NAFLD (Non-Alcoholic Fatty Liver Disease) in PCOS

I love when Dr. Fiona McCulloch shares her insight and expertise on PCOS Diva.  This month she is talking about Non-Alcoholic Fatty Liver Disease or NAFLD and the link to PCOS.   If you haven’t read her post on Adrenals or caught my interview with Dr. Fiona, you won’t want to miss these resources.  She shares some positive PCOS research and answers Divas’ questions.  You can listen to the 30 minute interview here.

GUEST POST: NAFLD in PCOS, and How to Reverse It with Diet and Natural Medicine

By Dr. Fiona McCulloch BSc ND

If you’re one of the 10% of women who has PCOS, you’ll know that you have many different things to worry about with regard to your health: hormonal imbalances, acne, excessive hair growth, and difficulty losing weight are just a few of them.

There is also a disease associated with PCOS that can be serious, even threatening to the health of the body, and most women who have it don’t even know it. This condition is non-alcoholic fatty liver disease, also known as NAFLD.

NAFLD is rapidly becoming the most common liver disease worldwide, affecting 20-30 percent of people in Western countries[1].  Fatty liver can also be associated with alcoholism, however by definition, NAFLD occurs when the liver becomes fatty despite the fact that little alcohol is consumed.

With this condition, fat accumulates in the cells of the liver. There are two stages of fatty liver, the first stage being NAFLD and the second stage, which is known as NASH (Non Alcoholic Steatohepatitis). NASH is a more serious disease wherein the fatty deposits are associated with inflammation, damage, and scarring in the liver.

NAFLD is more likely to progress to NASH in PCOS patients who are obese, have type 2 diabetes, high cholesterol, hypertension, or an increased waist-to-hip ratio.   NASH can even progress to full-blown liver failure and cirrhosis with irreversible scarring, which can even be fatal.

Let’s talk briefly about fat in general, about its role in the liver, and then we’ll go through an explanation of how fatty liver disease can cause liver damage.  Firstly, the overconsumption of calories, fructose, and refined foods, along with insulin resistance or decreased fat burning from a sedentary lifestyle causes more fat to be stored in the liver cells. The organ simply cannot keep up with the excessive amount of food energy flowing through it, or it may not have enough of the right nutrients to process and eliminate it.

What is most concerning is that the fat stored in the liver can easily undergo a form of destruction known as lipid peroxidation. This oxidation can damage the liver cells, and promote scarring and inflammation.

I’m not trying to scare you—I just want to let you know why it’s so important to deal with fatty liver. NAFLD is something that you want to reverse as quickly as possible.

A study released in January 2013 in the Journal of Human Reproductive Science looked at a group of 100 women, approximately half of whom had PCOS. It was determined that 67% of women with PCOS had a fatty liver, compared to only 25% of the control group. We know that women with PCOS are at risk for this disease, and it has been suggested by some studies that high levels of androgens—which most women with PCOS have—are a risk factor that can lead to fatty liver[2]. 

The most concerning thing about NAFLD is that it is an independent risk factor for cardiovascular disease. Yes, that’s right: just having a fatty liver, PCOS or not, increases your risk of artery hardening and heart disease. As such, when combined with the PCOS that also increases those same risks, you’ll really want to take action against this condition. The good news is that when NAFLD is in the first stage (fatty liver), it’s almost always reversible, so let’s get to work!

First, you’ll need to know what puts you at greater risk for having NAFLD so you can determine whether you might have it.

The factors associated with having a higher risk of NAFLD for women with PCOS are:

1)   Older age

2)   Increased abdominal circumference (ie: carrying your weight at your abdomen rather than at your hips)

3)   Higher Body Mass Index (BMI) or Obesity

4)   Insulin resistance as measured by the HOMA-IR  (This is the ratio of fasting glucose to fasting insulin that you can ask for your doctor to run for you. I typically use a goal of <1.6 for my PCOS practice)

5)   Low HDL cholesterol:  lower values of “good” cholesterol increase the risk

6)   High LDL cholesterol:  higher values of “bad” cholesterol may increase the risk in the presence of inflammation.

