MAFLD

Summary

In this informative lecture, Dr. Julius discusses the prevalence and impact of metabolic dysfunction-associated fatty liver disease (formerly known as NAFLD), highlighting its association with obesity and metabolic syndrome. He emphasizes the importance of early diagnosis, lifestyle interventions, and the role of hepatoprotectors like Essential Phospholipids (EPL) in managing the condition. The talk also covers the significance of monitoring liver health through non-invasive tests and the potential benefits of high-dose EPL treatment based on recent studies.

Takeaways

• 📊 Non-alcoholic fatty liver disease (NAFLD), now often referred to as metabolic dysfunction-associated fatty liver disease (MAFLD), is the most prevalent liver disease globally, affecting around 2 billion people.
• 🌐 The prevalence of MAFLD is closely linked to the prevalence of metabolic syndrome, with a significant portion of the global population affected by both conditions.
• 📈 There is a strong correlation between obesity, hypertension, diabetes, and the presence of fatty liver disease, indicating the importance of metabolic factors in its development.
• 🧬 The term NAFLD has evolved to MAFLD to better reflect the condition's association with metabolic dysfunction and to avoid the stigmatization related to alcohol intake.
• 🔍 Diagnosis of MAFLD can be facilitated by using medical calculators or fibrosis scores, such as the FIB-4 index or NFS, to assess the presence and severity of liver fibrosis.
• 🏥 Management of MAFLD primarily involves lifestyle changes, including weight loss, exercise, and dietary modifications, to address the underlying metabolic issues.
• 💊 Pharmacological treatments for MAFLD are still under investigation, with some traditional herbal remedies and hypolipidemic agents showing potential benefits.
• 🛑 Bariatric surgery may be considered for obese individuals with MAFLD, but its safety and efficacy have not been fully established and should be evaluated on a case-by-case basis.
• 🛡️ Hepatoprotective agents, such as Essential Phospholipid (EPL), have shown promise in improving liver function and reducing steatosis and fibrosis in some studies.
• 📚 Regular monitoring of liver function tests and non-invasive assessments, such as ultrasound or fibrosis scans, is recommended for patients with MAFLD to track disease progression and treatment response.
• ⚠️ MAFLD is a significant health concern with increasing prevalence, and proactive liver care is crucial for managing this condition and its associated risks.

Q & A

What is the current term used for what was previously known as NAFLD?

The current term is 'Metabolic Dysfunction Associated Fatty Liver Disease' (MFALD), which reflects a better understanding of the condition's association with metabolic syndrome.

What is the global prevalence of fatty liver disease according to the studies mentioned in the script?

The global prevalence of fatty liver disease is around 2 billion people, making it the most prevalent liver disease in human history.

Why is fatty liver disease often associated with metabolic syndrome?

Fatty liver disease is associated with metabolic syndrome because it is commonly found in patients with obesity, hypertension, and diabetes, which are all components of metabolic syndrome.

What is the recommended weight loss target for patients with fatty liver disease to improve steatosis?

To improve steatosis, it is recommended that patients aim for a weight loss of 3 to 5% of their body weight.

What is the significance of the FIB4 score in managing fatty liver disease?

The FIB4 score is used to assess the presence of fibrosis in the liver, which is important for determining the prognosis and management strategy for patients with fatty liver disease.

How often should patients with fatty liver disease have their condition monitored after diagnosis?

Patients should have their condition monitored every 6 months, including liver function tests and, if necessary, a fibrosis scan.

What is the role of EPL (Essential Phospholipids) in the treatment of fatty liver disease?

EPL is used as a hepatoprotective agent to help repair and regenerate damaged liver cells, restore liver function, and protect the liver from further damage.

What is the recommended dosage of EPL for the treatment of fatty liver disease?

The recommended dosage is 1,800 mg per day, which has been shown in studies to improve liver function and histological features of the disease.

Is there any evidence that fatty liver disease is reversible?

Yes, from steatosis to mild fibrosis, fatty liver disease is considered reversible, but once it progresses to cirrhosis, it becomes irreversible.

What is the impact of bariatric surgery on fatty liver disease?

Bariatric surgery can be considered for eligible obese individuals with fatty liver disease, as it has shown improvements in insulin resistance, liver function tests, and histological features of the disease.

Is there a recommended age for starting EPL treatment for fatty liver disease?

EPL treatment is generally recommended for patients 12 years old and above, with a dosage of 2 capsules, 3 times a day, totaling 1,800 mg.

Outlines

00:00

📚 Introduction to Nafld and Metabolic Syndrome

The speaker begins by addressing a minor technical issue and then dives into the topic of Nafld, now referred to as metabolic dysfunction-associated fatty liver disease (Mafld). They discuss the prevalence of this condition globally, highlighting its association with metabolic syndrome and the lack of awareness among the general population. The speaker emphasizes the importance of recognizing the connection between obesity, hypertension, and diabetes with fatty liver disease, noting that a significant portion of the population with metabolic syndrome also has fatty liver.

