With a bit of time, even things like the COVID virus are accommodated by our fears and broader concerns bubble back up.  One of the challenges faced by a lot of people with serious chronic illness is that they are alone physically or emotionally.

As I think about these past weeks and staying at home I realize that I am so very fortunate. My wife Rosemary makes my days in isolation a joy rather than a burden but I see messages in our patient forums that break my heart from people who are literally dying deaths of despair.  If you are well enough, reach out to those you know who are lonely. Chronic illness is difficult enough without having to do it alone.

Click the picture below for a link to a bit of fun on the subject of introspection. Many of you are old enough to remember this but it may be meaningful to our younger folks as well. (The picture isn't related, I just like it)

We are reaching the end of the beginning of the COVID pandemic. As society tries to return to some kind of normal the challenge is how, as an individual, to manage being a part of society if you have a medical issue.

If we look at some recent data from New York the issue is very clear.

Clearly, about 96% of the deaths are people older than 45. We have to remember that anyone can get it, but while it is hazardous for mature adults, most younger people will be OK. What that actually means is that it takes about 40 years for a typical person to develop some kind of chronic illness which puts them at risk.

That is all very interesting, but as part of the "at risk" population how do we think about the near term future? There aren't many good models but it is probably wise to keep a perspective even in the face of horrific news every day.

We are getting past the peak of the COVID deaths and we have used the strategy of social distancing and shutdown to try to prevent our hospitals from being overwhelmed. We all understand the tragedy of death by virus but the figure of merit that drove decisions by the government was ultimately ventilator supply and ICU occupancy. It really was an exercise in statistics.

Before you get mad at me, this discussion is about how our society makes decisions in the face of crisis. If you are a patient, or someone who may die some day, the way the system works is important so stick with me here. The way these processes work, in the back rooms and basements where real policy is made, matter to your life and you should understand it.

It is a fair analogy to think of this pandemic as a war. It is an invasion by a force which is hazardous and for which we have no defense. You might think of New York City as similar to the sinking of the Arizona at Pearl Harbor. We respond to the emergency with a host of defenses as we try to understand what we face. Some things work, some don't, but that is the nature of crisis.

As I watch the COVID tragedy unfold in the language of death rates and cytokine storms I find that Tennyson's poem, The Charge of the Light Brigade, which speaks of courage under fire despite the failures of command, comes to mind.

Forward, the Light Brigade!
Was there a man dismay'd?
Not tho' the soldier knew
Some one had blunder'd:
Their's not to make reply,
Their's not to reason why,
Their's but to do and die:
Into the valley of Death
Rode the six hundred.

In the manner of all armies, the healthcare workers and all of those that support them join the battle because it is theirs to do. Those of us who are high risk targets of COVID or are "non-essential" can but be humbled by the courage that is the definition of that profession.

How serious is this bug really?

We still see people arguing that this epidemic is overhyped and that we should not be closing the country down to fight it. Do they have a point?

One advantage of socialized medicine is that you get a consolidated database. Data from the Intensive Care National Audit and Research Center in London offers some perspective on how COVID-19 compares to the flu.

A recent report compares 2249 recent COVID-19 patients, whose mean age at admission was 60 years, compared to 4759 patients with non-COVID-19 viral pneumonia, most of them caused by flu with an average age of 58, who were hospitalized over the three complete years 2017-2019.

The Kabuki theater reveal is nearly here. The poorly orchestrated government response to COVID-19 is being forced to throw off the kimono.  We have watched the ratcheting up of the warnings for several weeks now and the step by step escalation of responses.  It is just the way of it I guess.  The government knew this information in late January. We wait too long for proof and consensus before we will take a difficult step.

The first thing to understand is the epidemiological facts about the virus. The big number is we should plan for a health crisis about 10 times as big as the flu.  The knee jerk announcements you are seeing today are in recognition of the risk.

Did you know that 20,000,000 Americans don't know they have asymptomatic liver disease?

Did you know that disease called COVID-19 is caused by the virus SARS-CoV-2?

Did you know that COVID-19 or SARS-2 is more dangerous to society than SARS-1.0 which hit in 2003 and killed 9.6% of those infected?

Did you know that if you have advancing fatty liver disease without any symptoms your risk of death from SARS-2 is higher than average?

