Liver Health: Key To Controlling Type 2 Diabetes

Susan Kim, MS, RDN, CCTD

Thank you, Dr. Will. My name is Susan Kim. As Dr. Will has mentioned, I’m a registered dietitian. I’m also a program manager for the Living Donor Wellness Program at the U.S. Transplant Institute. I help living-organ donors improve their health markers for candidacy. Then, before the Transplant Institute, I worked with Dr. Valter Longo at his research institute, and I’m also his former student. I’m happy to be here.

William Hsu, MD

Well, fantastic. You said quite a lot. The living donor and the liver. Tell us, why do we need living donors? What is that program about? Certainly, I’ll make sure to channel our conversation back to the interest of people living with type 2 diabetes.

Susan Kim, MS, RDN, CCTD

Sure. There is an organ shortage and over 100,000 people are on a waiting list for a kidney or a liver transplant. One of the most viable options for this issue is a living donation. Many times, family members, friends, or even strangers come forward to become donor candidates. However, because of the rates of obesity, diabetes, and fatty liver disease, a lot of these patients come through our evaluation, and they’re not candidates. Although this is a great solution for the organ shortage, we’re coming across barriers like chronic diseases and obesity that we’re trying to tackle. That’s where our living donor wellness program was created—to help donors optimize their health for our donation but also for their long-term health as well. We want them to be healthy after just the surgery.

William Hsu, MD

What an interesting angle here. There is an organ shortage, and you’re inviting people to be donors. But it is the same thing that impacts our society in general. The obesity and diabetes epidemics are also impacting the donor population. That’s an interesting way to look at the challenges of our society. We’re seeing that about 70% of the U.S. population is dealing with either overweight or obesity. That’s a challenge when you want to donate your liver.  To help other people, maybe a loved one, and others. 

The reason I stumbled across this is that USC, the liver transplant center at USC, is doing a high volume of transplants per year. I think it is one of the busiest centers on the West Coast. if you want to help your donors reach eligibility because that liver fatty liver situation prevents them from doing so. Maybe let’s start with kind of basics. What is a fatty liver? How does the liver get fatty, and how common is that problem?

Susan Kim, MS, RDN, CCTD

It affects about 40% of the population. It’s when there is excess fat infiltrated in the liver and an excess fat of over 5%. That’s considered, another word for fatty liver is hepatic steatosis, and that can progress. If you have had a fatty liver for a long period, it can increase inflammation and scarring. But what we do is we want to capture that early, and that can be reversed with diet and exercise. Many times, it’s an unhealthy lifestyle that has contributed to their fatty liver, obesity, poor diet quality, physical inactivity, and all of the other factors I mentioned. All of these factors can be reversed with a healthier diet or physical activity. Then one of the interventions that we’ve used is the fasting-mimicking diet as well.

William Hsu, MD

Yes, so we’ll come back to that in a second. This is interesting. 40%—you’re talking about the US population, 40%?

Susan Kim, MS, RDN, CCTD

Yes. 

William Hsu, MD

That’s amazing. That is incredible. That’s a very alarming number. But do you have it on the top of your head? What about the percentage of fatty liver in people with type 2 diabetes? I can only imagine that it is probably the same or higher.

Susan Kim, MS, RDN, CCTD

I think the estimates. Yes. Many people don’t realize they have fatty liver disease or diabetes.  There’s a percentage of people, and we’re kind of estimating that there are 40% or more. I’ve been in an interesting situation or opportunity because these are people that are coming from the general population. We don’t do extensive imaging blood work. It is the most comprehensive physical examination you will ever get when you decide you want to be an organ donor. One of the imaging procedures that we do is an MRI. 

Most people do not get an MRI until it’s indicated. We have people as young as 18 years old coming in for MRIs. I have this unique opportunity to read these reports and see that they have excess fat in their liver, which normally would not be captured in a regular physical exam with their primary care because they’re not doing MRIs. I’ve seen 22-year-olds that are of normal weight. They have a BMI of 21, and they have over 20% liver fat, which is high. Mild, close to moderate.

William Hsu, MD

How do people get diagnosed? I mean, you mentioned MRI, but that’s not a routine test that the doctors monitor. Our listeners, who are living with type 2 diabetes. What should they look for, or how should they advocate for themselves in front of their physicians? What tests should they be looking for?