05:04

👶 Pediatric Nafld and Its Progression

This paragraph focuses on pediatric Nafld, detailing the risks and progression of the disease in children. It mentions the high cholesterol, triglycerides, and low HDL levels commonly found in affected children, along with the increased risk of hypertension. The speaker also discusses the progression to advanced fibrosis or cirrhosis and the higher likelihood of pediatric patients progressing to compensated cirrhosis compared to adults. The paragraph concludes with the impact of Nafld on mortality rates and the shift in the primary cause of liver failure from alcohol to Nafld in patients under 50.

10:04

🔍 Diagnosis and Evolution of Mafld Terminology

The speaker explains the diagnostic criteria for Mafld, which includes the presence of steatosis by ultrasound and metabolic risk abnormalities. They discuss the evolution of the term from Nafld to Mafld, reflecting a better understanding of the condition's association with metabolic syndrome. The paragraph also touches on the importance of considering other etiologies that might contribute to fatty liver disease and the shift from an exclusionary diagnosis to a more inclusive one based on positive criteria.

15:07

📈 Assessing Fibrosis and Risk in Mafld Patients

The paragraph discusses the importance of assessing fibrosis in Mafld patients to determine their risk level. It outlines the use of medical calculators and fibrosis scores to identify the presence of fibrosis. The speaker advises on the appropriate actions based on whether the patient is at low or high risk, including referrals to specialists and the consideration of liver biopsies in borderline cases.

20:07

🏃‍♂️ Non-Pharmacological Management of Mafld

This paragraph emphasizes the importance of non-pharmacological approaches in managing Mafld, primarily focusing on weight loss and exercise. The speaker sets specific targets for weight reduction to improve steatosis and histopathology features. They also mention the role of structured exercise and the potential benefits of bariatric surgery in eligible obese individuals with Mafld.

25:07

💊 Pharmacological Treatments for Mafld

The speaker outlines various pharmacological treatments for Mafld, including standard treatments for metabolic syndrome, traditional herbal medicine, and hypolipidemic agents. They highlight the role of antioxidants and the use of essential phospholipids (EPL) as hepatoprotectants. The paragraph discusses the mechanisms of action of these drugs and the evidence supporting their use, particularly the medium probability of improvement offered by EPL.

30:09

🧪 Clinical Studies on EPL Efficacy

This paragraph presents clinical studies that demonstrate the efficacy of EPL in treating Mafld. It details a study involving liver biopsies before and after EPL treatment, showing a decrease in fat and reversal of steatosis. Another study is mentioned, which used a high dose of EPL and showed improvements in ultrasound and fibrosis scan outcomes across different categories of patients.

35:12

🌐 Global Recognition of EPL in Mafld Treatment

The speaker discusses the global recognition of EPL as a component of Mafld treatment guidelines in various countries, including Russia, China, Latvia, and Poland. They contrast this with the US, where more studies are needed for EPL to be included in guidelines. The paragraph also covers the benefits of EPL, such as its high bioavailability, ability to improve liver function tests, and safety profile.

40:14

🛑 Current Status and Future of Mafld Treatment

In this concluding paragraph, the speaker summarizes the current status of Mafld as a prevalent condition associated with obesity and the importance of lifestyle interventions as the cornerstone of treatment. They mention the role of pharmacological treatments, particularly EPL, as an adjunct to lifestyle changes. The speaker also addresses questions about the reversibility of Mafld, the recommended duration for monitoring patients post-diagnosis, and the use of EPL in children.

45:16

🤰 Clarifications on EPL Use in Special Populations

The final paragraph addresses specific questions from the audience regarding the use of EPL in pregnant patients, for whom it is not recommended. The speaker also reiterates the recommended dosage of EPL based on recent studies and emphasizes the importance of following the evidence-based dosage for effective treatment outcomes.

Keywords

💡Nafal d / NAFLD

Nafal d, also known as Non-Alcoholic Fatty Liver Disease (NAFLD), refers to a condition where there is a buildup of fat in the liver not caused by alcohol consumption. It is central to the video's theme as it discusses the prevalence and impact of this condition. The script mentions that NAFLD is now the most common liver disease globally, affecting around 2 billion people, and is largely unknown to the general population despite its association with metabolic syndrome.

💡Metabolic Syndrome

Metabolic Syndrome is a cluster of conditions that increase the risk of heart disease, diabetes, and stroke, including increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels. The video discusses its strong association with NAFLD, indicating that the prevalence of metabolic syndrome is similar to that of fatty liver disease, as seen in the script where it is stated that 'the population with metabolic syndrome is almost the same as the population with fat liver'.

💡EPL

EPL, or Essential Phospholipid, is a component discussed in the video for its role in the management of NAFLD. It is highlighted as a hepatoprotective agent, which means it helps protect the liver from damage. The script mentions that EPL is incorporated into the damaged membrane of liver cells, aiding in restructuring and stimulating liver cell regeneration, which is crucial for managing the disease.

💡Fibrosis

Fibrosis refers to the thickening and scarring of connective tissue, often as a result of inflammation or injury. In the context of the video, liver fibrosis is a consequence of chronic inflammation due to NAFLD, which can eventually lead to cirrhosis. The script discusses fibrosis scoring as an important aspect of assessing the severity and prognosis of the disease.

