Functional Medicine for Metabolic Syndrome and Fatty Liver Disease (MASLD)

What are metabolic syndrome and fatty liver disease?

Metabolic syndrome is a name for a group of risk factors that occur together. Having it raises the chance of heart disease, stroke and type 2 diabetes. It is also called insulin resistance syndrome.¹

You are likely to be diagnosed with metabolic syndrome if you have three or more of five signs. The signs are a large waist, high blood pressure, high fasting blood sugar, high triglycerides (a type of fat in the blood) and low HDL ("good") cholesterol. The diagram on this page shows the cut-off for each one.^{1, 5}

Metabolic syndrome is very common in the United States. About 1 in 3 Americans have it, and the risk goes up with age. Many of its risks are related to obesity. The two most important risk factors are extra weight around the middle of the body (an "apple shape") and insulin resistance. Insulin is a hormone that helps control the amount of sugar in the blood. With insulin resistance, some cells use insulin less well than normal, so the blood sugar level rises. Other risk factors include aging, genes, changes in sex and stress hormones, and lack of exercise.¹

Steatotic liver disease, formerly called fatty liver disease, happens when too much fat builds up in the liver. It is typical to have some fat in your liver cells, but too much can be a problem. There are two main types. One is metabolic dysfunction-associated steatotic liver disease (MASLD), which is not caused by heavy alcohol use. MASLD used to be called nonalcoholic fatty liver disease (NAFLD).^{3, 4}

Liver experts from around the world announced the new names in June 2023. Patients and doctors had said the word "fatty" can feel shaming. The experts wanted a name without that stigma. Now, MASLD means fat in the liver plus at least one of five heart and metabolic risk factors. The more serious form used to be called nonalcoholic steatohepatitis (NASH). It is now called MASH, short for metabolic dysfunction-associated steatohepatitis.^{3, 4}

MASLD is the most common long-term liver disease. It is more common in people who have type 2 diabetes or prediabetes, obesity, or high blood pressure. It is also more common in people with high cholesterol or triglycerides or metabolic syndrome, and in people who are middle-aged or older.³

MASLD has two main forms. In simple fatty liver, there is fat in the liver but little or no inflammation or damage. This form usually does not get bad enough to harm the liver. In MASH, the fat comes with inflammation and liver damage, which can lead to fibrosis (scarring). This scarring sometimes leads to liver cancer or cirrhosis, which is scarring that makes the liver work poorly.^{3, 7}

The cause of MASLD is unknown, and experts are still studying it. Research suggests that certain health conditions, your genes, and your diet and digestive system may make it more likely.^{3, 5}

Common symptoms of metabolic syndrome and MASLD

With metabolic syndrome, your symptoms depend on which of the five conditions you have. High blood pressure, high triglycerides and low HDL cholesterol usually do not cause any symptoms. Many people learn they have it from tests at a routine medical visit, such as blood pressure readings and blood tests.²

MASLD also usually has few or no symptoms. Signs and symptoms of these conditions can include:³

• A large waistline, which you or your provider may notice²
• Signs of high blood sugar: blurred vision, more thirst, urinating more often (especially at night), and tiredness and weakness²
• With MASLD, feeling tired or having discomfort in the upper right side of the belly³
• If liver scarring becomes severe (cirrhosis), swelling in the legs or belly from fluid buildup⁷
• Also with cirrhosis, yellow skin or eyes (jaundice), easy bruising or bleeding, and confusion⁷

How metabolic syndrome and MASLD are diagnosed and treated

To check for metabolic syndrome, your provider will examine you and ask about your overall health and any symptoms. Blood tests may be ordered to check your blood sugar, cholesterol and triglyceride levels. Taking medicine for high blood pressure, type 2 diabetes, low HDL or high triglycerides also counts toward the five signs. Lower waist cut-offs are used for people of Asian ancestry: 35 inches or more for men and 30 inches or more for women.¹

Because MASLD often has no symptoms, it is not easy to find. Your provider may suspect it if you have abnormal results on liver tests. To diagnose it, your provider may ask about your health history, alcohol use and medicines, and do a physical exam and blood tests. Imaging tests can check for fat and scarring in the liver. In some cases, a biopsy (a small tissue sample) is done to confirm the diagnosis and check for liver damage.³

The goal of treating metabolic syndrome is to lower your risk of heart disease, stroke and diabetes. Your provider will recommend lifestyle changes or medicines. These may include losing weight, regular exercise, and steps to lower your cholesterol and blood pressure. If you smoke, your provider can help you quit.¹

The first step in treating MASLD is usually weight loss. Losing weight can reduce fat in the liver, inflammation and fibrosis. A healthy diet and regular exercise can help. If your provider thinks a medicine is causing your MASLD, they may tell you to stop or switch it. But don't stop taking any medicine unless your provider tells you to. In March 2024, the FDA approved the first medicine for some adults with MASH (then called NASH). It is for people with moderate to advanced liver scarring but not cirrhosis, and it is used along with diet and exercise.^{3, 6}

How our care fits alongside your primary care doctor

Avicenna Functional Medicine does not replace your primary care doctor or the treatment they prescribe. Our role is to add to your care, not to take its place.

In a functional medicine visit, we look at insulin resistance, fatty liver and heart and metabolic risk together. We also look at factors that may contribute, such as inflammation and the gut microbiome, along with nutrition and physical activity. Research on the microbiome and MASLD is still early: studies have found differences in the gut bacteria of people with and without MASLD, but experts are still studying how the microbiome may affect it. Our aim is to understand the whole picture of your health and to support your overall wellbeing.^{1, 5}

Please do not stop or change any prescribed medication without talking to the doctor who prescribed it. Check with your provider before using dietary supplements, vitamins or herbal remedies, because some can damage the liver.³

What to expect at Avicenna

All visits are by telehealth, for patients located in Florida and Texas. We are a cash-pay practice, and we accept HSA and FSA. Care usually follows these steps:

• A free, 30-minute discovery call to talk about your health and whether our approach is a good fit for you
• A full intake visit with our health coach, under clinician supervision, covering your history, symptoms, current treatment and goals
• Testing chosen for you, where it is likely to be useful
• A personalized plan, with follow-up visits to review how you are doing and adjust the plan as needed

When to get urgent care

Contact your primary care doctor if you have signs or symptoms of metabolic syndrome. These include signs of high blood sugar, such as blurred vision, more thirst or urinating more often. If you have cirrhosis, get emergency medical help right away if yellow skin or eyes, or belly swelling, is new or quickly getting worse. Other warning signs include vomiting blood, confusion, or a fever over 101°F.^{1, 2, 7}

Telehealth visits with our team are not for emergencies. Call 911 right away if you have warning signs of a medical emergency, such as:⁸

• Chest pain or pressure that lasts two minutes or more⁸
• Trouble breathing or shortness of breath⁸
• Sudden confusion, unusual behavior or trouble waking up⁸
• Fainting or passing out⁸
• Sudden dizziness, weakness or changes in vision⁸
• Being unable to speak⁸
• Severe belly pain, or sudden severe pain anywhere in the body⁸
• Coughing up or vomiting blood⁸
• Thoughts of suicide or of harming someone else (you can also call or text 988)⁸