7)   Genetic predisposition to insulin resistance or high cholesterol

How to test for NAFLD:

What’s important to remember is that most people with NAFLD have no signs of the disease. Most of them even have normal liver enzymes. As such, if you have PCOS, and have any of the above risk factors, it’s still important to be screened. It’s even appropriate for young women and even teens with PCOS to be screened, if they are overweight or have one or more of the above list.

Some of the following tests can help to identify NAFLD:

1)   Elevated liver enzymes

2)   Ultrasound or other imagine such as a CT scan

3)   A liver biopsy to differentiate NASH from NAFLD (may be needed)

It’s also interesting to note that celiac disease can be a cause of fatty liver.   Celiac disease has been found in about 10% of patients with unexplained high liver enzymes, and in approximately 4% of patients with NAFLD as the only manifestation of the disease[3], so if you are diagnosed with a fatty liver it’s also important to rule out celiac disease as the cause.

What can I do about fatty liver if I have PCOS?

As it’s well known that insulin resistance is one of the leading causes of NAFLD, the most important change that can be made is to the diet.  A variety of dietary changes can be made that can reverse NAFLD altogether.

1)     Lose weight. Although this may be one of the most challenging in the list, it makes a significant difference in reversing fatty liver. Weight loss of merely 3-5% may be needed to improve the condition, so even losing a little bit of weight can make a big difference for your liver. If there is liver inflammation and NASH, 10% of weight loss may be required[4] to improve the condition. It’s also recommended that weight loss be gradual in patients who are obese so as not to aggravate the fatty liver. Exercise is recommended at 40 minutes per day.

2)     Eliminate sugar (especially fructose), refined grains, and processed foods. As the liver’s fat deposits are primarily made of triglycerides, sugar and refined carbs are quite simply the worst offenders in the list of causes for fatty liver.

3)     Avoid excessive alcohol, which only worsens NAFLD as it increases the fatty deposits and can produce inflammatory changes in the liver. Interestingly, light alcohol consumption may actually be helpful when it comes to combatting the illness: a study using the National Health and Nutrition data from 8000 participants found that the consumption of one glass of wine per day cut the risk of NAFLD by one half[5].

4)     Eat whole foods. Studies have shown that eating refined foods and not consuming those that are rich in natural nutrients and antioxidants such as vitamin E is a double whammy to the liver. Refined foods provide large amounts of energy to the liver that it is not able to excrete appropriately and has to store as fat.  This would ordinarily be negated by the antioxidants in whole foods which protect the liver from inflammatory lipid peroxidation. Remember that if you can prevent the progression of the fatty liver to the inflammatory state, it is reversible.

5)     Choline-rich foods. Choline has a special protective role in the liver in that it provides a way for the fat to be excreted through VLDL cholesterol. If there is a deficiency in Choline, the liver will be less able to package up and excrete fats into the bloodstream. Rich sources of choline include egg yolks, organic grass-fed liver, wild fish,(Table 1).  The amount of choline required to treat fatty liver depends on the diet: the richer one’s diet in refined foods, carbohydrates and poor quality oils, the more choline will be required. The RDA for Choline is 500mg, but in NAFLD the needs are likely much higher.

6)     Avoid the consumption of refined, poor-quality vegetable oils. As Chris Masterjohn explains in his breakdown of NAFLD (http://www.westonaprice.org/health-issues/nonalcoholic-fatty-liver-disease), consuming polyunsaturated vegetable oils when fatty liver is present will actually cause a quicker progression to the inflammatory NASH[6].  This is because these types of oils are quicker to oxidize and produce inflammation in the liver. Instead, choose high quality cold-pressed vegetable oils such as extra virgin olive olive oil for cold use, and extra virgin coconut oil for cooking, as they are more stable against oxidation at high temperatures.

