Liver Health With Dr Kieron Lim

Interviewer: Hi everyone! Welcome to the second in our series of doctors for good health. As many of you know, Dr Lim works out of Parkway Hospitals in Singapore. For all liver related queries, he's the person to talk to.

We have more than 1,000 people watching us right now and the numbers are increasing. I want to start by asking what we should know about the liver. We know that the kidney functions as a filtration unit, but what important functions of the liver are we likely unaware of?

Dr Lim: The liver is like a workhorse and a factory that goes on 24 hours. It's got multiple roles, for example, it's like a quality control centre. It is a filter and manufactures many important cells and molecules. I'll give you a few examples.

Firstly, it makes important proteins and a very important protein, which I'm sure everyone has heard of - albumin. Albumin has many roles, including helping with our immunity by binding certain molecules and producing antibodies. Again, it's all tied in with immunity.

The liver also produces clotting factors, which help maintain the proper viscosity of our blood. It also has an important role in detoxifying certain toxins which many people are aware of. This can be in the form of medications, in terms of natural toxins. A classic example is alcohol.

So, medications that are freely available over the counter, such as paracetamol, all need to be broken down by the liver. When taken in certain levels or if the liver is not functioning properly, these generally harmless substances can build up to toxic levels, significantly impacting health.

Interviewer: Wow that's a lot of work for the liver, isn't it?

Dr Lim: Yes, it is. One more point is that the liver, even though it's a very hardworking organ, it's also a very forgiving organ and has the capacity to repair itself and regenerate. Most people know about this in a certain way because they heard about living donation transplants.

When a liver is healthy, for instance if you hit it a few times or in the extreme form or if you remove a part of the liver (30 percent of a healthy liver), it can regenerate and grow back to normal size and maintain normal liver function. We see this in all our donors who donate part of their livers to their parents, spouse, their loved ones. Two months later, a scan shows that the liver has returned to its normal size

Interviewer: That's really good to know and it's really nice to think of the liver as someone who's like hardworking and forgiving, but that doesn't mean that we should be really abusing our livers, which really brings me to my second question: why do you think that liver diseases are on the rise? Is it because of our lifestyles or because of better medical intervention at an early stage? Which one do you think it is?

Dr Lim: I think you're right on both counts. There’s certainly greater awareness as information and the internet age makes information so freely available. With countries developing, people are more aware and more interested in their health. The shift I’ve seen in the last 20 or 30 years is that people are now more focused on prevention rather than waiting for something bad to happen.

Information is out there and people are more interested to find out more about how to stay healthy, not just what to do when they fall sick. At the same time, more information and more interest is that certain liver diseases are a global phenomenon, not just in Asia, India or Singapore. Conditions such as fatty liver disease is the fastest rising liver condition, unlike viral hepatitis, hepatitis B and C because antiviral medications can suppress and cure hepatitis C in a short time.

However, certain conditions like fatty liver run a parallel course with a lot of metabolic and lifestyle factors. As people now do not suffer from malnutrition, they suffer from overnutrition now instead. There's an increase in diabetes, hypertension and high cholesterol. The incidence of fatty liver is going up which is a global trend.

I've been seeing like many children as young as eight and nine being detected with fatty liver. This really freaks out their parents. They worry that it might lead to diabetes in the future and are unsure if it will affect their child’s lifespan.

Interviewer: Why do you think that fatty liver is on the rise with kids as little as eight to 10? What can parents do to prevent that? What should parents of children with fatty liver be aware of because most of them get detected with fatty liver of grade one or two. What is it that they should really know?

Dr Lim: That's a very good question. Number one, don't panic because at an early stage, if you say stage one or early disease, it's reversible. The things we need to do to reverse it actually sounds easier than it is. It involves maintaining a healthy lifestyle, good diet, adhering to dietary advice and regular exercise. In general, if you talk to a cardiologist or a renal physician, most of them will say the same thing. Having a healthy, sustainable lifestyle and diet together with regular monitoring is the cornerstone to good health and to prevention, preventive health.

