Heal Their Liver, Fix Their Inflammation?
INTERNAL HEALTH
Bryan Walsh
Chronic pain and inflammation are often symptoms with a broad range of etiologies and sequelae. Today’s pain management clinician must consider every possible cause of a patient’s pain because it is paramount in reducing and eliminating the problem in a healthy way. Furthermore, discovering and addressing the underlying cause of pain and inflammation is critically important when hying to minimize or eliminate a pharmaceutical approach.
Anti-inflammatory compounds, whether they are natural or pharmaceutical, rarely address the source of inflammation. Unfortunately, many pain relieving physical modalities can fall short of addressing deeper and often more serious causative elements. When positive treatment outcomes are not long lasting or they need to continue indefinitely in order to maintain an improvement in symptoms, one can rest assured they are not likely getting to the root cause. Pain management practitioners must broaden their view of potential contributors to pain and inflammation to properly support today’s ever-increasing complex patient population.
One largely overlooked organ as a potential contributing factor for pain and inflammation is the liver, including the most common form of liver inflammation known as steatosis, or fatty liver. This condition may also be referred to as nonalcoholic fatty liver disease (NAFLD).
Prevalence and Challenges of Diagnosis
Accurate statistics of fatty liver are difficult to ascertain. First, there are numerous methods to diagnose NAFLD, each with its own limitations. Serological enzymes, for example, often fail to detect fatty liver in most cases. In one study, more than 2,000 subjects, all diagnosed via ultrasound with NAFLD, had mean
AST and ALT levels of only 21.2 and 21.5, respectively. On the other end of the spectrum, liver biopsy, considered to be the gold standard of NAFLD diagnosis, only evaluates 1/50,000 of the total liver mass and can be prone to sampling error due to the “patchy” histological changes seen in NAFLD.
Another factor making NAFLD difficult to diagnose is the relatively asymptomatic nature of the condition. While some patients might complain of fatigue or diffiise right upper-quadrant pain, most individuals with NAFLD seemingly do not present with systemic complaints.
A conservative estimate for the prevalence of NAFLD is roughly 30% of the American population. The rates are slightly higher in men (42%) than in women (24%), and upward of 90% of obese individuals have NAFLD. Race also seems to play a role in the US, with the rates being highest in Hispanic Americans and lowest in African Americans.
Clinical Correlations
NAFLD is most frequently associated with obesity, insulin resistance, and diabetes, but is associated with other clinical conditions that could negatively impact patient compliance or results in clinical practice. For example, in a study using 567 subjects with NAFLD, 53% were diagnosed with subclinical depression and 45% were diagnosed with subclinical anxiety. According to research, individuals with NAFLD may also experience cognitive impairment and even loss of self-esteem.
Interestingly, it turns out that fatty liver (NAFLD) may also be associated with chronic pain, making its diagnosis potentially very important for pain management clinics or for practitioners who deal with pain management on a regular basis.
Fatty Liver and Musculoskeletal Pain
In a study published in 2007, researchers compared hepatitis C patients, a group of individuals known to have arthritis and arthralgia, to NAFLD patients to see if there was a correlation between liver disease and joint pain. Prior to this study, there was no known connection between NAFLD and musculoskeletal pain.
Researchers compared subjective questionnaires, as well as antinuclear antibody (ANA) levels, in both hepatitis C and NAFLD subjects. The findings indicated that joint pain was almost as common in the NAFLD group (65%) as it was in the hepatitis C group (67%), and reported that both groups had a similar prevalence of “low positive” ANA results.
Specific mechanisms for joint pain observed in NAFLD pa-
tients was not evaluated and, thus, leaves the possible causes up to conjecture.
One possibility for the strong connection between joint pain and NAFLD are cytokines, specifically tumor necrosis factoralpha (TNF-alpha). A number of studies have found cytokine elevations in NAFLD, such as interleukin-8, interleukin-6, and TNF-alpha, most of which improved with lifestyle changes such as diet and weight loss, except for TNF-alpha. Numerous studies have demonstrated the role of cytokines not only in the initiation of pain, but also in several transmission pathways in persistent and chronic pain.