💡Cirrhosis

Cirrhosis is a severe liver disease where the liver is permanently scarred and its function is significantly impaired. The video mentions cirrhosis as a potential outcome of untreated or advanced NAFLD, where chronic inflammation and fibrosis lead to liver failure. The script warns that patients with cirrhosis are at risk of complications from liver disease.

💡Hepatoprotectors

Hepatoprotectors are agents that protect the liver from damage or aid in its repair. In the video, the term is used to describe medications like EPL that are used in the management of liver diseases, particularly NAFLD. The script emphasizes the importance of hepatoprotectors in treating metabolic dysfunction associated fatty liver disease.

💡Muffin / MAFLD

Muffin, or Metabolic Dysfunction Associated Fatty Liver Disease (MAFLD), is the new term proposed for what was previously known as NAFLD. The video discusses the shift in terminology to better reflect the metabolic nature of the disease and its association with metabolic syndrome. The script explains that the new term includes criteria for diagnosis that go beyond the absence of alcohol consumption.

💡Ultrasound

Ultrasound is a medical imaging technique used to visualize body structures, including the liver. In the context of the video, ultrasound is a common method for diagnosing fatty liver by detecting the presence of fat in the liver tissue. The script mentions that ultrasound, along with other criteria, is used to diagnose MAFLD.

💡FibroScan

FibroScan is a non-invasive test used to assess liver fibrosis by measuring the liver's stiffness. The video discusses FibroScan as a tool for determining the presence and extent of fibrosis in patients with liver disease. The script explains that a FibroScan can help differentiate between low-risk and high-risk patients for further management.

💡Bariatric Surgery

Bariatric Surgery refers to surgical procedures that help promote weight loss in obese individuals by altering the digestive system's anatomy. The video mentions bariatric surgery as a potential treatment for obese patients with NAFLD, although it notes that the type, safety, and efficacy are still under investigation. The script suggests that such surgery may be considered for patients with a BMI greater than 40 or for those with BMI over 35 with obesity-related comorbidities.

Highlights

Non-alcoholic fatty liver disease (NAFLD) is now termed metabolic dysfunction associated fatty liver disease (MAFLD), reflecting its association with metabolic syndrome.

The prevalence of NAFLD is around 2 billion globally, making it the most prevalent liver disease in human history.

25% of the global population has NAFLD, with a higher prevalence in some countries, indicating a significant health concern.

Childhood obesity and its associated health issues, such as high cholesterol and hypertension, are on the rise, increasing the risk of NAFLD in younger populations.

10 to 25% of obese children progress to advanced fibrosis or liver cirrhosis by their third and fourth decade of life, highlighting the severity of pediatric NAFLD.

Pediatric NAFLD is associated with a 136% increase in mortality in 20 years following diagnosis, emphasizing the need for early intervention.

NAFLD has overtaken alcohol and hepatitis B as the leading cause of liver failure in patients under 50, reflecting a shift in liver disease etiology.

The term NAFLD has evolved to MAFLD to better reflect the current understanding of the disease and its metabolic associations.

Diagnosis of MAFLD now includes criteria such as steatosis by ultrasound and metabolic risk abnormalities like increased waist circumference and hypertension.

Patients with MAFLD can also have other liver diseases like alcoholic hepatitis or hepatitis B, indicating the complexity of liver disease diagnoses.

The natural history of NAFLD/MAFLD includes progression from simple steatosis to steatohepatitis, fibrosis, and potentially cirrhosis.

Most patients with NAFLD die from metabolic syndrome complications rather than liver disease, highlighting the broader health implications.

Non-pharmacological approaches, such as weight loss and exercise, are the cornerstone of MAFLD treatment, aiming to reduce liver fat and improve metabolic health.

Pharmacological treatments for MAFLD include standard treatments for metabolic syndrome, traditional herbal remedies, and hepatoprotectives like Essential Phospholipids (EPL).

EPL has shown promise in improving liver function and reducing liver fat in studies, making it a potential adjunct treatment for MAFLD.

EPL works by incorporating into damaged liver cell membranes, stimulating liver cell regeneration and protecting from hepatotoxic compounds.

High doses of EPL (1800 mg daily) have been shown to be more effective in improving liver health compared to lower doses.