I have some concern about writing this.  When we face a crisis, panic and reactions driven by fear can do great harm.  I do not wish to contribute to that, however, as an advocate for people faced with chronic illness, such as liver disease, I feel compelled to inform my community about the details.

Terminal illness is a fate that awaits us all. We know not the pathways of our personal  journey only that we will take one of those paths in a time not of our choosing.

I live in the land of the chronically ill. It is that time between health and end stage disease. The Foundation's niche is fatty liver disease but chronic illnesses of many kinds are passengers on the same train.

I deal with the newly diagnosed who are frightened and confused. I scheme ways to hold the devil back with stalwart warriors who fight for life. I comfort those for whom the journey is too hard and who are dying a death of despair. I walk with people who are triumphant after they receive liver transplants. I see the length and breadth and depth of this disease and as a society I see that we manage it badly.

In many cases where patients struggle with a heightened blood sugar level and/or excess weight and have Hashimoto’s thyroiditis; their blood tests reveal a fatty liver - with high liver enzymes. As you may know, there aren’t any overtly obvious symptoms when it comes to a fatty liver; but it can be quite dangerous. If someone’s liver is filled with excess fat, it will struggle with its detoxification role, result in higher inflammation - and in turn, a higher risk of a heart attack. But did you know that Hashimoto’s hypothyroidism may also play a role in your liver becoming fatty? We’ll explore the connection here in order to inform potential patients suffering from such issues.

My poor inbox groans under the weight of CBD articles and pitches. I've hesitated to jump into this pit again but I get a steady stream of questions from patients about using it.

We need to be clear about this issue.  CBD oil is biologically active. However, that doesn't mean it is good or bad for you. In reality we just don't know enough yet to have a valid opinion.

Let's be clear.  I'm not part of the debate about this plant.

This time of year I get a lot of questions about whether it is possible to manage NASH/cirrhosis entirely with diet and can a stage 4 liver fibrosis improve.  Most people say no.  Once you have cirrhosis it is hopeless. Is that necessarily true?

There are a lot of new year resolutions about better health and diet but what really matters? What is possible? I changed my lifestyle as my personal therapy and the question is does it work? Here is a chart of my results since diagnosis.

What have we learned from the SUNN Study?

As members and friends of the Foundation, you know about our efforts to promote early screening for advancing liver disease.  We believe it is morally wrong to allow people with advancing liver disease, but with no symptoms, to go untested until they develop stage 4 NASH, otherwise known as cirrhosis. Remember, that is the standard guidance of the medical profession. We believe that end stage liver disease is too late in the process to discover the problem. As a way to advance the argument we sponsored the SUNN Study (Screening for Undiagnosed NAFLD and NASH).

The Foundation (FLF) announced today it has successfully completed participant recruitment in the SUNN study, a proof-of-concept study of screening for undiagnosed nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) in a self-selected, at-risk population within non-traditional, community-based settings. SUNN study has completed recruitment of 1,006 participants across various communities in South Houston and Galveston, Texas. Full results of SUNN study are anticipated to be released in early 2020.

“Completing recruitment for this proof-of-concept study is another important step forward for FLF’s ongoing community outreach, education and advocacy efforts toward proactive screening for advancing liver disease among at-risk populations for NAFLD and NASH,” commented Wayne Eskridge, FLF’s Co-Founder and Chief Executive Officer.

Image credit: Vegan Liftz

What Type of Workout should People with Fatty Liver Disease Complete?

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease, owing in no small part to the increasingly high rates of obesity in the American population. In a 2019 study published in Gene Expression: The Journal of Liver Research, researchers found that physical exercise could benefit people with NAFLD - including those who had the disease in its most inflammatory form - nonalcoholic steatohepatitis (NASH). In their study, they relied on a moderate exercise routine lasting 20-to-60 minutes for four to seven days a week. The routine included both aerobic and weights/resistance training. Their results showed that the positive effects of exercise were observed whether or not participants lost weight.

Both Aerobics and Strength Exercises are Key

Around one in seven births are affected by gestational diabetes - a severe threat to maternal and child health - as stated by the International Diabetes Foundation. Gestational diabetes is one of the reasons why maternal programs include careful testing and control of glucose levels. The disease can have long-term health effects for mothers and their children, heightening the risks of obesity, diabetes, hypertension, and kidney problems in children. However, one consequence many women do not know about, is that of fatty liver disease.