NAFLD may also be associated with joint pain and other pain syndromes in other ways. NAFLD has been shown to increase
serum-free fatty acid levels that are known to stimulate “toll-like 4 receptors,” which can initiate nuclear factor kappa beta signaling. Subjects with steatosis also routinely demonstrate higher levels of oxidative stress markers than those without the condition. In yet another study, NAFLD was associated with elevated serum neopterin levels, indicating a possible connection with fatty liver and cell-mediated immunity.
Diagnosis
As discussed earlier, fatty liver can often be difficult to diagnose. However, when one considers that at least 30% of our population has some degree of fatty liver, and 90% of our obese population, it is likely quite a few patients go into a clinical practice with some degree of fatty liver. Fortunately, though, we have some tools at our disposal today that can help us determine who may have fatty liver and, thus, who may benefit horn nutritional support directed at improving then condition.
The fatty liver hidex is a scientifically validated calculation involving certain anthropometric measurements (BMI, waist circumference) and serum biomarkers (GGT, triglycerides) and may help predict which patients have fatty liver. According to researchers, a fatty liver index score greater than 60 predicts fatty liver, and a score of below 30 predicts a very low likelihood of fatty liver. It is beyond the scope of this article to go into the details of the calculation, but more information can be found in the references below.
Nutritional Support
Fortunately for practitioners, fatty liver
is relatively easy to support nutritionally, and improvement can be seen relatively quickly, sometimes as soon as two weeks. Here are some compounds that have strong scientific data in helping support fatty liver:
• Antioxidants: A review article, along with a number of other articles on individual compounds, suggests that antioxidants may be helpful in supporting biochemical and histological parameters in nonalcoholic steatohepatitis (NASH). Such compounds include vitamin E, silymarin, N-acetylcysteine, s-adenosylmethionine, astaxanthin, and pomegranate.
• Vitamin E: A meta-analysis determined that vitamin E not only unproved liver function, but also provided beneficial histological improvements in patients with NAFLD.
• Coenzyme Q10: One study demonstrated that 100 mg of CoQlO supplementation decreased liver aminotransferases, c-reactive protein, TNF-alpha, and the grade of NAFLD compared to the control group, also suggesting an improvement in systemic inflammation.
• Berberine: A number of studies have shown benefits of berberine supplementation on parameters of NAFLD. One study used 500 mg three times a day for 16 weeks and showed a number of improvements in subjects.
• Resveratrol: A number of studies showed benefits in preventing and improving NAFLD by supplementing with resveratrol. One study found benefits using 500 mg a day along with lifestyle modification.
• Amino Acids: Both methionine and taurine have been shown to have a restorative effect on NASH.
• L-Carnitine: One study using 2 g of 1-camitine daily, in divided doses, saw an improvement in histological manifestations of NASH, as well as lowered TNF-alpha and CRP.
• Choline: Choline deficiency is associated with increased prevalence and frequency of NAFLD in human and animal studies.
Summary
Chronic pain and inflammation can have many multifaceted etiologies. It is important not only to consider musculoskeletal, biomechanical, and other traditional causative factors, but also to think outside of the box and consider organic and physiological etiologies. As we continue to make greater strides in patient care, focusing on not only immediate relief but also long-term health, it is critical to consider all possibilities.
The research appeals to be clear as to a connection between chronic pain and inflammation and faulty liver function, known as fatty liver (NAFLD). Going the extra mile to consider these possibilities is often what makes or breaks a patient’s case.
References:
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Dr. Bryan Walsh is a nationally and internationally recognized speaker in the space of health care. He is an instructor at the Maryland University of Integrative Health and the University of Western States. Dr Walsh has a private practice in Maryland where he attends to patients from all over the world. Dr Walsh
currently serves as the director of education for Biogenetix, a leading U.S. nutritional company. To learn more about Biogenetix, visit www.biogenetix.com
From Page 23
By Bryan Walsh, DC
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