Transcripts

oh

I have no disclosure uh

uh Jovanna can you excuse me for a minute

I don't know a compassator and or earphones

sorry about that say it again

so

okay

I will go back to sharing my screen

so tonight I will be discussing with you uh

Nafal d and then I will discuss with you

the impact of the change of the temperature

from Nafal d now it is called uh

muffled or metabolic

dysfunction associated fatty liver disease

and then I'll uh

discuss the role of EPL in the management of Napoli

why does not fall qualify as a pandemic truly

in your practice

you will see it a lot of patients with fatty liver and

and then

now I will be teaching you how to deal with them

so as a proof novel this

the most prevalent liver disease is in human history

the prevalence is around 2 billion globally

uh it is largely unknown to the general population

because uh

despite the the the um

the many uh the

the even the global uh

public health community doesn't know that there's a

large uh

population with uh Nafaldi

I don't oh sorry

um

Joe Ben sorry

I have a troubled SA SA and Apal

lullaby

just slow down maybe I'll just maybe I'll just

check

it

out

sorry

there's really a large number of patients with

enough for the fatty liver

because it's

really associated with the metabolic syndrome

if you see how many of our patient has obesity

a hypertension

diabetes you will

you'll find out that if you do a autosound

actually they are fat liver

so actually more or less

the population with metabolic syndrome

is almost the same as the population with fat liver

so according to the studies done census in the US

they said that 25% of the global

is the global prevalence to be serving

one out of four person

so if you're sitting with somebody

one of you go upper cage

and one of you probably have body liver

so Asia it's lower it's 23.3

but some countries it's even higher up to 30% no

the the truth of the matter is because of obesity

of obesity you can see that maybe your seatmates

I'm sorry to tell to say that yeah

even myself is overweight so 1 out of 4 person is

has metabolic syndrome because of overweight

so this is also influenced by our how we eat

that's why childhood obesity is also becoming very high

it has rise for the past four years 10 times

and you know if a child has a fat delivery

it has increase in

the child is obese already during childhood

then when you check their

blood they would have a high cholesterol

high trigesrides

no HDL so that they have 20 to 30% of them um

is reported to be hypertensive already also uh

10 to 25% of them progress to

advanced fibrosis or liver serosis

by the third and fourth decade of life

that's why

pedratic novel patients are more likely

than adults to progress to the compensation

and also

because you can also see that obese children are

have high

high risk of developing diabetes

so that in

summary pediatric novel is associated with

1,360% increase in mortality in 20 years

following diagnosis

so that uh

you know that the liver transplant is the uh

ultimate uh treatment for liver failure

and you know before they were telling us that uh

alcohol was the most common cause of liver failure

but now uh for those patients less than 50 years old

the number one uh

cause of uh liver failure is already Nash

it has overtook uh liver

uh hepatitis B and also uh alcoholism

so really this is really

something that has evolved through the years

so that uh

they they came out to a term that uh

novel actually should be called muffin

before in our med school as you remember

uh we diagnosed napole by exclusion

so No. 1 if the patient doesn't drink alcohol

then if the patient has no viral hepatitis

or there's no ideology of hepatitis

uh other chology of hepatic status

then we'll say that uh

because uh you have you're not a drinker

so you're called nafall

or non alcoholic fatty libert disease

but into the years

they found out that the novel de patients

become some more that is prevalence increases

and they found out that actually

these non alcoholic fatty labor disease patients

most of them have metabolic syndrome

that is why they did because a lot of these

not for the patients are actually

have metabolic dysfunction

so they they now

change the term into metabolic

dysfunction associated fatty liver disease

which has this criteria

so if there's steatosis by ultrasound

plus one of the three

if the patient is overweight or obese

the patient is have diabetes

and at least two of the risks are abnormalities

metabolic risk abnormalities

which is a increase our weight circumference

uh hypertension high triglycerides

low HDL

prediabetic insulin resistance and increase in CRP

so because of this uh malfo then uh

it's easy to understand that uh

actually we don't use math

NAFOL or non alcoholic party liber disease anymore

but we use the metabolic sing

metabolic dysfunction associated fatty liver disease

with this then we can have

a patient can have a MFLD

and also I alcoholic fat deliver

and also have a chronic hepatitis

B hepatitis so then you

a person can have 2 or 3 causes of fat liver

so because of that diagnostic idea

to better reflect the current knowledge of

to capture the full spectrum of the deceased

now we know that novel dee allies actually maffody

now we know that uh because of this term

now we start to look for metabolic syndrome

in connection with fatty liver

it simplifies the diagnostic process

by using a positive criteria

rather than by an exclusionary process established

a conceptual framework grounded on science

considers

other geology that might contribute to fatty liver

that was I saying to you

that a person may have a fatty liver

may also have alcoholic hepatitis

may also have hepatitis B infection

a better disease

subtyping a little precision of medicine

now we know how to treat this

because we know this is associated with fatten uh

of uh associated with metabolic syndrome

so the new nepectors should convince the stigma

stigmatization of alcoholic intake

so now we know

so so that just to show you the natural history of

of not fall

now on the left side you see a normal reliever

then if if the patient becomes fat

then there will be

is theatosis or fat infiltration inside and the liver

no no

a lot of them later on

because of that fat will cause inflammation

so the inflammation

we call it inflammation of the liver or hepatitis

