Detoxing the Liver
Many proponents of natural health care recommend liver flushes, involving lemon/citrus juice or apple juice, water, and garlic, ginger, or cayenne to promote liver function. A simple way to gauge liver function is through stool color. Stools should be dark brown, according to International Wellness Directory, a webpage from the non-profit Minnesota Wellness Publications, Inc. Gray, yellow, pale brown, or dry and hard stool indicates too little bile, a sign of liver problems. Before doing a liver flush or similar detoxification regimen, it is important to support kidney and bowel function. Good kidney function and regular, timely bowel movements are necessary so that released toxins can be excreted without causing further damage. Liver flushes, however, are not the only way to detox the liver. Another option is to make daily choices that support liver health.

Some of the suggestions for liver care are the same as for any health regime: exercise, deep breathing, and the avoidance of processed foods. Beet juice, alfalfa juice, and wheat grass juice benefit the liver, according to International Wellness Directory. Diluted lemon accelerated hepatobiliary excretion in a 2006 Taiwanese study. A Japanese animal study found that lemon also protects against oxidative stress. Eating patterns also affect the liver. Overeating strains the liver. Fasting and small meals give it a rest. Supplements that can provide long-term support for the liver include liver extracts from organically raised and processed animals and milk thistle. In his newsletter Health and Healing (April 1993), Dr. Julian Whitaker recommends 200 to 250 mg/day of milk thistle (silymarin) for about a month to clean and rebuild the liver and then the same dose for just two or three times a months for liver support. People with damaged livers may need to take a higher dose (200 to 350 mg/day) for three to four months.

Cherng SC, Chen YH, Lee MS, et al. Acceleration of hepatobiliary excretion by lemon juice on 99mTc-tetrofosmin cardiac SPECT (Abstract). Nucl Med Commun. 2006 Nov;27(11):859-64. Available at: www.ncbi.nlm.nih.gov. Accessed September 11, 2007.

International Wellness Directory. Cleaning house – the correct way to detox. Available at: www.mnwelldir.org/docs/detox/clean.htm. Accessed September 4, 2007.

The Liver and Detoxification. Available at: www.liverdoctor.com/index.php?page=liver-detoxification. Accessed September 4, 2007.

Miyake Y, Yamamoto K, Tsujihara N, et al. Protective effects of lemon flavonoids on oxidative stress in diabetic rats (Abstract). Lipids, 1998 Jul;33(7):6879-95. Available at: www.ncbi.nlm.nih.gov. Accessed September 11, 2007.

Alpha-Lipoic Acid (Thioctic Acid) and the Liver
For over 30 years, Burton M. Berkson, MD, PhD has investigated the use of alpha-lipoic acid (ALA) to treat liver damage. His interest began while attending a patient with acute hepatic necrosis due to mushroom poisoning. The department chief told Berkson, then an internal medicine resident, that the man would probably die soon. Berkson, a former mycology professor, recalled an article about ALA and its use in Europe to treat severe liver damage. He managed to get ALA from Fred Bartter, chief of endocrinology at the National Institutes of Health (NIH), and administered it intravenously 30 hours after the man had eaten the mushroom. The man began to improve within an hour. He was discharged with almost normal laboratory values not long thereafter. The next weekend, Dr. Berkson had two more people with severe liver damage from toxic mushrooms. Berkson ignored hospital authorities' orders not to use ALA, and the couple quickly recovered. Berkson's results piqued NIH interest and led to a collaborative research arrangement with Dr. Bartter. Some time later, the Food and Drug Administration (FDA) granted Dr. Berkson the investigational drug permit for intravenous ALA.

In "Alpha-Lipoic Acid (Thioctic Acid): My Experience With This Outstanding Therapeutic Agent," Dr. Berkson says that ALA is a common treatment in Europe for liver damage. In his own practice, he has used it in the treatment of chronic hepatitis and liver cancer as well as mushroom poisoning. Conventional treatment for chronic hepatitis (interferon and antivirals) has less than a 30% response rate, according to his October 1999 article in Medizinische Klinik. Liver transplants do not provide a permanent solution, because some hepatitis virus continues to circulate in the blood and will infect the new organ. Dr. Berkson reports the successful use of "a conservative triple antioxidant approach": 600 mg of ALA, 900 mg of milk thistle extract, and 400 mcg selenium in two or three divided doses per day. (Vitamins C and E and CoQ10 may also be helpful.)

