Approximately one quarter (25%) of the United States population has non-alcoholic fatty liver disease (NAFLD). Patients with this reversible condition have accumulated fat in their liver cells. Over time, this creates inflammation and if left unaddressed, will eventually lead to permanent scarring or cirrhosis of the liver. The condition is highly associated with metabolic syndrome and insulin resistance, and it is projected to become the leading cause of liver transplantation by 2030.

Our guest on this episode of the podcast is Elizabeth Boham, MD. She is trained as both a medical doctor and nutritionist, teaches with the IFM and is the Medical Director for the UltraWellness Center.

She joins James to share:

  • Which symptoms and test results are red flags for NAFLD
  • That toxins and alcohol significantly impact liver health and metabolic syndrome
  • How lifestyle and nutrition strategies will help patients with the condition
  • Resources and approaches that will help your patients with cardiometabolic disease
  • And much more!


Non-Alcoholic Fatty Liver Disease | Ep. 300



Dr. Elizabeth Boham: So, when you see that high waist-to-hip ratio, when you see a high fasting insulin, when you see a high HOMA-IR score, of course, when you see signs like the liver function tests being high, all of that is raising your flags. On physical exam, when you see things like acanthosis nigricans, which is this velvety appearance in the neck area or in the armpit area, or you’re seeing skin tags, or your patient has a polycystic ovarian syndrome or hirsutism if they’re a woman, all of these things are making you think insulin resistance. You’ve got to be paying attention to the liver as well. And then, of course, you can do ultrasound of the liver. You can do a test that looks at the pliability of the liver. That’s some of the things that we do to determine if somebody has fatty liver.

James Maskell: This broadcast is brought to you by the Evolution of Medicine’s Practice Accelerator. For more than six years, we’ve helped doctors and health professionals build their own low-overhead, high-technology practice, making it efficient and effective at bringing in patients, educating them consistently, getting the right technology stack and building a strong, sustainable practice. If you want to find out more about the Practice Accelerator, go to goevomed.com/accelerator.

James Maskell: Hello and welcome to the podcast. We are going to be talking non-acute fatty liver disease today with one of the leading educators in the space of functional medicine, insulin sensitivity. You may have seen her on Dr. Hyman’s podcast. She works at the UltraWellness Center. I think she’s the Medical Director there. She’s also an educator with the Institute for Functional Medicine. Her name is Dr. Elizabeth Boham. In this podcast, we talked about non-acute fatty liver disease, we talked about liver cirrhosis, we talked about insulin resistance generally, and we got onto both the diagnosis and the treatment. I think this is really an area, like you’ll hear that Dr. Boham says, this is an area where I think functional medicine can really lead. It’s up to all of us to step in early and treat non-acute fatty liver disease. Because as you’ll hear, the numbers are staggering.

Thanks, as ever, to our sponsors, particularly the Lifestyle Matrix Resource Center. If you go and check them out, they have resources for cardiometabolic disease, educational tools, other resources that make it easy for you to educate your whole patient population in a really structured way. So, enjoy the podcast. Check it out and enjoy. Okay, great. So, a warm welcome to the podcast, Dr. Elizabeth Boham. Welcome, doctor.

Dr. Elizabeth Boham: Thank you, James. Thanks so much for having me. It’s great to be with you all.

James Maskell: It’s great to have you here for the first time, actually, on the Evolution of Medicine. So, I’m grateful to have you here. We’re going to talk today a little bit about insulin, we’re going to talk about metabolic syndrome, and we’re going to talk about non-acute fatty liver disease. I’d love to just, I guess, start with how you ended up being in the mix to being a leading educator in this space. I’ve seen you educate on The Doctor’s Farmacy working with Dr. Hyman, obviously. What was your journey to being on the cutting edge of this area?

Dr. Elizabeth Boham: My undergraduate and graduate degree was in nutrition, and so I always loved using food as medicine. And I remember I went through AFMCP in 2004, and it blew my mind in terms of functional medicine and how it helped me make sense of my medical school training and helped me bring in all my nutrition background, and have the tools and have the map to be able to use all my nutrition background within my medical practice. So, I’m so grateful for IFM to really have all those tools and the structure for me to be able to practice the kind of medicine I want to practice. And I’ve been teaching with IFM for a while.

Fatty liver is just such a really fascinating topic that I think functional medicine is really poised to really have a huge impact on. I think that non-alcoholic fatty liver disease, NAFLD or fatty liver, the prevalence is crazy. When we start looking at the numbers, it’s just overwhelming. They’re estimating that 25% of adults worldwide have fatty liver. Some of the statistics are 10% to 46% of adults in the US or 6% to 35% worldwide. But we’re looking at a quarter of the population, which is staggering. That has just exponentially increased over the years, doubled in incidence from 2009 to 2019.