For parents whose children have been found to have fatty liver, there are two main factors to consider - the number of calories consumed and the type of food that we eat, as well as sedentary lifestyle and lack of physical activity.

Simple measures need to start at home such as getting fresh air and walking more. However, these activities need to be done with a bit of caution at times of a global pandemic. Taking the stairs instead of the escalator or the lift is a simple habit to cultivate. I try to do that in the hospital, mainly because I'm too impatient to wait for the lifts. I always take the stairs, the lift at peak hours drives me crazy because it takes too long.

Global statistics show that fatty liver incidence is also on the rise in teenagers. This is seen both in developed countries as well as developing countries. It's a global phenomenon.

Interviewer: Yeah, do you see it on a bigger rise in the developing countries like India and Brazil and China, or do you think it’s more like a global trend?

Dr Lim: I think it’s more like a global trend. There are some publications from China which show that it's happening in the young. I've not seen any recent ones, but I'm sure they exist. I've just not come across it. I will not be surprised if it’s a global phenomenon.

Interviewer: When we're talking about the younger population, do you think exercise and activity is a must for them? Should parents or adults who have fatty liver ensure that they're able to spare time and make time for exercise at least an hour a day? Should parents prioritise sports and activity over homework for over homework for children and how do you think the lockdown is going to affect liver health in the long term, considering we are moving much less than we used to?

Dr Lim: Firstly, your first question about activity and exercise is a resounding yes, 101%. This has been borne out in many studies. Just to stay on the topic of fatty liver, it's been shown that if someone with fatty liver which some of you may know, is a spectrum you go from simple steatosis, which is just accumulation of the liver to steatohepatitis, meaning that's inflammation of the liver cells.

Overtime, that may result in scar tissue forming called fibrosis, liver fibrosis then leads to cirrhosis. Losing 5% body weight takes away and normalises the amount of inflammation and fat. If you lose 10% of your body weight, the improvement is even better and some of the scarring can resolve.

Losing 10% is not easy. It's not losing it; it's maintaining it as well. And the last session that we had together, we said sustainability is key. So that is a resounding yes for, for physical activity, regular exercise.

Interviewer: No doubt about it. Scientific studies prove it as well. What I loved about our last session together was that you emphasised sustainability and were completely on board with the idea that diets need to be sustainable. Do you think that extreme diets can mess up with your liver enzymes, and would you like to caution about that?

Dr Lim: Yes, absolutely. This is shown in scientific papers and in clinical practice. People who go on these rather extreme crash diets, of which there are many, may find them fashionable but they may not be sustainable for more than a very long time. In a hospital setting, we see people who have suddenly become very ill and need artificial feeding. We actually see rises in the liver enzymes. They can develop steatosis of fatty liver very quickly, paradoxically, so anything done in moderation and that is sustainable cannot be bad, and that's the way to go.

Anything that's sort of extreme at both ends of the spectrum. One, not sustainable. Two, it may have a rebound, a paradoxical effect on the things that we're trying to actually treat and improve. So, I'm totally on board with you that it's got to be sustainable, and baby steps.

Interviewer: Yes, we need to remember that because for most people, no one's interested in losing 10% of body weight. They want to just lose all of that body weight, but yes, you're right. It's baby steps right, it's not about being fit for the new year.

It's also about staying fit even when it's 2031. Do you see one gender being affected more than the other as far as liver malfunction goes? Are more women prone to it as compared to men or is it the other way around?

Dr Lim: I think it's the other way around, unfortunately. Men have the shorter end of the stick in more ways than one. But when it comes to liver disease and liver health, men have high incidence of liver cancer, liver cirrhosis, liver related death. So, it comes down to the fact that I guess women know how to look after themselves. But there are certain conditions where the gender difference is reversed and belly liver is one of them because studies have shown us that there is perhaps a hormonal influence on fatty liver as well. For instance, when it comes to alcohol, if a man and a woman drink the same amount over a long period of time, the woman is at higher risk of developing more severe liver disease.

