If your liver enzymes came back flagged and your heart dropped when you read them, this was written for you.

If what you got afterwards was cut down, lose a bit of weight, come back in 6 months, and no explanation of any kind, it was written for you.

If you have since done that. Actually done it. Given up the wine, lost the weight, walked every morning. And the number came back the same or worse, and nobody could tell you why. Then it was written for you.

And if you have spent an evening on your phone reading strangers’ results at 1 in the morning trying to work out whether you are the one who will be fine, it was written for you most of all.

I know what that evening is like. My wife had it, and I was asleep next to her while she had it.

I am going to tell you something I have never put in a patient letter.

For 18 years I have given the same advice to everybody who sat down across the desk from me. I gave it in good faith. It is what I was trained to say, it is what is in front of me on the screen, and it is still in the guideline today.

Then I had to give it to my own wife.

And 2 years of watching it not work, from 3 feet away, at my own kitchen table, taught me something about my own advice that 18 years of clinic never had.

I have not been able to say it the same way since.

Who I am

My name is James Whitmore. I have spent 18 years as a consultant hepatologist. Liver clinic, 2 days a week, for most of my working life.

I have had the fatty liver conversation several thousand times. I know the leaflet by heart because I helped write the local version of it.

I am, in other words, exactly the person your GP would send you to.

My wife is called Ruth

She was 51.

She is 5 foot 6 and 9 stone and has been since our wedding. Not slim because she works at it. Slim because she always has been.

She drinks. I want to be straight about that, because it is the first thing anybody assumes. 2 glasses of wine with dinner, a bit more at Christmas. That is it. That is all it has ever been.

She walks. She reads the labels. She has never smoked.

Put her on a clinic list and she is the one you do not worry about. She is the one I would have used as the control.

Her ALT came back at 147. Her AST at 98.

For a woman her size the top of the range is about 33 and 32.

So her ALT was more than 4 times where it should have been, and her AST 3 times, in a slim 51 year old who drinks 2 glasses of wine with her dinner.

I rang the lab. I have never once done that about anybody else’s bloods in 18 years. I assumed it was a mix up.

It was not a mix up.

So I scanned her myself, on the Thursday, in my own department, between 2 clinics.

Diffuse steatosis. Moderate to severe. No scarring I could see yet.

Fatty liver. The thing I diagnose most days of my working life, on my own screen, in my own wife.

Then I put her on the FibroScan, which is the machine that settles it.

It gives you 2 numbers and almost nobody is ever told the difference between them, so here it is.

The first is CAP. That is fat. How much of it is in the liver. Under 238 is nothing to speak of. Over 290 is severe.

Ruth’s CAP was 317.

The second is E, measured in kilopascals. That is stiffness. How much scar has been laid down. Under 7 is fine. Around 10 is advanced. Past about 13 you are talking about cirrhosis.

Ruth’s E was 5.1.

Read those 2 together, because it is the whole of what happened next.

Severe fat. Almost no scar.

She was in the window. The part that comes back out, and none of the part that does not.

And I was relieved. That is the honest thing to say, and it is the part I have to answer for.

No scarring. Reversible. I had given that news hundreds of times and meant it every time.

So I told Ruth what I tell everybody.

Mild. Reversible. Cut back on the wine, watch what you eat, get your steps up, and we will run the bloods again in 6 months.

Simple.

Except it was not simple. And it took me 14 months to find that out, because I went back to work and she went home and lived in it.

She was not tired. She was empty.

There is a difference and she had stopped being able to explain it to anybody.

3 in the afternoon and there was nothing left in her.

And the ache in her right side. High up, under the ribs, at the front. Not a stab. Dull and heavy and constant, and there so long she had stopped being able to date it.

She rests her hand flat on it. At the table, in the car, mid sentence about something else. She has no idea she does it. I have never said so, because the day I say so she knows I have been watching.

It is the symptom I ask about first in clinic and the one almost nobody volunteers, because it never gets bad enough to make an appointment about. It just never goes away either.

Swollen. Not fat. Swollen. She said she felt swollen all the time, every day, from about 2 o’clock.

Half a sandwich would do it.

The fog got into her work. She lost words. She read the same email 4 times and could not have told you what it said.

She stopped doing the crossword she had done every morning for 20 years, and did not mention that she had stopped.

And here is where I was no use to her whatsoever.

