Non-Alcoholic Fatty Liver Disease with Dr. Bob Rountree: Rational Wellness Podcast 101
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Dr. Bob Rountree discusses Non-Alcoholic Fatty Liver Disease (NAFLD) with Dr. Ben Weitz.
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Podcast Highlights
0:53 Non-alcoholic Fatty Liver Disease is the leading cause of liver disease in the US, even though many people have not heard of this condition. 75% of patients who are overweight have this condition, which consists of an accumulation of fat in the liver. Nonalcoholic fatty liver disease, NAFLD, is an asymptomatic condition, but it can progress to non-alcoholic steatohepatitis which can lead to fibrosis, cirrhosis, liver cancer and liver transplantation. Dr. Rountree described it as a tsunami that no one’s paying attention to. Technically, the definition is when 5% of your liver tissue is replaced with fat. What is usually seen first is that one of the liver enzymes (AST, ALT, or GGT) is mildly elevated on a blood test.
8:25 It’s not just that the liver stores fat, but it produces new fat. We know how to create fatty liver, which is when we produce fois gras. We do this by force feeding the goose or duck grains, which is turned into fat by the liver. It’s eating sugar and carbs and esp. high fructose corn syrup, that turn on genes in the liver that cause fatty liver and not eating fat that causes this. Big Pharma is investing billions of dollars trying to develop drugs to reverse the progressive form of fatty liver, known as Non-Alcoholic Steatic Hepatitis (NASH). Technically speaking, fatty liver doesn’t hurt you, but a percentage of people with fatty liver will develop fibrosis because the inflammatory pathways have been turned on–an auto-inflammatory process. If you lay down enough scar tissue, eventually you end up with cirrhosis or possibly liver cancer. It is expected that within the next 5-10 years, NASH will be the number one cause for liver transplants.
13:20 Studies show that when you track patients with fatty liver, they have much a higher incidence of mortality from other diseases. [Here is a good review paper on this topic: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5397356/?fbclid=IwAR19ujpU2qfD7mFaV-bAM96oN_SNZRoHiXb1BU3AbRM7xE4BLUmPUl-RW0g] The number one marker for this is C-reactive protein (HsCRP) and you start to worry especially when it is above 3. We also know that gum disease, like the existence of a bacteria known as Porphyromonas gingivalis in the gums, increases this risk. Also dysbiosis of the gut increases inflammation and leads to fatty liver.
15:56 We diagnose fatty liver first by measuring liver enzymes on a blood test, esp. ALT, AST, and GGT. ALT and AST are called transaminases because they move amino acids around–they’re part of the digestion process. Dr. Rountree feels that GGT, (Gamma-glutamyl transpeptidase), is a more sensitive test, though it is often not tested. GGT is an enzyme involved with glutathione metabolism. But when you discover that these enzymes are elevated, you must first make sure that they don’t have a virus, that they haven’t taken too much Tylenol, or have some other toxic exposure. After ruling these out, if you are suspecting Fatty Liver, then you should order an ultrasound. A biopsy would be more definitive, but nobody wants to have this procedure done.
19:37 Elevated triglycerides indicate a condition we call Metabolic Syndrome, which Dr. Rountree believes is an intersection between several different biochemical pathways that have gone awry, and at the core is a person who’s over-producing triglycerides. This means that you have insulin resistance, that your body is not responding well to insulin, which is why high triglycerides can be a tip-off that the person has fatty liver. High triglycerides and low HDL is a really big deal.
22:57 To reverse Fatty Liver the conventional medical approach is to put you on a statin or Metformin, which is a drug for diabetes. From a Functional Medicine perspective, the first thing to do is to get them to change their diet and stop drinking sweetened beverages and get rid of processed food and high fructose corn syrup and start eating fresh foods. Eliminate refined carbohydrates and sugar and go on a Mediterranean diet. You don’t need to go on a Ketogenic diet. And you have to get active and do some exercise every day and lose some weight. Exercise improves your sensitivity to insulin. High intensity interval training is the most effective form of exercise.
29:03 Dr. Rountree recommends the following nutritional supplements for reversing fatty liver:
1. Curcumin phytosome–500 mg twice per day. This is a form of curcumin that’s better absorbed because its blended with lecithin. There are at least three published studies showing that this resulted in dramatic improvements in fatty liver. Here is one study that I found using Curcumin phytosome for NAFLD: Efficacy and Safety of Phytosomal Curcumin in Non-Alcoholic Fatty Liver Disease: A Randomized Controlled Trial
2. 800 IU of vitamin E in the mixed tocopherol form
3. Fish oil is sold as a drug that lowers triglycerides, so it shouldn’t be a surprise that it improves fatty liver. Dr. Rountree recommends 2-3,000 mg of EPA and DHA per day.
4. Milk Thistle phytosome
5. Berberine at a dosage of 1500 mg/day helps to reverse fatty liver. Berberine can also help with blood sugar and compares with Metformin, so it can also be thought of as a anti-aging compound. Dr. Roundtree notes that berberine can cause upset stomach, so if that happens you can start with just 500 mg and take it with food and work your way up to 1500. If you take berberine long term, you should take it with probiotics so that you don’t have an adverse effect on the microbiota.
41:02 One of the reasons that Dr. Rountree likes the curcumin and milk thistle phytosome/phosphatidylcholine supplements is because they are also good sources of choline. Many people don’t get enough choline, which can result in fatty liver. I asked Dr. Rountree about Dr. Stanley Hazen from Cleveland Clinic who has developed a test for measuring TMAO levels and he has found that elevated TMAO levels contribute to heart disease. Dr. Hazen tells patients that they shouldn’t consume choline or L carnitine because it’s going to increase their TMAO. But Dr. Rountree thinks that TMAO is actually a marker for choline deficiency. When TMAO is up that means that bacteria in the colon are consuming dietary choline and turning it into TMAO. The problem is not the TMAO but the reduction in choline. Therefore you need to take more choline, not less. Choline is a great source of methyl groups and undermethylation is a major cause of fatty liver.
