Diabetes Self-Management Blog

It may surprise you to know that, for many people, Type 2 diabetes is primarily a liver disease. The pancreas damage comes later. Is there anything we can do to heal a diabetic liver?

Liver issues in diabetes are complicated. An article in the journal Clinical Diabetes explained that diabetes can cause liver disease; liver disease can cause diabetes; or both can arise together from other causes. Whichever comes first, the sick liver may produce way too much glucose, enough to overwhelm the body’s insulin.

Why would a liver start pumping out unneeded glucose? Unhealthy livers tend to have a lot of fat in them, a condition called nonalcoholic fatty liver disease, or NAFLD.

You don’t have to be fat to have a fatty liver (although overweight and obesity are risk factors). Thin people get it too, and the causes of NAFLD are unknown. Some are thought to be genetic. However, a recent animal study published in the journal PLOS One found that prenatal exposure to alcohol (from a mother who drank while pregnant) is strongly associated diabetes-like glucose production by the liver. There are probably other causes as well, including environmental chemicals and possibly unhealthy diets.

A rat study in the Journal of Biological Chemistry found that fatty livers became more resistant to insulin. The researchers found processes by which insulin normally tells the liver to stop producing unwanted glucose. Excess fat in the liver seemed to block these processes, so too much glucose was produced.

Human livers apparently act the same way. An Italian study in The American Journal of Medicine found that subjects with NAFLD had high fasting and postmeal insulin levels, high insulin resistance, and high triglyceride levels. (Triglycerides are a kind of blood fat.) High insulin levels can be a cause or a result of insulin resistance.

Again, these Italian subjects were not necessarily fat or obese. They just had fatty livers as shown by ultrasound.

How the liver raises blood glucose
I thought that diabetic livers caused high blood glucose levels by breaking down stored starch (glycogen) into glucose, but the reality is different. The liver actively creates brand new glucose out of proteins and fats, a process called gluconeogenesis, or GNG. People with diabetes tend to have far more GNG, so they produce much more glucose.

GNG is a fascinating process. Without it, we would all be dead from low blood glucose while sleeping or when missing some meals. According to Wikipedia, GNG is “generation of glucose from non-carbohydrates…such as pyruvate, lactate, glycerol, amino acids, and odd-chain fatty acids.”

Ruminant animals like cows and sheep get much of their energy from GNG. But in humans, out of control GNG is a major concern in diabetes.

In 2011, Web Editor Diane Fennell reported on Diabetes Self-Management that excess levels of a protein called FOX06 in the liver lead to inappropriate release of glucose. Study author H. Henry Dong, PhD, wrote that “Glucose overproduction in the liver is a major contributing factor for high blood sugar in diabetes, Type 1 and 2.”

So is fatty liver the same as Type 2 diabetes, or the main cause of it? It’s not so simple, because many with fatty liver do not get diabetes, and many with diabetes may not have fatty livers. An article in the American Journal of Physiology reported that increased glucose production usually appears only when insulin levels are low. They also found that high insulin resistance in the muscles “contributes as much or more to glucose elevations” as high GNG does.

I should also mention the effect of glucagon. Glucagon is the anti-insulin. It tells the body to break down fat, starch, and protein and make more glucose. If your liver is exposed to too much glucagon, it can overpower the insulin.

So it appears that what we call “Type 2″ is really several different diseases. One is mostly caused by the liver overproducing glucose; another by insulin resistance in the muscles. Still others seem to result from damage to the pancreas or the signaling systems the body uses to direct insulin. Of course, more than one of those is usually going on.

Can we help our livers?
Is there anything we can do to fix livers that leak glucose? The drug metformin is the most-used way. It seems to replace insulin in telling the liver to hold on to glucose. Reader Jim Snell has told us he corrected chronically high blood glucose levels by taking metformin five times a day — with each meal, at 10 PM, and midnight. Skipping even one dose sends his glucose level back up.

Unfortunately, not everyone can take metformin because of the side effects. And even if it works, it’s not a cure. You have to stay on it, possibly for life.

Former Editor Tara Dairman reported here in 2008 that exercising regularly “significantly reduces the amount of fat in and around the liver.”

The liver is generally pretty good at healing itself. In the 600-calorie-a-day-diet study from England in 2011, and in other studies, MRIs showed that most participants’ livers quickly lost all excess fat and started functioning normally again. But we don’t know how long that benefit lasted after the end of the study.

The herbs milk thistle, dandelion, and bitter melon, as well as vinegar, are often used to help livers heal. We know bitter melon and vinegar are good for blood glucose levels. Diet and exercise can make a difference. Vegetables like broccoli, collard greens, and kale, and small fish like sardines are often recommended. An article on Livestrong.com suggests vitamin B complex, vitamin C, and coenzyme Q10 for liver health.

I wish I had more, but that’s all I found. I’d start with the bitter melon or vinegar.

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Comments
  1. Very well timed, thank you!

    I am baffled by this problem right now. My liver is spitting out too much glucose, for some odd reason, particularly at night. My fasting BGL is elevated every morning.

    My doctor started me on metformin - I haven’t really seen much improvement, honestly, and I’m on 1000 mg ER, which I take every night before bed.

    I just got a bottle of bitter melon extract (have been unable to find the tea) and am going to try it. Has anyone had luck with bitter melon or vinegar? When would one ingest the vinegar?

    Thanks for the great information on this site - I’m grateful that you take the time to stay abreast of the research and put it into layman’s terms. I am truly grateful.

    Posted by Kelly |
  2. David: - excellent report.

    My heart and soul go out to say thanks for providing this excellent review of present data and work. As you wish you had more data; I wish science was now digging deeper in this area of the liver and other involved organs and hormones.