The protocol I have handed out for 18 years opens with lose weight.

Ruth had nothing to lose. There was no first line for her. So I gave her the rest of it, and I gave it to her with confidence, because it is what is on the screen in front of me and it is what is in the guideline.

She did all of it. Then she went and found more.

• Intermittent fasting. 16 and 8. Every day, for 8 months.
• Whole foods, properly. Old fashioned oats. Fresh and frozen fruit and veg. Lean protein. Greek yoghurt. Nuts. Beans.
• The desserts went. All of them.
• 4,000 steps after dinner. Every night. In the dark, in the rain, in February.
• The wine cut right back.
• The Mediterranean diet. The real one, not the magazine version.
• And black coffee. Pints of it, because she had read it was one of the few things with actual evidence behind it, and she was right about that.

8 months of that.

Nothing changed. Not the exhaustion. Not the ache in her side. Not the fog.

Then the repeat bloods came back. ALT 139. AST 94.

8 points. After 8 months.

That is not a result. That is a rounding error with a year of her life inside it.

She rang me at work and I could hear it in her voice before she said anything.

“So what was all that for?”

Ruth

I did not have an answer for her. 18 years, a doctorate, a consultant post, and my wife asked me what 6 months of her life had bought her and I said we would keep an eye on it.

That is when she stopped asking me.

I found out later what she did instead. She started going up at 10 and sitting on the edge of the bed with her phone.

Other people’s blood results. Forums full of strangers posting their numbers at 1 in the morning asking if they were going to be alright.

My wife. Married 26 years to a liver consultant. Asking the internet.

She never told me. Not once in a year.

And then in the October she said the thing this whole article is actually about.

We were in the kitchen. She was not upset. She said it like she was reading it off a list.

“I keep trying to work out what I’ve done to myself.”

Ruth

Not what happened to her. What she had done to herself.

She had given up the wine. Lost the stone. Walked in the dark before work all winter. Done every single thing her husband the consultant had told her to do.

And she had decided the reason none of it worked was her.

I have thought about that sentence more than anything else in 18 years of medicine.

Because she did not get it from nowhere. She got it from us.

Cut down. Lose some weight. Come back in 6 months.

Say that to somebody with no explanation attached, and when it does not work there is only one place left for them to put the blame.

Two questions for you

I have not written all of that down so you feel sorry for my wife.

I have said it out loud to 3 patients since and all 3 stopped me somewhere in the middle. One of them stopped me at the phone at 1am.

So, 2 questions.

• What time of day do you stop being comfortable? You will know the answer to within about half an hour.
• Go into the photographs on your own phone and count how many you are actually in this year, against how many you took.

When Ruth did that she said, “I did not realise I had arranged my whole life around it.”

That is the bit nobody puts in a leaflet.

It is never the number on the blood test that takes your life apart. The number sits on a screen in a surgery. What takes it apart is the 100 small arrangements you have quietly made around it, none of which felt like a decision at the time.

And I have not told you yet what Ruth’s number was doing through all of this. I am going to. But you need 2 things explained first, or it will not mean anything to you, and one of them is the reason I stopped sleeping properly in the October.

What failed, and why

I am not going to stand here and tell you the advice I gave her was wrong. Reducing alcohol is right. Losing weight is right. I would tell you both of those today.

But it was incomplete, and I did not know it was incomplete.

Every line of that protocol is aimed at what goes in. Not one of them does anything for the organ that has to deal with what is already there.

And I want to say something about how that advice gets delivered, because I have delivered it that way myself for most of my career.

Cut back. Lose some weight. Come back in 6 months.

That is not a plan. It is a holding pattern with a review date on it. It gets said in under a minute, usually with a hand already on the door, and the person it is said to walks out of that room with no explanation of what is wrong with them, nothing to actually do, and 6 months to sit in.

I have watched people leave my clinic angry and I used to think they were angry about the diagnosis. They were not. They were angry that they came in frightened and left with nothing.

Nobody trained me to think about it that way. 6 years of medicine and 8 more of specialist training, and the hours spent on what you could actually give a liver to work with came to about none.

That is not a scandal. It is much duller than a scandal, and the reason is the most useful thing in this article, so I will come back to it.

So I went back to the papers underneath the guideline

4 months of evenings. Ruth would go up at 10 and I would still be at the kitchen table at 1.