Dr. Bob Rountree is an MD with certifications in Family Medicine, Nutrition, Herbology, and Mind-Body Medicine and he is in private practice in Boulder, Colorado and he is the Chief Medical Officer of Thorne Research, a nutritional supplement company. He has written three books on Integrative Medicine, Immunotics: A Revolutionary Way to Fight Infection, Beat Chronic Illness, and Stay Well (Putnam, 2000); Smart Medicine for a Healthier Child (Avery Publishing, 1994); and A Parent’s Guide to Medical Emergencies (Avery, 1997). He also teaches regularly for the Institute of Functional Medicine.
Dr. Ben Weitz is available for nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111 or by going to www.drweitz.com.
Podcast Transcripts
Dr. Weitz: This is Dr. Ben Weitz with the Rational Wellness podcast, bringing you the cutting edge information on health and nutrition from the latest scientific research and by interviewing the top experts in the field. Please subscribe to the Rational Wellness podcast at iTunes and YouTube and sign up for my free ebook on my website by going to drweitz.com. Let’s get started on your road to better health. Hello, Rational Wellness podcasters. Thank you so much for joining me again today. For those of you who enjoy listening to the Rational Wellness podcast, please give us a ratings and review on iTunes. That way more people can find out about the Rational Wellness podcast.
Our topic for today is Nonalcoholic Fatty Liver Disease with Dr. Bob Rountree. While many people have never heard of it, nonalcoholic fatty liver disease is actually the leading cause of liver disease in the United States, and as obesity rates continue to rise, so does this condition. It’s estimated that 75% of patients who are overweight and 90% of patients who are morbidly obese are afflicted with nonalcoholic fatty liver disease. Nonalcoholic fatty liver disease, NAFLD, is an asymptomatic condition meaning, you have no idea that you have it and it’s marked by an accumulation of fat in the liver. And while it’s traditionally been considered a benign condition, it can progress to nonalcoholic steatohepatitis which can lead to fibrosis, cirrhosis, liver cancer and liver transplantation.
Dr. Bob Rountree is an MD who’s one of the founding members of Functional Medicine along with Dr. Jeffrey Bland and Sidney Baker, et cetera. In today’s parlance, he would be referred to as an OG. Dr. Rountree has certifications in family medicine, nutrition, herbology and mind-body therapy. He’s written three books in integrative medicine, Immunotics, Smart Medicine for a Healthier Child, and A Parent’s Guide to Medical Emergencies. He also teaches regularly for the Institute of Functional Medicine. Dr. Rountree, thank you so much for joining me today. I’m very excited to get an opportunity to speak to you.
Dr. Rountree: You bet. It’s a real thrill to be on.
Dr. Weitz: Good. So, maybe you can tell us how you first got involved with Functional Medicine.
Dr. Rountree: Oh, my God, that’s a long story. When I was in training in my residency, one of my fellow residents went to a conference put on on Integrative Medicine, and Dr. Jeffrey Bland was one of the speakers, and this resident came back and said, “You will not believe this guy. He talks about nutrition from a highly educated standpoint where he cites all of the research and connects the dots in a way that no one has ever done.” So I got intrigued and I ended up tracking Jeffrey down and went to hear him lecture, and then when I finished residency I spent a week at a place called the Omega Institute in upstate New York, and I studied with Jeffrey Bland and Leo Galland, Sid Baker, and a guy named Neil Ornstein, who are the founding fathers of Functional Medicine. That was about 38, 39 years ago.
Dr. Weitz: Cool.
Dr. Rountree: So there was no Functional Medicine at the time, but this is this group of forward thinking people, were putting these ideas together and eventually I continued to follow their work and go to Jeffrey’s seminar year after year after year, and eventually it became what we call Functional Medicine. I actually taught in the very first Functional Medicine training, which was out at the Orchid Hotel in the Big Island in Hawaii. It was a lovely experience.
Dr. Weitz: Cool. Yeah. I used to listen to Dr. Bland’s audio tapes every month. I think it was originally called preventative medicine update, and …
Dr. Rountree: Yeah. PMU.
Dr. Weitz: Used to get those little cassette tapes, pop them in the car …
Dr. Rountree: Yeah. Yeah. I still got a stack of them in my closet. Yeah. Yeah. Well, Jeffrey still had it. I just heard him on a conference last weekend, and he’s still cranking away and he’s in his mid-70s now, and quite robust and healthy and alert and his brain is just going 100 miles an hour as always.
Dr. Weitz: That’s great. Yeah, I know, he’s got his preventative, PLMI Institute. Right?
Dr. Rountree: Preventative Lifestyle Medicine Institute.
Dr. Weitz: Right. Cool.
Dr. Rountree: Yeah.
Dr. Weitz: So tell us about nonalcoholic fatty liver disease and what causes it.
Dr. Rountree: Oh, my God. This is one of these huge problems that nobody’s ever heard of. Right? They call it the tsunami because this is such a huge problem that doctors aren’t paying attention to. In the past, if you read a typical mainstream medical article on metabolic syndrome or prediabetes, they would always say, “Oh, and you can have this complication of fatty liver.” And they just described it as, “Oh, it’s not that big a deal. You’ve a little bit of fat in your liver and it could cause some problems,” and now we’re realizing that fatty liver may be the problem. It may be one of the main causes of diabetes, not the other way around. So, what is it exactly? It’s an accumulation of fat in the liver, just like the name says. It’s not caused by drinking alcohol or a toxin. I mean we know there’s toxins out there like acetaminophen or Tylenol.
Dr. Weitz: Yeah. The number one cause of acute liver failure, right?