    Posted by jim snell |
  3. Excellent information as always. This is the first I’ve heard of exercise affecting a fatty liver. I’ve just returned to a program of heavy exercise after being off a while due to severe lower back pain associated with spinal stenosis. I will be interested to see if my readings improve and maybe if I have a liver scan in the future if inprovement is shown.

    The 600 calorie a day diet is easier said than done. I think it bears noting that at that level of consumption it’s *extremely* easy to become malnourished in one or more nutrients, and this diet should not be attempted without direct medical supervision.

    I’m also still looking for bitter melon tea locally. So far all I’ve found is the fresh whole fruit. Any idea how to utilze that instead?

    Posted by Joe |
  4. Wow David, talk about timing! I’m in the midst of trying to find the right bedtime Lantus dose to lower my morning BGL. I feel like I’m becoming a Lantus addict — I adjust the dose, have good numbers for a day or two, then back to high numbers. Adjust, repeat. I’m up to 40u and it’s still not enough.

    A couple of weeks ago, I took a bitter melon tablet before bedtime, and while my morning BCL was right on target, I had pain in my liver area, mild diarrhea and tiredness for a couple of days just on that one dose. I read that the symptoms go away in a few days, but I was afraid I was killing my liver, so I didn’t take it again. Was I overreacting?

    I am going to try Jim Snell’s idea and split up my metformin dose so I get some at bedtime.

    Thanks so much for your posts!

    Posted by Andrea |
  5. For Andrea: I assume you are checking blood sugars at bedtime before taking the Lantus dose. I have often seen prescribers who keep increasing the Lantus, not realizing a high bedtime blood glucose is dragging the fasting level up too. You do not want to get low at night, but sometimes some short acting insulin for correction along with the Lantus can go a long way. A sign you are trying to do too much with the Lantus is getting low just before meals or during the night. A low during the night may cause a rebound as the liver spits out more glucose to compensate and you can wake up high without realizing you may have been low at 3 AM. It may be a good idea to set an alarm and check at 3 AM for a few nights too. Good luck.

    Posted by bk cde |
  6. Hi Andrea,

    Yes, do try Jim’s approach to get some later metformin. I’m sorry about your reaction to bitter melon. I don’t think you overreacted, but I might suggest trying a cup of the bitter melon tea and seeing if you get the same response.

    Kelly, you might ask your doctor about switching from extended-release to regular metformin taken at night. Vinegar is usually taken with meals and sometimes at bedtime. If you do the bedtime dose, you might want to take it with a small amt of food to protect your stomach and rinse your mouth quickly to protect your teeth.

    Posted by David Spero RN |
  7. Joe,

    Whole bitter melon can be cooked like any squash — but check out online recipes to try and make it taste good. If you don’t have Asian groceries or pharmacies where you live, you can order the tea online.

    You’re right about the 600-calorie diet. It’s only safe for short-term use, and it wouldn’t hurt to take supplements while doing it.

    Posted by David Spero RN |
  8. Andrea:

    Jim Snell recommends you work with your Doctor/Diabetes team and not experiment on your own.

    One of the issues will be - what is minimum dose that will work when you split larger dose. For me that was 500mg dose after splitting . Less than that and dose seemed to have no effect on my body.

    Be sure to check diet and exercise as well.

    Information on Bitter Melon is intriging
    Best wishes and good luck.

    Posted by jim snell |
  9. Hey Joe

    I have just started eating bitter lemon or bitter gourd here in UK, first time I’ve seen it for sale in my local supermarket. In the Philippines my fiancĂ©e would wash it well then slice it in half, then scoop out the inner seeds and pith which is not good to eat. She’d then slice it as you would do a cucumber and add it to salad. This is what I’ve started to do here as well but it takes a while to start showing results. I haven’t seen the tea but bitter lemon gourd is an acquired taste, and although I do like it, it’s not everybody’s cup of tea. I can’t see that the taste of the tea would be better, although if it does the job I wouldn’t condemn it. Good Luck

    Posted by Peter Edwards |
  10. Thanks to all who responded!

    bk cde — yes, I do check my BGL at bedtime. It doesn’t matter if it’s low, normal, or high — morning BGL is always high. And yes, I have checked at 3 AM as well and it is usually normal.

    David — I’ll keep the tea in mind. Perhaps a liquid will move through better than a tablet.

    Jim — I work closely with my endo. She’s great, but sometimes TOO caring — when I suggested testing/dosing at 3 AM, she didn’t want me disturbing my sleep to do it (even though I have to get up once a night anyway). I’m taking 4 metformin 500 — 2 at breakfast, 2 at dinner, with good levels before and after meals, that’s why I don’t think a splitting experiment would hurt me as long as I test often. We’ll see. (And no, I won’t blame you if it doesn’t work — it’s something I’ve thought of trying before!)

    Posted by Andrea |
  11. BE VERY CAREFUL TAKING BITTER MELON IF YOU ARE ON METFORMIN!
    Bitter melon can drasticly lower your blood sugar. Sometimes too much. Start out with small doses and carry glucose tablets in case you over react.

    Posted by KM |
  12. Thanks for the information. I believe that it is important to keep in mind that both type 1 and type 2 can have several possible underlying causes.

    Unfortunately common medical practice is to only treat the symptoms. I guess from this common perspective that cause does not matter–since they are not looking for potential solutions.

    Thanks again. Your writing style helps simplify some of these complex topics. You are providing a great service!

    Best Regards,
    David

    PS I have been battling diabetes for over 6 years. It has only been recently that I have begun to win this battle!

    Posted by David |

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