Understanding Fatty Liver & Metabolic Liver Disease

[00:00:00] Pete Waggoner, Podcast Host: Hi there, and welcome to Beyond the Checkup, brought to you by Stellis Health, where Neighbors Care for Neighbors. I’m Pete Wagner, ready to guide you to a healthier, happier life. Today we’re here to inspire, explore, and help you thrive in your health journey. So let’s dive right in as we have a great podcast.

[00:00:17] Pete Waggoner, Podcast Host: Today we’re joined by Dr. Kari Fabian and Maura Romanshek. And Maura, of course, is a PA certified, and we are going to be talking about fatty liver, metabolic liver disease. And I’m very intrigued with this because this is something coming in here I had never heard of. Now I am intrigued and I wanna learn more and I’m sure listeners will most likely feel the same way.

[00:00:40] Pete Waggoner, Podcast Host: So, good morning to the two of you and thanks for joining us here today. 

[00:00:44] Kari Fabian, MD: Thank you for having us. 

[00:00:45] Pete Waggoner, Podcast Host: Let’s talk a little bit about this, Dr. Fabian. Your journey has been pretty extensive here at Stellis Health as you’ve been here for quite some time. 

[00:00:52] Kari Fabian, MD: I have. I joined Stellis Health in about 2011. Prior to that, I was practicing medicine in the Twin Cities [00:01:00] for about 10 years.

[00:01:01] Kari Fabian, MD: So I’ve been doing this for a long time now. My background is in internal medicine, but for the past maybe 15 years or so, I’ve. Pretty much focused on type two diabetes, I should say, diabetes in general. 

[00:01:17] Pete Waggoner, Podcast Host: I wanna get into that a little bit later for sure. And Maura, tell us about your journey here. You came here right around pandemic time.

[00:01:24] Pete Waggoner, Podcast Host: Yep. Didn’t you? So 

[00:01:25] Maura Romanshek, PA-C: I started in January of 2020. I practiced family medicine for about three and a half, four years, and then transitioned over to helping patients manage diabetes and weight management. 

[00:01:38] Pete Waggoner, Podcast Host: So the two of you obviously work closely together, I assume? 

[00:01:40] Maura Romanshek, PA-C: Yes, we do. 

[00:01:41] Pete Waggoner, Podcast Host: So, Dr. Fabian, I’m kind of curious as to your path, leading you toward the diabetes end of things. What led you there? 

[00:01:51] Kari Fabian, MD: I did primary care for about 10 years and, discovered that I really liked taking care of people with [00:02:00] diabetes. When I first was coming out of training, I didn’t think I wanted to specialize in anything else.

[00:02:05] Kari Fabian, MD: I liked everything. And over time I just realized the thing that I was most passionate about was diabetes. And there is a shortage of. Diabetes specialists really all over the country. Shocking, isn’t it? 

[00:02:19] Pete Waggoner, Podcast Host: Because it’s so prevalent. It 

[00:02:20] Kari Fabian, MD: is extremely prevalent, 

[00:02:22] Kari Fabian, MD: And it’s getting more complicated, to take care of.

[00:02:25] Kari Fabian, MD: There’s more medications and more technology, and it is hard to keep up with that if you don’t focus all of your attention on it. So that’s kind of what led me here and for a long time I was the only one doing that here at Stellis, and it got to be. More than one person could do. And that is when Maura joined me and transitioned from primary care to working with me.

[00:02:49] Kari Fabian, MD: And now that is all we do. Diabetes and weight management as well. 

[00:02:54] Pete Waggoner, Podcast Host: And all that plays into our topic, fatty liver. And what’s this Metabolic Liver [00:03:00] disease. Why is it called that? 

[00:03:03] Kari Fabian, MD: It’s called that with the understanding that it is related to obesity and diabetes and high blood pressure and abnormal lipids.