Dr. Berkson and colleagues also published a case report about the use of intravenous lipoic acid and low-dose naltrexone and its possible contribution to the long-term survival of a man diagnosed with pancreatic cancer with metastases to the liver: "The patient was told by a reputable university oncology center in October 2002 that there was little hope for his survival. As of January 2006, however, he was working again, "free from symptoms, and without appreciable progression of his malignancy." Dr. Berkson believes that widespread use of high-dose, intravenous ALA therapy would decrease the need for liver transplants.

Berkson BM. Alpha-lipoic acid (thioctic acid): My experience with this outstanding therapeutic agent. Journal of Orthomolecular Medicine. 1998; 13(1): 44-48. Available at: http://orthomolecular.org/library/jom/1998/pdf/1998-v13n01-p044.pdf. (110KB .pdf) Accessed September 1, 2007.

Berkson BM. A conservative triple antioxidant approach to the treatment of hepatitis C. Combination of alpha lipoic acid (thioctic acid), silymarin, and selenium: three case histories. Med Klin. October 15, 1999;94 Suppl 3:84-89. Available at: www.health-science-report.com/cgi-bin/alotek.cgi?topics=7&article=306. Accessed September 12, 2007.

Berkson BM, Rubin DM, Berkson AJ. The long-term survival of a patient with pancreatic cancer with metastases to the liver after treatment with the intravenous lipoic acid/low-dose naltrexone protocol (abstract). Integrative Cancer Therapies. 2006; 5(1):83-89. Available at: http://ict.sagepub.com/cgi/content/abstract/5/1/83. Accessed September 12, 2007.

Physician Satisfaction
Time pressures and changes in family structure and expectations have created a crisis in medicine, according to Louis Weinstein, MD and Honor M. Wolfe, MD. In their article "The Downward Spiral of Physician Satisfaction," they say that young physicians are unwilling to dedicate all their energy to work while a spouse has sole responsibility for home and family care. Physicians born in Generation X (born 1964-1980) and Generation Y (born 1981-2001) "are an equal gender mix, with the majority of couples being dual career in nature. Parenting and household chores are equally split." An 80-hour workweek, typical for residents, makes equal sharing of chores impossible. Time pressures at work also contribute to physician dissatisfaction. "There is less time for each patient encounter," Weinstein and Wolfe write, "more time required for documentation to justify reimbursement, more time necessary to deal with practice management issues."

One-fifth of Swiss resident physicians, taking part in a recent survey, said that they regretted choosing medicine as a career (BMC Health Serv Res. 2006;6:98-110). Patient care provided too little gratification, and balancing work and personal life was too difficult. Research by B.E. Landon and colleagues finds that "the dissatisfied physician is two to three times more likely to leave medicine than the satisfied physician" (Med Care. 2006;44:234-42). In addition, physician dissatisfaction negatively impacts patient care and safety.

Dr. Weinstein and Dr. Wolfe see the growing dissatisfaction with the practice of medicine as an oncoming crisis. Their article targets time management in professional and personal arenas as a possible solution. Suggestions include increasing the use of job sharing (as residents and practitioners) and limiting work hours. They also advocate teaching both residents and practitioners how to budget their time and money in order to reduce stress. This article is a plea and a warning. The teaching and practice of medicine has to promote a better work-life balance to attract and keep the next generations of doctors.

Weinstein L, Wolfe HM. The downward spiral of physician satisfaction. Obstetrics & Gynecology. May 2007;109(5):1181-1183.