And I think functional medicine really is the way that we need to look at this. Really, I look at it that way with all the things we deal with in health and healthcare and wellness. But this is really important because there’s so many things we need to be doing from a lifestyle perspective, but also really looking deeper at how, for each individual person, there may be multiple different things going on. We need to identify for those people where we need to work to help improve their health. Is it toxins? Is it microbiome? Those are all the things we can delve into a little bit today.

James Maskell: Let’s dive into that. I’m excited to start that. I guess one of the reasons, in my estimation, why this hasn’t become a bigger thing and why conventional medicine’s not talking about it as much as you hear in functional medicine is that… I guess the first thing is that it’s not really a symptomatic issue. The symptoms are shrouded inside broader metabolic symptoms as opposed to having its own symptoms. Am I right about that?

Dr. Elizabeth Boham: Well, fatty liver is the deposition of fat into our liver cells. Over time, it’s going to cause, of course, a lot of issues because you’re going to be damaging the liver and the function of the liver, which is going to really damage everything from our ability to detoxify to digest our foods. But a lot of times, that takes a long process for somebody to get from having fatty liver to more progressed damage in the liver where you’re starting to see more signs and symptoms. Many times, of course, when we wait until somebody is either in NASH or… So, let’s just back up for a second. So, you’ve got fatty liver, which is steatosis, which is very reversible. And then you have fatty liver with inflammation, which is NASH, which is also reversible. It can progress for some people into cirrhosis, which is where there’s scarring in the liver cells, which is not reversible.

Non-alcoholic fatty liver disease is estimated to be the leading cause of people needing liver transplant by the year 2030. In the US, it used to be that 5% of people needing liver transplant had non-alcoholic fatty liver disease. They’re estimating that that’s going to be… Or now, it’s actually 25% of the liver transplants are because of that. As I said, they’re estimating that one of the major causes or going to be the number one cause of liver transplant is going to be because of this, which is crazy.

Why are we not paying attention? I think I don’t know the answer to that. So often in Western medicine, we are waiting until the shoe drops. We are waiting until somebody’s really sick and then saying, “Oh no. What do we do now? Let’s transplant the liver.” As opposed to saying, “Okay, let’s try to find this early so we can prevent it or reverse it,” which we know we can do, which is phenomenal. Both fatty liver and NASH is truly reversible. We need to be paying attention to it, we need to be acting, and really getting involved early so we can prevent this from becoming a real big issue for people and our children. Other statistics that just throw me is that about a third of boys and a quarter of girls who are obese have signs of fatty liver already. So, you can just imagine how that’s going to progress, how that’s going to impact their overall health. When are they going to need a liver transplant, right?

James Maskell: I know for a number of doctors who have gone through the Institute for Functional Medicine’s training, Michael Stone’s session where he does the reinvigorating the physical exam, and I’ve seen, I guess, x-rays of non-fatty liver disease and what that looks like. What would you say from a diagnostic point of view? What do you rely on in what order to help you determine whether it’s happening or not?

Dr. Elizabeth Boham: You’re looking at, of course, the liver function tests, the AST and the ALT. So, if they’re starting to be elevated, you’re thinking, okay, could this be because of non-alcoholic fatty liver disease? There are some scores, there are some algorithms where you can put in—many people have used these, the liver function tests as well as some other biomarkers—and get a sense of, does this person have fatty liver? Of course, we are paying attention to signs of metabolic syndrome because that is such a major cause of non-alcoholic fatty liver disease.

So, when our patients have insulin resistance, metabolic syndrome, you’ve got to be thinking that they could potentially really have some fat deposition in their liver. Because really, when somebody has insulin resistance, that’s one of the things that happens, is the body is putting more fat into the liver, and that is really a major cause of fatty liver disease.

So, when you see that high waist-to-hip ratio, when you see a high fasting insulin, when you see a high HOMA-IR score, of course, when you see signs like the liver function tests being high, all of that is raising your flags. On physical exam, when you see things like acanthosis nigricans, which is this velvety appearance in the neck area or in the armpit area, or you’re seeing skin tags, or your patient has a polycystic ovarian syndrome or hirsutism if they’re a woman, all of these things are making you think insulin resistance. You’ve got to be paying attention to the liver as well. And then, of course, you can do ultrasound of the liver. You can do a test that looks at the pliability of the liver. That’s some of the things that we do to determine if somebody has fatty liver.