[00:03:13] Kari Fabian, MD: It used to be called and often is still called non-alcoholic fatty liver disease. And. That has evolved. People are now calling it more metabolic liver disease or because of the understanding that it really has absolutely nothing to do with alcohol and it has to do more with the way that we eat.

[00:03:33] Kari Fabian, MD: And it’s associated with being overweight and having diabetes. And that’s really the way it’s evolving to being called metabolic liver disease. 

[00:03:41] Maura Romanshek, PA-C: Well, what is it exactly then? What is the core of what the disease is? 

[00:03:47] essentially when fat comes in and it deposits itself into the liver, it can make the liver function in a way that it’s not supposed to, it it’s not as effective.

[00:03:56] Maura Romanshek, PA-C: And over time it can cause some inflammation which can [00:04:00] cause scarring in the liver and lead to further progression of liver disease. And over time, if left untreated, can lead to liver cirrhosis. 

[00:04:08] Pete Waggoner, Podcast Host: And do you know what that timeframe is? Is that years, decades. Months. Like what, what is the, or is that just person to person?

[00:04:16] Pete Waggoner, Podcast Host: I think 

[00:04:17] Maura Romanshek, PA-C: it’s different for everybody. 

[00:04:18] Kari Fabian, MD: Yeah. Although we’d be talking about on the order probably of decades. It takes a long time for that to happen. I think. What’s the reason that we’re more aware of it now, and we’re screening for it now. So we’re seeing people that are farther along in that journey with the hope that if this becomes embedded in primary care and that it is normal to screen for it, we’ll see people who are at risk earlier in that journey and be able to do something about it so that they never go on to develop scarring or cirrhosis.

[00:04:48] Pete Waggoner, Podcast Host: Are you finding an age bracket for this? 

[00:04:51] Maura Romanshek, PA-C: No. 

[00:04:51] Maura Romanshek, PA-C: It used to be older populations, adult populations, but they are finding evidence of fatty liver in kids as young as kindergarten. 

[00:04:59] Pete Waggoner, Podcast Host: Holy smoke. [00:05:00] Really? Yeah. Wow. Okay. So there’s gotta be a cause, I mean, you’ve been going at it at, for five years, six years when you’re getting here, what are the leading factors to causing this?

[00:05:10] Maura Romanshek, PA-C: A lot of it has to do with diet. So with the evolution of processed foods and things like high fructose corn syrup. Okay. We’ve learned over time that your liver metabolizes that in the same way that it metabolizes alcohol, which is part of what causes some of the long term problems. 

[00:05:28] Pete Waggoner, Podcast Host: Well, I think when you think about alcohol processing the sugar, it turns, you know, a lot of sugar there.

[00:05:33] Pete Waggoner, Podcast Host: I suppose that’s a lot of that theme too. Correct.

[00:05:35] Kari Fabian, MD: It’s, it seems to be. Specific to fructose. 

[00:05:38] Pete Waggoner, Podcast Host: Oh, wow. Okay. Yeah. Interesting. Okay, so, beyond diet, is there anything you’re seeing in this that could be genetic at all or hereditary? Or is this pretty much a behavior driven process?

[00:05:52] Maura Romanshek, PA-C: I suppose there some component of genetics as well, just like there’s some component to your propensity 

[00:05:58] Maura Romanshek, PA-C: for getting 

[00:05:59] Pete Waggoner, Podcast Host: Wow. Nice [00:06:00] 

[00:06:00] Kari Fabian, MD: diabetes. Yeah. Or so we know that those things are, there’s a genetic component to type two diabetes. There’s a genetic component to obesity, and because those two things are associated with fatty liver disease, in a sense, you could say, it could be that there’s a genetic component.

[00:06:17] Pete Waggoner, Podcast Host: Yes. Got it. Okay. Is this a silent situation? Could you be rolling along and not knowing anything about having it? 

[00:06:24] Maura Romanshek, PA-C: absolutely. There’s no, sign or symptom that you have fat that’s depositing into your liver and causing long-term issues. It’s something where you notice it maybe incidentally on some imaging that you’ve had done for another reason.