Glycan Test for Liver Cancer
Cuiying Chen, PhD and colleagues at Ghent University (Ghent, Belgium) are investigating the use of serum N-glycan profiling to diagnose liver cancer in patients with cirrhosis. The researchers profiled N-glycan levels (carbohydrate concentrations) in the blood samples of 440 patients with hepatitis B from four Chinese hospitals and 130 healthy controls. Among those with hepatitis, 143 had liver fibrosis, 80 had cirrhosis alone, and 147 had cirrhosis and liver cancer. Cirrhosis precedes liver cancer in 60% to 80% of all cases. Two glycan concentrations differed significantly in people with liver cancer, compared to those with cirrhosis alone.

This GlycoHCCTest, as the Belgium researchers call it, may improve the accuracy of liver cancer diagnosis. The log ratio between the two glycans differentiates cancer patients from those with cirrhosis alone with 81% accuracy, according to the article in Hepatology (August 2007). Serum a-fetoprotein (AFP), the test presently used to diagnose liver cancer, has a diagnostic accuracy of 78%. The researchers claim that the GlycoHCCTest can find about 50% of liver cancers missed by AFP. Using both tests together should provide greater diagnostic accuracy. The researchers were also able to predict tumor stage by using the log ratio and the concentration of the two glycans. More study is needed, however, before GlycoHCCTest is available to practitioners.

Bankhead C. Glycan test may aid diagnosis of liver cancer. Medpage Today. Available at: www.medpagetoday.com/HematologyOncology/OtherCancers/tb/6382. Accessed September 4, 2007.

Hepatitis and Ascorbate
"Viral hepatitis of all types, in my experience, is one of the easiest diseases for ascorbic acid to cure," Robert F. Cathcart III, MD wrote in a 1981 article for Orthomolecular Psychiatry. Dr. Cathcart began using high doses of ascorbic acid to treat a variety of acute viral illnesses in the 1970s. He traces his interest in vitamin C to the research of Fred R. Klenner, MD, Irwin Stone, and Linus Pauling. Dr. Klenner published a paper in 1949, relating his use of high-dose vitamin C to cure 60 cases of polio (available at www.orthomed.com/polio.htm). Dr. Cathcart says that intravenous sodium ascorbate, as much as 200 grams in a 24-hour period, can successfully treat flu, mononucleosis, viral pneumonia, and other acute self-limiting viral diseases – including acute hepatitis.

Jonathan Wright, MD gives an example of ascorbate's therapeutic power in "A Case of Hepatitis" from his Book of Nutritional Therapy. Dr. Wright gave a young woman with hepatitis four intravenous treatments consisting of 25 grams of sodium ascorbate, ten cubic centimeters of vitamin B complex to support the stress of illness, and one gram of calcium over the course of a week. Dr. Wright uses calcium to prevent tetany (abnormal muscle contractions) that can result from high doses of ascorbate. Ascorbate acts as a chelating agent; apparently, it binds to and removes calcium from the bloodstream. In addition to the intravenous treatment, Dr. Wright recommended that the young woman "take as much vitamin C as she could orally." She consumed about 100 grams within the three-and-a-half days after her first doctor's visit. The day after the first IV treatment, the young woman reported that her nausea was nearly gone. Also, her jaundice has lessened, and urine was less brown. By the fourth treatment, about seven days later, her SGOT had declined from 4,580 units (normal is 25-70 units) to 337 units. Even though the woman felt well, Dr. Wright recommended that she continue taking 20-30 grams of ascorbate per day for ten days, then taper down to four-to-six grams and continue at that dose for several months, gauging her need by bowel tolerance.

Bowel tolerance refers to Dr. Cathcart's discovery that the amount of ascorbic acid that a person can consume without producing diarrhea is directly proportional to how sick the person is. Taking more ascorbic acid by mouth than the body needs to fight illness produces a hypertonic situation and diarrhea. Intravenous administration, however, never produces diarrhea. Dr. Cathcart says, "Intravenous sodium ascorbate actually increases bowel tolerance to ascorbic acid orally if administered at the same time." He says that the ideal way to take ascorbic acid orally while treating a serious illness is to sip ascorbic acid crystals dissolved in water almost continuously. In lieu of that, he suggests dividing the daily amount into several doses, given throughout a 24-hour period, at the first sign of illness. Postponing treatment with ascorbic acid reduces its effectiveness.

