As an ob/gyn doc I have wrestled with this my whole career. The pediatricians need to intervene early . By the time I see them for menstrual irregularities or secondary amenorrhea ;behavioral and dietary changes that need to change , are difficult to overcome. If they get pregnant , PIH / preeclampsia and / or gestational diabetes rears its ugly head. As older adults, this leads into your discussion for today . Exhausting. 😢
The thing is … those willing to change their diet are next to zero. They are addicted to sugar…
I just arrived in Iceland for a 2 week camping trip… I always limit restaurant food and try to source whole, ideally organic foods… not a lot of options here… I went to Kronan supermarket — found organic apples…some tinned sardines (this fish is not farmed)… didn’t even have any frozen organic veg options…. really a struggle…
Every single item I looked at (including refrigerated pickled herring) contained sykur….(sugar)… No wonder everyone is obese and in terrible health… everything is laced with this toxic shit…
At least I can cook lamb and wild fish on the trip…. found a specialty market online that has a small selection of organic veg… otherwise I’d be eating apples and sardines for two weeks!!!
I have been working the engines and for sure the active substance in D supps is the same as what is used in rat poison - albeit in a much lower dosage.
The 'research says it is not harmful... but end of the day poison is poison ... I am concerned about the long term effects of taking a daily small dose.
Thank you Dr. Marik for all you do. I love your writings . . . easy to read, to the point, well documented, and always relevant. I never get lost in the weeds!
Thanks for this great article! I was shocked to find so many brands of peanut butter containing HFCS, even one marked "Natural". And this is just one item. I imagine the stores are full of products like this.
My mom would buy the natural peanut butter, without hfcs or other fats. Kids would ask me how I could stand it, but it was the extra sweet additive filled peanut butter I disliked!
Great article Paul. AASLD changed the nomenclature recently. NAFLD was changed to MASLD, and NASH was changed to MASH. Both changes reflect the metabolic dysfunction associated with their development, as you well document in this article. Also, it was great to see you last weekend in Dallas at IMA.
Is becoming increasingly difficult to keep with the constant changes in the names for this disease. But the fundamentals outlined in the article remain true.
Thanks Dr. Marik. Sweet drinks, even orange, apple and grape juices, are also a habit that harms the liver, not merely alcohol.
I am compelled to say that artificial sweeteners do their own metabolic harms, so it is necessary to just “kick the habit”, as the TV commercials used to advise.
Metabolic liver disease is about to (or has already) displace alcohol as the leading cause of liver disease, that’s why this topic is so important.
The association between fructose, innocently regarded by many as better because is a “natural” sugar, is the worse substrate for the liver due to the cascade of events clearly outlined in this post. Fructose is indeed a natural sugar, that much is true. But as outlined here, the source matters.
When consumed from fresh fruit, the structure of the fruit itself makes the difference. In fruits fructose is mostly found combined with glucose as a disaccharide we called sucrose and when combined with the fiber structure in the fruit itself, it modulates and slows down absorption which keeps the liver from becoming overloaded. On the other hand when consuming products containing high fructose corn syrup and other industrially processed sweeteners, that’s when the liver gets exposed to high load of fructose, rapidly absorbed and overwhelming the liver metabolic pathways leading the the process described in article, leading to the production of excess fat (that starts accumulating inside the liver) and other toxic substances that overtime lead to liver damage.
One point that I believe needs additional clarification — smoothies/juicing. Is important to understand that neither smoothies or juices are equivalent to whole fruit regardless of what the healthy food industry keeps telling you. When you consume a bottle of 100% fruit juice, you are essentially drinking water + sugar and small amounts of other micronutrients. The fiber structure that modulates carbohydrate absorption is left behind causing a sugar and insulin spike which is not metabolically healthy. Commercial smoothies are even worse, usually having little fruit juice with additives, industrial sweeteners and texture modifying substances.
If you like smoothies limit to those you make at home. Don’t use fruit juice, rather use the whole fruit, or at least the part of the fruit you’d normally consume such as is the case for pineapple.
Thank you for the format in which you presented this information. Very easy to follow and scroll through to find various points. Also, as fruit farmers, we appreciated the comments about fruit. We do eat a lot of our own crops, but we also grow vegetables and nuts and try to live close to the land. For the past 40 years, the only white thing we’ve eaten is cauliflower.
NASH is best understood as a hepatic manifestation of systemic insulin resistance, where excess substrate flux and mitochondrial stress drive lipotoxicity and inflammation rather than fat alone. The evidence consistently shows that reducing refined sugars and improving metabolic health directly lowers hepatic fat and inflammatory signaling, reinforcing that the root pathology is metabolic, not organ-specific.