[00:06:38] Maura Romanshek, PA-C: It’s maybe something where you notice a gradual progression in some of your liver enzymes over time, just based on some screening labs. 

[00:06:46] Kari Fabian, MD: So that’s really why we want to get the message out that we should be screening for a metabolic liver disease. Just like we screen for high blood pressure, we screen for diabetes, we screen for various [00:07:00] cancers, we screen for lots of things in medicine.

[00:07:02] Kari Fabian, MD: And fatty liver disease obviously is not new, but what is new is this recognition that it’s something that we should actually be screening for because like Maura said, there are no symptoms of having fat in your liver. And so unless we actually are looking for it and screening for it we won’t know that it’s there and patients won’t know they have it.

[00:07:20] Pete Waggoner, Podcast Host: How do we get to the process of screening? Do you just like randomly say, you know, we should maybe do this, or what do you do? 

[00:07:26] Maura Romanshek, PA-C: No there’s been a push in primary care to do more lab, more screening labs, like we will check liver enzymes. They’re, they’re known as trans transaminase enzymes. So there is the A LT and the A ST, and then we can just do a basic blood count and look at the platelets.

[00:07:39] Maura Romanshek, PA-C: And you can take those factors and put them into an equation called the FIB four score. Based on the FIB four score, it will risk stratify patients from low risk to advanced liver disease, to intermediate risk to high risk. And based on that we can sue some additional screening and testing. 

[00:07:58] Kari Fabian, MD: So patients that we [00:08:00] would think about screening, anybody with type two diabetes, anybody who’s overweight and anybody who has other metabolic risk factors like high blood pressure, abnormal cholesterol, increased weight circumference, those are the kind of patients that we would say we should be screening you for.

[00:08:17] Kari Fabian, MD: This 

[00:08:17] Pete Waggoner, Podcast Host: kind of sounds like it’s common sense to those. I mean, it all kind of plays together. 

[00:08:23] Kari Fabian, MD: Yes, a hundred 

[00:08:23] Pete Waggoner, Podcast Host: percent. 

[00:08:23] Kari Fabian, MD: Yeah. The estimate is that there’s probably 25 to 30% of the adult population in the United States has some degree of fatty liver. 

[00:08:33] Pete Waggoner, Podcast Host: What happens when we get diagnosed? What’s next? 

[00:08:37] Kari Fabian, MD: So if the Fib four score, so again, that equation that we talked about is elevated the next.

[00:08:44] Kari Fabian, MD: Thing that we would often do or recommend is a test called a fibro scan, which is a test that we can do here at Stellis Health. It is a painless, procedure imaging, a painless imaging test that is able to [00:09:00] measure, essentially measure the stiffness of the liver, really. Yeah. So the, the liver should be soft, kind of the consistency, I guess, of jello probably.

[00:09:08] Kari Fabian, MD: Wow. Good Minnesota thing. Right on. Right on. That’s good. And so this test is really, it’s not even really taking pictures of the liver, it’s measuring. The potential stiffness of the liver. Stiffness implies scarring. So that’s really the next place that we go to is to say okay, your fib four score was elevated.

[00:09:32] Kari Fabian, MD: Is there a suggestion that your liver actually has some stiffness and scarring? So that would be then the next step that we would typically recommend along with lifestyle changes. 

[00:09:42] Pete Waggoner, Podcast Host: So is this process, it sounds like it’s a consistency thing of what, what you got going on is this process more like. Is it more of an MRI type thing or an ultrasound thing?

[00:09:52] Pete Waggoner, Podcast Host: What is the imaging like? What can, what can a patient expect when that happens? 

[00:09:56] Maura Romanshek, PA-C: So the fibro scan is an ultrasound technique , and essentially it [00:10:00] sends a sheer wave through your liver. And like Dr. Fabian said, it measures how stiff your liver is. So all you have to do in order to get the test done is you have to fast for three hours beforehand, and you have to be able to lie with your right arm over your head, kind of in the shape of a banana.

