Conquer Your Weight

Dr. Sarah Stombaugh: Before we get into the episode, I am thrilled to announce we are launching an online course, The GLP Guide. The GLP guide is a must have resource for patients who have been prescribed any of the GLP medications such as Wegovy, Ozempic, semaglutide, Zepbound, Mounjaro, tirzepatide, Saxenda, liraglutide. There are a lot of them and this course is available for anyone to purchase. We often hear from people who haven't been given much information about their GLP medications. No one has told them how to handle side effects, what nutrition recommendations they should follow, or what to expect in the longterm. And it can be really intimidating and simply frustrating to feel like you're alone in your weight loss journey. With the GLP guide, you'll get access to all of the answers to the most common questions for patients using GLP medications, not sure how to use your pen, struggling with nausea, wondering how to travel with your medications. We've got you covered for only $97 for one year access. This is an opportunity you do not want to miss. The course is launching on October 1st. For more information and sign up, please visit www.sarahstombaughmd.com/glp. You don't have to be on this journey alone. We are here to guide you. And now for today's episode, this is Dr. Sarah Stombaugh and you are listening to the Conquer Your Weight podcast. Announcer: Welcome to the Conquer Your Weight podcast, where you will learn to understand your mind and body so you can achieve long-term weight loss. Here's your host, obesity medicine physician and life coach, Dr. Sarah Stombaugh. Dr. Sarah Stombaugh: Hello everyone and welcome to this week's episode of the Conquer Your Weight podcast. I have a guest with me today, Dr. Uchenna Agbim. She is a transplant hepatologist and I'm really excited for this topic. One of the things I've been talking about recently is that we've been recording this podcast for a while and realizing, oh my gosh, there's some major topics that somehow have just flipped through the cracks and today this is one of them. We are going to be talking about fatty liver disease, what that has to do with overweight and obesity because what we now know is that there's a huge connection between obesity and fatty liver disease. And correct me if I'm wrong, but it's actually the primary cause of liver disease at this time. And so welcome Dr. Agbim. Thank you so much for joining us today. Dr. Uchenna Agbim: Thank you for having me. Thank you for having me, Sarah. I appreciate it. Dr. Sarah Stombaugh: Yes, absolutely. So thank you. I would love to hear a little bit more about you. Tell me about your background and how you came to be practicing even just medicine in general, but now as you've gotten into this more niche field, tell us a little bit about that. Dr. Uchenna Agbim: Sure. So I've always been interested in public health and actually I have a master's in public health and really focused in on behavioral education and health promotion. I went to medical school actually after I received my public health degree and in medical school really interested in liver. I ended up doing internal medicine, which is medicine for adults and ended up specializing in gastroenterology that's GI with the intent of doing hepatology study of liver and transplant. And so I am board certified in gastroenterology as well as transplant hepatology. And then in 2020 I also got board certified in obesity management. And my overall clinical research interests are metabolic issues in people who have added transplants and really trying to optimize their health transplant. Dr. Sarah Stombaugh: Wonderful. Well thank you so much for joining us and it's kind of fun for us to reconnect. We were talking about this a little bit earlier, but we actually studied for the obesity medicine boards together and it's hard to believe it's been five years since that happened. We were so lucky. We got our boards in days before the world shut down for the pandemic and so did that certification and February 2020 and we've both been utilizing that certification in different ways. So I'd love to hear today we're going to get to some of the basics of the, I guess let me use the new definition, the metabolic dysfunction associated the hepatitis. And so there's been some name changes recently in this area of liver health. Previously we used to use terminology non-alcoholic fatty liver disease was the common terminology. But recently over the last year or so we've seen transition to this metabolic dysfunction associated steato hepatitis as well as then the progression of that to MASH. So I'd love to hear a little bit about both of these two conditions. Tell me what are they? Dr. Uchenna Agbim: Certainly. The MASLD, that's M-A-S-L-D, metabolic dysfunction-associated steatotic liver disease is an umbrella term and by umbrella it incorporates a lot of, or it consists of a lot of things. It can be simple fatty liver disease, meaning fat accumulation in the liver. It can also be fat accumulation with associated inflammation. So injury to the liver cells and that in particular is called steatohepatitis. MASLD also incorporates or includes mash, which is metabolic dysfunction associated sato hepatitis with fibrosis. And so fibrosis is scarring. So the medical term for scarring is fibrosis and in MASLD fibrosis is really what predicts long-term liver related outcomes. So it's really important to understand how much scarring, fibrosis someone has if they have MASLD and in stage scarring or fibrosis is cirrhosis. So not everyone who has MASLD as cirrhosis necessarily, but if they have extensive scarring that could lead to cirrhosis. So it's important to detect and prevent it from progressing once someone is diagnosed. Dr. Sarah Stombaugh: Okay, excellent. And so we've