Dr. Rountree: Absolutely. I just saw a patient a couple of weeks ago that had a routine blood test and her liver enzymes were both elevated and I said, “Well, this is either fatty liver,” she was a bit overweight, so I said, “This is either fatty liver or it’s Tylenol.” It turned out she was taking 1,500 milligrams of Tylenol every day. She stopped and her liver enzymes came back to normal, so she got off the hook for the fatty liver. But that raises the point of the fatty liver, is when you got something going on with the liver, it’s not because of another proveable condition like a toxin or alcohol, which is a toxin. So they call it nonalcoholic fatty liver. Technically, the definition is that when 5% of your liver tissue is replaced with fat, you have fatty liver. 5%. So, in order to get that you’ve got to have some kind of scan of the liver. You can’t tell that based on blood tests alone. Typically what would happen is a person’s getting a routine screen, like the patient I mentioned, and she’ll get told, “Okay, your hepatic transaminases, the ALT and the AST, one or both of these are increased.” And again, the first thing you think is, “Well, is there a toxin, or is there … does she have a virus or something like that?” But when you’ve ruled those things out, you go, “Why will the liver show an increase in these enzymes?” It’s because there’s a very mild level of inflammation that’s going on there. In the past, they would have said that fatty liver doesn’t really cause a problem. It’s a consequence of other problems, and as I said, the newer thinking is, no, this may actually be at the core of the problem.
Dr. Weitz: Why does the body store fat in the liver?
Dr. Rountree: Well, everything’s being processed through the liver, if you think about it. When you’re ingesting foods, right, the extract of the food goes into the lymphatic system and that drains into the liver. The liver is like a big sponge.
Dr. Weitz: Right.
Dr. Rountree: But it’s not just that the liver is storing fat, it’s actually making new fat.
Dr. Weitz: Okay.
Dr. Rountree: This is a really important point. So, how do you create fatty liver? Well, we’ve been doing it for centuries. It’s called fois gras. Right? That’s fatty liver. And how do you produce fatty liver in a goose or in a duck? You force feed them grains. Right? It’s not fat. So the logical thing would be to think, “Okay, you eat too much fat and so the liver just stores it.” Instead, what happens is, you eat too much sugar and the sugar actually turns on genes in the liver that tell the liver to convert that sugar into fat, into what’s called triglyceride, the triglyceride form of fat. So it’s a partially genetic thing. So, yeah, if you eat, you know, gobs and gobs of fat in your diet, some of that will end up in your liver and get stored there, but a big proportion of the fat in the fatty liver scenario is from high fructose corn syrup. That’s a big wow, right?
Dr. Weitz: Yeah. Yeah.
Dr. Rountree: Wait, wait a minute. I get fat from eating sugar. Yes.
Dr. Weitz: Right. Sure. We know that most of the cholesterol in the body is produced by the liver. That and drugs don’t work by blocking the cholesterol that we eat. It stops the liver, reduces the liver from producing cholesterol.
Dr. Rountree: Well, there’s this old notion. Somebody’s got high cholesterol, so maybe it’s just ending up in the blood stream. They’re eating too much high cholesterol food therefore they have high blood cholesterol. Well, now we know that even going on a low cholesterol diet doesn’t change blood cholesterol levels that much.
Dr. Weitz: Right.
Dr. Rountree: Even restricting cholesterol and fat from the diet doesn’t change blood cholesterol.
Dr. Weitz: Right.
Dr. Rountree: Right? It’s because the liver’s making that cholesterol and the odd thing is that even, as the same scenario with fatty liver, eating too much sugar can actually stimulate the liver to make more blood fats.
Dr. Weitz: Yeah. It’s interesting when you talk about fois gras. I guess the aliens are fattening us up for a big meal.
Dr. Rountree: They’re getting ready for a big meal. Yeah. They’re preparing us for the yummy feast. Yeah. Either that or if it’s not the aliens, it’s the big agricultural companies. They’re really … they’re having a field day with us.
Dr. Weitz: Oh, yeah, absolutely. And Big Pharma, right?
Dr. Rountree: Big Pharma. You know, so Big Pharma knows that this fatty liver problem is an epidemic, right. They’re not denying it at all. And they are investing billions of dollars in drugs, because they figure, if we find the drug that will reverse … It’s not so much reversing fatty liver, but reversing, as you mentioned, the progressed form of it, which is called NASH. Now NASH is the concern here. So, technically speaking, fatty liver doesn’t hurt you, but it does increase your risk of other diseases. But the problem is a certain percentage of people with fatty liver will develop fibrosis, and you get the fibrosis because you turn on inflammatory pathways. The immune system gets involved. You don’t want that. Once the immune system is involved, you’re in trouble. When the immune system gets involved, you start laying down scar tissue, and if you lay down enough scar tissue, then eventually you end up with cirrhosis or possibly liver cancer. So, for that reason, they’re expecting that within probably the next five to ten years that fatty liver NASH, the progressed form of it, is going to be the number one cause for liver transplants in this country.
Dr. Weitz: Wow.
Dr. Rountree: And that’s what they mean by the tsunami. We don’t have enough livers for all these people.
Dr. Weitz: Right. Wow. So, essentially when you say the immune system gets involved, we’re creating autoimmune liver disease.
Dr. Rountree: I guess you could call it an autoimmune thing because the body is attacking itself.
Dr. Weitz: Exactly.
Dr. Rountree: Technically, we call it autoinflammatory. So it’s not quite … autoimmune be like very specific attack on the joints. Right? Autoinflammation is like autoimmunity but it’s more like there’s inflammation in a certain area, like hardening of the arteries, arthrosclerosis, that’s autoimmunity.
Dr. Weitz: Right.
Dr. Rountree: That’s autoinflammation.
Dr. Weitz: Okay.
