How I Treat MASLD/MASH: A Sidney Barritt, MD
Dr Barritt explains how he works with patients (MASH) to to encourage and implement lifestyle interventions that can ameliorate metabolic-associated steatotic liver disease (MASLD) and metabolic-associated steatohepatitis.
A. Sidney Barritt IV, MD, MSCR, is an associate professor and transplant hepatologist and the Director of Hepatology in the UNC liver center at the University of North Carolina in Chapel Hill, North Carolina.
TRANSCRIPT:
Hello. My name is Sid Barrett, and I'm a transplant hepatologist at the University of North Carolina. I have a clinical and research interest in metabolic dysfunction associated with steatotic liver disease or MASLD. And this is a very exciting time to be involved in MASLD, both from a research and a clinical care perspective. There are a lot of new pharmacological interventions, one that has been recently FDA approved, and several others that are likely on the way. But a cornerstone of our therapy for metabolic dysfunction associated with the steatotic liver disease, or or MASLD and MASH— metabolic associated steatohepatitis—remains lifestyle intervention. But lifestyle intervention can be challenging. And so I'd like to give some of the tips that I use in our multidisciplinary MASLD and MASH clinic to see what can help you as a GI provider.
First of all, I'd like to talk about what doesn't work. And this is a product of years of mistakes. If we focus only on the liver, that often does not resonate with patients. Though the liver is abstract, the liver is a black box to many of our patients and talking about eventual decompensation events and symptoms of cirrhosis that may not come for years if not even decades later down the road, doesn't really resonate with a lot of patients. And so unless a patient has a personal family experience with somebody with cirrhosis or end stage liver disease, talking about some of these complications may not fully resonate.
What does work is first, I start with an appeal to the gut. And what I mean by this is nutritional advice. There is so much information and frankly so much misinformation available to patients these days, they have a very difficult time parsing through what's real, what's good advice, what's bad advice. You want your patients to get their nutritional information from reliable sources rather than from influencers on social media. So I will refer any patient who will listen or any patient who will take advice to a nutritionist or a dietitian who can go through first the nuts and bolts pieces of macronutrient composition that are important for patients. How much protein do patients need? How much fat do patients need? How much carbohydrates do patients need as part of a regular diet? How to figure out what is an 1800- or 2000-calorie diet and where to practically get this in the grocery store.
I think this is very important because we have a lot of misconceptions about what's good for us. Many patients may experience through the ‘80s and early ‘90s the time where we vilified fat and everything became fat-free. And I feel like that pushed our diet to a very carbohydrate-heavy diet, which is where we see both the diabetes and the obesity epidemic really take off. We need to let patients know that fat is not necessarily a bad guy and having a little bit of fat and protein say for breakfast may keep them full throughout the day and not raiding the pantry when they get home.
I also have a lot of patients who have perhaps well-meaning but maladaptive habits when it comes to nutrition. Maybe skipping meals or milk is good for you and drinking too many liquid calories, things like that. So I think having a nutritional advice from a professional is very important. In the limited time in clinic that I have with patients, what I like to focus on are the good types of things. While not one single diet is particularly good or better for or MASLD and MASH, there are some things that make sense, like a Mediterranean diet. So, things that are cardiovascularly healthy for patients are going to be good for their liver as well, too.
Things to avoid. Again, liquid calories. Here in North Carolina, people like to drink a lot of sweet tea and a lot of sodas. These are things that patients should definitely avoid. Alcohol is important to avoid as well, too. Not just because of the toxic effects of alcohol in the liver, but we have to remember that alcohol is a calorie-dense liquid and as part of a low-calorie diet or reduced calorie diet, avoiding these calories is critically important.
One of the other things I like to do is what I call an appeal to the mind. And by this, I mean utilizing my health care colleagues in behavioral or psychological therapy. In the liver world, it's very easy for us to recognize the patient who might be abusing alcohol because they're using that alcohol to self-medicate boredom, stress, anxiety, grief, PTSD. Well, it turns out we do very similar things with food as well too. Many of my patients will describe themselves as emotional eaters, stress eaters, comfort eaters. We eat because we're bored. We eat because we've got nothing else to do. In society, we eat when we celebrate, we eat when we grieve. And while that's all good, we need to make sure that we're not using food as a coping mechanism for some of these other things here. And so having a behavioral therapist can help give insight as to why we eat what we're eating, why we eat when we're eating, and perhaps make patients more aware of some of these habits that they might have.
Finally, I make an appeal to the heart. And what I mean by this is putting patients’ overall health care in a part of a much larger picture here. For the patients with or MASLD and MASH, the number 1 cause of death remains cardiovascular death. The number 2 cause of death is cancer-related death. Liver disease rises from number 9 or 10 in the general population up to number 3. So when I think about these top 3 sources of morbidity and mortality for our patients, putting heart disease and cancer at the top of the list really puts things in context. Here in the South, we have sayings like, ‘as serious as a heart attack.’ Patients get this. And so what I try to let them know is whatever is good for the heart is going to be good for the liver.
And fortunately, doing a lot of these interventions, like maintaining a healthy weight, can also reduce cancer risk as well, too. Treating a heart disease or cardiovascular risk factors is critically important. Patients need to get good control of their diabetes. This will also help their liver. Patients need to have their cholesterol treated. This too will be good for the liver. Often, many providers and patients alike are scared off of the statin class of medications to control cholesterol. These, I think, are part of the treatment and risk factor modification for treating or MASLD and MASH.
And the final piece of the appeal to the heart is exercise. We have become very deconditioned in general —as you see here, I'm sitting in my office and I'd rather be outside. We need to get outside, we need to exercise, we need to move more. But this can be challenging for any number of my patients. Patients who suffer from obesity and have had long-standing obesity for years, if not decades, may have a bad back, bad hips, bad knees, bad ankles. And so we need to figure out a way to get into exercising in a way that's appropriate for our patients. Sometimes this may require a referral to physical therapy to work on training exercises that can build core strength. This will also help with reducing risk for falls and also help for sarcopenia or muscle loss as well too. Often swimming or water aerobics can also be a good outlet for patients with bad hips, and bad knees, et cetera.
Patients will ask, well, what type of exercise should I do? Should it be more aerobic exercise where I get my heart rate up? Or should it be more resistance training or anaerobic exercise in terms of muscle building and resistance training? Well, it turns out that both of these are good. The caloric benefit and cardiovascular benefit for aerobic exercise can certainly help burn off extra salaries. But let's not discount resistance training and anaerobic exercises well too. By building core strength, patients will increase muscle mass, and that will help with insulin sensitivity and combat insulin resistance. Additionally, this can again help with falls and make patients safer as well, too. There's data that suggests that all of this works, not just for cardiovascular health, but for or MASLD and MASH as well too. And a number of meta-analyses of exercise studies do show a benefit.
It's important to tell patients, too, that it's never too late to start an exercise regimen. Even among my patients with cirrhosis, I know that they will benefit from exercise. A study was done out of Barcelona several years ago that looked at patients with BMIs greater than 40 and or MASLD cirrhosis and showed that those patients who lost weight could actually reduce their prototype retention. Additionally, by doing more aerobic training, patients will combat frailty, and if they do need liver transplants later on down the road, will become better operative candidates in the eyes of our surgeons.
That's all I have for now for my lifestyle interventions for patients. I hope this has been helpful. Thank you.