so we call now if there's inflammation

we call this a non alcoholic uh steato hepatitis

then because of that hepatitis

that chronic inflammation patients uh

or only immune system will heal

and take care of the inflammation

which produces fibrosis in return

so if there's a lot of fibrosis

because of a prolonged process of repair

repairing the the hepatitis

the inflammation

then at the end one will have liver cirrhosis

well one may also have uh docelocancide from

from histheatosis to mild fibrosis

there is five times increase in cardiovascular disease

actually most of our patients with Napoli die

not of the liver disease but they die of uh

the metabolic syndrome

and they have five times increase in risk of uh

uh car job events

while those patients who proceeds to become a cirotic

then that's a time that we see the

these patients die of

complications from liver diseases

so as you can see in this uh slide

this is uh uh

the sequential path of ecological state of novelty

and its progression

so on the top you can see that this is a not

there's novel which is a fatty liver

then going down there is a next step will be H

which is hepatitis because of the inflammation

and afterwards go down

then you will have fibrosis the more fibrosis

the more severe the patient will have will be no

and also the more risk um risk HCC risk

uh the more metabolic syndrome uh

uh items like a southern entire lifestyle obesity

insulin resistance

increase of age this also increase

the morbidity and mortality of liver disease

but then you will see that not all my faulty are uh

actually obese actually one of the uh there

one of more than six of 10 of patients with diabetes

nine out of 10 severely obese have not for the

but one out of four people have not for the

regardless of the weight

but then if you see the progression

and the characteristic and the implication of these uh

two uh subset of patients comparing the lean patients

lean enough old

and comparing them with the obese patients

actually they go on the same route

they go from uh

fat delivered and inflammation and fibrosis

but uh this uh this study shows that uh uh

the the the the pathway is the same

so we should treat those patients with lean and

and fat uh

fatty livers the same way

so uh let me tell you how to diagnose uh

fatty metabolic dysfunction

fatty liver disease so number one is

you know the

we did a ultrasound to a patient

and a patient comes to us with a

ultrasound of fatty liver and a high

sgpts with that what should we do now

now we can see on the left hand

left hand side it officially obese

which is uh if the BMI is more than 23

uh for Asians no then we can already

a fat deliver an ultrasound plus an overweight

a BMI of more than 23 then we can uh

confidently say

this patient has metabolic syndrome associated

fatty liver disease likewise on the right hand side

if the patient has fatty liver and ultrasound

then the patient is diabetes

then we that is the two

the criteria is also already says that are

makes us conclude that this is a metabolic dysfunction

associated body for deceased

but if the patient is lean

then you have to look for other

uh two metabolic

risk abnormalities to consider them to have mphd

so if the waste circumference is more than one

uh is more than 90 for Asians in men or 80 in women

so I hope you know the waistline

the waistline is not the belt line

the waistline is the the line above the umbilicals

is the narwest portion of our uh torso

now if uh in men it's 90 centimeter

so it's around if it's more than 35.5 centimeter

glycerides is more than 1:50

the L hdl is less than already diabetes

okay if the

if there's insulin resistance

and if there's a high CRP

there are two of these then you can consider them

plus a fatty liver and ultrasound

we can already consider them to have metabolic syndrome

associated fatty liver disease

now if you are presented with a patient

now you know that this patient has

the reason for their high sgbt is fat deliver

is metabolic in nature so what should we do now

we should next check for the fibrosis assessment

as you say as I said before

the fibrosis score is very important

because it tells us about the prognosis

so how do we do a fibrosis scoring

how do we know that the patient has fibrosis or not

then we can use the calculators

medical calculators using the V4 or the uh

NFS or fiber test there's a lot in our

you can just

use it in our phone or just request for a fiber scan

and a fiber scan will tell us if

the patient has fibrosis or not

now if there is no fibrosis

then the patient is considered to be low risk

if there's low risk

you don't have to refer to us other specialist

you just you know this patient the nature is metabolic

so just go ahead and treat the metabolic problem

and just repeat this non invasive test

every two to three years

but if the patient is high risk

which means the patient has fibrosis

and it's better to refer the patients to a gastro

because then we will be uh

looking for just the clinical uh

the clinical symptoms of liver cirrhosis

and treat them accordingly

because you know that if there's already cirrhosis

then we have to look for a viruses because

you know viruses is one of the

cause of mortality of these patients

we need to check for hypotocellar carcinoma

and if we need to do or check for

if the patient has a science of the compensation

the compensation like ascieties and encephalopathy

so we have to treat that according

now if if the patient is in the borderline

then the recommendation is to do liver biopsy

but then because a liver biopsy is uh

is difficult and it's uh invasive

and it is very difficult to convince a patient

just to see if there's fibrosis

we want to do a liver virus

so if you uh in in our case if we

if the patient is in the

in between fibrosis and the normal

so we will just go ahead and aggressively treat

the metabolic syndrome and likewise

screen patients for viruses or other

complications of liver disease

so just to tell you this is the

this is what I use in my clinic to

to check for fibrosis

so I usually use the FIB4 because it's the easiest

it consists only of four that's why it's FIB4

so you just need the age

the ASPLD and the platelet come so you can just always

you uh request for your regular blood chem

you just need to put in uh

the CBC platelet

because you need a platelet and the Alt and iced

