Paul Cherry was in his mid-40s when he first felt ill enough to go to his GP. ‘I was so tired, I was sleeping all the time and felt unusually irritable,’ the father of two recalls. ‘It also hurt to pee.’
Paul was diagnosed with type 2 diabetes and was initially given metformin to lower his blood sugar, later starting daily insulin. At the same time, he was also diagnosed with NAFLD – nonalcoholic fatty liver disease, a buildup of fat in the liver that is a common precursor to cirrhosis (liver scarring).
As the name suggests, NAFLD is not related to alcohol consumption: risk factors include a family history of fatty liver disease and type 2 diabetes. It usually affects overweight people, although liver specialists say normal-weight people can also develop it – known as ‘lean’ NAFLD.
Although he was about a stone overweight at the time, Paul was not obese. Instead, his doctors believe he developed type 2 diabetes from a diet high in junk food and sugar – NAFLD followed when his blood sugar became chronically high and his liver damaged.
Paul Cherry used to drink up to three large bottles of soda a day
However, in the nine years since his diagnosis, Paul has not made the lifestyle changes that doctors recommended, such as exercising more and cutting out cake, candy and soda.
As Paul, 56, admits: ‘I loved doner kebabs and would drink up to three large bottles of soft drink a day, even though I was told it was bad for my liver.
‘Although I tried to eat more healthily, I didn’t take it seriously enough, possibly because I wasn’t actually overweight. I just wasn’t scared enough – but I should have been,’ says Paul, a driver for a fleet support company, who lives in Stevenage, Hertfordshire, with his wife Kim, 56, a teaching assistant.
But his soda addiction was one of the reasons he became so seriously ill that he had to undergo an emergency liver transplant last year.
One problem is that you can have mild NAFLD without knowing it. It can then gradually worsen until the liver becomes so inflamed and scarred that it results in cirrhosis (with symptoms including a dull ache in the upper right side of the abdomen, extreme fatigue, weight loss and weakness, sometimes occurring suddenly).
It is also possible to have “a perfectly normal BMI but a fatty liver,” explains Professor Jonathan Fallowfield, an honorary hepatologist at The Royal Infirmary of Edinburgh and spokesperson for the British Liver Trust.
Such patients are often described as “thin on the outside but fat on the inside — with fat surrounding the organs, including the liver,” he says.
Paul weighed around 16st for most of his adult life, but didn’t look overweight for his height – 6ft 2in. As a relatively slim-looking gym-goer and lifelong non-drinker, he wrongly thought he would be the last person to develop liver disease.
His story is not unique. As a nation, we are not looking after our livers – liver disease has quadrupled in the past 50 years, according to the British Liver Trust. It is the only major disease where mortality rates are rising.
The liver is the body’s largest internal organ, and its job is to break down toxins. But if its function is impaired, they build up in the blood, leading to a variety of problems, including mental confusion. The liver also stores glycogen, which our muscles use as fuel (which is why liver damage can cause muscle weakness).
Problems begin when fat builds up in the liver and causes damage over time. In severe cases, this can lead to cirrhosis – between 2019 and 2021 alone, the number of cases of this condition increased by 21 percent.
But liver damage can be reversed if caught early. While being overweight is known to be a risk factor, studies show that ‘a poor diet – including ultra-processed foods – also increases the risk, even for people who are leaner,’ the British Liver Trust told Good Health.
Professor Fallowfield explains that a range of ‘dietary disorders’ can damage the liver, including high sugar consumption, which not only directly contributes to obesity but also to high blood sugar levels, which can damage blood vessels and organs.
To protect us, the body removes the sugar and stores it as visceral fat, a particularly dangerous type of fat that accumulates around the internal organs.
Professor Fallowfield explains that visceral fat is ‘associated with higher levels of inflammation, insulin resistance (a precursor to type 2 diabetes) and liver scarring’. ‘But what is now becoming clear is that you don’t have to drink a lot of alcohol or be obese to get liver damage – up to 20 per cent of people with a normal BMI have NAFLD,’ he says.
And it appears the number of “lean” people with fatty liver is increasing, according to a 2023 US study. It identified a “subgroup of individuals… known to have lean NAFLD… that is becoming increasingly common”.
When fat builds up in the liver and causes damage over time, it can lead to cirrhosis
There is currently no approved treatment for an unhealthy liver, says Professor Fallowfield. Although so-called liver supplements such as milk thistle and turmeric “won’t do you any harm”, he says dietary changes and regular exercise are the “best, in fact the only, cure”.
He advises switching to a Mediterranean diet, rich in fish, fruits and vegetables, and being as active as possible.
One problem, he adds, is that people with lean NAFLD are not suspected of having fatty liver disease the way overweight patients are. This can lead to a late diagnosis, when the disease has already progressed to a more severe stage.
And sometimes symptoms can come on suddenly, as in Paul’s case. After his diagnosis, he visited a liver specialist twice a year and there was no change in his liver function. Then, out of nowhere, in mid-2022, he became acutely ill.
He felt tired and irritable, ‘then I stopped eating and started losing a lot of weight – four stone in three months. I also felt confused and had no control over my muscles.’
Paul also kept falling – once breaking two ribs. He recalls: ‘I needed help getting dressed. I didn’t know what was happening to me.
‘Then, one night in 2022, we were sitting at home watching TV when I suddenly felt an unbearably sharp pain in my stomach. I rolled on the floor. I thought I was going to die.’
Paul was taken to hospital where a scan revealed problems with his liver, which was so badly damaged that Paul was transferred to the Royal Free Hospital in London where specialists told him he needed an emergency transplant.
He says: ‘I was very afraid that I would not see my daughter married (he also has a son), or see my grandchild grow up. I still get tears in my eyes when I think about it.’
Paul was sent home to await a donor liver, but his condition continued to deteriorate.
Failing liver function caused fluid to leak from his liver veins, causing a buildup in his abdomen and legs; several liters had to be drained every two weeks in hospital. It was, he says, “a bleak, stressful time.”
His poor health meant his driver’s license was taken away, he lost his job of 28 years, and doctors advised him to make a funeral plan. ‘I was on the scrap heap at 54,’ he recalls. ‘Everywhere I went, I had a bag packed; just in case we got a phone call. My wife, daughter and I cried most days.’
But then, on the day of the coronation, in May last year, he got the phone call: a liver had been found. He recalls with tears in his eyes: ‘I said goodbye to my wife and daughter, in case I didn’t make it.’
The transplant was a success and Paul has since planted a tree in his garden as a memorial to his donor. All he knows is that the donor was male.
Paul is counting his blessings and has changed his diet: he now eats brown bread, lean meat, pasta and fruit and vegetables that he grows himself in his new vegetable garden – and water instead of soft drinks.
He is still a kilo overweight, but feels “100 times better,” walks to the store instead of driving and carefully reads food labels for sugar and fat content.
“I’m living proof that fatty liver disease can happen to non-drinkers,” he says. “I still get flashbacks to when I was seriously ill. I’m never going back to that point.”