So, while more men drink compared to women, women are actually at increased risk if they drink the same amount for the same duration of time. So that's the sort of subtle difference. But if you look at the big picture, the statistics for the men, they are terrible.

Interviewer: This is really interesting to know that maybe women are more prone to fatty liver as compared to men, at least at the same quantity of alcohol. But when it comes to more complications, men seem to be much more vulnerable to them as compared to women. For a normal person, does liver disease cause any kind of symptoms? Is there something that people should be watching out for on a day-to-day basis? How will one know that their liver is not functioning optimally?

Dr Lim: In early disease and sometimes even in some advanced cases, the patient feels absolutely fine. I've seen patients in my daily practice who feel fine even though they have liver cirrhosis, liver cancer and normal liver function tests.

They're still working, they're functioning, firing on all cylinders and it's because of a certain tumour marker or friend that says “Hey, you better get it, get yourself checked up. You're, you're hitting 50 soon” and they go for all these screening tests and then they find something.

On the other hand, symptoms are quite common in patients who have advanced liver disease. If you have early disease, it's more likely that you feel fine. The more advanced the liver disease, the more likely he or she will feel unwell. This brings back your very first question about what are the roles of the liver, the functions of the liver.

Imagine those are the things that the liver does in health. If the liver is sick, it will not produce enough albumin and therefore all the immunity, the clotting factors and detoxification processes will decrease. Patients with decompensated liver disease are more prone to infection. They have low albumin, therefore get fluid retention, puffy feet, swollen ankles and fluid accumulating in the abdomen. They also have clotting issues, leading to bleeding. The skin can bruise very easily, and simple medications, which we often take for granted like paracetamol, can be problematic.

They can take normal levels of paracetamol, but they may not be able to metabolise it at what a healthy liver can do. Therefore, some levels can become a dangerous or toxic range. These can happen in somebody with an unhealthy liver.

Interviewer: Wow, in our session together the last time, you also spoke about lean NASH which I thought was really interesting because most times we worry about overall metabolic health only when we are obese or when we are at a high BMI. But like the way we were discussing last time, you said that even thin people could have a liver issue too so what's lean NASH and what can one do about it?

Dr Lim: Fatty liver NASH spectrum is normally associated with metabolic syndromes. People who are generally overweight or obese, have high cholesterol, and central obesity or adiposity, are the typical phenotype or characteristic of patients with fatty liver. It’s closely linked with metabolic syndrome. There's a movement now to rename NAFLD (non-alcoholic fatty liver disease) because there's a stigma with the word alcohol in it.

Methyl, MAFLD, and that is Metabolic Associated Fatty Liver Disease. Many people regard fatty liver as the sixth hallmark of metabolic syndrome. So that's the classical clinical characteristics of somebody with fatty liver.

But now, with more studies and so much interest worldwide in fatty liver, we actually see that even people with a normal BMI can get a fatty liver. This threw the whole thing into a bit of a disarray to say how thin people can have fatty liver. Fatty liver is actually much more complicated than what we initially thought, and there are so many things that interplay. There are certainly genetic factors, environmental dietary factors, and medications that can cause it.

As we learn more, more research is coming through, revealing many factors that can affect this, not just being overweight and having high cholesterol. The challenge is, how can you tell somebody with a BMI of 20 to lose 10% of their body weight? So, that's the theory. The issue is you still encourage them to be active because going for a brisk walk, a job, a run, a swim, lifting some weights, all that strength training, when muscles are active and contracting, they need energy and they will burn fat.

This fat can come from subcutaneous fat under your skin as well as the visceral fat in organs like the liver. While the targets may not be the same, having enough physical activity and exercises that burn will certainly help patients who have a normal BMI with a fatty liver.

