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The World Health Organisation defines obesity as "abnormal or excessive fat accumulation that presents risk to health". It is increasingly recognised that the risk which excess body fat poses to health is dependent upon where that excess body fat, or adipose tissue, is stored. Individuals who have a tendency to accumulate of fat in the visceral compartment and in non-adipose tissue compartments such as the liver and heart may be regarded as having poor "fat health" which can result in adverse health consequences. We have evolved to store body fat as fuel; an energy store, accumulated in times of plenty, in order meet our demands in times of need. Subcutaneous fat storage, particularly in the lower-body, "gynoid" distribution is generally considered to have a low association with the development of chronic disease such as type 2 diabetes and cardiovascular disease. Approximately 20% of people who meet the BMI criteria for obesity are insulin-sensitive and metabolically normal, despite having large amounts of body fat. The ability to expand the subcutaneous compartment in situations of positive energy balance may have a protective effect in preventing storage of fat in the visceral compartment and in non-adipose tissue such as liver and muscle.
However BMI is a rather blunt tool for individual patient assessment as it gives no information regarding where the excess body fat is partitioned. Increased waist circumference measurement identifies individuals who have a tendency to store their body fat centrally. In addition to the supply of NEFA, visceral fat is also a source of many fat-derived hormones "adipocytokines" and inflammatory mediators which are associated with the development of insulin resistance, raised blood pressure and atherogenesis.
The "hypertriglyceridaemic waist" phenotype is a useful concept to characterise those who may be at risk of developing type 2 diabetes and cardiovascular disease as a result of a tendency to store excess body fat in the visceral compartment.
These relatively normal weight individuals may be characterised by a reduced lean tissue (muscle) mass and raised waist circumference.
In obesity abnormal accumulation of body fat can occur in non-adipose tissue - organs such as liver, heart and skeletal muscle. The most frequently encountered biomarker of fatty liver disease is an isolated raised ALT, particularly in association with a raised waist circumference.
It is important to exclude other possible causes of abnormal liver function, particularly in cases where other biomarkers of liver disease are abnormal, prior to considering a diagnosis of NAFLD.
The development of sophisticated imaging techniques, such as magnetic resonance spectroscopy (MRS), has allowed both quantification of fat deposition within the heart muscle (myocardium) and correlation between heart function and extent of abnormal fat deposition. Emerging evidence suggests that fat deposition in the form of excess triglyceride (TG) within heart muscle cells is associated with impaired cardiac function (diastolic dysfunction). Due to the observed relationship between central adiposity and myocardial TG content, it could be postulated that lifestyle modification to reduce weight and waist circumference could result in reduction in myocardial TG content. Skeletal muscle is designed to metabolise fatty acids as a predominant fuel supply, but has capacity to switch to metabolise glucose when this is available, for example after meals. An increase in fat deposition in skeletal muscle cells (intramyocellular lipid accumulation in the form of lipid metabolities diacylglycerol (DAG), Ceramide and fatty acyl CoA) interferes with insulin signalling and leads to insulin resistance. As a result of excess lipid accumulation interfering with insulin function, skeletal muscle loses metabolic flexibility to metabolise glucose in those who are overweight or obese. Nonalcoholic fatty liver disease (or NAFLD) is a recently recognized chronic liver disease, strongly linked to obesity. The presence of NAFLD is strongly linked to obesity, diabetes and an associated condition called insulin resistance.
People who are obese, diabetic, have high blood lipids (especially triglycerides) and high blood pressure are at greatest risk of developing NAFLD.
NAFLD is suspected when routine blood testing shows increased liver enzymes (specifically, increased AST and ALT values). Physicians at our San Francisco Center for Liver Disease are skilled at managing fatty liver disease.
It is important to understand how the storage of body fat in various compartments can have an impact on health.
Women have evolved a capacity to store excess body fat to cover the demands of both the mother and the nursing child for several years.
Women tend to accumulate lower body fat, reflecting subcutaneous fat in the gluteo-femoral distribution. These individuals are regarded as metabolically healthy but obese subjects (MHO) and are characterised by predominant subcutaneous adipose tissue accumulation.
In this way, the subcutaneous adipose tissue acts in a somewhat protective manner - a "metabolic sink".
A BMI within the overweight or obese range therefore most commonly indicates an excess of body fat. This is particularly important in the assessment of individuals whom we suspect may be at risk of health consequences due to excess fat accumulation in high-risk depots such as the visceral compartment and in nonadipose tissue. Waist circumference measurement therefore provides a simple clinical tool to screen those who may have an expanded visceral fat compartment.
Visceral fat undergoes an increased rate of lipolysis in relation to the more stable subcutaneous compartment.