got this really big umbrella term. We think about the whole, it's really a mouthful, this metabolic dysfunction associated stenotic liver disease. MASLD, right? M-A-S-L-D, and we'll put some of those abbreviations I think into the show notes so that people are familiar with that. So this is the umbrella term then of all of the liver dysfunction associated with metabolic disease of which that incorporates fatty liver being, I'll even quote sort of the mildest version of this, the earliest stages of this. And then there can be this progression into which someone is seeing fibrosis and then ultimately that they could see something like cirrhosis. Is that a fair way to describe it? Dr. Uchenna Agbim: Right. And really what is going to lead to the fibrosis is associated inflammation. So not everyone who has MASLD has MASH, the inflammation part, but if they do have MASH, then we get concerned about fibrosis occurring. Dr. Sarah Stombaugh: Okay, excellent. And tell us if someone has obesity or even maybe just in general we do see this with elevated body fat percentage. And so when we think about obesity, not necessarily just by BMI criteria, but by maybe body mass percentage or this fat mass disease where we have excess fat mass in our body. Tell me about the association of overweight obesity, this fat mass and muscley Dr. Uchenna Agbim: Certainly. So excess weight, particularly weight and the midsection, the abdominal area, we call that area visceral fat, excess weight there is particularly problematic. It is certainly more dangerous than a, that accumulates in the buttock area, kind of what we call the gluteal femoral area. And that fat, a lot of that fat can be deposited in the liver and in associated area pancreas. There can also be epicardial fat and so forth. But the deposition of fat, particularly in the midsection or visceral fat often is associated with insulin resistance. Insulin resistance is a condition which also can lead and worsen diabetes, cardiovascular disease. That is to say when there is lack of blood to the heart or even blood vessels, stroke and kin disease. So that's to say that the factors that also contribute to MASLD and also contribute to cardiovascular disease. In fact, the majority of people who have MASLD end up dying not from cirrhosis or liver disease, but the majority of people end up dying from cardiovascular disease. Dr. Sarah Stombaugh: Oh wow, okay. I actually didn't realize that statistic, but it's easy to believe knowing what we know about the risk of insulin resistance and cardiovascular disease. Right. Wow. Okay. And so tell us, we know that many of these conditions, we think about insulin resistance and that is at the core of so many things, whether it is overweight and obesity or whether it is these associated conditions like MASLD, like diabetes, pre-diabetes, certainly polycystic ovarian syndrome, heart disease, et cetera, et cetera. As you were describing, how does someone know if, maybe if they're just at risk for MASLD, so maybe sort of a leading question, but how would someone know if they're at risk for it? Or even then with lab tests or that sort of thing? How do they know, oh gosh, do I have this condition? Dr. Uchenna Agbim: Right. So what I particularly tell people is people who, like I said, who have excess weight in their abdominal area, people who have a higher BMI who are overweight or what is termed as obese by body mass index, people who also have prediabetes diabetes in particular as well as high blood pressure, high cholesterol, those people are at particular risk for developing MASLD. There are certainly people who have ma d and don't have diabetes or they don't have high blood pressure, but in terms of the aspects that really put people at risk include excess weight in the visceral area, the abdominal area as well as diabetes. And some of these other conditions I mentioned high blood pressure as well as high cholesterol. Dr. Sarah Stombaugh: Okay. And how is that diagnosed? How does someone know if they have macd? Dr. Uchenna Agbim: So the diagnosis of MASLD can be made on imaging. For example, an ultrasound may show a fatty liver or fat in the liver. Oftentimes liver enzymes may be elevated, particularly the ALT, although I would like to say that it's important to look at the trend of the ALT as well as AFT because one particular value does not give you the entire picture, but an overall trend over a period of time is important in understanding what the liver enzymes are doing. Other ways to diagnose MASLD include something called elastography and there are many forms of elastography. Elastography is basically a measurement of scarring in different organs and we look at the liver here. And so there can be ultrasound elastography, there can also be what is known as FibroScan, that's the trade name FibroScan, which is what we call vibration controlled transient. And there's also MRI elastography which can also give an understanding about scarring particularly in the liver. So the elastography tells more about scarring. The ultrasound fiber scan as well as MRI Elastography can tell about scarring as well as if the liver looks fatty. Additionally, one can also have a liver biopsy, which is the most invasive form, but it is the gold standard in identifying macd. A liver biopsy can determine how much scarring is in the liver as well as quantify the amount of fat as well. Dr. Sarah Stombaugh: Okay, excellent. And so this is really maybe then depending on how concerned we are, the liver biopsy being certainly the gold standard, but that's something you're going to do in a patient who maybe has had the fibro scan has showed that there's concern for fibrosis there. Tell me. So in my practice, for example, so at this point I see all patients who are working on obesity medicine from a medical