Dr. Rountree: So, autoinflammation. They overlap. They’re very similar. So, this is an autoinflammatory disease, it’s inflammation that’s somewhat confined to the liver. Now here’s a little interesting tidbit about it. Well, I don’t know if you’d call it interesting if you have the problem, but, people with fatty liver, again, were not thought to have any consequences of it, but what they’ve done is they’ve tracked people with fatty liver, know their diagnoses for years, and they found their incidence of mortality from other diseases goes way up. And probably the number one marker for that is something called the C-reactive protein which I’m sure you’re aware of.
Dr. Weitz: Sure. Absolutely.
Dr. Rountree: Yeah. If your CRP, if you’ve got fatty liver and your C-reactive protein is up, which is a marker for inflammation, then that’s a very bad sign, right? That tells us that your risk of dying or getting ill from a number of different diseases goes way up.
Dr. Weitz: And when you say the CRP is up, do you mean anything over 1, or anything over 3, or …
Dr. Rountree: Oh, over 3 is when you start to get worried. When you get up to 4 or 5, then it’s a real concern.
Dr. Weitz: Okay.
Dr. Rountree: But hopefully not over 1 or a lot of us would be in trouble.
Dr. Weitz: But I guess a lot of us Functional Medicine practitioners now are using 1 as the optimal range.
Dr. Rountree: Right. So we’re talking about optimal, but when you get into the danger ranges, more like your 3, 4, 5 et cetera. I find a lot of people, if they got a C-reactive protein of say 2, they can get it down just by flossing their teeth. Because bad gums can definitely cause inflammation in the body.
Dr. Weitz: Yeah, it’s amazing what bad gums can be involved in. They can increase your risk of heart disease, as we know, that’s why a lot of people get dental work and they get prescribed antibiotics to decrease the possibility of a heart infection, and recently we’ve seen research correlating it with Alzheimer’s disease.
Dr. Rountree: Yup. Yeah. Absolutely. There’s actually a bacteria that gets under the gums called Porphyromonas gingivalis. You probably heard of it.
Dr. Weitz: Yes.
Dr. Rountree: That’s one of the bad guys, and I bring this up in the context of the discussion on fatty liver, because now there’s a lot of research coming out showing that dysbiosis, which is unhealthy bacteria in the intestines, can actually lead to fatty liver.
Dr. Weitz: Right. Which-
Dr. Rountree: You know, powerful.
Dr. Weitz: From a Functional Medicine perspective, not surprising at all, because essentially dysbiosis seems to be a factor in everything.
Dr. Rountree: Every chronic disease.
Dr. Weitz: Yes. So, how do we diagnose fatty liver?
Dr. Rountree: Well, it’s mostly diagnosed in people as part of a routine screening. What’s called a chemistry profile or a liver function test. I would say a large percentage of patients in my practice came to see me because they’d been to a health fair and had a routine screen, and said, “Gee, I thought I was healthy. I’m just a little overweight. I got a little paunch going on, but otherwise I thought I was pretty healthy, then I went to a health fair, and lo and behold, my liver enzymes were elevated and they told me, go see a doctor.” Those liver enzymes, as I mentioned earlier, can be a tip-off that something’s wrong but you’ve got to first make sure it’s not a virus, make sure they’re not overdosing them on Tylenol which isn’t hard to do, make sure they don’t have any toxic exposures, and when all that’s left, you get, “Okay, let’s get an ultrasound.” The ultrasound is really the best test, I think, to determine it, because it will tell you whether there’s a lot of fat in the liver. Unfortunately, ultrasound doesn’t specifically say, you have 8% fat or 10% fat or 15. It just says, you’ve got enough fat that you qualify for having at least 5% of your tissue replaced with fat. So, again, starts with abnormal liver enzymes and then it’s confirmed with an ultrasound. Now, if you want to be technical about it, you probably should get a biopsy, but nobody wants to do that. Right? If you don’t have any symptoms and your doctor says, “I think you’ve got this bad condition that could lead to something even worse,” and then you say, “And I want to stick this huge needle into your liver and get a piece of your liver and see what it looks like there,” that’s not going to go over very well. So, no one gets a biopsy for fatty liver.
Dr. Weitz: So, which of the liver enzymes are most important? And how much do they need to be elevated to indicate this?
Dr. Rountree: They don’t need to be very elevated. So the two that we look at, there’s three actually, ALT, AST and GGT. Those ALT and AST are called transaminases and they’re called that because they move amino acids around. They’re part of the digestion process. And when the liver has this fat built up and for some reason it will leak these enzymes into the blood stream. But an even more sensitive test that a lot of doctors don’t do is called the GGT, Gamma-glutamyl transpeptidase, that’s involved in our old friend, glutathione. And you know that if an enzyme that’s involved in glutathione metabolism is elevated, that’s not good news.
Dr. Weitz: Right.
Dr. Rountree: Because you’re only increasing your glutathione processing enzymes if you’ve got some kind of toxin to be processing. Right?
Dr. Weitz: Right.
Dr. Rountree: The liver’s saying, “I’m under stress and I need more glutathione.” That’s actually … It’s a better enzyme but for some reason doctors don’t do it that much, so I always add it on. If I get a chemistry profile, I always add on the GGT.
Dr. Weitz: What about alkaline phosphatase and, or elevated triglycerides? Are those potential indicators as well?
Dr. Rountree: Though alkaline phosphatase can be, it’s generally not the first one that goes up. It’s a little bit later in the process, but, yeah, alkaline phosphatase can definitely be increased. I just saw it in a patient the other day.
Dr. Weitz: Okay.
Dr. Rountree: And your other question was about triglycerides, and there, again, there’s this condition that we call metabolic syndrome, right? And metabolic syndrome is either its own deal or it’s prediabetes depending on whether you’re a diabetologist or not. Diabetologists say you either have diabetes or prediabetes.
Dr. Weitz: Right.
