As we noted in our last post, close to a third of the world’s population suffers from MASLD (metabolic dysfunction-associated steatotic liver disease). This is a huge global health crisis, and one that should inform patient care in our practices.
The problem is that most practitioners focus on the liver in isolation. They focus on weight loss or blame overeating. In effect, they fall into the classic trap of “symptom management” and wonder why their patients don’t improve.
As functional medicine practitioners, we must be better than that!
Because how we diagnose and treat patients with liver issues is so crucial, we need to start with a solid foundation. This means understanding the factors that drive liver diseases such as MASLD (aka fatty liver disease), lest we also merely treat the symptom and not the cause.
Dr. Yousef Elyaman, the owner and medical director of Absolute Health, a high-volume functional medicine practice, has taken this charge to heart. He spent three years digging into fatty liver disease and its causes. As a result, he has developed a comprehensive approach to identifying the seven key metabolic drivers of fatty liver disease.
Factor #1: Insulin Resistance
At least 50 percent of type 2 diabetics also have MASLD. While the nature of the correlation isn’t exactly known (it’s a classic chicken-and-egg scenario), it’s clear that insulin resistance plays an active role in liver disease.
High insulin levels impair the body’s ability to suppress lipolysis, which leads to a host of liver-damaging effects:
- An increase in free fatty acids, a precursor of fatty liver disease.
- An increase in iron uptake in the liver, leading to inflammation.
- An increase in the liver’s production of triglycerides, which also leads to MASLD.
The bottom line: When insulin resistance kicks in, the body has to compensate—and the liver pays the price.
Factor #2: Fructose and Uric Acid
What effect does elevated fructose have on the liver? According to Dr. Elyaman, it increases uric acid—which can cause fatty liver—and advanced glycosylation and products. This leads to oxidative stress, an increase in fat storage, and reduced fatty acid oxidation.
And this isn’t just Dr. Elyaman’s opinion. Studies like this one have proven that the adverse effects of fructose include “oxidative stress, inflammation, higher serum uric acid levels, hypertriglyceridemia, higher systolic blood pressure, and insulin resistance.”
The result? High fructose intake partners with insulin resistance, setting the stage for inflammation, cardiometabolic disease, and fatty liver.
Most practitioners treat fatty liver in isolation. They prescribe a GLP-1 agonist or recommend a liver cleanse. But when you treat only the liver, you’re treating the symptom, not the disease.
Dr. Yousef Elyaman obsessed over what actually causes fatty liver disease for three years. As a result of his efforts, he was able to create a proven, systematic approach that identifies root causes and reverses fatty liver disease.
And now he is offering his approach to you. In the newest Kharrazian Institute Master Class, you’ll learn the seven unified driving pathophysiologies most doctors miss, master noninvasive fibrosis assessment, and implement evidence-based protocols for disease reversal. This isn’t theory. It’s what transforms patients in real practice.
Factor #3: Adipokine Abnormalities
Inflammation, in particular, leads to a host of other issues. For one, inflamed fat cells produce low levels of adiponectin, a hormone that normally helps the body clear lipids and suppress inflammation.
Dr. Elyaman notes that inflamed fat cells may be one of the big contributors to fibrosis. These dysfunctional cells also produce high levels of leptin, which further promotes the hardening of liver tissue, and resistin, a pro-inflammatory hormone that increases insulin resistance.
Summing up: Inflammation can rear its ugly head in the liver.
Factor #4: Iron Accumulation
Excessive iron accumulation in the liver is another key factor for MASLD.
The reason? Per Dr. Elyaman, when iron accumulates in the liver, it leads to the generation of free oxygen radical species that cause destructive oxidative stress throughout the body. Moreover, the results of liver biopsies have shown a direct correlation between hepatic iron and hardening of the liver.
The takeaway: Elevated hepatic iron is a clear sign of liver fibrosis and should never be ignored.
Within 20 years, fatty liver disease is predicted to surpass hepatitis C and alcoholic liver disease as the leading cause of liver transplantation. But since MASLD is typically asymptomatic until advanced fibrosis develops, this presents a problem: How can you diagnose and treat it before it’s too late?
Dr. Yousef Elyaman’s Kharrazian Institute Master Class distills three years of obsessive research into a systematic approach that identifies root causes and reverses fatty liver disease. Dr. Elyaman draws from his high-volume practice—a living laboratory of what actually works with thousands of patients.
When you register and attend, you’ll walk away with the knowledge you need to identify the specific metabolic dysfunction in each patient, assess fibrosis progression objectively, and implement precision protocols matched to root causes—not guesses.