Dr. Cathcart says that chronic viral hepatitis, unlike the acute infection, needs more that ascorbic acid alone. In addition to high doses of ascorbic acid (by mouth), he has found the additions of alpha lipoic acid, selenium, vitamin E, and silymarin and the strict restriction of sugar helpful.

Cathcart RF. The ascorbate effect in infectious and autoimmune diseases. Available at: http://orthomed.com./auto.htm. Accessed September 4, 2007.

Cathcart RF. Massive Doses of Ascorbate – A Paradigm Shift. From the syllabus of the 15th International Conference on Human Functioning (Wichita, Kansas), September 22-24, 2000. Available at: http://orthomed.com/shift.htm. Accessed September 4, 2007.

Cathcart RF. The method of determining proper doses of vitamin C for the treatment of disease by titrating to bowel tolerance. Orthomolecular Psychiatry. 1981;10(2):125-132. Available at: http://orthomed.com/method.htm. Accessed September 4, 2007.

Wright J. "A Case of Hepatitis." Book of Nutritional Therapy. Emmaus, PA: Rodale Press, Inc.;1979:252-260.

Liver Disease and Parenteral Nutrition in Infants
Researchers at Children's Hospital Boston discovered that fats hold the key to preventing and repairing life-threatening liver damage that develops in some young children with short bowel syndrome. These children require intravenous feedings with two different solutions for months or years until their digestive system can assimilate food. One solution contains vitamins and other nutrients. The other, a soy-based formula called Intralipid, provides calories. Intralipid is made by Fresenius Kabl and was approved by the FDA in 1975. Unfortunately, many children on long-term, parenteral nutrition (PN) eventually develop liver damage.

Another Fresenius Kabl product, a fish oil emulsion called Omegaven, prevents liver disease in the children, according to research by pediatric surgeon Mark Puder and pharmacist Kathleen Gura. In a Pediatrics article (July 1, 2006), Puder, Gura, and colleagues say that the soybean oil may actually contribute to liver damage in these children. "Soybean-based lipid emulsions are comprised mainly of omega-6 fatty acids that are relatively proinflammatory," they explain. "They also contain phytosterols that have been suggested to contribute to liver injury." Fish oil, however, contains eicosapentaenoic acid, an omega-3 fatty acid known to reduce triglyceride production in the liver. It also has enough arachidonic acid to prevent essential fatty acid deficiency, they say. Their Pediatrics article details the histories of two infants whose severe parenteral nutrition-associated cholestasis reversed within eight weeks with the use of Omegaven. Like other infants in this situation, these babies were facing progressive damage that would eventually require liver transplants. No one had expected them to improve. Doctors at Children's Hospital have used Omegaven to treat over 29 infants with parenteral nutrition-associated liver damage successfully.

Dr. Puder and Dr. Gura have asked Fresenius Kabl to apply for FDA approval to use Omegaven in children receiving parenteral nutrition. At this time, Omegaven is considered experimental in the US. Hospitals must ask for FDA approval for each individual patient before using it and then buy the drug on their own, since insurers do not usually cover experimental treatments. Fresenius Kabl refuses to seek FDA approval for Omegaven, because it has another product that it believes will be more effective. The company is unwilling to spend money and time on gaining FDA approval for both products. Fresenius Kabl has sent samples of its preferred product to Dr. Puder and Dr. Gura for use in animal experiments. Faced with infants who need help now, the researchers are unwilling to drop Omegaven, which has shown itself to be safe (so far) and effective and start all over. Dr. Puder and colleagues have received money from the March of Dimes to conduct a clinical trial to assess Omegaven's ability to prevent liver damage in children receiving parenteral nutrition.

Children's Hospital Boston. The right kind of oil (Press Release). July 3, 2006. Available at: www.eurekalert.org/pub_releases/2006-07/chb-trk062806.php. Accessed September 4, 2007.

Gura KM, Duggan CP, Collier SB, Jennings RW, et al. Reversal of parenteral nutrition-associated liver disease in two infants with short bowel syndrome using parenteral fish oil: implications for future management. Pediatrics. July 2006;118(1):e197-e201. Available at: http://pediatrics.aappublications.org/cgi/content/full/118/1/e197. Accessed September 4, 2007.