Dr. Rountree: The endocrinologists, who are not diabetologists, and the cardiologists, they say there’s a whole other syndrome called metabolic syndrome that it’s own deal that can lead to diabetes. And the reason that’s important is because I’m in that camp. I think metabolic syndrome is a phenomenon, it’s an intersection between several different biochemical pathways that have gone awry, but at the core of it is the person who’s over-producing triglycerides.
Dr. Weitz: Okay.
Dr. Rountree: Why is this a big deal? Because, in the old days when we did a cholesterol panel, we looked at their LDL cholesterol and HDL cholesterol, and that’s all that mattered. Well, occasionally, you’d see a person whose high triglycerides were part of the deal, and we would tell them, “Oh, that’s no big deal.” No big deal. Now we know … I mean, high triglycerides and low HDL is a really big deal. What it means is that the body is not responding well to insulin. It means you have insulin resistance. And insulin resistance, it’s not the only cause of fatty liver, but it’s clearly one of the major causes, so the same thing that causes metabolic syndrome causes fatty liver. And so, that’s why, high triglycerides could be a tip-off that the person has fatty liver. We generally think, if a person is a Type 2 diabetic, if they’re at the point where they have to take drugs to keep their hemoglobin A1C down, chances are 70% that they’ve got some degree of fatty liver. If they’ve got metabolic syndrome, it’s not quite as high but it’s definitely moving in that direction.
Dr. Weitz: Right. And when the ALT is elevated, it could be like, say, 45 instead of below 40, right? It doesn’t have-
Dr. Rountree: It doesn’t … it’s only a slight increase. In fact, when you have these super high increases, you actually don’t think of fatty liver, you think of virus or a toxin.
Dr. Weitz: Right.
Dr. Rountree: Right? You think there’s been some kind of damage and there’s certainly viruses like Epstein-Barr virus that people can get. Even a younger person who gets Kissing disease, mono, you know, their liver enzymes can go through the roof.
Dr. Weitz: In the thousands, even.
Dr. Rountree: Yeah, in the thousands. So when I see that, I don’t think fatty liver. I only think fatty liver when, if the normal range is up to 40 and they’re 45 or 50. So, it can stay that way for months or years, and that’s your tip-off as you go … You know, the first thing is if you see these enzymes and they’re 3 points up, the first thing I think is, “Okay, I’m going to repeat this in a month and see if it’s real.”
Dr. Weitz: Right. So, when we have patients with this condition, how do we reverse it?
Dr. Rountree: Well, that’s the million dollar question. As I said, you know, the drug companies-
Dr. Weitz: Is that going to be revealed in the next Dr. Rountree book on fatty liver?
Dr. Rountree: Well you know, my wife was saying, “Why don’t you write a book about it?” I’m like, “Who’s going to buy a book called Your Liver May Have Fat In It.” It’s not exactly what you’d call a sexy topic for the public in general, but I tell you, so many people have it and the doctors are not recognizing it, and then they go on from fatty liver to NASH and they go, “Why didn’t anyone tell me? Why hasn’t anyone said anything about it?” Well, so that gets us back to, how do we treat it? You know, the drug companies are saying, “Let’s run-
Dr. Weitz: You don’t call the book that. You call the book This Is Going to Rejuvenate Your Sexuality, Make You-
Dr. Rountree: Yeah, you’re right. Right. Win Free Something. Win and free has got to be in the title if you want it to sell.
Dr. Weitz: Sex is somewhere in there too.
Dr. Rountree: You know what the drug companies think? They’re expecting that there’s about a 35 billion dollar market in drugs for NASH.
Dr. Weitz: Wow.
Dr. Rountree: 35 billion dollar market. But the first drug they came up with was a total failure.
Dr. Weitz: Not surprising. Right?
Dr. Rountree: And I think it’s because they’re going at the wrong thing. I mean the first thing you do, really, is look at it from a Functional Medicine perspective. I think Functional Medicine has got the solution.
Dr. Weitz: They never do that.
Dr. Rountree: They never did that
Dr. Weitz: They went on one pathway, the one drug that blocks out one pathway …
Dr. Rountree: Yup. And so, let me put you on statin.
Dr. Weitz: Yeah.
Dr. Rountree: Or let me put you on Metformin, which is a drug for diabetes. Well, those drugs, they’re somewhat helpful, but they don’t make that big a difference. Now if you look at it from the Functional Medicine perspective, the first thing you ask is, “What are your lifestyle factors that are … What’s contributing to this condition?” Right? And a lot of times it’s got to be the person drinking a lot of pop or eating a lot of foods that are processed and have the high fructose corn syrup. Now people say, “Wait, it’s corn syrup. How could it be a problem?” Well, it is a problem. There’s no question. There’s many published papers on it, so the first thing is to get rid of the sweetened beverages, and to get rid of processed food. Almost all processed food has got high fructose corn syrup in it. So, look for that on the label, or better yet, just stop eating things with packages. You know, go to fresh, all the time. It doesn’t even have to be organic. Just fresh.
Dr. Weitz: Right.
Dr. Rountree: That’s going to make a huge difference. So, that’s the first step. The second thing is to cut back on any kind of refined carbohydrate, any kind of sugar or sweets, candy, things like that. Do you have to go to a ketogenic diet, extreme low carb? It doesn’t have to be. It’s just carbohydrate restricted. In fact, studies have shown that the single best diet for people with fatty liver is the Mediterranean diet. That’s not a super carb restricted diet, but it’s minimal carb, there’s minimal sweets, there’s a nice mix of fruits and vegetables, there’s a lot of olive oil, not a ton of meat but some meat, a fair amount of fish. So, that doesn’t even have to be a really kind of crazy, elaborate diet, just a basic Mediterranean diet. But then you got to have people working out. That’s a stumbling block for a lot of people. If they’re not working out, if they’re not exercising, you’re never going to burn that fat.
Dr. Weitz: Right.