First I worked through everything she had already wasted money on. If I could not explain the failures, I had no business recommending anything.

• Dandelion root. Months, she was on this. It is a diuretic. That is the entire mechanism. You pass more water, the scales say a pound less, and it feels like something is happening. Come off it and the pound is back in a day, because it was water, and none of it was ever anything to do with the liver.
• Detox teas. Read the back of one. Senna, usually, which is a stimulant laxative. The same trick at the other end. Emptying a bowel faster does not clean an organ.
• The liver flush. Olive oil and lemon juice, and in the morning you pass green stones and everybody photographs them. They are not gallstones. They are soap. Olive oil and citrus react with your own digestive fluids to make them, and explaining that to a woman who believed she had passed 20 years of disease into a toilet is one of the worse conversations I have had.
• The “liver complex” bottles. 14 ingredients on the label, 20mg here and 15mg there beside them. Quantities that exist to be printed rather than to do anything. Every one is on that label because it is recognisable, not because there is a dose of it in the bottle.
• Cutting alcohol further. Where I had put her. Worth doing, and it does not do a single thing about what is already there.

When I took all of that away, something was still standing.

One compound, over and over, in trials with actual biopsies in them.

Ferenci, 1989. Cirrhosis patients followed for years, a survival difference in the treated group. Chan, 2017, biopsy proven NASH, real tissue under a microscope before and after. And a Cochrane review pulling it together.

Not a drug. A plant extract.

That was the old work, and old work on its own is not enough to change what I tell a patient. So I went and got the recent papers, the ones published while I was busy handing out the leaflet.

These are the 5 I ended up printing. I have put the conclusion of each one underneath it, in plain words, and the full titles and sources are at the bottom of this page so you can pull them up yourself.

Read number 3 again and then read number 5, and you will see why I had to put my highlighter down and sit there for a while.

Number 3 says it got more people's ALT back into range than the standard treatment did. The standard treatment is mine. It is the one on my screen.

Number 5 is Ruth exactly. The diet, the walking, the wine cut back, all of it done properly, with one compound added on top. That is the trial she had been running in our house for 8 months, except she was running it with the one part missing.

And then I looked at what was actually in the capsules

This is the bit I would have skimmed as a younger doctor, and it is the bit that matters most.

Look at what they gave people. Most of those trials did not use milk thistle powder. They used silymarin standardised to 80%. The measured extract, at a strength somebody had checked before it went in the capsule.

That is not a footnote. That is the study. When a paper says silymarin worked, it is telling you that that worked. It tells you nothing whatsoever about a tub of ground seed.

And one of the trials went the other way, and used large doses of ordinary unstandardised silymarin to try and make up the shortfall.

Which closes off the obvious idea, and I want to say plainly that it was my idea first, sat at that table with a highlighter. If the cheap one is weak, take more of them.

No. You do not get there by swallowing more of a weak extract. The strength is in the capsule or it is not, and I will come back to how you check that on a label, because it is the single most useful thing in this article.

And I know what you are thinking, because I thought it first. This is the aisle. The aisle I have spent 18 years telling patients not to waste their money in.

It turned out I was completely right about the aisle. And wrong about the plant.

What your number actually measures

First you need to know what your blood test actually measures, because almost nobody is told and it changes how frightening it is.

ALT and AST are enzymes. They are not supposed to be in your blood at all. They live inside your liver cells, sealed in, doing their job.

The only reason a blood test can see them is that some have leaked out.

So a raised ALT is not a measure of how much of your liver is damaged. It is a measure of how much it is currently leaking.

That is the difference between a verdict and a gauge. A verdict is a door closing. A gauge is a reading you can change.

What keeps those enzymes sealed in is the wall of the liver cell, and what keeps that wall intact is a reserve the liver holds. Glutathione. Its own antioxidant, consumed every time the liver deals with anything at all.

Alcohol drains it. So does ordinary modern food. So, quietly, does getting older.

When the reserve runs down the walls start to weep, and the number on your form goes up.

Which is what Ruth’s had been doing while she followed my instructions to the letter. 71, 65, 79.

I looked at that on my own laptop, at my own table, with her asleep upstairs. She had been better at my protocol than any patient I have ever had.

A liver in this state does not have one problem. It has three.

Here is what I had never put together in 18 years, until I was reading about my own wife at 1 in the morning. Three problems, in the same cells at the same time.