weight standpoint and medical weight loss. When I look at my patient population, it's very common that we see sometimes these low level liver enzyme elevations and we see that they're elevated or as you said, looking at that trend can be important because you see these reference ranges. And so a lab may have a range and you may see that someone over time they were sort of smack dab of the middle, but then it's getting closer to the upper end of normal and then a little closer to the upper end of normal and then maybe finally before it creeps over the edge. And so with that, what I'm commonly seeing is these low level elevations of the liver enzymes and in patients that we know have insulin resistance are having other areas of their life that are sort of concerning for insulin resistance. And so it often will point me in the direction of, hey, this may have something like MASLD going on, for example, but tell me even sort of a step back, are the liver enzymes maybe the earliest thing if someone's working with their primary care physician, if they're getting their annual labs, what would be one of the earliest things that someone would see or be concerned about that made them think, oh gosh, I might have this condition going on? Dr. Uchenna Agbim: I think liver enzymes are very important to understand and what I will say is that the reference ranges at our labs are not completely normal. What I mean for that is that for example, an ALT in some labs may as listed as normal when it is as high as 50. But in terms of looking at liver disease, actually for a woman it shouldn't really be higher than mid twenties, higher twenties, like 29, and poor man, it really shouldn't be higher than 33, 35. And so what I would say is that anything higher than those is abnormal. I think people need to be cautious when they look at liver enzymes because even though it may not be red, if it is higher, if someone's ALT is persistently 45, 50, 60, that is not normal. And so certainly liver enzymes are quite easy to obtain. It's just a simple blood draw. And so oftentimes that is what triggers people to obtain further testing when it is noticed that the liver enzymes are abnormal, however other people are diagnosed incidentally or for example, say they may have abdominal pain and they get an ultrasound done for abdominal pain and on that ultrasound the liver may look enlarged and fatty. And so that is another way that people can be diagnosed. And oftentimes I see those types of patients who are referred to me in my clinic and that their liver looks abnormal, their liver is fatty and so forth. And so from then we do additional investigation. And oftentimes that investigation does include obtaining liver enzymes as well as obtaining elastography to understand if there is any and how much if so. Dr. Sarah Stombaugh: Okay, I love that explanation because I mean as you're sort of implying this can be a really silent disease for some people or certainly an unrecognized disease. And so it's not early on it's not causing any problems. You mentioned the patient with abdominal pain, I see that a lot as well where they're being evaluated for gallstones maybe or for some other indication. And then that fatty liver is found incidentally and it's not the cause of the abdominal pain, but it's seen on that imaging. And so patients have this experience of feeling totally fine having no lab abnormalities. They've maybe not had imaging or if they do have, it's for another reason. And I mean correct me if I'm wrong, this can be a really sort of silent, maybe silent killers extreme is what I was about to say, but silent thing that can sneak up on us. So tell me about that. Dr. Uchenna Agbim: Absolutely, absolutely. In fact, I have many patients who tell me that they had no idea they had liver disease. Oftentimes they think that liver disease, most people who have liver disease have a liver disease because they drink alcohol and so forth. And I think that's particularly important to note because under the microscope liver disease due to alcohol is basically indistinguishable from liver disease due to MASLD. In fact, MASLD used to be called non-alcoholic fatty liver disease, but that name was changed to really highlight the importance of it's because there are issues with metabolism and I think it's never really appropriate to call a disease what it is not non-alcoholic. You need to be specific about what the actual cause is. And so I'll have patients tell me that their doctor was positive they were consuming alcohol, they were drinking alcohol, but the patients are like, I don't drink alcohol, I don't drink at all. But here they are, they may have many of the risk factors for MASLD. And so what I would say is that I don't think that the liver is paid as much attention to when thinking about some of these issues because some people just gloss right over elevated liver and enzymes thinking it's really not going to cause much damage. But oftentimes that's really far from the chin. Dr. Sarah Stombaugh: Absolutely. And the reality is it sounds like we don't really understand if there's damage until we're doing some of these additional testing like the LS topography or potentially even a liver biopsy, CMK, is it just sort of just I'm doing air quotes, but just fat around the liver versus has it progressed to causing fibrosis or even cirrhosis. Dr. Uchenna Agbim: Right. And you need better testing for that. Oftentimes that is elastography. And I do want to make a point, which I forgot to mention earlier, there are some tests that you can use with just the lab parameters, for example, A-S-T-A-L-T as well as platelets and they call the B four to understand how much scarring is in the liver. And sometimes people use this to initially understand how much scarring or fibrosis is in the liver and