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Gastroenterologist Anuj Vikrant Sharma discusses his article, “Fatty liver disease is no longer reserved for older adults.” He warns of a quiet epidemic of metabolic dysfunction-associated steatohepatitis (MASH), a serious liver condition now increasingly appearing in people in their 20s and 30s who may not appear outwardly unhealthy. Anuj explains that a primary, and often overlooked, driver is the gut-liver axis. The modern Western diet, high in ultra-processed, low-fiber foods, disrupts the gut microbiome, leading to a “leaky gut” that allows harmful substances to travel to the liver and cause inflammation and fat accumulation. The conversation explores why this connection explains the rise of MASH in younger, non-obese patients and makes a compelling case for a “gut-first” strategy. Listeners will learn why we need earlier screening and a renewed focus on food quality over calorie counting to prevent and reverse this silent but progressive disease before irreversible damage occurs.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Anuj Vikrant Sharma. He’s a gastroenterologist. Today’s KevinMD article is, “Fatty liver disease is no longer reserved for older adults.” Anuj, welcome to the show.

Anuj Vikrant Sharma: Well, thank you so much for having me on the show.

Kevin Pho: All right. So you are a gastroenterologist. Tell us a little bit about your practice.

Anuj Vikrant Sharma: My name is Anuj. I’m a gastroenterologist. I’ve been practicing medicine and have been treating GI and related conditions for several years now. I’ve been always drawn to GI because it allows both procedural work and long-term patient care.

And over time, I have seen the field evolving, especially in IBD and liver disease. Lately, what really caught my attention was the changing face of MASLD, or metabolic dysfunction-associated steatotic liver disease, previously known as NAFLD.

Kevin Pho: All right, so you wrote about that, of course, in your KevinMD article. For those who didn’t get a chance to read it, tell us what it’s about.

Anuj Vikrant Sharma: The article I wrote for KevinMD stemmed from real patient encounters. I was seeing young adults, people in their twenties who didn’t drink excessively and weren’t obese, yet had early signs of fatty liver disease or MASLD. Many were shocked to learn that they had a liver problem at all.

So that’s what prompted me to look into the broader picture and start asking questions about what has changed in the environment, in our diet, and in our gut health that could explain this. That’s what led me to take a deep dive into the science of the gut-liver axis, which is basically an anatomical and biochemical pathway that links our intestinal health directly to our liver.

Kevin Pho: So before we get into that, let’s get everyone on the same page. Just give us a 30-second primer of what fatty liver disease is.

Anuj Vikrant Sharma: Fatty liver disease, now known as MASLD, as I said, metabolic dysfunction-associated steatotic liver disease, is a disease where you have inflammation in the liver which can be attributed to metabolic dysfunction. It is generally considered linked with obesity and insulin insensitivity, but lately, we are seeing this even in younger or healthy patients with an otherwise normal BMI.

What happens in this condition is you have fat accumulation in the liver, and that leads to inflammation. The inflammation can eventually lead to scarring, advanced fibrosis, cirrhosis, and in some cases, liver cancer. So it’s very important to catch this condition early on and prevent it from progressing to avoid these harmful outcomes.

Kevin Pho: Now, I’m a primary care internal medicine physician. Typically, when I see fatty liver disease, like you said, it’s in older adults who drink and who are obese. They typically present with elevated transaminases, which leads to an ultrasound, and then that’s how fatty liver is diagnosed. In these younger patients, though, who, like you said, are otherwise healthy, how are you finding fatty liver in them?

Anuj Vikrant Sharma: That is part of the challenge, right? How to figure out those people who are in their thirties who exercise regularly and don’t drink. I think having a low threshold to screen for those patients is important. Anytime we see any abnormality in triglycerides, the lipid panel, insulin insensitivity, or even a high glucose level noticed on the BMI, it should prompt you to look for it.

The tests that we have available are very non-invasive. A simple blood test, a mild elevation in ALT, or non-invasive testing such as an ultrasound, which is widely available, can help us diagnose this condition early. So I think education is part of it. Knowing that it’s happening even in patients we don’t anticipate is part of the struggle here. The education or the push here is to spread this information out there to all the primary care physicians.