Dr. Rountree: And I’ve certainly, I’ve seen it in patients where their liver enzymes will go up and down depending on how much they’re exercising. And the standard complaint I hear is, “I don’t have to time to exercise. I can’t fit it in. I got too many things going on.” It’s like, you know, “Would you rather …” So, the whole joke is, “Would you rather exercise for 30 minutes a day or be dead 24 hours a day?”
Dr. Weitz: Exactly. Yeah, that’s no excuse. I just tell patients, “What time do you wake up? Whatever time it is, wake up an hour earlier, and that’s when you get your exercise in.”
Dr. Rountree: You’ve got to do it, and studies have shown that exercise lowers fat in the liver regardless of weight loss. So, it’s not that you’re exercising to lose weight. Probably what’s happening when you exercise is you get more sensitivity to insulin. So, again, at the core of this problem is resistance to insulin.
Dr. Weitz: Right.
Dr. Rountree: When you have resistance to insulin, then for the same level of blood sugar your body makes more insulin because it’s harder to get that blood sugar down, but when you make more insulin, insulin turns on the genes that generate fat in the liver. So, you exercise, you decrease the insulin resistance, you increase the sensitivity to insulin. And how much do you need? Probably about 150 minutes a week. That’s 30 minutes, five days of the week. Not a huge amount, and it doesn’t have to be super-duper intense, although it’s better if it is. So high intensity interval training works better than anything.
Dr. Weitz: Cool.
Dr. Rountree: And you know what that’s about. That’s telling the person to get on the treadmill, go all out for 20 to 30 seconds. Just as hard as they can until they can’t stand it anymore, doesn’t have to be a long time, then you rest, then a few minutes later you do it again. If you do that, you can get as much benefit from 15 minutes of exercise as you do from two hours of slow walking.
Dr. Weitz: Right. And weight training is high intensity exercise also.
Dr. Rountree: Absolutely. Yeah. When you’re doing these really intense reps, you know, that’s definitely working your muscles.
Dr. Weitz: I was at the gym this morning.
Dr. Rountree: At the gym doing that, getting your insulin sensitivity up.
Dr. Weitz: Absolutely. So besides losing weight, what else can we do about this condition? What nutritional supplements can be of benefit?
Dr. Rountree: Oh, I’m glad you asked that question. As it turns out, there’s a lot-
Dr. Weitz: I never ask that question.
Dr. Rountree: Okay. Well, you know, what would surprise you is that if you look at the mainstream text books where articles that have been written on fatty liver, they say there’s no proof drawn, and you go, “Wait a minute. So that means there’s nothing you can do but lose weight and exercise?” No, actually, if you do what I did, which is you start talking to my friend Mr. Google, or I should say, Dr. Google. And just started messing around looking at articles that people have written, what do you find? You actually find that there’s a huge number of dietary supplements that have been studied, and really good studies, for fatty liver, and you think, “Why doesn’t the mainstream doctor know about this?” It’s because there’s no financial incentive, there’s no drug rep that’s going to come in and say, “Hey, you should take curcumin, which is an extract of turmeric. You should take milk thistle, you should take berberine.” So I’ve already listed a couple of my favorites-
Dr. Weitz: Right.
Dr. Rountree: Probably the top of the list is curcumin phytosome. Curcumin is the active ingredient in the herb turmeric, curcuma longa. Turmeric is fine for general health purposes, but it’s not well absorbed, so there’s a version of it called curcumin phytosome where it is mixed with lecithin, which is a substance that you find in soy and sunflower, you can find lecithin in eggs, and when you combine the curcumin with the phytosome, it dramatically enhances absorption. Well, I mention that form of it because there’s at least three, and maybe four published studies where they took people that had significant fatty liver based on ultrasound and they gave them curcumin phytosome, 500 milligrams twice a day. That’s the dietary supplement that you can get, it’s pretty widely available if you ask for that specific form. They found dramatic improvements with the dropping of liver fat, people lost weight, their liver enzymes came down on every single study they’ve done on. So here’s something that is inexpensive, it’s easy to take, it’s non-toxic, and it’s been proven in three to four studies, that are all published in medical journals. So that’s my first choice. I put everybody on that.
The second one would be vitamin E. Now vitamin E is actually something that the mainstream liver specialists agree on. The American Association for the study of liver diseases, you know that’s kind of the mainstream organization that is an advocate for doing something about fatty liver, they actually say, “Everybody with fatty liver should get vitamin E.”
Dr. Weitz: And you prefer the high Gamma-tocopherols?
Dr. Rountree: Yeah. Well, it’s mixed tocopherols that are high in the Gamma-tocopherol. So, that’s the way … I don’t … So a lot of Vitamin Es that you buy or d-alpha-tocopherol
Dr. Weitz: Yeah, the synthetic form. Yeah.
Dr. Rountree: I’m not a big fan of straight d-alpha-tocopherol because the active form of vitamin E is actually Gamma-tocopherol.
Dr. Weitz: Correct.
Dr. Rountree: But I don’t think you have to isolate the Gamma-tocopherol, I think you just get the mixed tocopherols. And a typical dose of that is 800 international units, or IUs a day. So, everybody with fatty liver should be on that. The third thing would be fish oil, right? The Omega-3 fatty acids. There are very good studies showing that fish oil can improve fatty liver. Well, that shouldn’t be a surprise because fish oil is actually approved by the FDA as a drug. Fish oil is a drug to lower triglycerides. Well, it’s going after the same thing. Again, if a person didn’t understand this, they might say, “Wait a minute, you’re recommending a fat, which is fish oil, to treat fatty liver. That doesn’t make any sense.”
Dr. Weitz: Right.
Dr. Rountree: Except that what the fish oil does is it decreases inflammation and it actually improves the genetic activity in the liver so it stops making all that fat. How much do you need? About 2 to 3,000 milligrams of the active ingredient, which is EPA plus DHA. And that ends up being somewhere between 2 to 4 caps a day, or about a tablespoon of cod liver oil. So everybody can do that.