then they go on to elastography the better testing and so forth. Dr. Sarah Stombaugh: Well, and I think that's a great point. I remember learning about the FIB four score when I was in residency and we are thinking about the functional pieces of the liver. We think about AST and ALT in terms of the traditional liver enzymes, but platelets really as a measure of how properly is the liver functioning. And so the FIB four is really a nice way using those numbers to calculate if someone is at risk. And so in the primary care space, that was something I found myself doing often. And until you put those numbers into the calculator, I remember finding patients pretty often that we were concerned about. Oh my goodness. And then doing a fiber scan in my previous system, we would always do the fiber scan, but it sounds like maybe appropriate for other types of elastography as well. So tell me, when we think about the sort of whole patient population, what is the prevalence of MASLD? Dr. Uchenna Agbim: Well, globally, the prevalence of MASLD is around, I want to say about 30, 35%. Actually no, about 38%. And with kids it's about 14% globally. However, given the trends in obesity, diabetes, that is certainly expected to increase I believe by 2040. It's projected to be around 55% and adults globally. So this is a condition that a lot of people have. But like I said before, it is not benign. It certainly can cause significant disease and should be taken seriously for that reason. Dr. Sarah Stombaugh: Okay, absolutely. And if we think about this whole population, I mean that's huge. We're talking about a third at least of our adult population that may be struggling with this condition. And I think as you were implying with the estimates is that a lot of this, because it is undiagnosed and then therefore untreated, some of these things are estimated based on patient population studies, for example. And so that is a huge amount of adults worldwide who are struggling with this condition, many of whom are undiagnosed at this point. And I think that piece that, so there's fatty liver and then the progression then as we've been talking about from fibrosis and to cirrhosis potentially, what does that progression look like? I mean certainly there may be some people, and maybe there's not even numbers there, but some people who just have a fatty liver and don't see progress to others who do see progress to more significant stages of disease. Dr. Uchenna Agbim: So in terms of the time force, I think that's slightly hard to say. I think it could be, it really depends. One, if there are other reasons for someone also to have liver disease, sometimes people do consume excessive amounts of alcohol and certainly alcohol with MASLD can also contribute to further inflammation and scarring. So it's slightly difficult to say what the time course is for people to progress. There's five stages of fibrosis, like to say stage zero is no scarring, no fibrosis, and there's stage one, stage two, stage three, and stage four we call stage two and above significant fibrosis. Stage three and above is advanced fibrosis or scarring, and stage four is cirrhosis. So if you're asking me if someone is stage one fibrosis, what is a time course if things do not change in which they can develop stage two, again, it's really hard to say, but what I do for these patients is I am assessing typically regularly, by regularly, I mean every year, particularly in patients who have stage two or so significant scarring or significant fibrosis and above, I am trying to see if they are progressing or regressing. And it is absolutely possible in people who have stage three and below scarring to improve for that scarring to resolve with weight loss. And one of the prime studies, which I think is quite interesting, was a study where they did a exercise nutrition program for a year. They took liver biopsies before and then after 52 weeks. And what we know is that people who were able to lose seven to 10% of their body weight were able to have improvement in their scarring from one full stage. So someone who has stage three, they went to stage two, if they were able to lose seven to 10%, someone who was stage two went to stage one. And so I think that's really important, something that I encourage my patients to do in terms of really focusing on weight loss that is sustainable. Dr. Sarah Stombaugh: And I love that you brought up this piece because we're starting to talk sort of all doom and gloom. There's a lot of concern that can happen with liver disease and there's a possibility for regression and even resolution of disease in some patients. And so the mainstay of treatment and what I'm always working on my patients with is medical weight loss, that surgical weight loss as well for my patient population, we're thinking about that medical piece, but helping patients to lose weight in a clinically significant way that is going to improve their health in many ways, including the liver health. Are there other things that patients should be doing or treatments for patients who have maybe any degree of masty? Dr. Uchenna Agbim: So there are some treatments that are especially some new treatments, particularly for stage two and above fibrosis. One that's FDA approved is a medication called resmetirom. And what that is, it's a medication that is very specific to the thyroid hormone receptor beta in the liver. So basically the liver is only one of the only places that this thyroid receptor is located. And what resmetirom on helps do is basically decrease fat in the liver. And it's been proven to improve fibrosis as well as steatohepatitis. That is the inflammation associated with fat in the liver, particularly when it is combined with lifestyle interventions, weight loss and so forth. So whereas resmetirom is one