Susan Kim, MS, RDN, CCTD

Blood work. We check their blood work. There’s a comprehensive metabolic panel that checks for liver enzymes. Sometimes the liver enzymes are normal, and I still see donors that have access to fat in their liver. Also looking at your fasting glucose, hemoglobin A1C, other risk factors are a large waist circumference for women and an excess waist circumference of over 35 inches for men over 40 inches. We also measure body composition at our clinic so that we can see the percentage of body fat where the weight is distributed. There are a lot of tests and markers that we can look at to see if they have something called metabolic syndrome, which puts you at risk for diabetes and fatty liver disease.

William Hsu, MD

It’s just way too common. There’s this challenge, but being unaware of this risk factor or this health condition is yet another challenge. For people with type 2 diabetes, there are so many carriers and so many other comorbidities; sleep apnea is another one. We have another episode addressing that, and certainly, periodontal disease is another one. Yet here, the fatty liver is yet another challenge. Let’s talk a little bit about what happens if unchecked and diagnosed and continues for a long time. What happens to somebody with a fatty liver and what are the complications? It’s in store for those who don’t get checked out and don’t take care of this specific condition.

Susan Kim, MS, RDN, CCTD

It can lead to inflammation of the liver, or we will see the liver enzymes elevated, and over some time, the inflammation will continue, which will lead to fibrosis or scarring in the liver. Then that can lead to end-stage liver disease. I also see recipients as well. I see patients with end-stage kidney and liver disease, and many of those patients have type 2 diabetes and have had type 2 diabetes for many years that’s been uncontrolled. Liver health and diabetes do go hand in hand because a lot of those metabolic markers overlap.

William Hsu, MD

That’s an important message there. These two conditions, even though they have separate names, all come from this disturbance of the metabolic balance in the body. Let’s talk about the diagnosis. You talk about the definition; we talk about the consequences. What do we do about it? As a dietician, by the way, is there a drug now approved for the treatment of fatty liver, or is it all dietary?

Susan Kim, MS, RDN, CCTD

Is the standard of care, diet, and exercise, 7–10% weight loss, and changing your dietary habits to healthier patterns, like the Mediterranean diet?

William Hsu, MD

This is why we’re having this conversation. The power is in your hands, our listeners. It’s not something that a physician can prescribe for you; they could just take care of it the next day. This is something that’s within your grasp, and you can control your destiny. This is where the stand in the next 10 minutes is probably going to be the most important conversation around this. As a dietician, you have many different tools. From a dietary perspective, let’s always talk about some of these things: weight loss, nutrition approaches, and then the fast-mimicking diet, let’s go there.

Susan Kim, MS, RDN, CCTD

As you mentioned it. Nutrition is a powerful tool. I start with empowering patients to let them know all of this is completely in their control and to utilize these tools. The first thing I do is start with education, and I educate them on healthy dietary patterns, such as the Mediterranean diet. I also assess their healthy lifestyle systems, what is in place, and what’s working. I look at gaps. What could be contributing to their healthy or unhealthy lifestyle? Is it a time factor? Do they need to improve their time management? Are they not getting enough physical activity? Are they not choosing the foods and following these healthy dietary patterns? I see where the gaps are. 

Then we work on educating them on healthy carbs, proteins, and fats, and reading food labels. I believe that’s the foundation of nutrition. Then, once we have a baseline or foundation in place, I monitor. Then I also use additional tools like the fasting-mimicking diet that can help boost weight loss and improve their health markers if their weight loss has plateaued; it’s helpful as well. I think it also boosts a lot of confidence, too, because the results are pretty remarkable in a short period. Yes, I just build a strong foundation for them and nutrition and then use these additional tools.

William Hsu, MD

The most important thing I hear is that this condition is reversible through lifestyle changes.

Susan Kim, MS, RDN, CCTD

Yes.

William Hsu, MD

That’s such an important message here. It’s reversible. You have to take action now. Susan, you mentioned that weight loss is critical. You mentioned the Mediterranean diet. But we also know that it is challenging to adhere to everyday lifestyle changes. If our patients and our listeners could have done that from day one, they wouldn’t have developed diabetes. Now the way bag is again, the strict regimen of these dietary changes, and this is where I feel the relevance of the fasting-mimicking diet comes in. 

Susan, can you tell us what fasting can do for your diet? As many of our listeners have heard about this reference to the fasting-mimicking diet from a research angle from being a student with Professor Valter Longo, tell us a little bit about the fasting that it can go through.