But when you look at those statistics, you got to be thinking about it for so many people. When we’re talking about a quarter of the adult population, we’ve got to be paying attention to so many people’s liver. As I said, from a functional medicine perspective, I think this is really important to recognize everything. The research in this area is going in this way. It’s a multi-hit model. There’s many things that are coming into play. There are many things that can be out of balance that are influencing whether this progresses with one of our patients or not. We just want it to be on our radar because it has such a huge impact on quality of life. You don’t want to wait until somebody’s really in detriment and their liver’s not functioning for you to intervene. Because as we know, it’s so much easier to intervene when it’s early.

James Maskell: That’s so true. How do you get people excited to want to participate in intervening with you? So, you’ve identified that there might be an issue. Most people, and especially men, will wait until the very last moment to do something about it, hence why it turns into cirrhosis of the liver. So, when you’re working with patients, how do you get patients to cross that gap of doing, participating, first and foremost, and participating in a way that can create health when they don’t have maybe acute issues connected with it?

Dr. Elizabeth Boham: I think a lot of people don’t understand how concerning metabolic syndrome is and insulin resistance. I don’t think they really appreciate how much damage it can cause to their health in so many ways, with non-alcoholic fatty liver disease being just one area. I think we have to do really good interviewing so we know where our patients are coming from, what matters to them, and what we help them understand to get them motivated to want to make some changes.

With the whole insulin resistance, metabolic syndrome, for some people, they get motivated because of weight. For some people, it may be because of erectile dysfunction. For somebody else, it may be because of fatigue. Sometimes, people aren’t as worried about the liver as we are as clinicians, but you try to talk to them about how important the liver is. We’re seeing signs of this fatty liver and this is very reversible at this stage. If we can figure out what’s going on here, then that can just help you improve your health all over. Decreasing risk of heart disease and stroke and cancer, because it’s all interrelated, isn’t it?

James Maskell: Absolutely. What are some of the recommendations that you’ll make early to patients? Because obviously, it’s non-alcoholic fatty liver disease, but obviously, alcohol is playing a role in fatty liver as well. But then there’s a dietary pattern. So, what are some of the things that you recommend early on to patients and how do you get them started?

Dr. Elizabeth Boham: That’s a great point about the alcohol. There’s been conversation about changing the name of NAFLD to metabolic-associated fatty liver, I think. They’re thinking of changing the name so we don’t make it sound like alcohol is not important to pay attention to. But they came up with NAFLD to distinguish it from fatty liver that was caused mostly by alcohol. But you’re absolutely right, alcohol and other toxins have a huge impact on whether somebody progresses, if their fatty liver progresses, and how advanced it becomes. So, we do have to pay attention to dealing with alcohol and getting an understanding of what our patients are consuming.

But in addition, when I’m looking at the matrix, some of the areas I really focus on is toxin exposure. Because we know that toxins involving… They’ve done research on everything from pesticides to PFAS, those forever chemicals, to air pollutants to air pollution. All of these things have been associated with increased risk of non-alcoholic fatty liver disease. So, I’m thinking about, what is somebody’s toxic load and how is their body detoxifying? We know that patients with a lower glutathione level have a higher risk for non-alcoholic fatty liver disease and the progression of it. So I’m paying attention to, what is their glutathione levels? What is their markers of oxidative stress?

And then I’m thinking about the microbiome because we do know there is a definite association between dysbiosis and fatty liver disease. We’ve known for years about the association with dysbiosis and high levels of lipopolysaccharides that come from these gram-negative bacteria, certain lipopolysaccharides, triggering insulin resistance in metabolic syndrome. We know that this dysbiosis and high lipopolysaccharide levels have been associated with non-alcoholic fatty liver disease.

There is that gut-liver axis, that communication between the liver and the gut that is always communicating. When there is increased intestinal permeability, when there’s leaky gut, it’s more likely that these endotoxins, the lipopolysaccharides, other toxins from the gut can get into the body, can influence the liver, and increase risk of fatty liver disease. So, we know that there’s this association and a lot of research is going into the connection between our microbiome and risk for non-alcoholic fatty liver disease. So I’m thinking about, okay, we’ve got the bio transformation detoxification node, we’re thinking about dysbiosis, we’re thinking about the assimilation and defense and repair nodes.