Stop on that third one, because it is my entire speciality.

Fat comes back out of a liver. Inflammation settles. Scar does not. Whatever fibrosis goes in, stays in.

There is a man I have looked after for 9 years. 54 when he came to me, slightly overweight, drank a bit more than he should, which is to say he was every second man on my list. He did most of what he was told.

He is 63 now, and last month I had the conversation with him and his wife about what happens next, and there is no version of what happens next that either of them wanted.

Nothing dramatic happened to that man. No crisis. He spent 9 years in the holding position, doing roughly the right things, while it was quietly decided in tissue nobody was looking at.

That is what my speciality actually is. Not drama. Watching people lose an argument slowly, over a decade, that nobody told them they were having.

And in the October, at my kitchen table at 1 in the morning, I worked out that my own wife was 2 years into exactly that, on my instructions.

I have written a lot of things here that were uncomfortable to type. That is the one.

“She was not failing to follow my advice. My advice was the thing keeping her still.”

Dr James Whitmore

One compound. All three problems.

Milk thistle only does anything at all because of one compound in it. It is called silymarin. Everything else in that seed is packaging.

And silymarin is not one thing that does one job. That is what I had missed, and it is what makes it worth your attention.

• It sits in the wall of the liver cell and makes it harder for things to get through.
• It raises glutathione. It puts the reserve back.
• And it acts on the stellate cells, which are the cells that lay down scar tissue.

One compound. All 3 problems. That is not something I can say about anything else I prescribe.

Why nobody told you

So why had no one ever said this to me? I want to give you the real answer rather than the exciting one.

There is no conspiracy. Nobody is hiding it. Ferenci is on PubMed and has been since 1989 and anybody can read it this afternoon.

The reason is duller and worse.

You cannot patent a plant.

Which means there is no company that stands to make the sort of money that funds a large trial. No large trial means it never gets into a guideline. Not in a guideline means it does not appear in my training, does not appear in the protocol on my screen, and no representative ever came through the door to tell me about it over a sandwich.

Statins had that. Metformin had that. This has nobody.

So it sits in the literature, perfectly visible, and it never reaches the 4 minute conversation you had with your GP. Not because anyone decided to keep it from you. Because there is no one whose job it is to bring it up.

The milk thistle problem

Now here is where I was right for 18 years. Almost everything on that shelf is worthless. I could not have told you why until I started reading labels properly.

Pick up a high street tub. The front says 1,000mg, in the biggest type on the bottle. And 1,000 is a bigger number than 300, so you would put the 1,000 in your basket. Anybody would. I would have.

Think about a cup of coffee.

You would never judge how strong a coffee is by asking how many millilitres are in the cup. A pint of dishwater is more coffee than a double espresso. Nobody is confused about which one will keep you up.

The volume is not the strength. It never was.

Milk thistle works exactly the same way, and the whole industry is counting on you reading the millilitres.

The 1,000mg is how much ground plant is in the capsule. It tells you nothing about how much of the active is in the plant.

So turn it over and look for the silymarin percentage.

On most of them it is not there at all, because it is ground seed and the content might be 4%. It might be 10%. Nobody is required to tell you, so mostly nobody does.

At 4%, a 1,000mg capsule gives you 40mg of the only compound that does anything. The trials I had spent 4 months reading were built on several hundred.

A very large cup of very weak coffee.

So somebody takes one a day for a month, feels nothing, and concludes that milk thistle does not work.

I went and got the tub out of our own kitchen cupboard while I was reading this. The one Ruth had bought herself, because she had run out of things to try and nobody had told her not to bother.

1,000mg on the front, in gold. Nothing on the back. No percentage anywhere on the label.

She had taken it every morning for 4 months and it had never had a chance, and she concluded from that, quite reasonably, that milk thistle does not work.

So had I. For 18 years. From exactly the same evidence.

What Ruth takes

The one Ruth takes is called Uvera. It is made by a small British company.

I looked at a lot of labels before this one. It was the first that put the number on the front instead of leaving me to guess.

Every milligram printed. No proprietary blends, which in my experience is where an underdosed formula goes to hide.

One capsule. Taken with food, because silymarin absorbs poorly on an empty stomach and that alone is the difference between a dose and a waste of money.

What happened

I am going to give you Ruth’s, and only Ruth’s, because it is the one I watched.