[00:10:16] Maura Romanshek, PA-C: So just with your body curved a little bit for about 15 minutes, that’s all there is. 

[00:10:21] Pete Waggoner, Podcast Host: Okay. So it’s harmless. Harmless and, and you’re not getting into a tube. There’s nothing. No. Okay. So we’re all good there. Okay. So there’s no excuse to not have this done now that we got that established. Yes. When you, when you get your results and, and you take a look at the next steps, 

[00:10:36] Pete Waggoner, Podcast Host: can this be reversed? What are the next steps in terms of treating it? 

[00:10:41] Maura Romanshek, PA-C: So when liver disease is caught early, the really great thing about your liver is that it can heal itself. It can correct itself. The biggest thing that we need to do is we need to, we need to catch it early, and then we need to encourage and enforce those dietary and lifestyle changes.

[00:10:57] Maura Romanshek, PA-C: So weight loss can be a way to help with [00:11:00] that, but even more so than weight loss, dietary changes where you’re eliminating a lot of that fructose from your diet. So you can adhere to things like the Mediterranean diet where it’s a lot of fruits and vegetables, limited meats, whole foods based diets or the dash diet are common ones. 

[00:11:18] Pete Waggoner, Podcast Host: What, are fructose type foods to avoid? 

[00:11:21] Kari Fabian, MD: So fructose is the sugar in fruit, but we want to emphasize that people do not need to avoid. Fruit. When you consume fructose in food, there’s a fiber that offsets some of the absorption of that fructose.

[00:11:36] Kari Fabian, MD: So getting fructose in the form of whole foods like fruit is not at all dangerous, but when you are consuming a lot of high fructose corn syrup, which is really just an industrial sweetener made from corn. That is a product that the liver does not metabolize very well. And so it’s fructose in the form, again, of these industrial [00:12:00] products that is dangerous to the liver.

[00:12:03] Kari Fabian, MD: Getting fructose in actual whole foods is not dangerous. In fact, it’s good for us. 

[00:12:08] Kari Fabian, MD: So, yes. Our biggest message to patients, first and foremost is mostly eat real food, fruits and vegetables and low fat dairy and lean meat and just healthy fats, food and healthy fats , but basically just eating food. Food that we recognize as food that came from. The earth as opposed to things that come out of boxes and packages.

[00:12:32] Pete Waggoner, Podcast Host: Fair enough. Okay. And then if you get to the level with this, where it’s maybe that won’t, maybe it’s too far progressed, what happens next with the liver? 

[00:12:43] Kari Fabian, MD: So there are a few other things that we can recommend. As far as lifestyle changes go beyond weight loss and again, avoiding processed foods coffee actually may be beneficial for the liver.

[00:12:55] Maura Romanshek, PA-C: Seriously. Yeah. 

[00:12:56] Kari Fabian, MD: We often think of coffee as a vice because you know, contains caffeine, [00:13:00] which is addictive. But coffee may actually. Be very beneficial to the liver, possibly caffeinated tea as well. That there have been studies that have been shown that people who consume coffee and black tea and green tea derive benefit from that unless, of course it’s being filled with lots of syrups and sweeteners that are processed 

[00:13:21] Pete Waggoner, Podcast Host: when you go through the process here and you start doing the dietary. Lifestyle health changes and do those things. How engaged and involved are the two of you in Stellis health with the next steps of the journey? You can’t go home and you know, open the cupboard form, obviously, but I mean, what level of engagement do you have?

[00:13:42] Maura Romanshek, PA-C: Yeah, so I do this a lot with patients. When we work on weight management in particular, we do a very detailed assessment in terms of what does their lifestyle look like right now? What do their dietary habits look like right now in physical activity? And then we set some goals and we set some goals that are specific to that person [00:14:00] and their lifestyle are realistic for that person to be able to do.