And then, of course, I’m really paying attention to signs of insulin resistance. Does this person have sleep apnea that’s causing their insulin resistance? What is their diet like? Are they eating this SAD, crappy diet? Are they not moving? Do they have sarcopenia and that’s causing their insulin resistance? It’s important, as we always are doing with functional medicine, is we’re trying to figure out for that individual patient where they need to focus so we can get the best bang for our buck. For somebody, it might be their diet. They’re eating a lot of refined and ultra-processed foods. For somebody else, it may be a toxin exposure that’s complicating this.

We know that 43% of people with non-alcoholic fatty liver disease in the US are not obese. We do know that obesity is a definite risk factor, but there’s lots of other things at play, given somebody’s genetics and their toxin exposure and their microbiome. It’s really kind of this really interesting area where, by gathering that good history, we can really get a sense of where we need to focus with that individual patient.

James Maskell: I’m so glad you mentioned that. Because in the last year, I’ve had a chance to spend some time in the lifestyle medicine community. It’s been really interesting because obviously, if you take a step back and say, “Look, here’s a disease that is being caused generally by what we eat.” You can see, okay, fructose has gone way up and people having are too much fructose, and therefore, it’s this thing. The simple answer would be, well, let’s just get them having less fructose. In a certain percentage of the population, if you change the diet and you move away from sugar and you move into more healthy food choices, you would see improvement in non-fatty liver disease.

But what you just shared and thinking about the matrix and the nodes of the matrix, that’s why I believe that functional medicine will be the operating system for the future of care because there will be people who, if you take them and change their diet alone, that won’t improve. That’s because are these underlying other factors that are affecting the insulin sensitivity. You mentioned a couple of them, but I’m sure there’s all kinds of feedback loops that are happening in everyone’s body that might lead it to. I really appreciate you sharing that because I just feel like it’s another reinforcement to me that while lifestyle medicine is really this zero to one that is needed, and it’s really exciting to see how many organizations and systems and health systems are getting on board with lifestyle medicine because it’s so hard to argue with. There is this other layer that is necessary if we want to really get to the root cause of what’s going on in the physiology of these numbers of individuals.

Dr. Elizabeth Boham: I think that for some people, it’s not going to be enough to just do lifestyle. I think sometimes some docs will say, “Well, it’s not just lifestyle because I’m seeing these cases of people that it’s not lifestyle.” So, it’s both. It’s all of it. That’s where I think functional medicine shines is because we are really working on that personalized care and looking for that individual person, where do we need to focus? Though everybody could work to remove high-fructose corn syrup and lower fructose in their diet and get rid of the ultra-processed foods, and get more vegetables and phytonutrients to help support their detoxification system and balance their blood sugar and get better sleep and all that stuff.

There’s other things going on. We’re seeing this explosion. This is not just lifestyle. We’ve got to be paying attention to the toxins we’re putting into our environment and how is that impacting things. We’ve got to be paying attention to the shifts in the microbiomes in us that have been going on because of this explosion of antibiotic use 50 years ago or over the last 70 years. We’ve got to be paying attention to that because that has really shifted us, and it is really part of this whole equation here.

James Maskell: Absolutely. I guess what are some other things that you’ve learned? You’ve gone through so much of training, you’ve been at this for a decade or more, you’ve been educating providers around the world. As you’ve got more sophisticated and honed your craft, what’s some advice that you would give to clinicians who are just getting started where this level of complexity is a little overwhelming? And that they’re looking to really help their patients, but maybe they have patients that just aren’t getting better with the first level interventions that they’re using. What else would you recommend as far as… What other clinical pearls have you developed in treating insulin resistance, non-acute fatty liver disease, that will help clinicians get better outcomes?

Dr. Elizabeth Boham: That’s an interesting way to look at it. I always start with food first. We have nutritionists on our team. My background’s in nutrition, but all of our patients see a nutritionist. We also have health coaches on our team, and really trying to work on that lifestyle piece, the motivational piece, the group piece, to help people do those baseline things, those personalized lifestyle factors, which are so important.

And then there are those really tricky patients where you’re like, “Oh my goodness. They’re doing everything right. Why is their body not responding?” I think one of the first things that I look at, and in this area I think is really important, is the microbiome. I do test for leaky gut all the time. I know not all practitioners do. For a lot of times, there’s a cost perspective. But I do look for signs of increased intestinal permeability. On the test that I use, it looks at antibodies against lipopolysaccharides, which is, as we were talking about earlier, one of the things that can trigger the metabolic syndrome and the insulin resistance in our patients. I’ve definitely had multiple patients where they’re doing everything right with lifestyle. Why aren’t they getting better? I’ll see this high level of increased intestinal permeability or I’ll see high levels of these antibodies against lipopolysaccharides. That signals to me is I’ve really got to do more in terms of treating the dysbiosis. I’ve got to be more aggressive in the 5R program.