if it's a less than 1.3 then it will solve fibrosis

if it's more than 3.25 it predicts fibrosis

you can just put it in your medical calculator

and your phone will do the

the calculation for you

or you can use the NAFL d fibrosis core

now with comprises of the HLD

SD platelet called BMI

albumine and impaired fasting glucose okay

so you can use this to test okay

so now that in the beginning

you have a patient who came into you with a fat liver

and ultrasound then you what will you do

you have to check for the fibrosis score

now if you know now the fibrosis score

now you know

if it is a low risk intermediate is a high risk now

now I will be telling you about how do we manage them

what do we keep so

so why do we treat because there's you know

there's a long term outcome of patients with maffody

and Nash

compared for the controlled population

of a metabolic syndrome is

if one has metabolic syndrome plus fatty liver

the increase

there's increase overall motority compared to the

those with no muscle and it processes risk for CBD

higher risk for CBD events

no uh

it poses greater risk for hypertension and diabetes

than diabetes alone so it also poses a risk for CKD

colorectal cancer

in the chronopathies and osteoporosis

so

just want to

not due to you

to know that

if you are doing a test for metabolic syndrome

please do include finding people with

also with ample d by by checking for the asdld

and the ultrasound of the liver

not only that uh why do we treat Malfo

because when

when the deceased progress it goes to become a

if there's a lot of fibrosis

then it it will produce a severe liver disease

which will later on uh go to cirrhosis and ACC

so uh

so that the the goal is from fibrosis we want them

why want to bring them down to steato

hepatitis and then going down to a hepatic steatosis

so these are the very important thing to do

which is the non pharmacological approach

because this is the core

this is the cornerstone of treatment

so we need to have a weight loss

we don't only tell patients to lose weight

we have to tell them

we should have a target weight loss uh

target weight loss

so uh if we want to improve statosis

we want to to reduce the the fat in the liver

we have to decrease the weight by 3 to 5%

but

and if you want to improve the histopathology features

such as you want to decrease fibrosis or the degree of

uh inflammation

then you need to decrease the weight to a 7 to 10%

so that it is very important to

emphasize on the target weight loss

not only just telling them to lose weight secondly

exercise exercise alone may prevent a reduces slatosis

but its ability to improve other aspects of

liver astrology needs further investigation

so when you tell them to exercise

need to tell them that it

they should have a structured exercise

or they should go to a

somebody who can help them in the gym

so they should exercise around uh 150 minutes

uh in a week so that means that maybe you can do a uh

two forty five minutes or

uh three forty five minutes or uh

I'm sorry 1:21

20 minutes per week so that you need to do a 40

40 minutes three times a week

so you can buy 40 minutes three times a week

or you can do swimming 40 40

40 minutes three times a week or you can do Zumba

40 minutes or three times a week

or one hour twice a week

so that is that is the cornerstone

so these two these two areas we should emphasize

now how about bariatic surgery

it can be considered in otherwise eligible

obese individual with my phone

it's the premature and to consider bariatic surgery

the type safety efficacy are not yet established

so that it's still difficult to

recommend a certain type of biotic surgery

and in patients we compensated

Nash or cryptogenic sclerosis

biotic surgery may be considered case to case basis

because it may cause more harm than good

so uh when do we recommend bariatric surgery

if the BMI is greater than 40

if if while if the BMI is more than 35

but plus obese obesity related comorbidities

the patient is hypertensive and BMI is more than 35

then we might uh

send them to uh for uh bariatric surgery

so

because a small

prospective studies has already showed that there's in

there's improve instrule resistance

liver function test

and it really improves the path of cerepathic

seposis and fibrosis no

but then it's a because there's no well designed

randomized control trial

and we cannot recommend what particular

bariatic surgery to do

also because our patients are wise

they weight there will be rate weight regain

because they will adjust their eating habits to the

to the size of their stomach

so that usually patients are regain their weight

so that's about uh non pharmacology and a bariatry

now we go to pharmacology

you have this four uh types of uh treatment or

or uh medical treatment

1 is a standard treatment for metabolic syndrome

which targets the

the um targets sugar fasting diabetes

so that my included on this area is metformin

people are setting mob DPP GLP

so we can use this if our patient has diabetes

then secondly is a traditional herbal

uh included in this list is uh automeric or uh

in a set of sustain okay

uh the other thing uh

I'm not uh really part uh familiar with and

and another is the hypotheprotectives which we use for

for the longest time we use EPS in the marine vodka

vitamin B um dotation same

and uh there are new things that uh

on the block

that still investigatory of betacolic acid uh

and so on so because uh

there's inconsistent evidence for standard medication

using comorbid conditions is not for uh

traditional agents uh

while the traditional agents are

lack supportive research

the only thing we can give

at this moment are the hypata protectives

it is it remains to be important

reliable part of our treatment

so you can see that uh

on the left left hand side this

the mechanism of this all this uh gamut of drugs

so No. 1 on the left hand side

we want to decrease the free fatty acid in our body

so we so on the left hand side is diet

exercise and weight loss or weight

or drug that induce weight loss

well uh

we can also give uh uh

antioxidants because we want to target the oxidative uh

stress uh

this includes a vitamin E

eps limarine

uh their mode of action is uh towards uh

uh be having antioxidants

uh and then uh lower down is uh

they say that uh bacterial translocation also uh