[00:14:03] Maura Romanshek, PA-C: And we start small and we just really focus in on maybe changing like two or three things at a time. Once they get really comfortable with that, then we build on that because it is really overwhelming to sell, tell somebody to go home and start eating the Mediterranean diet. Like what does that mean to them?

[00:14:20] Maura Romanshek, PA-C: Right? How does, how does that, how do they put that into practice in their life? So I found that that’s been really helpful for patients and for me. I’m pretty involved in that, where we meet regularly and talk about how that’s going for them and change things as needed. 

[00:14:35] Pete Waggoner, Podcast Host: Doesn’t sound like it’s easy, but No, but you have an approach to me, which is, you know, step by step, incremental.

[00:14:44] Pete Waggoner, Podcast Host: You know, not trying to take the whole thing, but just get to the end result. Slowly but consistently fair. 

[00:14:52] Maura Romanshek, PA-C: Absolutely. And I mean, there’s a lot of give and take too. I, if somebody’s going from drinking a case of soda in a [00:15:00] day and your goal is to get down to 10 over the course of the next month, that’s a win when you achieve that goal and then slowly dialing it back from there or scaling it back from there.

[00:15:11] Pete Waggoner, Podcast Host: And then in the diabetes world. When this is happening, there has to be positive results to that too. 

[00:15:19] Kari Fabian, MD: Absolutely, yes. These, things are very intertwined, right? So when people lose weight, their liver is healthier, blood sugars are lower blood pressure sometimes drops, and there’s obviously a lot of other beneficial consequences to losing weight.

[00:15:34] Pete Waggoner, Podcast Host: Do you guys blend in levels of just walking and moving and, and an exercise regimen to this whole process too? Does that assist, I assume? 

[00:15:44] Maura Romanshek, PA-C: Absolutely. And sometimes it’s just finding ways to build intentional movement into your day. Maybe you don’t have time or the funds to get a gym membership or have any desire to go to a gym.

[00:15:57] Maura Romanshek, PA-C: There are ways that you can build in activity [00:16:00] at home. Maybe it’s your family goes for a walk after dinner. Or maybe you start doing some free weights at home, or maybe it is simply just dancing to five minutes of music a day. Whatever it is that you want to do to make yourself move more 

[00:16:13] Pete Waggoner, Podcast Host: that’s great stuff.

[00:16:14] Pete Waggoner, Podcast Host: Any thoughts there? 

[00:16:15] Kari Fabian, MD: Yeah. Our goal is really to meet patients where they are. That it is not, helpful. We don’t think to just, you know, give people a handout and say, you should eat this way and you should exercise this much, and this is what we say you should do, and so you should just go home and do this.

[00:16:32] Kari Fabian, MD: Because we’re all unique people with unique lives and motivations, and so we. We just work with patients where they are and help them move along at the pace that they’re ready to move in terms of changing eating, changing activity, that sort of thing. 

[00:16:49] Pete Waggoner, Podcast Host: So I just met the two of you today, and there’s a level of trust in that.

[00:16:54] Pete Waggoner, Podcast Host: What you just said, doctor, that I think really matters because. As someone that’s not shy [00:17:00] of the dinner table here, you know, sometimes you, you can fear that maybe you’re being, I don’t wanna say shamed, but that’s an easy word to say, but you know what? You really, nobody ever wants to feel scolded, I think.

[00:17:11] Pete Waggoner, Podcast Host: And you’re definitely not getting that here with the two of you, with what you two are doing. It’s very obvious. I think it’s very important for people listening to this to know they need to come see you and it’s okay to look at this and you can help. 

[00:17:27] Kari Fabian, MD: Absolutely. There’s so much that we can do to help and it isn’t just about saying.

[00:17:33] Kari Fabian, MD: You have to lose weight and here’s how you do it. Just follow this thing. And the emphasis really to us even isn’t on weight so much at all, is just incorporating healthier behaviors that minimizing the high fructose corn syrup and that sort of thing, even in the absence of weight loss, can help the liver get healthier.