Susan Kim, MS, RDN, CCTD

I think the five-day diet is structured every day. Every day is carefully planned. It’s a diet in which you get the benefits of fasting while still eating a minimal amount of calories, between 700 and 1100 calories. It can help increase and boost metabolic markers, reduce waist circumference, promote weight loss, and promote your health and longevity. It was, and it’s backed by 20 years of research. I also like the diet because it’s very structured. I know that it’s safe. It’s gone through clinical trials. I know exactly what my patients are eating. There’s been so much research and so much information in the media about the benefits of fasting, but I always worry about how my patients are fasting. Is it safe? I feel a sense of relief when I’m able to give them something that I know is proven to be safe and efficacious.

William Hsu, MD

It looks like this five-day fasting is a precision medicine or traditional position nutrition, as I should say, that gives you the benefits of fasting without actually going through the five-day water-only fast and structured meal plan. One doesn’t have to go shopping. You don’t have to go figure out what to eat every day in the five-day box. A lot of people are maybe asking, Is it the same as intermittent fasting? Why can’t I just do intermittent fasting? Susan, your mind is five-day mimicking fast versus just intermittent fast. Do you see similarities or differences, and how do you differentiate them in the program that you run?

Susan Kim, MS, RDN, CCTD

There are different ways to fast. There’s a 5/2-day diet, two days out of the way. You’re eating 500 calories or less. Some people fast every other day and consume 500 calories or less. I like the fasting-mimicking diet because you’re not doing it weekly. You’re doing it once a month until you reach your goal, and then you can do it periodically as a boost. I think it’s more feasible for people to sort of have this mindset of, okay, this week for five days I’m going to be fasting and then I don’t need to do this until next month, or I’m going to do a three-month monthly cycle of this. I think doing it every week can make you a little fatigued. I see that with patients where it’s not feasible long-term. I think that with the fat diet, it sort of eases that fatigue.

William Hsu, MD

It looks like people have to kind of schedule ahead a little bit. Plan out when those five days are going to take place. Now in your program, what do you do for people for the rest of the 25 days?

Susan Kim, MS, RDN, CCTD

I adjust their regular diet to go to a healthier dietary pattern similar to the Mediterranean diet. We start with that. I model, and I help them educate them on what a healthy diet looks like. Once they are well established in that area, we can introduce the fasting-mimicking diet, because I think after that, the fast is just as important as those five days. After all, you want to maintain those results. I think if you have that baseline of nutrition education and then incorporate the fasting-mimicking diet, it’s much easier to transition after the diet.

William Hsu, MD

That’s fantastic. I know that, as in academic centers, you guys always have outcomes. You look at progress, you evaluate your program, and that leaves. You also submitted an abstract for a presentation for potential donors. They have gone through a fasting-mimicking diet. Is there something you can share with us? Is it a kind of public knowledge?

Susan Kim, MS, RDN, CCTD

Here’s the way we have used the fasting-mimicking diet with a few of our donors, and we’ve seen a reduction in 50 to 75% of their liver fat in 2 to 3 cycles. That is, you’ve got to remember that.

William Hsu, MD

You’ve got to repeat them. You’ve got to repeat those numbers. Those are what you said?

Susan Kim, MS, RDN, CCTD

It’s a 50–75% reduction in liver fat. In addition to fasting and mimicking diets, we’ve also integrated the Mediterranean diet as well. I think those two factors have contributed to the results being extremely impressive. Yes.

William Hsu, MD

This is pretty amazing here in 2 to 3 cycles. You talk about a 2- to 3-month period. You’re combining the five-day fast-mimicking diet with a Mediterranean diet pattern of eating. You’re able to reduce 50 to 70%.

Susan Kim, MS, RDN, CCTD

Yes. That’s a unique opportunity in a situation where we are evaluating living donors. We do this. The MRI testing can be done in the following month.

William Hsu, MD

Yes.

Susan Kim, MS, RDN, CCTD

I don’t think there’s any other clinical setting where they would do it so quickly and retest so quickly.

William Hsu, MD

Do you find these donors to be especially motivated because they have somebody they care about? That they want to get parts of their liver, too? Are they super motivated, or do you think they’re just run-of-the-mill motivation?

Susan Kim, MS, RDN, CCTD

But there is another layer of strong motivation because they’re doing it for a loved one. But it is something that many of the donors will tell me. I’ve been thinking about losing weight for a long time, and what better opportunity than now? They think of it as I get to help somebody I care about. I also get to help myself. I’m improving in this process, so it becomes a win-win situation.

William Hsu, MD

It is a win-win. That’s amazing. Well, this is interesting because, with a low-calorie diet, you could reduce weight, but there seems to be a very specific effect on the liver through fasting. Maybe you can share with us, on average, how many pounds people lose after two or three cycles. I mean.

Susan Kim, MS, RDN, CCTD

They’re.

William Hsu, MD

What is its number?