Marcus AD. A doctor's push for drug pits him against its maker. The Wall Street Journal. November 13, 2006; A1, A15.

Coffee and Liver Cancer Risk
Drinking coffee is associated with a lower risk of liver cancer, even in people with hepatitis. (Hepatitis is the biggest known risk factor for liver cancer.) As little as one or two cups of coffee a day appear to reduce cancer risk among people with hepatitis B and C, according to a Japanese case-control study. Italian researchers performed a meta-analysis using ten studies: six case-control studies from southern Europe and Japan involving 1551 cases of hepatocellular carcinoma and four cohort studies from Japan with 709 cases of cancer. The Italian team also found an inverse relationship between coffee and liver cancer but said, "…inference on causality remains open to discussion." Other studies have associated coffee use with lower liver enzyme levels and a lower risk of cirrhosis, but no one has yet identified the factors that account for coffee's liver-protecting effect. Whether or not decaffeinated coffee has the same effect as coffee with caffeine is unclear. Few people in these studies consistently drink decaffeinated coffee.

Presumably, most of the coffee in these studies is conventionally grown using pesticides. However, Fair Trade and organic coffees have become increasingly popular. Fair Trade certification guarantees participating coffee farmers and cooperatives at least US $0.10 more pound for their coffee, providing some protection against market fluctuations. In exchange for certification, growers agree to minimize the use of agricultural chemicals, safely dispose of waste, and maintain soil and water quality. Although it does not forego chemicals, Fair Trade does forbid the use of several hazardous pesticides. Organic certification avoids the use of agricultural chemicals altogether.

Bravi F, Bosetti C, Tavani A, Bagnardi V, et al. Coffee drinking and hepatocellular carcinoma risk: a meta-analysis (Abstract). Hepatology. 2007 Aug;46(2):430-5. Accessed September 4, 2007.

Coffee may reduce liver cancer risk. New Scientist. February 26, 2005. Available at: http://media.newscientist.com/article.ns?id=mg18524885.700&print=true. Accessed September 4, 2007.

Hitti M. Liver cancer appears to be rarer in coffee drinkers than in people who don't drink coffee. WebMD Medical News. August 2, 2007. Available at: www.medicinenet.com/script/main/art.asp?articlekey=83013&pf=3&page=1. Accessed September 4, 2007.

Tanaka K, Hara M, Sakamoto T, Higaki Y, et al. Inverse association between coffee drinking and the risk of hepatocellular carcinoma: a case-control study in Japan (Abstract). Cancer Sci. 2007 Feb;98(2):214-8. Available at: www.ncbi.nlm.nih.gov. Accessed September 4, 2007.

Taylor DA. Certified coffee: does the premium pay off? Environmental Health Perspectives. September 2007;115(9). Available at: www.ehponline.org/members/2007/115-9/spheres.html. Accessed September 4, 2007.

"An Epidemic of Diagnoses"
Drs. H. Gilbert Welch, Lisa Schwartz, and Steven Woloshin assert in a powerful New York Times essay that American medicine's disease orientation has created "an epidemic of diagnoses." Physical and emotional sensations that were once viewed as a normal part of living have become signs of disease that need intervention. Studies push for ways to identify people "at-risk" of specific diseases so that they can receive medical treatment before they ever become sick. Technological advances let doctors find abnormalities and "subtle structural defects" to make diagnoses in people who have no symptoms.

"If more than half of us are sick, what does it mean to be normal?" the authors ask. "Many more of us harbor 'pre-disease' than will ever get disease, and all of us are 'at risk.'" They explain that this emphasis on illness actually contributes to ill health. Labeling people as "at risk" or dysfunctional can foster anxiety and vulnerability. Labeling children with medical diagnoses for conditions that are mild or transient is particularly worrisome to the authors. In addition to the emotional stress of being diagnosed with a disease, people expose themselves to potential harm when seeking medical treatment. "Not all treatments have important benefits, but almost all can have harms," the authors state. Sometimes, it takes years for the possible harms to be recognized. People who have no or mild symptoms are least likely to have a real benefit from treatment and are most likely to be harmed.