7)     Include a high quality B vitamin supplement, including B12, B6, and Folate. Eat spinach, which is a rich source of betaine. These nutrients will help to spare choline in the body, helping the liver to excrete excess fat.

8)     Alpha-lipoic acid. In a new study on mice with choline deficiency induced fatty liver, it was found that administering alpha lipoic acid improved the health of the liver by increasing antioxidant status and reducing damage-causing inflammation.[7] It also helped to reduce the peroxidation of fats in the liver.

9)     Milk thistle.  A 2012 randomized control trial on 179 patients with fatty liver disease found that milk thistle (also known as silymarin) improved liver enzymes, HOMA-IR, and produced a more normal cellular appearance of the liver. [8] Milk thistle can be taken as a tea, or in capsule or tincture form.

NAFLD is a potentially serious condition that all women with PCOS need to be aware of, but it is also one of the most reversible conditions if addressed in its early stages. Liver health is definitely one of the most important keys for healthy hormone balance in the body. Reversing NAFLD can greatly improve your hormone balance, your cardiovascular system and your overall health and well being. 

Sources of Choline

TABLE 1. Choline in Selected Foods
Data taken from the USDA Database for Choline Content of Common Foods

Dr. Fiona McCulloch is a board certified Naturopathic Doctor who has been in practice for 13 years in Toronto, Canada. She graduated with a Bachelor of Science degree (Biological Sciences) from the University of Guelph and went on to graduate from the Canadian College of Naturopathic Medicine. She is the founder and owner of White Lotus Integrative Medicine, a busy clinic specializing in women’s health and fertility.  Her clinical focus is on the treatment of a wide range of fertility and hormonal conditions, and she is an avid writer and researcher, having published articles in major naturopathic journals.  Fiona has been able to reverse her own PCOS with natural methods and is thrilled to be able to share what she has learned with other women suffering through the same concerns.  Her first book: 8 Steps to Reverse Your PCOS is now available.  She lives in Toronto with her husband and 3 boys.

[1] Bellentani S, Scaglioni F, Marino M, Bedogni G. Epidemiology of non-alcoholic  fatty liver disease. Dig Dis. 2010;28(1):155-61.

[3] Abenavoli L, Luigiano C, Larussa T, Milic N, De Lorenzo A, Stelitano L, Morace C, Consolo P, Miraglia S, Fagoonee S, Virgilio C, Luzza F, Pellicano R. Liver steatosis in celiac disease: the open door. Minerva Gastroenterol Dietol. 2013 Mar;59(1):89-95.

[4] Fan JG, Cao HX. Role of diet and nutritional management in non-alcoholic fatty liver disease. J Gastroenterol Hepatol. 2013 Dec;28 Suppl 4:81-7.

[7] Stanković MN, Mladenović D, Ninković M, Ethuričić I, Sobajić S, Jorgačević B,  Luka SD, Vukicevic RJ, Radosavljević TS. The Effects of α-Lipoic Acid on Liver Oxidative Stress and Free Fatty Acid Composition in Methionine-Choline Deficient  Diet-Induced NAFLD. J Med Food. 2013 Dec 10.

[8] Loguercio C, Andreone P, Brisc C, Brisc MC, Bugianesi E, Chiaramonte M, Cursaro C, Danila M, de Sio I, Floreani A, Freni MA, Grieco A, Groppo M, Lazzari  R, Lobello S, Lorefice E, Margotti M, Miele L, Milani S, Okolicsanyi L, Palasciano G, Portincasa P, Saltarelli P, Smedile A, Somalvico F, Spadaro A, Sporea I, Sorrentino P, Vecchione R, Tuccillo C, Del Vecchio Blanco C, Federico A. Silybin combined with phosphatidylcholine and vitamin E in patients with nonalcoholic fatty liver disease: a randomized controlled trial. Free Radic Biol  Med. 2012 May 1;52(9):1658-65.