple fatty liver have normal transaminases, while a few patients with simple fatty liver may have elevated transaminases. 40-50% of patients with steatohepatitis have elevated transaminases, and the elevation is usually less than 3 times the upper limit of normal. In other words, even if the transaminases are not high (normal liver function), you may still have steatohepatitis. It is thus clear that the presence or absence of symptoms, their severity, and the degree of normal and abnormal liver function are not proportional to the degree of inflammation and fibrosis in the liver histology and, likewise, do not correlate significantly with the progression of other metabolic syndromes that accompany them. Therefore, one should never judge the severity of fatty liver based on the presence or absence of clinical symptoms or the normalcy of liver function based on perception, so as not to mislead the condition. Fact 5: Treatment of fatty liver is a systematic project, not a personal one, and needs to be carried out under the guidance of a doctor. The empty phrase “eat less and move more” alone will not cure fatty liver. While diet control and exercise are basic measures to treat fatty liver, it is important to realize that the treatment of fatty liver is a long-term, systematic and individualized systemic project. Taking weight loss as an example, weight loss does not just mean weight reduction, but a serious scientific act. If you don’t lose enough weight, you won’t be able to achieve the treatment goal; if you lose too much weight, it will not only be difficult to stick to it, but also cause many complications, which will not be worth the loss. How to eat, what to eat, how much to eat, how to exercise, what kind of exercise to use, how to control the amount of exercise, and whether to supplement with medication, all of these must be done under the guidance of a doctor, not just a personal behavior. At present, some medical institutions in China, such as our Renji Hospital, have opened specialized and special outpatient clinics for fatty liver, where gastroenterologists, endocrinologists, nutritionists and rehabilitation physicians are on duty at the same time to give fatty liver patients a full range of treatment services. The specific treatment process is as follows: First step, pre-screening. Measure height, weight, blood pressure, waist circumference, abdominal circumference and body fat for the doctor’s reference. Step 2, diagnosis and drug prescription. Patients go to the gastroenterology and endocrinology doctors, who will formulate a clear diagnosis and medication recommendation based on the medical history, physical examination and laboratory tests. Step 3: Nutrition prescription. Based on the patient’s height, weight, abdominal circumference, body fat, degree of liver fat and underlying diseases, the nutrition doctor will formulate a personalized nutrition prescription, including how much total calorie intake per day, how to reasonably match nutrients, which foods must be eaten and which foods are best not eaten. The fourth step is exercise prescription. Based on the patient’s age, gender, weight, basal heart rate and other conditions, the rehabilitation doctor will make a reasonable exercise plan, such as how to exercise, when to exercise, how long to exercise, etc. In other words, patients with fatty liver should be given three prescriptions after consultation – drug prescription, exercise prescription and nutrition prescription. Clinical practice shows that the only way to receive significant results is to use a “three-pronged approach”. If any one of them is neglected, you will get half the result with twice the effort. Fact 6: The danger of fatty liver is not only limited to the liver. Fatty liver is in the same vein as diabetes and coronary heart disease, and fatty liver patients face many chronic disease threats. Unlike chronic viral hepatitis and alcoholic fatty liver, the dangers of non-alcoholic fatty liver are not limited to the liver. The contribution of fatty liver to disorders of glucolipid metabolism and its related events far exceeds that of hepatitis and liver fibrosis. The main factors affecting the survival and quality of life of the majority of patients with fatty liver are diabetes and atherosclerosis-related cardiovascular diseases, not cirrhosis of the liver. Epidemiological surveys have found that the prevalence of fatty liver is high and severe in patients with obesity, diabetes, and hyperlipidemia. Many patients with fatty liver were in the normal range of weight, lipids, blood glucose and blood pressure at the time of diagnosis, but further follow-up studies revealed that these patients rapidly developed hyperlipidemia, diabetes and atherosclerosis and their related complications within a few years of fatty liver detection. I have followed 358 patients with fatty liver detected by ultrasound as well as 788 employees of a Shanghai company for an average of 6 years. It was found that patients with fatty liver were more prone to new metabolic disorders than the control population – the incidence of obesity, hypertriglyceridemia, hypercholesterolemia, hypertension, and diabetes were significantly higher than in the control population. It is now believed that fatty liver is an independent risk factor for complications of cardiovascular disease in patients with type 2 diabetes. Fatty liver is an early lesion of diabetes and atherosclerosis, and fatty liver is in the same vein as diabetes and atherosclerosis. Cardiovascular events and diabetes mellitus may be earlier, more frequent and more fatal than cirrhosis in patients with fatty liver. Therefore, patients with fatty liver should also enhance the treatment of systemic diseases, such as hypotension, glucose and lipid lowering, while treating fatty liver. Fact 7: A normal ultrasound report does not completely rule out fatty liver. Ultrasonography can only detect cases of moderate or above liver steatosis. The accuracy of ultrasonography in diagnosing fatty liver is generally 60% to 70%. The fatty liver that can be detected by ultrasound is generally a moderate fatty liver with steatosis of 33% or more. In other words, mild fatty liver with less than 33% liver steatosis can easily be missed. In order to improve the detection rate of fatty liver, CT and wave-spectrum MRI have been gradually carried out in the clinic. Spectral MRI, in particular, can detect mild cases of fatty liver with only 5% hepatic steatosis and can measure the triglyceride content of the liver. It should be noted that the diagnosis of fatty liver should not rely solely on ultrasonography, but should be based on a comprehensive analysis and judgment based on medical history, weight, abdominal circumference, body fat, and whether other diseases are combined. Researchers in the United States have performed liver puncture examinations on hundreds of patients with obese metabolic syndrome who were asymptomatic and had normal liver function and ultrasound examinations. Some foreign experts advocate that even if there are no abnormal findings on ultrasonography, as long as there is a history of diabetes mellitus for more than 5 years, the patient can be considered to have fatty liver.