Factor #5: SIBO (Small Intestinal Bacterial Overgrowth)
SIBO is commonly associated with fatty liver disease. According to Dr. Elyaman, this correlation exists for several reasons.
First, SIBO increases the risk of intestinal permeability, allowing particles and bacteria to leak into the gut that shouldn’t be there. And when you don’t have the right bacteria in your gut, the liver has double the work to do to detoxify the body.
Second, these “bad” gut bacteria are prone to creating lipopolysaccharides (LPSs). LPSs leak into the bloodstream and travel to the liver, where they trigger inflammatory cytokines like TNF-α. TNF-α can cause different disease states, but it can also worsen fatty liver.
The upshot: The body is an interconnected system. Gut dysbiosis can wreak havoc on the liver too.
Factor #6: Thyroid Dysfunction
The thyroid can also play a major role in MASLD. Why? Thyroid hormones regulate the liver’s metabolism.
When you have a healthy amount of thyroid hormones, the liver metabolizes and breaks down fat as it is designed to do. Dysregulation of the thyroid, however, disrupts the flow of hormones to the liver, reducing its ability to break down fats.
This naturally leads to increased accumulation of fat in the liver, which, of course, is fatty liver disease. In fact, low levels of active T3 or a low free T3-to-free T4 ratio are significant predictors of increased fat accumulation and the progression of MASLD.
What to remember: Thyroid issues might be directly contributing to your liver patients’ health concerns.
Factor #7: Bile Flow and Gallbladder Motility
The final driving factor for fatty liver disease is sluggish bile flow, or cholestasis.
Cholestasis causes bile and its associated toxins to back up into the liver, leading to inflammation, cell death, and fibrosis. Studies, including this one from 2018, have found a bidirectional relationship between fatty liver and gallstones, cholecystectomy (gallbladder removal), and fatty liver disease.
Moreover, gallbladder removal in particular significantly increases the risk of liver disease and cirrhosis. Dr. Elyaman states that this is due to the disruption of normal bile flow and the resulting gut dysbiosis.
The final analysis: Evaluating gallbladder and cholecystectomy patients for liver disease is essential.
Dr. Yousef Elyaman’s Fatty Liver Disease Master Class
Dr. Elyaman spent years identifying the actual drivers of MASLD. Through his research and a high-volume practice complete with an integrated lab, he has developed a systematic, evidence-based approach to identifying root causes and reversing disease. His approach will allow you to move from symptom management to truly positive health outcomes for your liver patients.
His five-hour course on fatty liver disease includes:
- Comprehensive video instruction covering all aspects of fatty liver disease pathophysiology, assessment, and management
- A downloadable diagnostic cheat sheet with key labs and reference ranges
- A disease-progression visual aid for patient education showing the spectrum from healthy liver to steatosis to fibrosis to cirrhosis
- Real-world knowledge based on thousands of cases
When you take this master class, you’ll learn the functional medicine approach to fatty liver disease and bring healing to your toughest liver patients. Enroll today!
Frequently Asked Questions
Why is MASLD (fatty liver disease) considered a systemic condition rather than a liver-only disease?
MASLD is driven by multiple metabolic and inflammatory factors, including insulin resistance, gut dysfunction, iron overload, thyroid imbalance, and bile flow issues. Treating the liver alone often leads to poor outcomes because the root causes remain active elsewhere in the body.
How strong is the link between gut health and fatty liver disease?
It’s very strong. SIBO and gut dysbiosis increase intestinal permeability and toxin exposure, which drives liver inflammation through cytokines like TNF-α. Addressing gut health is often necessary to reverse liver disease progression.
What role does iron play in the progression of MASLD?
Excess iron increases oxidative stress and accelerates fibrosis in the liver. Elevated ferritin or transferrin saturation should prompt further evaluation.
How does thyroid dysfunction contribute to fatty liver disease?
Low or poorly active thyroid hormones reduce the liver’s ability to burn fat. A low free T3 count or free T3-to-free T4 ratio is often associated with increased liver fat and disease progression.
How can practitioners learn to assess and treat these drivers in a structured way?
Dr. Yousef Elyaman’s Fatty Liver Disease Master Class teaches a step-by-step clinical system for identifying the key metabolic drivers of MASLD, assessing fibrosis noninvasively, and applying targeted protocols that work in real-world practice. It’s designed to help practitioners move beyond symptom management and confidently reverse fatty liver disease.