A 2019 Study Showing the Link between Gestational Diabetes and Fatty Liver

A recent study by Sarah R. Donnelly et al found that women with gestational diabetes mellitus (GDM) have an increased risk of fatty liver disease nine to 16 years after giving birth. This is the case because chronic hyperglycemia is a risk factor for liver fat accumulation and potential liver dysfunction. Specific liver enzymes are created at

I was recently asked to talk about the patient view of liver disease by a group known as ICER, A nonprofit group that studies fair drug pricing.  They are working on how drugs for #NAFLD and #NASH might be priced.  The team includes a wide range of expertise which includes some doctors and during the discussion I talked about the fear people experience when diagnosed with cirrhosis or stage 4 NASH.

I was surprised when a primary care doc reported that he didn't see that much fear in his practice which made me wonder why our views of the average patient response was so different.

I think the answer lies in the nature of the relationship.  When we go to a doctor we are dealing with a power figure.  We hope for solutions to our  troubles and we want the doctor to think well of us and to help us.  We want to be a "good" patient and we are more likely to do our best to present our problems and to listen respectfully to what the doctor has to say.  It is a process which engages our attention. Most of us, even if we express our fears, will be reluctant to try to describe or act them out in front of the physician so it has an element of intellectual control even if fear grips us in the doctor's presence.

Big news, red and processed meats are now OK.  Another example of how the news and the drive of researchers to publish is making us crazy.  We all remember the butter bad, margarine good mess or eggs bad, no eggs ok.  Health news is designed to be something for everyone.  You can find support for anything you think you might like to try.  Entertaining I suppose and lots of jobs are created but if you are a patient, particularly a liver patient, this is all dangerous.

Here is the latest bombshell that all the talking heads are exploding over.

Red and processed meat are OK to eat, controversial new guidelines claim.

Since you are here you must be interested in liver disease so keep that in mind.  One of the irritating aspects of so much research is they speak about heart, diabetes, and cancer then generalize the comments as though the information is good for everyone.

A major issue here is saturated fat and the claim it is not an issue.  Well, for what they studied that is true.  The heart, for example burns almost nothing but fat and does pretty well with any of them.  Diabetes is a sugar issue and cancer is vastly complex but liver cancer is kind of in a class by itself and they don't address that.

CBD oil is all the rage and many people want to try it. The health hustlers are gearing up to take advantage of the fear of sick people and they have no concern about whether you live or die.

CBD shows promise but we don't really know the details yet and you can be confident that it won't be a miracle drug for everyone.  The issue today is that you have no idea what contaminants will be in the product you are buying.  CBD is being added to hundreds of products and recent testing is very disturbing.  How about these facts as food for thought?

Recent testing of the top-selling 240 CBD products for 300 contaminants showed 70 percent of them to be "highly contaminated" with heavy metals like lead and arsenic, herbicides like glyphosate (the active ingredient in RoundUp) and a host of other contaminants including pesticides, BPA and toxic mold. One product — by Ananda Hemp — contained levels of lead so high, it exceeded by 100 times what the EPA would consider actionable for drinking water.

In the land of the blind, the one eyed man is crazy ... he sees things that others do not and dreams of things that are thought impossible by the blind.

We have reached our initial goal of screening 1,000 asymptomatic people who have no diagnosis of having liver disease.  We will be reporting the results in due time but this is a milestone rarely reached by non profits to be the sponsor and to execute a formal study.

Your sweet tooth and poor dental care could increase your chances of developing serious liver conditions. People of all ages with poor oral health, bleeding gums or loose teeth, have a 75% increased risk of developing non-alcoholic fatty liver (NAFLD) and liver cancer. Meanwhile, a study by a researcher at the University of California has linked regular consumption of added sugar to a number of serious conditions, including NAFLD.