Dr. Weitz: Yeah.
Dr. Rountree: The next supplement that I recommend a lot that’s actually got good research on it, is milk thistle. We know that milk thistle has been around for a long time, for a wide range of liver conditions. Now, similar to the curcumin, the milk thistle extract called silymarin is not well absorbed, and there are a number of studies using the phytosome which complex with lecithin showing that the phytosome is much better absorbed and actually works really well in the liver. I believe that that’s actually a trademark name and I would say this, I’m not plugging a specific company’s product, but this is what’s in the medical research, it’s called Siliphos. That’s made by a company in Italy. A lot of companies will sell the Siliphos, so it’s sold under different brand names, but that’s the one you want to look for and there’s two or three published studies showing that that improves fatty liver.
Dr. Weitz: Cool.
Dr. Rountree: So that’s a good one. Another one I love is called berberine. I’m sure you’re familiar with berberine.
Dr. Weitz: Use it all the time. Yup.
Dr. Rountree: Berberine, you know, why mainstream doctors don’t know about it just completely beats me.
Dr. Weitz: There’s been studies where it’s gone head-to-head with metformin and this is useful.
Dr. Rountree: It works just as well as metformin for diabetes. Sometimes I actually combine the two for a person that’s got bad diabetes, and when I do that it keeps me from having to go to insulin or more powerful drugs. So, berberine is a yellowish chemical that’s found in a lot of medicinal plants. Plants are found basically all over the world. In China, it’s in a plant called coptis chinensis. A European plant that’s used a lot is Berberis vulgaris. Here in the United States we have a plant called Oregon-grape root, and all of them have berberine.
Dr. Weitz: Do you think it matters where it comes from, because some of the products on the market have it from four different sources, some don’t.
Dr. Rountree: Berberine is berberine.
Dr. Weitz: Okay.
Dr. Rountree: In my opinion, and there are studies using different sources of it, but berberine is the active ingredient. Now, berberine for years is mostly used to treat infections in the gut.
Dr. Weitz: Absolutely. SIBO, dysbiosis.
Dr. Rountree: Yeah. Dysbiosis. Candida. We used it for years for that. And the way I understand it is that some astute doctor in China said, “Wait a minute, my patients are taking berberine to treat dysbiosis or treat infectious diarrhea, that kind of thing, but gee, their blood sugar is getting better.”
Dr. Weitz: Right.
Dr. Rountree: So it was some chance discovery. The berberine had been around for a long time, but nobody thought of using it for diabetes, but the Chinese jumped on that, started doing some studies and found out that it lowers blood sugar. And it’s fabulous for that.
Dr. Weitz: What dosage do you like for the berberine?
Dr. Rountree: If a person’s got full-on fatty liver, they need about 1,500 milligrams a day.
Dr. Weitz: Okay.
Dr. Rountree: And that’s of berberine, that’s not of Oregon-grape root, or Berberis vulgaris, right? So you’ve got to say, how much of the active ingredient, 500 milligrams up to three times a day. Now there’s some caveats with that. Berberine is a very powerful substance. It can’t interact with certain prescription drugs. For example, it can interact with statins and when you take the two together, it can make the blood level of the statins go higher, so if somebody is on a statin and they take berberine, then they may need to reduce the dose of the statin. So not a problem if they’re not on prescription drugs, but if they’re on prescription drugs and they want to do berberine, they should probably either talk to a pharmacist or a doctor about it.
Okay? So that’s number one thing that they should be concerned about, but the other thing to be aware of with berberine is that it can cause upset stomach, and the way you get around that is you start with one a day. 500 milligrams, take it with food, and generally take it for one to two weeks, make sure the stomach is settled down, and then you bump it up to two a day, and then eventually three a day. Is it worth it? I mean, what? Why, that sounds like a hassle. It could upset your stomach, could interact with drugs. Well, I mean, the amazing thing about berberine is that, again, it works as well as metformin for lowering blood sugar. That’s a powerful effect.
Dr. Weitz: Anti-aging.
Dr. Rountree: It has the anti … Well, I just gave a lecture on longevity pathways at a conference and I was looking at some of the drugs that are being touted. There’s a drug called rapamycin-
Dr. Weitz: Yes.
Dr. Rountree: … being touted as an antiaging product.
Dr. Weitz: mTOR, yeah.
Dr. Rountree: It’s an mTOR inhibitor. I was looking at metformin. There’s actually a study that the FDA approved looking at metformin as an antiaging drug. But then I started diving through my friend Dr. Google’s research, and I found a paper saying, “Could berberine be acting as an antiaging drug the same way that metformin is.”
Dr. Weitz: Absolutely.
Dr. Rountree: And the doctors were saying, “Yeah, actually it’s doing the same thing as metformin, but it’s cheaper and easier. It’s not prescription. It’s safer.” So, yeah, berberine may be something you would take, maybe a lower dose. I wouldn’t take the 1,500 just for anti-aging, but 500 to 1,000 a day, seems plenty safe. People can use it for a long period of time, but they should take probiotics with it, regularly.
Dr. Weitz: Right. To make sure. You don’t want to kill off too much of your microbiota.
Dr. Rountree: Yeah. You don’t want to mess with your microbiota. Now, I haven’t actually seen it be a problem with the microbiota, but it’s so this is a theoretical concern.
Dr. Weitz: Right.
Dr. Rountree: But it’s the real deal. Now, what about fatty liver? There’s several published studies showing that berberine can decrease fatty liver. There are animal studies showing it and human studies showing it. So it’s not hypothetical, it’s not theoretical, it really does work, so it’s well worth it. But berberine, I don’t put it in my first level, right, because it’s stronger, it’s more potent, and some people do get the upset stomach. So, again, I start with the curcumin phytosome, the vitamin E, the fish oil, the milk thistle phytosome, the Siliphos. I try those things first and if I need something stronger, I go to berberine.