Unfortunately, the US medical system thrives on diagnosis of disease. Drug and medical device manufacturers, hospitals, physicians, disease advocacy groups, even research groups derive money from the presence and diagnosis of disease. Even the US legal system contributes to this "epidemic of diagnoses." Physicians are sued for failing to make a diagnosis or for making an incorrect diagnosis, but few think about the dangers of diagnosing too freely. What would happen if emphasis shifted from finding disease to reducing the need for medical services? What if focus turned toward health and the number of people who do not need medical care, instead of the number who do?

The authors say, "…doctors need to remember the value of reassuring people that they are not sick." I wonder, however, if their patients – inundated by advertising and press releases about illness – would believe them.

Welch HG, Schwartz L, Woloshin S. What's making us sick is an epidemic of diagnoses. The New York Times. January 2, 2007. Available at: www.nytimes.com/2007/01/02/health/02essa.html. Accessed January 6, 2007.

Carbohydrates and Fatty Liver Disease
Low-fat (high-carbohydrate) diets appear to increase the risk of non-alcoholic fatty liver disease (NAFLD) and liver inflammation, according to small research studies. NAFLD, which is more common in obese people or in those with diabetes, can eventually lead to fibrosis and then cirrhosis. In one study of 74 morbidly obese patients undergoing bariatric surgery, S. Solga and colleagues compared each patient's diet (inferred from a standardized 24-hour food recall) to biopsies taken during surgery. Neither total caloric intake nor protein intake had a significant association with steatosis (presence of fat), fibrosis (fibrous connective tissue), or inflammation. The researchers conclude that "…higher CHO [carbohydrate] intake was associated with significantly higher odds of inflammation, while higher fat intake was associated with significantly lower odds of inflammation. In conclusion, present dietary recommendations may worsen NAFLD histopathology" (emphasis added).

Another study, led by O. Benjaminov, involved 14 candidates for bariatric surgery. Liver enlargement caused by NAFLD complicates bariatric surgery. In the hope of reducing the candidates' liver size, researchers put them on a low-carbohydrate diet for four weeks. The participants underwent computed tomography (CT) scans before and after the diet period to evaluate liver density and volume. The diet reduced liver fat content and liver size. The researchers conclude, "This approach may render bariatric surgery or any foregut operations less difficult in morbidly obese patients and may be a useful treatment for nonalcoholic fatty liver disease."

In a February 2007 study, five obese patients with biopsy evidence of NAFLD were put on a low-carbohydrate (<20g/day) diet with nutritional supplements (not identified in the abstract) for six months. This study reported that the "diet led to significant weight loss and histologic improvement of fatty liver disease."

Not all fats benefit the liver. Research by A.A. Nanji and colleagues shows that linoleic acid produces fatty liver, necrosis, and inflammation in alcohol drinkers, while saturated animal fats does not.

Benjaminov O. Beglaibter N, Gindy L, Spivak H, et al. The effect of a low-carbohydrate diet on the nonalcoholic fatty liver in morbidly obese patients before bariatric surgery (Abstract). Surgical Endoscopy. August 2007;21(8):1423-1427. Available at: www.springerlink.com/content/b78n532r75t66282. Accessed September 4, 2007.

Second Opinions. Cirrhosis of the liver: dietary causes. Available at: www.second-opinions.co.uk/cirrhosis.html. Accessed September 1, 2007.

Solga S, Alkhuraishe AR, Clark JM, Torbenson M, et al. Dietary composition and nonalcoholic fatty liver disease (abstract). Digestive Diseases and Sciences. October 2004:49(10);1578-1583. Available at: www.springerlink.com/content/j5x175u643225546. Accessed September 4, 2007.

Tendler D, Lin S, Yancy WS, Mavropoulos J, et al. The effect of a low-carbohydrate, ketogenic diet on nonalcoholic fatty liver disease: a pilot study (abstract). Digestive Diseases and Sciences. February 2007:52(2);589-593. Available at: www.springerlink.com/content/r5170lh8532t7452. Accessed September 4, 2007.
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