such medication that's FDA approved another medication that is under investigation. But there was some really exciting news about it at our annual liver meeting this past November is semaglutide, many people may be familiar with this medication because it's the GLP-1 receptor and it also has been shown to help with scarring as well as inflammation in the liver in phase two trials. I believe it was phase two trials that have come out recently. And so I think there's certainly more investigation regarding semaglutide, but I think that is very promising as well. And so for people who do have diabetes and are on, or those people who have excess weight and can obtain semaglutide, I think this could be very overall promising for also decreasing liver fat and starting to reverse fibrosis in the liver. Dr. Sarah Stombaugh: Okay, excellent. And so we know that weight loss, whether really maybe from any means, but then especially some of these medications that can be more supportive, there's medication specifically for the treatment of liver fibrosis. Tell me if someone is concerned about maybe do I have liver fibrosis, what should they be asking their primary care physician, how does someone know if they should be seeing someone like yourself? Tell me a little bit about what that would look like and how a patient can best advocate for themselves if they're concerned about this. Dr. Uchenna Agbim: Certainly. So I think something that they can do is calculate a fib four and it's actually to put the numbers into a computer and the FIB four will give you a, there's two cutoff values, but if someone is in the intermediate cut off value, that means they may need further testing. And so I would ask their primary care provider to refer them for an elastography, whether that be a fiber scan or ultrasound and or MRI elastography and then certainly see a gastroenterologist or liver specialist for further recommendations. Dr. Sarah Stombaugh: Okay, excellent. And so knowing that there's treatment available understanding if you even should have concern about this disease, I think that piece is really important because a lot of people maybe listening to this and like, oh my gosh, do I have liver disease? Is this something I should be concerned about? And I guess as you're saying, you could even calculate it at home. You can type in FIB-4, FIB-4, you might not necessarily know what to do with the results. So probably best to do it in combination with your physician, but it doesn't take a lot. It's from a CBC test from a metabolic panel, it's labs that you would probably have done at your annual physical for example. So with that information, you're going to have all of that to be able to calculate that initial score and then decide from there, does it make sense to do further evaluation? Do I need to see a specialist? And then certainly regardless of that working on the underlying cause then of how do I support myself in my weight loss goals to decrease my risk of metabolic disease, whether it's other metabolic diseases or liver health specifically. Okay. Excellent. Well, tell me, you look like you want to say something. So tell me as we're thinking about this topic that is so underdiagnosed, so undertreated as we're wrapping up, is there anything you haven't yet shared with my listeners that you think is really important them to know? Dr. Uchenna Agbim: So in terms of particular populations to be concerned about or that I may have a heightened concern, I would say people who do have diabetes, those are patients that I am concerned about. And I certainly think that patients who have diabetes assessing their risk for MASLD is going to be very important because these are people who I often, not always but often see MASLD and complications thereof. So just in terms of who should be asking anyone certainly who has excess weight, particularly in the abdominal area as well as patients who carry diagnosis of diabetes as well. Okay, Dr. Sarah Stombaugh: Excellent. That's very helpful. And let me ask you, if people are interested in learning more about you, if they're maybe in the St. Louis area and interested in working with you, where can they go to learn more about you or to work with you as a patient? Dr. Uchenna Agbim: Certainly, well, on a social media I can be found Instagram account, Uchenna Agbim MD, Instagram, and then my Twitter, I call it Twitter. I don't know if I can ever call it X. Dr. Sarah Stombaugh: Totally just used to seeing things Dr. Uchenna Agbim: I know, right. My handle there is Uchenna Agbim. So those are kind of the two places where people can find me on social media right now. Yeah. Dr. Sarah Stombaugh: Okay. Excellent. And we will make sure to have that information in the show notes as well as the link to where to find you at St. Louis University. Well, thank you so much. I feel like this is such an important topic. We just really brushed the surface of it, but I'm so glad that we had an opportunity to talk about it to help share with my audience about this topic. So thank you so much for coming on today. Dr. Uchenna Agbim: Absolutely. Absolutely. Dr. Sarah Stombaugh: All right. And for all of my listeners, thank you for joining us as I'm always looking for podcast topics. This podcast even came from the request of a listener as we were sort of shuffling through and oh my gosh, what have we not yet talked about? And so if there's anything you're listening and thinking, why has Dr. Stombaugh not yet addressed that it may be something we missed, things slip through the cracks, and this is a perfect example of that. So please reach out to us at any time info@sarahstombaughmd.com. And if you're looking for a doctor in Illinois, Virginia, or Tennessee, reach out. We would love to have you as a patient in our practice. See you next week. Bye-bye.