[00:17:54] Kari Fabian, MD: So, we don’t want people to fear. It’s like, oh, well, if I can’t lose weight, then there’s absolutely nothing that you can do to help [00:18:00] me, because that just isn’t true. There’s lots of healthy things that people can do to improve the health of their liver, even in the absence of dramatic weight loss.

[00:18:08] Pete Waggoner, Podcast Host: Important to remember earlier in this podcast, we didn’t really say this new in age either, and so this isn’t just for those that are aging up. This is for kindergartners and this is for everybody. And I would say if anyone is listening to this and they say to themselves, you know what, next time I go in, is it okay if they ask 

[00:18:30] Pete Waggoner, Podcast Host: can you check that? 

[00:18:32] Kari Fabian, MD: Yes, definitely. I think people should be empowered to, take control of their own health. So, we definitely think that if a patient has a concern about something, they should bring it in and say, I’ve heard about metabolic liver disease.

[00:18:46] Kari Fabian, MD: Is that something that I’m at risk for? Is that something that I should be checked for? 

[00:18:50] Pete Waggoner, Podcast Host: Beautiful. If one person hears that and says, I wanna do that, I, that’s a win for me with what we’re doing here. So I think that’s excellent. ’cause where there’s one, there’s two. [00:19:00] And then there’s more, and that’s the whole point.

[00:19:02] Pete Waggoner, Podcast Host: Any other parting thoughts on anything we may have missed that is important to what the two of you are doing? 

[00:19:07] Kari Fabian, MD: I think it’s important to know that there are also medications that can be helpful for people who need that. Now, not everyone does, and there are lots of lifestyle changes that can help the liver, but there are also medications that can help the liver.

[00:19:22] Kari Fabian, MD: They might be things that people have already heard of because they’re commonly advertised and talked about. So medications like semaglutide and Tirzepatide that are used for the management of type two diabetes and obesity. Do you have a role in reducing the scarring related to liver disease?

[00:19:39] Kari Fabian, MD: Unless it’s very advanced. So again, that’s another reason to get screened early because if issues are discovered prior to severe scarring, there’s a lot of things that we can do. Once the liver is severely scarred, it’s hard to reverse it. So there is a role for medications. There is also a [00:20:00] medication that has been FDA approved.

[00:20:02] Kari Fabian, MD: Specifically for metabolic liver disease with scarring that we tend to not use here because we’re more likely to prescribe drugs that are helpful for diabetes and obesity. But I think it’s helpful for people to know that there are medications that can help reduce the risk of developing cirrhosis.

[00:20:23] Pete Waggoner, Podcast Host: So detection here really matters. 

[00:20:25] Kari Fabian, MD: Detection matters. Yes. Big time. 

[00:20:26] Pete Waggoner, Podcast Host: And so does this process. So if you got anything from this podcast get looked at, fair enough? 

[00:20:32] Maura Romanshek, PA-C: Absolutely. This is awesome. 

[00:20:34] Pete Waggoner, Podcast Host: You two have been great to work with really good information. I’ve loved every minute of it. I know you’ve got patients to see and people to work with, and we appreciate all of your time. 

[00:20:43] Kari Fabian, MD: Thanks for having us. Yeah. Thanks for getting the word out about metabolic liver disease. 

[00:20:47] Pete Waggoner, Podcast Host: Thank you. That’s gonna be a wrap for today’s episode of Beyond the Checkup, brought to you by Stellis Health, where we believe in neighbors caring for neighbors. I’m Pete Wagner thanking you for joining us on this journey to better health. 

[00:20:59] Don’t forget to [00:21:00] subscribe to Beyond the Checkup for more health insights and stories. Share this episodes with friends and family, and let’s spread the word on living healthier, happier lives together.

[00:21:10] Pete Waggoner, Podcast Host: Thanks for listening.