Interviewer: Before I start taking questions from the ground, I want to ask what are your plans for Christmas and how do you plan to unwind because I know that day in and day out you're dealing with people's liver, liver health and liver is something, I guess, when someone's affected bit, poor liver function it takes a toll not just on the person who's affected, but also on their families, so what would you like to say about that? Have you seen families suffer because of one of their loved ones having poor health with that liver?

Dr Lim: For the first part is yes and some of the patients in cases that I see are truly heartbreaking. I've seen young patients and when I say young, I'm talking about the 40s, 50s because nowadays people live to their 90s. People in their 40s and 50s with advanced liver disease, advanced cancer, have young children in primary school, are waiting to start a family, or just got married need a transplant and sometimes there is no transplant or the transplant cannot occur in time. I followed some of them through to the end and it is heartbreaking. It’s difficult to not get too attached. After a while we treat patients like our own family.

If we tend to often make the right choices, it's difficult, especially when we see modern medicine not being able to save that. Hopefully with more public education and knowledge, people will come forward. Earlier on when medicine and technology could still make a difference, if someone presents with a very advanced disease, being jaundiced, in a coma, there's a 10-centimetre tumour in the liver, unfortunately, even the best medicines that we have will not be able to extend life.

And at that point, it's really about quality time with the family and I think the objectives of care will change depending on the status. So yeah, I mean the end of the year is a time for being with family and having a good time. But there are patients out there who will not be able to do that so we still have to come to work at Christmas and New Year's Eve to look after them.

Interviewer: That is a solid commitment you have there. Is it ok if I ask a couple of questions?

Dr Lim: Yes, of course.

Interviewer: What's the relationship between high triglycerides and liver health? If I have high triglycerides, am I likely to have liver disease in the future?

Dr Lim: In general, high cholesterol, whether it's LDL or triglycerides, will put you at a higher risk of developing fatty liver. Usually, when people have their health screening done and if they have high triglycerides or high LDL, the doctor who ordered those tests would have also ordered a liver function test for you. Especially if your liver enzymes are also a little bit elevated, I would suggest that you, or if it's not already done, get a simple ultrasound of the liver. That will give us some clues as to whether there's truly fatty liver or any other findings that may need to be acted upon more urgently.

Interviewer: All right. Since you also mentioned that the liver plays a role in immunity and in building antibodies, how do you think the whole coronavirus situation is going to affect our liver? What's the relationship between a new virus and our liver? Can it just make antibodies on its own? How does that work?

Dr Lim: So again, very topical question. There's been a few publications on that. I did one paper together with some of my colleagues in Singapore mainly to see how the COVID 19 virus affects patients with liver disease. From the data that's available from the U.S, Europe and in Asia, we do actually see a rise in the liver enzymes in patients with COVID 19. However, we think that's not a direct effect. For example, in dengue fever, which is very common in Asia, we also see a rise in liver function, but that's transient and it comes down.

The other reason we think there's a blip in the liver test is because of some of the medications that doctors and hospitals around the world have been using in the more severe cases. Those have also been known to cause a rise in liver tests. Whether or not you can bounce back from COVID infection if you contracted it based on your liver health, I don't think there's a direct correlation. But certainly, the more medical problems you have, including diabetes, heart disease, chronic illness, and liver cirrhosis, the chances are you will have a more serious cost of COVID 19 than somebody say a fit 21-year-old with no medical disease.

So, I think that is the indirect link with liver health, immunity, and overall response to how well we can fight a viral infection like COVID. But I don't think that it means that if you have a healthy liver, you'll be unscathed. I don't think anybody is protected from COVID until we all beat it together the whole world over because we're so closely connected now. The world is so small.

Interviewer: Absolutely. Yes, that's true. Well, there's one more question for you. How does one cleanse one's liver? Is there anything like that? Can you clean up your own liver?