Susan Kim, MS, RDN, CCTD

Five to 7%, which is the target that we’re looking for?

William Hsu, MD

Yes. We’re not talking about 20 or 30% body weight loss.

Susan Kim, MS, RDN, CCTD

No. Just 5 to 7% can make a significant impact on your liver fat.

William Hsu, MD

This is the important point here. You don’t have to put in a Herculean task to achieve a reversal of the fatty liver, which is 5 to 7% of weight loss. In my mind, this combination of the five days of fasting that has a specific target for the liver and then the modified Mediterranean diet could be great. Just a 5–7% reduction in your body weight can lead to a 50–70% reduction in the fat in the liver. This is amazing.

Susan Kim, MS, RDN, CCTD

It’s significant. As you said, you don’t have to lose 20, 30, 40 pounds. Even 5% will make a huge impact on your liver fat, your bloodwork, your health markers, and your metabolic health. I think with the fasting-mimicking diet, another point that I wanted to add was that we also know the body composition. I can look at the skeletal muscle mass. We don’t see a reduction in that skeletal muscle mass. We don’t want to see muscle wasting during fasting or through any sort of diet. I see a reduction in fat, the body fat percentage, and I don’t see any fluctuations in muscle mass.

William Hsu, MD

Yes, this is a very important point. The research studies with the fasting-mimicking diet show that there is visceral fat reduction. Now remember, liver fat is part of the visceral fat. part of the fat that’s in the organ system surrounding the organ system. There’s a reduction in visceral fat. It’s fat-driven weight loss. Number two is that you will also maintain muscle mass, unlike with a chronic, low-calorie diet. Just five days of stress causes growth hormones to go up, and the growth hormones then protect the muscle mass, in contrast to an everyday low-calorie diet where the body is going to go to the muscle and burn the fat, and the body is going to go to the fat and burn as a source of energy. What I get is a unique mechanism of action here. 

This is terrific news for all listeners. Type 2 diabetes and liver health go together. When you do the same thing, when you introduce that intervention through the fasting-mimicking diet and then through the Mediterranean diet, when you put it together, it treats both. It supports both conditions. What great news there. At the Liver Donor Center, how many people are you helping each cycle? Are you looking for blood donors, in other words?

Susan Kim, MS, RDN, CCTD

Yes, we are. We’re always evaluating whether our program is growing. I think there’s been a lot of outreach with donations nationally, too. There are also even other donor centers looking to help donors improve their metabolic health. That’s been a big conversation in living donation nationally. I think this is an important topic. Organ donation or liver fat. I think the difference between liver donors and kidney donors is that you don’t have the same safety net as kidney donors and dialysis recipients. It is an urgent need to increase the number of liver donors we have nationally. I think with interventions like fasting-mimicking diets, I’m just glad that I’m able to provide an additional nutrition tool for patients because sometimes just the Mediterranean diet does it. Is it effective? I’m able to bring in additional tools and resources to help our donors. I think it provides and creates more opportunities for people.

William Hsu, MD

I can imagine that this must be fulfilling work that you’re doing, helping not only people to receive healthy livers but also helping the donors to take care of their health. This is such a win-win situation. I want to thank you. Yes, yes, I can imagine. Yes. 

But Susan, I wanted to thank you for all you do, and the information you share is so relevant to our listeners. Many of them probably have not realized that there is this common origin—this metabolic syndrome—that drives type 2 diabetes and also the fatty liver. not surprisingly, The path to returning to true health is still fundamental. It’s dietary. While we have this tried-and-true Mediterranean diet, it’s been tested in so many different clinical trials. Now we also have this emerging tool called the fasting mimicking diet in its various forms to help people not only reverse insulin resistance but also address some of the root causes of these metabolic conditions. 

Well, thank you, Susan. I want to do that again to just thank you for all you do here. If people wanted to learn more about what you do or about your Liver Donor Program, where could they find out more about this exciting program?

Susan Kim, MS, RDN, CCTD

We have a website in the U.S. Transplant Institute at Keck Medicine of the USC. I can be reached by email. My email address,  I can share with you. [email protected]. I’d be happy to discuss this in more detail with any potential liver donor candidates. 

Thanks for having me. I think this is an important topic, liver health, and I think I’ve been in a very unique situation to be able to see how quickly these changes can be made with just a few small changes in a matter of 2 to 3 months. Thanks for having me and letting me share.

William Hsu, MD

Thank you. This will conclude this episode of Reversing Your Type 2 Diabetes Summit 2.0. Until next time.

Susan Kim, MS, RDN, CCTD

Thank you.