Dr. Weitz: And one of the reasons why you like the phosphatidylcholine supplements it’s because of their benefits of choline, right?
Dr. Rountree: Well, okay. I’m glad you asked that question. Again, for a long time, we thought that fatty liver was only a result of being overweight, having insulin resistance and eating too much sugar or high fructose corn syrup. But now we know that there are people that can have a genetic abnormality in the ability to process folic acid. It’s called the MTHFR. I’m sure you know all about it and probably talk to your listeners. Right?
Dr. Weitz: Yes.
Dr. Rountree: Well, the fact that methyl compounds can help fatty liver has kind of opened up this whole new realm of research, right? A lot of people aren’t aware that choline in the diet, which you can find in eggs and meat and dairy products, that choline is actually a great source of methyl groups, and it turns out that undermethylation is a major cause of fatty liver. Why is this a big deal? Because we think fatty liver affects somewhere around 20 to 25% of the population. Nutritional surveys that have looked at choline intake and what percentage of the population you think gets enough choline?
Dr. Weitz: Probably most don’t.
Dr. Rountree: Yeah. Most don’t, and up to 20, 25% are actually deficient in choline. So that is totally parallel to the people that get fatty liver.
Dr. Weitz: And yet you have a doctor from Cleveland Clinic measuring TMAO levels and telling patients that they shouldn’t consume choline or L carnitine because it’s going to increase their TMAO.
Dr. Rountree: Yeah, that’s doctor Stanley Hazen’s hypothesis. I think TMAO is a marker for choline deficiency.
Dr. Weitz: Interesting.
Dr. Rountree: It’s the other way round. So I think when TMAO is up, that means bacteria in the gut are consuming dietary choline and turning it into this toxic compound. Well, I think, the problems you see associated with the TMAO are a result of the choline deficiency.
Dr. Weitz: Ah. I see.
Dr. Rountree: Now, what’s the evidence for this? If you take people that are, for some reason they can’t eat and they get all their feeding intravenously, called total parenteral nutrition. So, you put it in an IV and you give them all their food intravenously. If you leave choline out of that formula so that they have a totally controlled formula, you know everything that’s going into their body. If you don’t put choline in there, 100% of those people will get fatty liver, 100%. And if you add the choline back in, then the fatty liver goes away within a couple of weeks.
Dr. Weitz: Wow.
Dr. Rountree: Very clear, very elegant. So, again, these phytosomes are a source of phosphatidylcholine and I think they’re quite beneficial. So not only am I not concerned that they’re contributing to the TMAO, I think the high TMAO is an indicator that they need more choline.
Dr. Weitz: Wow, we should take two groups of patients that have elevated TMAO levels and give one group choline and then measure their liver and their …
Dr. Rountree: Do their ultrasound. Look at their ultrasound and see … Yeah, they’ve done similar kind of tests, again with these people getting total parenteral nutrition, with the ultrasounds before and after where they add the choline. That’s a similar kind of experiment to what you’re talking about. They just need to add in the TMAO and see which direction that’s going.
Dr. Weitz: Interesting.
Dr. Rountree: Yeah. So, choline is a good thing. You know, you can actually take choline as a separate supplement and a typical dose is about 500 milligrams twice a day. Who needs choline the most is pregnant women.
Dr. Weitz: Oh, yeah?
Dr. Rountree: Yeah, for the baby’s brain.
Dr. Weitz: Absolutely. And it’s added to some of the newer supplements in the Functional Medicine world. [crosstalk 00:45:08] back in the day taking choline and inositol to help clean out your liver.
Dr. Rountree: It’s an all kind of naturopathic formula which they called lipotropics.
Dr. Weitz: Yup.
Dr. Rountree: I thought it was interesting because I, for years, I kind of used them but didn’t know why.
Dr. Weitz: Right.
Dr. Rountree: My naturopathic friend said, “This is good for your liver.” “Well, why?” “Well, because they’re lipotropics.” “Well, why are they lipotropics?” “Because they’re good for your liver.” Right? They’re just kind of a natural observation. And one of the things that in this lipotropics is called trimethylglycine, TMG. TMG is great for the liver, so that’s another source of methyl groups. Well, where does TMG come from? It’s made from choline.
Dr. Weitz: Ah, interesting. What about inositol? That probably would be beneficial too.
Dr. Rountree: I’m not … Maybe. I’ve not seen any research on inositol for fatty liver.
Dr. Weitz: Yeah, we use it for PCOS right now.
Dr. Rountree: I use it for mood disorders.
Dr. Weitz: Oh, okay. Yeah.
Dr. Rountree: You know, in high doses, like 10 to 20 grams a day.
Dr. Weitz: Right.
Dr. Rountree: Really good for mood. For panic, anxiety, things like that.
Dr. Weitz: Yeah. Cool. So, this has been a great discussion, Dr. Rountree.
Dr. Rountree: Cool.
Dr. Weitz: How can our listeners get hold of you and find out more about your programs and your books, et cetera, or be able to contact … Are you available for consultations? You do-
Dr. Rountree: Well, my practice is pretty full right now because I’m mostly on the road traveling, but I do have a LinkedIn website so that’s probably the best place to find out more about my practice, is just go to LinkedIn.
Dr. Weitz: Okay.
Dr. Rountree: Type in my name and Boulder Wellcare, or I highly recommend that people go to the Institute for Functional Medicine website. So they don’t … I do have people occasionally fly in to see me, but if there is Functional Medicine doc near you, like, what about you?
Dr. Weitz: All right. Absolutely. What about me?
Dr. Rountree: Yeah. What about you? So that, Institute for Functional Medicine has got a great referral network.
Dr. Weitz: Yes. Absolutely. Awesome. Thank you so much for spending some time with us, Dr. Rountree. This was a great podcast!
Dr. Rountree: You bet. It’s been a pleasure.
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