Thank you so much for this very informative article, but how do elderly people do this when everything has it in it. Every cereal has it many can foods, it’s in everything. It like they want us dead. It is hard on a budget they put the things you can afford as the most toxic foods you can eat. Help🥴💙
You are right. They are trying to make us sick, then to force us to buy their expensive medications. Try buy real food that does not come in a box or can. If it looks like food its probably food. Good luck. Paul
Hello, this was a great article, thanks. But on another subject, as a paid subscriber I clicked on your article below this one, "The Cholesterol Myth is Crumbling..." but it won't let me read the whole thing stating I need to subscribe?
I agree that excess fructose and processed carbohydrates clearly play a major role in driving liver and metabolic dysfunction. No question about that.
But what I am wondering is if everything the brain and body does is for its survival, then insulin resistance might not be purely a pathological state, meaning it is a compensatory response—an attempt by the body to maintain energy availability under conditions where regulation has become impaired.
In that sense, the dietary factors clearly are contributing to the dysfunction, but there may also be a layer of adaptation happening within the system at the same time.
That body itself is not failing—it is adapting…but those adaptations can become the very thing that perpetuates disease.
I may not have said that as clearly as I intended.
I’m not suggesting insulin resistance is a good thing in terms of outcome. I agree it’s associated with significant downstream harm.
What I’m exploring is whether it might, at least initially, represent a compensatory response—similar to how inflammation or elevated cortisol can be protective in the short term but problematic when they become chronic. Not so much good or bad, but part of how the body responds under certain conditions.
So more about its role in the system rather than its value.
This is interesting. I would agree. Watching my husband (25-30lbs overweight, and struggles to lose) who does not eat processed foods, sugary drinks, seed oils, exercises, and has fatty liver disease beginnings…his only vice, alcohol. Definitely a metabolic dysfunction disease happening.
As an ob/gyn doc I have wrestled with this my whole career. The pediatricians need to intervene early . By the time I see them for menstrual irregularities or secondary amenorrhea ;behavioral and dietary changes that need to change , are difficult to overcome. If they get pregnant , PIH / preeclampsia and / or gestational diabetes rears its ugly head. As older adults, this leads into your discussion for today . Exhausting. 😢
Agree
The thing is … those willing to change their diet are next to zero. They are addicted to sugar…
I just arrived in Iceland for a 2 week camping trip… I always limit restaurant food and try to source whole, ideally organic foods… not a lot of options here… I went to Kronan supermarket — found organic apples…some tinned sardines (this fish is not farmed)… didn’t even have any frozen organic veg options…. really a struggle…
Every single item I looked at (including refrigerated pickled herring) contained sykur….(sugar)… No wonder everyone is obese and in terrible health… everything is laced with this toxic shit…
At least I can cook lamb and wild fish on the trip…. found a specialty market online that has a small selection of organic veg… otherwise I’d be eating apples and sardines for two weeks!!!
Would any of the medical folks here be able to comment on this article that slams Vitamin D supplements https://unbekoming.substack.com/p/the-vitamin-d-paradox-what-they-dont
I have been working the engines and for sure the active substance in D supps is the same as what is used in rat poison - albeit in a much lower dosage.
The 'research says it is not harmful... but end of the day poison is poison ... I am concerned about the long term effects of taking a daily small dose.
I generally do not trust 'the research'...
I agree. Over 80% of Americans have a serious addition.. SUGAR
Thank you Dr. Marik for all you do. I love your writings . . . easy to read, to the point, well documented, and always relevant. I never get lost in the weeds!
Thanks my friend,,,
Thanks for this great article! I was shocked to find so many brands of peanut butter containing HFCS, even one marked "Natural". And this is just one item. I imagine the stores are full of products like this.
My mom would buy the natural peanut butter, without hfcs or other fats. Kids would ask me how I could stand it, but it was the extra sweet additive filled peanut butter I disliked!
Great article Paul. AASLD changed the nomenclature recently. NAFLD was changed to MASLD, and NASH was changed to MASH. Both changes reflect the metabolic dysfunction associated with their development, as you well document in this article. Also, it was great to see you last weekend in Dallas at IMA.
Thanks for that update.
Is becoming increasingly difficult to keep with the constant changes in the names for this disease. But the fundamentals outlined in the article remain true.
Thanks Dr. Marik. Sweet drinks, even orange, apple and grape juices, are also a habit that harms the liver, not merely alcohol.
I am compelled to say that artificial sweeteners do their own metabolic harms, so it is necessary to just “kick the habit”, as the TV commercials used to advise.
Agree 100%.. fruit juices are toxic contrary to what people think.
Most fruit juices are concentrated sugar. Why the pulp and natural fiber is removed is insane.