is have a role in this in in national

some are already advocating uh

the use of probiotics on a higher up

you can see that on the right hand side

that insulin synthesizers

metformin and the other side is also the antioxidants

so just to tell you of all this

this

these drugs on the market

you can see that on the vertical line

you can see that level of existing scientific evidence

low from below is low medium high

very high you can see where EPL stands

it stands on the middle medium existing evidence

while others like Silly Marine is on the low side

well if you see on the horizontal

uh lack of improvement low probability

medium probability high probability of improvement

or very high probability you can also see that uh

EPL is on the medium probability

compared to other medication suites

they did not have they were not able to prove their uh

their drug to be uh improve

uh in a randomized control

randomized control trial to be uh effective no

so uh what is the medical mechanism of action of EPL

so it it

incorporation of EPL

into the damage membrane of the liver cells

so that it uh

helps in the restructuring of the damaged membrane

it increased the cell membrane fluidity

it increased transmembrane exchange in

stimulate liver cell regeneration

that's why it uh it uh

reinstate metabolis metabolism

and then enzymatic process to restore and maintain

liver function

it stimulates regeneration of the liver cells so that

to restore and maintain liver integrity

and likewise it protects from hepatotoxic compounds

the restoral maintain liver resilient

so this is the main uh uh

motive action of this disease

as this is a very important study

it involves the liver biopsy

because who wants to have a liver biopsy

because before they need to uh

do a liver biopsy

so that they will be able to document

if the fibrosis has improved or not

so this study

comprise of 30 patients with histologic proven

fatty liver disease who are diabetic and

but HBS negative or not hepatitis B patients

so these patients the the first

document that they have

fatty liver by doing liver biopsy

and then they give 1,800

milligram per day for 6 months of BPL

after which they do another biopsy

and you and it shows that the

the esthetos is the amount of fat actually decrease

um there's a reversal of stenosis when you give EPL

in this study

so uh this is another studies

uh Central Force Philippines

a supportive adjunct management of uh

patients with now for the

this is uh I think uh

very very recent

this is uh 19 uh

this is 2,015 uh

this uh

they they group the patients with navaldy alone

navaldy with diabetes navaldy with dyslepidemia

and then they give uh the regular uh

standard diet and physical

of the activity of 30 minutes walking

5 times per week

and they give a high dose of EPL

of 1,800 of BPL daily for 24 weeks

and then they bring it down to 900 for the

for another 48 weeks and they

they check for the outcomes

which is the aotsd ultrasound and fibrous fibrosis scan

so in all in all category

you can see that there's improvement

whether it's belong novelty

diabetic novelty disability big novelty

when they check the ultrasound

they see that the fat infiltation decreased no

in overall at a at a at a rate of 29 point

okay so

our EPL is an essential component of all cellular

subcellar membranes

that's why it incorporates to our liver cells

that's why it helps in healing

so the mode of action is

actually helps in the repair or regeneration of damage

liver cells

and uh it is very uh

highly uh bioavailable

it's 90% absorb in our body

uh compared to silly marine and uh uh same

uh it was proven to decrease altsd and GGT

it is uh it was able to improve the lipid profile

it was able to improve the stenosis and fibrosis

it was also able to improve the

as an adjunct to to diabetes treatment is

improves the clinical outcomes

and also it was able to prove that histologically

it was able to decrease stenosis

and you can take it with or without meals okay

it is safe

it is no drug

drug interaction compared to Silly Marine and others

so because of that our EPL is already included in the

in the many guidelines in the

in the guidelines of enough of the

in other countries such as in Russia

in China in Latvia and Poland

so they are already included in their guidelines

but for us and us uh

it's still not yet uh uh

they

the USD still has to

needed more studies for them to be

convinced that EPL really works

but then in other countries

they already included their guidance

so uh currently

there is no stop this pharmacological treatment

uh but evidence shows that positive effect of back

autoprotectants maintaining lose

maintaining weight loss of 5 to 10% is important

to improve astology

moderate physical activity

moderate physical exercise improves

markers of insuring uh

sensitivity in my phone

that's why it also it helps in improvement of uh

fatty liver uh

colalic

caloric restriction is the main driver for weight loss

and these are all adposities of cutaneous fat

and liver fat reduction so um

so in summary muffal is a pre existing pandemic

even as we don't know that

because of it is highly associated with obesity

muffal continues to increase in prevalence

and worse during Covid because of people were inactive

lifestyle event

intervention

remains the cornerstone of the treatment of my faulty

which is to eat less to lose weight to exercise

then also in our part we can then give an adjum

if you want to give an adjum

if the patient can afford them

please do choose a medicine that has studies like EPL

which has a little

I've shown you all the studies that

they were able to do

so with that

I want to thank you for your kind attention

I would be glad to answer any questions

thank you thank you very much

Doctor Julius sir

sorry I know for the very competitive lecture

okay let's proceed with our some of the questions here

uh prepared by our colleagues

okay a first thing to ask our question

doctor is the very common is uh

a segregational of his specialist uh

is partially reversible

no uh

they say it's fat it

it can so fat deliver

there's a spectrum right

there's a fat deliver

then uh

so there's a fat liver then if you have a fat liver

then you will have uh

inflammation and there's a fibrosis and there

and then you go to the extreme cirrhosis

from fat liver stenosis to mild fibrosis

it is reversible