Dr Lim: Good question again, I've been asked this many times. If you do an internet search, no matter where in the world you are, you will find many many hits on a magic potion, a special program that can make you pure and wholesome again like a newborn, a perfect liver. We need to have a little bit of discernment about these matters.

To be honest, if you think that all these things were the answer and the cure, then after whatever magic potion, nobody will have any form of liver disease anymore because you'll detoxify everything. You'll cleanse the liver from every single virus, every single toxin. Clearly that's not the case. We still have a world with people with liver cirrhosis, liver cancer.

Be cautious about things which may have been recommended or you read on the internet. I've seen patients myself, in Singapore and when I was working in the U.S and London, who have been promised this wonderful outcome, this magic potion may come in the form of a pill, solution, and natural juice. In the end, two weeks later, four weeks later, or two months later, the patients in ICU in liver failure.

When we do the testing to have all those samples analysed, sometimes it's actually a concoction of all kinds of Western medications. That actually tipped the patient into liver failure as opposed to doing what it was supposed to do.

The safest way is again, baby steps, something sustainable, something simple. Avoid harming the liver by abusing it with too much alcohol, too much unnecessary medication. Nowadays one of the things I try to do actively in my practice is to actually ask patients what they're actually consuming in terms of Western medication, prescription medications, over the counter supplements. I ask them what they use these for. Half the time they tell me my friend recommended it, they're unsure why they're taking it.

Medications that need to be there need to be taken. Everything else we need to ask ourselves “is this going to be beneficial or is it potentially harmful?”. While we look for this wonderful magic bullet that will detoxify and cleanse us and make our livers totally healthy again, the main thing is to have a very rational and common-sense approach to staying healthy.

Interviewer: You mentioned that there is no magic cure out there to really cleanse your level, that it is baby steps and sustainable and simple things that you do on a daily basis, which will really keep your liver and your body in a good shape. I mean that was really wonderful. I’ve one last question. I do know that you see a lot of patients from India. Is there something that you need to, or would say we need to change in the way we are living our lives so that we have lesser incidences of liver diseases? Is there anything that you have seen which could be specific or more common in Indian culture which needs to be addressed as far as overall health and liver health goes?

Dr Lim: There are quite a lot of parallels with the sort of metabolic makeup of people in your country and people in my country. As people get very busy, they tend to not pay so much attention to setting aside time to exercise or have a healthy home cooked meal.

Even in COVID and on lockdown, they are Skyping their company and colleagues around the world with the time difference. They're having suppers at midnight, going to bed at 3am. They said they're too scared to go to the gym or to the park. We can always have a lot of reasons not to do things, we just need to have a sort of protocol or habit and try and sustain that. Certainly, in Singapore, we have a very high incidence of diabetes. It's one of the highest in the world and the highest also a very high incidence of chronic kidney disease, this parallels things like fatty liver.

Similarly, the drive for being very busy at work, caring for our kids, multitasking all day long, and putting aside or relegating all these other factors into the background, including “I have no time to eat, I'll just skip it and I'll make up for it at dinner and supper”, I think it's similar and I try and connect with my patients to say that I know it's difficult but we need to try and squeeze out that little bit of time and effort. When we start doing it, we see the benefit both in the labs in the, on the paper in front of us, as well as how we feel every day.

One of my mentors when I was a fellow in the U.S, I took my hat off to him. He works 13 hours a day and he still has time to exercise. It’s like how do you find the time? He says “I read the papers and I have my coffee, I'm on my treadmill or my stationary bike at home at 5am. I read the news, I'm watching CNN, and I'm actually burning some calories at the same time”. If someone who's so busy can find an additional half an hour, all of us should be able to at least try. I don't think that the populations are actually very different in both our countries and there's a lot of overlap. Certainly, liver disease is an issue with both our countries.

Interviewer: Thank you very much, it was a wonderful session Dr Lim and you really simplified a lot of concepts for us. I do hope that people put it to good use, take your advice on taking baby steps and building a more sustainable lifestyle for themselves.