Sometimes, I find that it’s helpful for me. Sometimes, testing can help me because not everybody can take 20 supplements. We don’t want everybody to take 20 supplements. We need to figure out sometimes where they really need to focus. So, getting signs of dysbiosis, whether it’s a stool test or an organic acid testing or, as I said, high antibodies against lipopolysaccharides on intestinal permeability testing, then says to me, “Liz, be more aggressive in terms of your 5R program.” I might then really work to do some herbs or even pharmaceuticals that get rid of the dysbiosis, really work to replace some of the good bacteria using certain probiotics.

A lot of this is experimental, but it does help people. So, we are using some of the probiotics that have been shown to help with blood sugar support. You’re using a lot of prebiotics, so really focusing on getting more of the phytonutrients in the diet. Or even prebiotic fibers and the things that… The anthocyanins in pomegranate helps with feeding the Akkermansia, which lowers inflammation in the gut, and may be helpful in terms of blood sugar balance, maybe. But those are things that we’ll try to increase those phytonutrients. And of course, increasing fiber and that kind of things. Sometimes, I’ll give butyrate just to help with healing the gut lining and other things that help with healing the gut lining. Glutamine, zinc, vitamin A. I might be more aggressive with that 5R program when I see that.

And then the other area, I think, when people aren’t getting better or they’re sicker than you would think based on their lifestyle, that’s when you see signs of issues with toxins, I find. Listen, I had cancer when I was 30, 23 years ago, so I really pay a lot of attention to toxins. But definitely, when you see people who get cancer young or they have diseases where you would be like, “Why are they so sick? They’re doing all this good stuff with lifestyle.” Then I’m paying attention to toxins. What are their genetic SNPs that impact how they make glutathione? What are their toxin levels? What are their markers of oxidative stress and glutathione levels?

And then we’ll really sometimes work harder in that area to both avoid toxins, to lower that toxic load, as well as support their body’s detoxification capacity by more polyphenols, more phytonutrients. Maybe add in some NAC, sulforaphane, which I love, just to help the body make more glutathione. Sometimes, I give glutathione. I love giving glutathione also. But those are areas where I’ll really be more aggressive and try to test for toxins. I wish I had better testing for toxins. But try to test for toxins and if I see signs of them, work to lower them in a healthy, supportive way. James, I can’t hear you for some reason.

James Maskell: Sorry. I think that’s really comprehensive and valuable. Thank you for sharing your insights. I think, as you said at the beginning, I really feel like this is an area where the functional medicine community can lead. I think that it’s just so obvious that it’s a huge problem, if you look at those numbers that you’ve shared throughout the podcast. And ultimately, without lifestyle medicine, you really can’t do anything about it. And then without functional medicine, you’re going to miss the ability to help the person in front of you if they have these other causative factors. So, that web of the symptoms, the web of understanding, the systems biology approach, super critical. I’m really grateful for you to be part of the Evolution of Medicine podcast. I know I’ve been wanting to have you on here for a while, so thank you so much for sharing. If people want to find out more about your work, where can they follow?

Dr. Elizabeth Boham: I’m at the UltraWellness Center, so we’re ultrawellnesscenter.com. I’m Elizabeth Boham MD on Instagram and Facebook, and Dr. Boham at Twitter.

James Maskell: Well, thank you so much for being part of it. If you enjoyed this episode, please share it with conventional medicine colleagues. This is really why we create all of this content. The whole point of the Evolution of Medicine at the beginning was to make it really easy to… I used to use this word more obviously because it was a Jeff Bland favorite, but to infect, right, the rest of medicine with the bug of functional medicine. Because ultimately, we need to slowly… Actually, we need to much faster teach the medical establishment on what is driving some of today’s biggest issues and what is the way back. I think what you’ve shared today is a really reasonable way back.

I see green shoots of progress with regard to health systems getting on board with lifestyle medicine. But I think what you’ve shared here today is some of the other areas in which you really need this systems biology and functional medicine framework to help everyone that comes through your door. So, thank you so much for being part of the podcast. I’m your host, James Maskell. Thanks so much for tuning in. We’ll see you next time.

Thanks for listening to the evolution of medicine podcast. Please share this with colleagues who need to hear it. Thanks so much to our sponsors, the Lifestyle Matrix Resource Center. This podcast is really possible because of them. Please visit goevomed.com/lmrc to find out more about their clinical tools like the group visit toolkit. That’s goevomed.com/lmrc. Thanks so much for listening and we’ll see you next time.

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