Kevin Pho: So now take us through the pathophysiology, especially in the younger patients. Why is this happening?

Anuj Vikrant Sharma: When I started seeing this in my younger patients, I researched more to see what is essentially triggering this inflammation in otherwise healthy patients. The main focus or the main theme that I encountered was diet. It was a dual focus. We always focus on the gut-healthy diet, the Mediterranean diet—the diet which is high in fruits and vegetables. But I think the one aspect that we’re missing was eliminating the gut-damaging diet, the diet which is high in processed food and emulsifiers.

So it’s a dual focus which I think needed to be done in the case of MASLD. That’s what I was noticing as a common theme or a missing link in patients who were otherwise healthy: that even though they were eating a healthy diet, they were also eating an unhealthy diet in bulk, which led to the inflammation.

Kevin Pho: When you say these highly processed foods in your patients, are we talking about just a lot of processed snacks? Are we talking about refined carbohydrates? What are some examples of an unhealthy, gut-damaging diet that we’re talking about?

Anuj Vikrant Sharma: It’s a bit of both. Processed food is pretty much a low-hanging fruit, so to speak. Those are easy to identify, but things such as emulsifiers, which are the products you use to mix things which are not otherwise easily mixable, for example, oil and water, are also pro-inflammatory. They are commonly found in peanut butters and baking products. It’s widely available, but it can trigger high inflammation.

An emulsifier such as polysorbate 80 can trigger inflammation. And then of course, your simple sugars are also readily available, which can trigger a pro-inflammatory state. There is evidence that suggests they increase the expression of microbial genes which lead to the inflammatory cascade. That shift leads to increased gut permeability, which basically drives hepatic inflammation.

These things are very, very easily missed if you’re not looking for them or if you’re not educated about them. So I think awareness is the key here. Just talking about it and spreading it out there will be useful.

Kevin Pho: So just to be clear, you mentioned these emulsifiers being found in foods like peanut butters and baking products, but you also mentioned a COVID vaccine. Is that on the same scale? Because you’re getting a vaccine once every year versus food that you potentially can eat several times a week. Is it the same scale?

Anuj Vikrant Sharma: It is not on the same scale, and the data has obviously shown that it does not have the same impact as, for example, food which you eat regularly on a daily basis. The one emulsifier is polysorbate 80, which is the one found in the COVID vaccination. And from what I know, there’s no direct evidence linking those vaccinations to a pro-inflammatory state.

But the point I’m trying to make is that it’s widely available, from the supermarket all the way to the clinics where you get the vaccination. So, just having an awareness of it, reading labels, and just knowing what you’re putting in your body helps and goes a long way in maintaining good health.

Kevin Pho: So you mentioned finding this early, especially in younger adults. For screening, what ideas do you have for that?

Anuj Vikrant Sharma: Universal guidelines are still lacking, so I think it’s multifactorial when you talk about screening. A blood test just checking liver function enzymes is a good start. If there’s a mild elevation in liver enzymes, it should be followed by some sort of non-invasive testing, such as an ultrasound or elastography. If there’s any question or abnormalities in liver enzymes, then a prompt consultation with a local gastroenterologist or hepatologist should be made.

These tests are readily available pretty much everywhere, and that is the basic framework that should prompt or start the workup. If there’s any further question, a specialist consultation is warranted.

Kevin Pho: Now, in your article, you mentioned the potential of things like probiotics to prevent fatty liver. What’s the evidence there?

Anuj Vikrant Sharma: The American Gastroenterological Association recommends the Mediterranean diet in the context of gut microbiome health and probiotics. Basically, the role of dietary fibers is that they act like a broom, which helps nurture the good bacteria. The prebiotics help in modulating the gut microbiome, and they mitigate the gut dysbiosis in fatty liver disease.