More detailed assessment of these patients may uncover risk factors for heart disease and type 2 diabetes despite a relatively normal body weight. Although in NAFLD a raised ALT can occur in isolation, it is often encountered in the context of raised fasting triglyceride levels or possibly coexisting pre-diabetes or frank type 2 diabetes. Visceral fat accumulation is demonstrated to correlate with myocardial TG content, suggesting that measures of central adiposity such as waist circumference could serve as an indirect and inexpensive surrogate measure of myocardial TG content. Insulin produced in response to meal ingestion facilitates entry of glucose into skeletal muscle cells for utilisation and an energy source. Physical activity and weight loss are associated with improvements in muscle insulin sensitivity, demonstrating that it is possible to restore metabolic flexibility and improve glucose uptake and utilisation by muscle.


Pathogenic potential of adipose tissue and metabolic consequences of adipocyte hypertrophy and increased visceral adiposity. Enhanced fat oxidation through physical activity is associated with improvements in insulin sensitivity in obesity. Access to the materials on this web site for the sole purpose of personal educational use only.
As the number of obese Americans has doubled in the past three decades, not surprisingly, NAFLD is becoming increasingly common.
NAFLD is an umbrella term, referring to several forms of fatty liver disease of increasing severity and importance.
These factors are often associated with high blood insulin levels and a reduced sensitivity of the liver and muscle to the effects of insulin - termed insulin resistance. However, there are many exciting and promising treatments currently being evaluated and new agents are anticipated within the next 12 months. We work closely with California Pacifica€™s Metabolic Center and our on-site nutritionist to outline a comprehensive treatment program for individuals with NAFLD. But I think everyone needs to get over making every Beth Ditto shoot about her being a fat old biffer. The need to evolve a relatively long term body fat depot has meant that women in general have a greater capacity than men to expand the subcutaneous adipose tissue compartment. Raised fasting triglycerides particularly in association with raised waist circumference would therefore suggest visceral fat accumulation. This "dual fuel" system was first described by Sir Philip Randle and has been named the Randle Cycle. Downloads of patients monitoring sheets may be freely copied and where appropriate a single print out of a reasonable proportion of these materials may be made for personal education, research and private study. It may be the result of infection, a chronic skin condition, or contact with an allergen or irritant. The hallmark of persons with NAFLD is having too much fat in the liver.This fat is deposited within the cells of the liver (the medical term is steatosis) and this steatosis in turn can cause varying degrees of further liver injury. In addition, there is inflammation, liver cell damage and some scar tissue (fibrosis) present. Careful physical examination by a physician may demonstrate a slightly enlarged liver and acanthosis nigricans, a patchy dark discoloration of skin especially commonly over the neck and under-arm areas. Onea€™s physician may request additional blood tests to exclude other liver diseases that can also cause fat in the liver such as hepatitis C.Unfortunately, elevated AST and ALT values do not discriminate between the presence of simple steatosis or the more serious NASH. It is generally recommended that patients who have NASH and are obese should try to lose weight and optimize their control of diabetes, hypertension and hyperlipidemia if present. Physicians and their patients are offered prompt access, which facilitates the accurate assessment, diagnosis and coordinated management of all forms of fatty liver disease.
In some cases these is evidence of an associated inflammatory response within the liver - non-alcoholic steatohepatitis (NASH). Materials should not be further copied, photocopied or reproduced, or distributed in electronic form. Importantly, while too much alcohol can also cause fat to build up in the liver, the term NAFLD refers specifically only to people with liver fat who drink little or no alcohol and therefore for whom their level of alcohol use has little to do with their liver disease. This condition is characterized by too much fat in the liver, but without any other liver injury as a result of the fat. They include increased oxidative stress inside the liver cells and release of toxic inflammatory mediators (such as cytokines) by the fat cells. As the disease advances to cirrhosis, symptoms such as weakness, fatigue and jaundice may develop. As a result, referral to a liver specialist (hepatologist) may be necessary to determine the presence and severity of NASH.
Weight loss, especially if sustained, will improve fatty liver disease, though this is challenging in our calorie-rich environment. California Pacific Medical Center, part of the Sutter HealthOpens new window network, offers specialized care in liver disease and liver transplant. Simple steatosis is often suspected when liver enzymes are elevated, and after excessive alcohol use and other liver diseases associated with fatty liver have been excluded. Of concern, reports are emerging of older teenagers developing NASH and even cirrhosis as a result of NASH.Not surprisingly, cirrhosis due to NAFLD is becoming increasingly common and can progress to liver failure that may even require liver transplantation. Genetic factors - including variation in genes controlling liver fat metabolism - are also important in the development of NAFLD.The mechanism of liver injury in NAFLD is not completely understood. Our program is based in San Francisco and has outreach locations throughout Northern California and Nevada.Fatty Liver Clinic at CPMC2340 Clay Street, 2nd FloorSan Francisco, CA 94115Tel. Any other unauthorised use or distribution of the materials may constitute an infringement of Cut the Waist Limited's copyright and may lead to legal action.