Great write up Paul!
Metabolic liver disease is about to (or has already) displace alcohol as the leading cause of liver disease, that’s why this topic is so important.
The association between fructose, innocently regarded by many as better because is a “natural” sugar, is the worse substrate for the liver due to the cascade of events clearly outlined in this post. Fructose is indeed a natural sugar, that much is true. But as outlined here, the source matters.
When consumed from fresh fruit, the structure of the fruit itself makes the difference. In fruits fructose is mostly found combined with glucose as a disaccharide we called sucrose and when combined with the fiber structure in the fruit itself, it modulates and slows down absorption which keeps the liver from becoming overloaded. On the other hand when consuming products containing high fructose corn syrup and other industrially processed sweeteners, that’s when the liver gets exposed to high load of fructose, rapidly absorbed and overwhelming the liver metabolic pathways leading the the process described in article, leading to the production of excess fat (that starts accumulating inside the liver) and other toxic substances that overtime lead to liver damage.
One point that I believe needs additional clarification — smoothies/juicing. Is important to understand that neither smoothies or juices are equivalent to whole fruit regardless of what the healthy food industry keeps telling you. When you consume a bottle of 100% fruit juice, you are essentially drinking water + sugar and small amounts of other micronutrients. The fiber structure that modulates carbohydrate absorption is left behind causing a sugar and insulin spike which is not metabolically healthy. Commercial smoothies are even worse, usually having little fruit juice with additives, industrial sweeteners and texture modifying substances.
If you like smoothies limit to those you make at home. Don’t use fruit juice, rather use the whole fruit, or at least the part of the fruit you’d normally consume such as is the case for pineapple.
Keep up the great work!
— Carlos
Thanks agree.
Thank you for the format in which you presented this information. Very easy to follow and scroll through to find various points. Also, as fruit farmers, we appreciated the comments about fruit. We do eat a lot of our own crops, but we also grow vegetables and nuts and try to live close to the land. For the past 40 years, the only white thing we’ve eaten is cauliflower.
Thanks..
Can you do an article on GLP-1’s?
Thanks. Good idea
NASH is best understood as a hepatic manifestation of systemic insulin resistance, where excess substrate flux and mitochondrial stress drive lipotoxicity and inflammation rather than fat alone. The evidence consistently shows that reducing refined sugars and improving metabolic health directly lowers hepatic fat and inflammatory signaling, reinforcing that the root pathology is metabolic, not organ-specific.
Thank you so much for this very informative article, but how do elderly people do this when everything has it in it. Every cereal has it many can foods, it’s in everything. It like they want us dead. It is hard on a budget they put the things you can afford as the most toxic foods you can eat. Help🥴💙
You are right. They are trying to make us sick, then to force us to buy their expensive medications. Try buy real food that does not come in a box or can. If it looks like food its probably food. Good luck. Paul
Sad thing is you buy fruit or vegetables they don’t last. Frozen is good, but meat wow cost a fortune. Thanks buddy stay frosty!
Such useful information, Dr Marik. Thank you very much!
Hello, this was a great article, thanks. But on another subject, as a paid subscriber I clicked on your article below this one, "The Cholesterol Myth is Crumbling..." but it won't let me read the whole thing stating I need to subscribe?
That’s odd. I will fix that.
I agree that excess fructose and processed carbohydrates clearly play a major role in driving liver and metabolic dysfunction. No question about that.
But what I am wondering is if everything the brain and body does is for its survival, then insulin resistance might not be purely a pathological state, meaning it is a compensatory response—an attempt by the body to maintain energy availability under conditions where regulation has become impaired.
In that sense, the dietary factors clearly are contributing to the dysfunction, but there may also be a layer of adaptation happening within the system at the same time.
That body itself is not failing—it is adapting…but those adaptations can become the very thing that perpetuates disease.
I have a post coming up on insulin resistance. I dont think it is ever a good thing.
I may not have said that as clearly as I intended.
I’m not suggesting insulin resistance is a good thing in terms of outcome. I agree it’s associated with significant downstream harm.
What I’m exploring is whether it might, at least initially, represent a compensatory response—similar to how inflammation or elevated cortisol can be protective in the short term but problematic when they become chronic. Not so much good or bad, but part of how the body responds under certain conditions.
So more about its role in the system rather than its value.
I agree. It may be an attempt by the cell to prevent energy overload
This is interesting. I would agree. Watching my husband (25-30lbs overweight, and struggles to lose) who does not eat processed foods, sugary drinks, seed oils, exercises, and has fatty liver disease beginnings…his only vice, alcohol. Definitely a metabolic dysfunction disease happening.
Good article. Reminds me of Roy Taylor’s work.