Both the American Association for the Study of Liver Diseases and the American Heart Association recommend that any food that increases good gut health should help in preventing heart disease and liver disease. So that’s where the probiotics and prebiotics come in. There are not that many that are studied, except VSL#3. So most of the products that we find in supermarkets are not well-studied.

But in theory, if they contain all the prebiotics that are stated on any product, and if that’s truly what’s in there, then those do help maintain a healthy gut microbiome, which in turn leads to a healthy liver and a healthy heart.

Kevin Pho: Now, is steatohepatitis or fatty liver reversible once we find it early?

Anuj Vikrant Sharma: Yes, it is reversible to some degree. There are new drugs coming up that are FDA-approved, too, which can be given, but it’s also reversible mainly through diet and exercise. Weight loss does remain the primary treatment. It is recommended to lose seven to 10 percent of current body weight if the BMI is higher. But of course, if the BMI is normal, in that case, the diet remains the primary treatment, which again is a topic here: how we can eliminate the inflammatory diet. So there is some degree of reversibility to that.

Kevin Pho: And just to give us an idea of the timeframe, if someone discovers they have fatty liver and makes your suggested changes with their diet, what kind of timeframe are you looking at to notice the improvement in the fatty liver?

Anuj Vikrant Sharma: This is a very emerging field. I’m also curious to see how it evolves in five to 10 years, so it’s very hard to put a timeframe to it. But I reckon within… usually in our clinical practice, we repeat an ultrasound or elastography every two to three years to trace the progression. So, I think within five years, I would suggest you start noticing any evidence, at least radiologically, on an ultrasound. But you can notice an improvement in liver enzymes within a few months.

The ALT can go down within a few months, especially in a patient who has a higher BMI. If they lose seven to 10 percent, by the next clinic visit, you can repeat the liver enzymes, and they normalize or are at least trending down. So there are both immediate results and long-term improvement, both objectively proven with liver enzymes or with an ultrasound or elastography. The results can vary from months to years, depending on the modality you’re using to objectify those results.

Kevin Pho: Now, if I’m a younger adult, someone in their twenties or thirties listening to you now, tell us the single biggest change they should do to help prevent potential fatty liver.

Anuj Vikrant Sharma: The single biggest prevention thing you can do is stop eating processed food, which is high in sugar. Your body will react to what you put in it. OK. A diet rich in additives, emulsifiers, and artificial sugar not only affects your liver, it affects other organs. More often than not, as specialists, we focus on one organ, but your body is not one organ. It’s just an indication of what’s going on throughout your body. Even though the liver is the one being damaged, the heart is the main reason why people with fatty liver disease end up having high mortality.

Reading labels and being conscious about what you’re eating is going to go a long, long way. Restricting the eating window to eight to 12 hours per day, time-restricted feeding, avoiding late-night caloric intake, or coffee consumption, which is also associated with a reduced risk of hepatic steatosis and fibrosis. Those are simple things which you can do. You don’t have to go taking out your wallet to buy expensive, healthy food. But these are just lifestyle modifications, just eating during the daytime and avoiding late-night snacks and those kinds of things, which will go a long way in improving your health.

Kevin Pho: We’re talking to Anuj Sharma. He’s a gastroenterologist. Today’s KevinMD article is, “Fatty liver disease is no longer reserved for older adults.” Anuj, end with some take-home messages that you want to leave with the KevinMD audience.

Anuj Vikrant Sharma: The key message that I want to leave is mainly for my colleagues, especially the primary care physicians: fatty liver disease is rising in young people, and the gut may be the missing link. This is not a benign or distant problem. It’s happening now, often silently, and it is preventable. The earlier we screen, educate, and intervene, the better chance we have to stop this condition and its progression to cirrhosis and liver disease.

We need to move beyond weight loss and start thinking holistically, not just about the quantity, but the quality of the food, and hopefully, it’s taken early so it does not turn out to be something like cirrhosis, which, of course, we know is a disease that carries high mortality.

Kevin Pho: Anuj, thank you so much for sharing your expertise and insight, and thanks again for coming on the show.

Anuj Vikrant Sharma: Thank you.