but onwards it is irreversible

okay that's a very clear

thank you very much doctor for your kind insight

doctors do you have any question regarding the election

if you want some clarification regarding the

new name and picture on

the metabolic association with disease

and its management so yeah yeah stop that

I'm going to ask them what is

how many months from first diagnosis of my phone

what did the management

did you hear that doctor

how many months how many months

how many months do hold on let me just use the mic

good

evening

abdominal ultrasound doctor

how many months should they uh

contact with after 5 days

uh that after diagnosing it

oh then um

um patterned on the status

if the management was effective or not yes

the pattern to the studies uh

they usually do the repeat uh

monitoring of the not only the the ultrasound

but also the uh

liver function test liver every 6 months

but every 6 months yeah

but but um

uh we don't do uh

ultrasound as a guide to see improvement okay

so the

the the parameter to say that there's improvement

it's actually is the loss of inflammation

so sgbt and a L t s g o

t is the parameter that tells us that

there's inflammation if the if the liver is inflamed

the sgbt will go high so once you treat with EPL

you want to know if you have already

if you have controlled the information

so the test to be

the test that should be done is actually SGPT and SGOT

now if you want to know if there's

there is a reversal of stentosis

like what I'm telling you from fibrosis

if there's a reversal of from mild fibrosis

it become uh

uh stenosis right

or no fibrosis so you have to request for a fiber scan

no fiber scan is a

it's a kind of special ultrasound which can uh uh

actually uh

it's a it's a astography which means that it

it does

sends a autosound signal to relieve liver cells

and it goes back to the to the to the receiver

then if the the if the liver is stiff now it's hard

then you will have a

then the fibrosis score will be high

but if there's a low so there will be no fibrosis

so that if you want to know if the

if there's reversal in this histologic features

then you have to request for a fiber scan

and I do fiber scan every year

okay that's good doctor

that this is available here in Beagle

is that correct yes okay

yeah

it's available

I have a question here

doctor from our from the chat box okay

coming from okay good evening doctor

thank you doctor for the very good lecture

question lamp

what is the recommended age to take essentially

thank you very much

uh I'm not particular with uh

don't know about uh really pediatic patients but uh

I usually give uh

EPL when the when the patient is heavy enough

like if there are big kids like uh

uh 50 kilos above yeah

but then I

I'm not sure job it maybe you can help it out

yeah me

help me out with information

in terms of the judic doses here

based on the patient information detailed

and then as we also recommend

the age starts from 12 years old in a Bob

so we have no studies that should be taken 11 years old

middle so as recommended

12 years old and above to be taken 2 capsule

3 times a day

so total of 1,800 mg

any more questions for a clarification

about what

and something that bothers you about mouthful

hypothe protectors management

okay doctor the question is

they recommended dosages to capsule three times a day

or total of 1,800 mg the question is doctor

if uh can they lower the dose

from one template or one capsule or two capsule per day

so based on your recommendation

and make sure that that's

what is your comment on this

yeah thank you for that question because uh

you can see that uh because of

because essentially has been

or EPL has been there for a long time now um

and then it be actually in a while

it became a over the counter medicine right

so that them it is actually given as a

as a non therapical

you can just give once a day or twice a day

but then because of that before

they were not able to see a significant improvement

with that low dose

uh

with regards to a L t with regards to astology now uh

now they're advocating a high dose because they

they found out that if you give a high dose

then there's really improvement

so maybe the

those that were using before is not high enough

that's why the studies were not really that good

the the results of the studies were not good

but now 2,015 2,020

all these studies are using 1,800 milligram EPL

and they and they show these results

so you know uh

because of that uh

I cannot recommend to have the same result

if you have a if you gave a

if you give a lesser dose because that is a

this is according to the studies

our recommendation is according to the Statistan

okay the player

I have a question here from the chat boss area

how about study regarding pregnant patients

well okay

she go to the doctor I can answer that for you so

okay so basically based on again

from the patiently

that it is not recommended for pregnant women

so just to be sure just to be

any more question doctor

I hope I was able to to answer clearly the questions

yeah if you have follow up questions please do so

you can reach Doctor Julius in Naga

so are you okay now doctor

okay

I think I was

I think doctor

that is the last question that from the group

and thank you very much doctor for reaching out for us

and at this point of time

thank you doctor for increasing this location

and give this a chance to show to us

the effectiveness of hepathoprotectors

in treating metabolic associative fatabilities

and the importance of pro active liver care

again Doctor Julius

thank you very much hope to see you soon

our future activities enjoy your dinner

we're having dinner here okay

thank you thank you for kind

let's hear our Territory Manager for that here

um good evening doctors again

uh internet

first I would like to thank our doctor

Doctor Julius sponsor Yana

for giving his invaluable sign to share his experience

it's been an honor

and privilege to have you as our speaker

second I would like to thank all the doctors

who participated in our IPD

and it's been a pleasure for giving us the opportunity

to to be part of your CMP activities

on behalf of Professional Insights

Marketing Services

Incorporated and Sandalpi Consumer Healthcare

we are indigrateful to the doctors of Saug

this is done together with our MCE surgeon Jonas

and Sir James