Often times, if the enzymes remain persistently elevated and a liver biopsy is performed, the biopsy may confirm that the total liver fat contenta€”described as the combined small and large droplet (vesicle) fata€”is greater than 5% (the upper limit of normal) and is consistent with simple steatosis. NASH-related cirrhosis is now the third most common reason that liver transplants are performed in the U.S.
Research efforts are being pursued to study the reasons why some people develop the more severe forms of injury and to develop safe and effective means to arrest and reverse this liver damage.
Cirrhosis is characterized by replacement of liver tissue by extensive scar tissue and is associated with progressive loss of liver function (the manufacture of important proteins and the clearance of toxins ingested and made as part of onea€™s daily metabolism). Liver X-rays including ultrasound or CT scans may be used to confirm the presence of fat in the liver but do not help determine more important featuresa€”the amount of inflammation or scarring. It is important to emphasize that even modest reductions in weight (5-10%) can result in substantial reductions (~40%) in liver fat.


It is now recognized that patients with NRC also appear to have a substantially increased risk of developing liver cancer (hepatocellular carcinoma) and therefore should be screened for this devastating complication every 6 months using an imaging study such as ultrasound or CT scan combined with a liver tumor blood marker (an alpha fetoprotein or AFP). Also, several investigators are developing techniques to assess the presence and severity of liver injury that do not involve the need for a liver biopsy. As a consequence of cirrhosis a person may develop water retention, gastrointestinal bleeding, confusion; disorientation or coma. The definitive method to confirm both the presence and severity of NASH is to perform a liver biopsy.
Many experts recommend restricting alcohol use to a limit of two drinks per day or less for men (half that for women). It is intended for general informational purposes only and does not address individual circumstances. Based on our current understanding, simple steatosis is not a serious condition as it appears to rarely progress to the more severe forms of NAFLD. In this procedure, a very small sample of liver tissue is obtained by inserting a needle through the skin into the liver. The medications which appear to offer the best hope for treating NASH in preliminary studies, and perhaps not surprisingly, are those which have been used for several years to also treat diabetes. It is not a substitute for professional medical advice, diagnosis or treatment and should not be relied on to make decisions about your health.
The tissue is examined under the microscope to confirm the precise nature of NAFLD and its severity. These address the fundamental metabolic abnormality in persons with NAFLD- liver resistance to the effect of insulin. Never ignore professional medical advice in seeking treatment because of something you have read on the WebMD Site. In this case, the presence of excessive fat in the liver results in liver inflammation and further injury to the liver cells which can then lead to liver scar tissue (fibrosis) formation in some patients. These medications, called insulin sensitizers, may ultimately be used in persons with fatty liver disease, even if diabetes is not present.
At this time, the presence of NASH can only be accurately determined by examining liver tissue obtained by biopsy. Currently, there are no blood tests or scans available that can reliably provide this type of information.
To confirm both their safety and efficacy, large scale clinical studies are nearing completion in evaluating these and other medications in the treatment of NASH. Skin inflammation, changes in texture or color, and spots may result from infection, a chronic skin condition, or contact with an allergen or irritant. Persons with NASH should be referred to a liver specialist (hepatologist) or fatty liver disease program for further management. If you think you have one of these common adult skin problems, have your doctor check it out. About 20% of individuals with NASH have the potential to progress over 20-30 years to the most severe form and consequence of NAFLD: the development of NASH-related cirrhosis. NASH-related cirrhosis (NRC) is the most serious form of NAFLD and indicates scarring throughout the liver. You’ll recover, but pain, numbness, and itching might linger for months, years, or even the rest of your life.
Causes include extreme temperatures, infections like strep throat, and allergies to medications, foods, and food additives. Doctors aren't sure what makes eczema start in the first place, but they do know that stress, irritants (like soaps), allergens, and climate can trigger flares. To minimize razor bumps, take a hot shower before you shave, pull the blade in the direction your hair grows, and don't stretch your skin while you pull the razor across it.
They're usually found on the neck, chest, back, armpits, under the breasts, or in the groin area.
They aren’t dangerous and usually don't cause pain unless they become irritated when clothing or nearby skin rubs against them.
Pores that stay open and turn dark are called blackheads; completely blocked pores are known as whiteheads. Bacteria and hormones trigger acne, which most often shows up on your face, chest, and back. To prevent it, don't share shoes with an infected person or walk barefoot in areas like locker rooms or near pools.
You get them from exposure to sunlight, which is why they tend to appear on your face, hands, and arms. If it doesn’t go away on its own after the baby comes, you can treat it with prescription creams and over-the-counter products. They may be dark or multicolored, and they usually have a grainy surface, though they can be smooth and waxy. You don't need to treat them unless they get irritated or you don’t like the way they look.



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