Fructose Increases Risk of NAFLD

Non-alcoholic steatohepatitis (NASH) or non-alcoholic fatty liver disease (NAFLD) affects nearly 10% of children in the US, aged from 2 to 19 years old. The condition has become more common in children over recent decades, partly due to an increase in childhood obesity. Parents and families have an important role in not just spotting signs of fatty liver disease in their children, but in addressing lifestyle and dietary changes in their family to help reduce their child’s risk of developing the condition.

Fatty Liver Disease In Children

An article by Jackie

image credit My Fit Station

There are no medical treatments for non-alcoholic related fatty liver disease, according to the American Liver Foundation – indicating the extent to which a healthy diet and exercise are key to preventing or reversing early-stage fatty liver disease. Far from having to excessively count calories or otherwise follow an intensely strict dietary regimen, people with fatty liver disease can progress significantly by embracing a nutritious, delicious Mediterranean diet. Known as ‘the heart-healthy diet’, it is also rich in healthy Omega-3 essential fatty acids and low in refined sugars, and can be a nutritious tool against fatty liver disease.

Why The Mediterranean Diet?

Getting Ready For A Hospital Stay

As many as 30 million American adults have non-alcoholic steatohepatitis (NASH), a fatty liver disease characterized by inflammation and scarred tissue. More commonly referred to as non-alcoholic fatty liver disease, a patient will often have no symptoms and may have only come to medical attention when tests have been carried out for something else. This may happen if an ultrasound shows that your liver looks unusual or if you have an abnormal liver enzyme test. You will likely be required to have a series of tests to determine the diagnosis and severity of the disease. Most of these tests and later any required treatment will likely require a stay in hospital.

Preparing For Hospital Stay

We don't normally write about alcohol abuse, but for people with an injured liver from other causes alcohol is particularly dangerous.  Since many people have cirrhosis without symptoms they likely won't appreciate the increased risks they have due to alcohol use.  This is becoming a bigger problem for our older population and the link below is to an excellent article from the National Council for Aging Care that is useful even if you are young.

Alcohol is a major part of the culture of the United States. In 2014, alcohol sales—which include beer, wine, liquor, and other alcoholic beverages—totaled nearly $225 billion. The following year, more than 15 million Americans over the age of 18 reported having Alcohol Use Disorder (AUD), known more commonly as alcoholism. That number is even higher among people who haven’t reported the disease or have yet to see a doctor for a diagnosis.

A number of people in that group are seniors. About 10 to 15 percent of people don’t start to drink heavily until they are older in age, according to UCLA professor Dr. Alison Moore. Because of this, alcohol-related emergency room discharges among the elderly reached nearly a three-quarters of a million in 2012. This number—as well as the number of alcoholics who are also seniors—is expected to rise as the senior population grows to 80 million by the year 2050.

To first understand the severity of alcohol addiction among the elderly, though, we must first understand what an alcohol addiction is and can look like.

https://www.aging.com/alcohol-abuse-amongst-the-elderly-a-complete-guide/

Fighting A Fatty Liver As We Age

When people think of an unhealthy liver, they most often think the leading cause to be alcohol-related, but an even greater concern is Non-Alcoholic SteatoHepatitis (NASH), an abnormal accumulation of fat in the liver which can lead to cirrhosis. In the U.S. about 16.5 million people have NASH, with a majority of sufferers between the ages of 60 and 74 years old according to a 2018 report by the National Aids Treatment Advocacy Project. On the bright side, a fatty liver is a reversible condition at any age that can be managed and minimized by concentrating on healthy diet and lifestyle changes. 

Recognizing A Fatty Liver

Non-Alcoholic SteatoHepatitis occurs in every age group but is most prevalent in seniors who are more prone to obesity and type 2 diabetes, both leading causes of NASH. An annual blood test is the simplest way to detect a fatty liver along with physical warning signs that include a swollen belly, red palms, a yellowish hue to the skin or eyes and larger than normal breasts in men. Whether the senior with NASH still resides at home or is being cared for in an assisted living facility, there are diets and programs that caregivers or family members can oversee to reduce the liver's size and prevent further damage.

What if you had a liver disease but nobody told you until it was too late?

Wayne Eskridge, Fatty Liver Foundation

Typically, nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are silent diseases. They have no symptoms. Even if cirrhosis has developed, there are often no symptoms until the liver has become so damaged that the only option is a liver transplant.

Early screening for NASH is essential, but obstacles abound. While there is a quick, easy and economical method to screen for fatty liver disease, it is not widely available and screening in the absence of symptoms is often not part of standard medical practice policy. Medical coverage for the test also may not be available if the patient isn’t sick or doesn’t have symptoms.

This article was recently published in Real World Health Care.  Here is a link if you are interested in reading it.

https://www.realworldhealthcare.org/2019/07/nash-a-disease-without-symptoms-but-lots-of-hope/

Sorry to those who have been here and are already serious about your health but we have a lot of new people who are trying to understand how to be kinder to their livers and who need to understand things that matter.

Lipid metabolism, big words that mean how does your body use fat.  We see endless articles about fat in our diets.  Endless contradictory claims about special diets, miracle foods, buy my secret pills, doctor invented. blah blah.  Very confusing if you aren't a bio-chemist.

The subject is vastly complex.  In this note I'll try to simplify just one subject that you can have some control over.

There are many paths to the inflammation that is NASH/cirrhosis and a potential killer.  Your food is really a complex soup of chemicals that the body uses to your benefit or tries to defend itself against.  With inflammation or NASH the balance between things that make it worse and those that make it better, in simple terms, determine the outcome of fibrosis and cirrhosis resulting from NASH.

Since you are on my mailing list you know about NASH, unlike most of the people.  We had the 2019 version of NASHday on the 12th and  as I think about how that event went I am struck by the fact that as a health outreach it was unusual.

I'll explain why but first, the punchline, NASHday was about people's lives and not about money.

We have every kind of "DAY" that you can think of.  Every cause has a day or a month, some peg to hang the cause on and to focus attention. Just as an example, these are the top five unofficial holidays according to toptenz.net.

1.      Black Day.

2.      Autistic Pride Day.

3.      International Free Hugs Day.

4.      Monkey Day.

5.      Record Store Day.

A blog post by Jackie

The United States healthcare system spends an estimate of $32 billion annually on the treatment of Non-alcoholic fatty liver disease (NAFLD). Despite these huge figures, not every person suffering from NAFLD is able to receive treatment due to the high medical cost as the state covers just a fraction of it. Although people take health coverage to pay for medical costs, a survey conducted in 2017 showed that 11.3% of adult Americans had no medical coverage and those that have, it is limited to a certain amount leading to patients of NAFLD to seek alternatives to cover the deficit. Sadly, this disease is silent with over 100,000,000 Americans living with fatty liver and are not aware of it.

Cost of Treatment for NAFLD

The annual cost of care for a NAFLD patient that has a private insurance poloicy is $7,804 and for new diagnosis is $3,789 - without treatment. Treatment cost for non-alcoholic fatty liver disease is very high according to a study presented at the International Liver Congress 2019 in Vienna. The annual cost of treating NAFLD has been approximated to range between $20,000 to $100,000 annually based on a study by a group of Israeli researchers. To meet these expenses, many have to rely on loans; however, it’s important to bear in mind that consumer debt is not the same as medical debt, as medical debt is not incurred voluntarily and does not involve credit extension.

We support health writers who wish to spread their work to a wider audience.  This article was submitted by Natalie Shae.

Note, the study cited in the article was very small with children under physician care but if you are a liver patient it is a cautionary note if you are considering CBD oil.  We are not aware of any research that would suggest using it more broadly but consult your doctor.

Liver Damage and CBD Oil

June 4, 2019 by Natalie Shae

The FDA has approved a CBD-based drug named Epidiolex®. The drug was researched and made by Greenwich Biosciences, and the company’s vice-president of U.S. professional relations, Alice Mead, has stated to the FDA that CBD is “potentially” a liver toxin. She said this during the FDA’s first public hearing on CBD oil on May 31, 2019.

What is CBD oil?

Cannabidiol oil is extracted from the hemp plant, which is in the same family as marijuana. Unlike THC in marijuana, CBD does not cause a “high” or chemical dependence. CBD that is extracted from the hemp plant is legal, but individual states have laws to regulate it.

Because CBD oil is not considered a drug, it can be a common additive in many products. This includes e-cigarettes (vape oil), lotions and various herbal supplements. It has also been shown to relieve symptoms of different disorders like epilepsy, anxiety and multiple sclerosis.