• Week 1. Nothing. I want to say that plainly, because you will read a lot of pages that tell you otherwise.
• Week 2. The 3 o’clock wall stopped landing. She noticed before I did. She got to the end of a Tuesday without going near the sofa.
• Week 3. She ate a dinner and did not end up back in the kitchen at 10 looking for something. Neither of us clocked it until the week after.
• Week 6. Repeat bloods. 79 down to 52. 27 points in 6 weeks, against 6 points in 3 months of doing everything I told her. I ran it again. I did not believe it, and I am the man who ordered the test.
• Week 10. She ate a curry. I know how that reads written down. But she had not eaten a meal without paying for it afterwards in 2 years. That night she ate a proper dinner and then sat in the same chair for another hour talking, and not once did her hand go to her stomach.
• Month 4. ALT 31. Inside the range for the first time since this started.

And in the November she stayed at a party until midnight. I know how small that sounds written down. She had not done that in 2 years. I watched her at about half 11, stood up, in the middle of a conversation, not looking for a chair and not looking for me.

What it costs

The money is the least interesting part of this, and it is the only part anybody ever puts in an advert.

Here is what 2 years actually cost my wife.

• 2 years of going to bed frightened and not saying so.
• Every evening after 8 o’clock for 2 summers.
• The cryptic crossword she had done every morning since she was 31.
• Eating a bowl of soup at lunchtime without paying for it until bedtime.
• A stone, which she gave up wine and bread and 6 months for, and which bought her nothing at all.
• A year of believing she was the reason none of it worked.

You cannot put a figure on that one. I have sat and tried, because I am the sort of man who reaches for a number when he does not know what else to do with a feeling.

Here is the money, and I will be quick, because after that list it is almost embarrassing.

The dandelion, the teas, the cortisol capsules, the berberine, the juice programme, the dietitian. Several hundred pounds over 2 years, to move a number 6 points in the wrong direction.

A private liver panel, if you cannot wait 3 months to find out, is about £180.

And the thing that actually worked comes out at 39p a day.

We spent 2 years, several hundred pounds, a stone of my wife’s weight and one sentence from our daughter, finding out something that would have cost us 39p a day to have known at the start.

Whatever the equivalent of that list is for you, and you will know exactly what is on it, it is being written right now, at 39p a day, while you decide.

The guarantee

90 days, money back.

I want to point out why the length of that matters more than the fact of it. A 14 day guarantee on a liver product tells you the company does not understand the organ. Nothing meaningful happens to a liver in 14 days.

90 days is roughly one full cycle of bloods. Which means you can take it, get retested, and make the decision on a number rather than on a feeling. That is what I would want and it is what I would tell a patient to do.

Who this is not for

Since I have put my name to this, I am going to tell you who it is not for.

• If you have been told your fibrosis is advanced, or you have been given a diagnosis of cirrhosis, this is not the article you should be acting on. Go back to your consultant. I mean that.
• If you are hoping for something you can feel by Friday, do not buy it. Ruth felt nothing for a fortnight.
• And if you are looking for permission to drink more than you do now, you have misread me. This does not make alcohol safe. It was never going to.

What it does is give the organ something to work with, which is the one thing the protocol I gave out for 18 years never did.

Availability, and the clock

2 practical things and then I will leave you to it.

The first is that it runs out. The 80% is the constraint. Every batch is tested to confirm the silymarin really is at 80 before any of it leaves, and that testing takes weeks, so it is made in small runs.

Ruth has gone to reorder and found it gone twice. The second time it was 3 weeks. She stood in our kitchen turning an empty bottle over in her hand, and I have not let it get low since.

If you look and it is not there, that is the batch, not the company.

The second is the clock, and I will say this as a doctor rather than as a husband.

It took 2 years to do what it did to my wife, and it never announced itself. No month where it was noticeably worse. Every one of those years felt, from the inside, like a year in which not much happened.

That is what I cannot get across in a 10 minute appointment. Fibrosis does not hurt while it is being laid down. The man I told you about, the one who is 63, felt fine for most of the 9 years.

Feeling fine is not information. It never has been.

So the weeks between now and whenever you get round to this are not neutral weeks. Something is being decided in them, whether or not you have got round to it.

That is the whole of the urgency. There is no countdown on this page and there does not need to be one. You already know how long you have been meaning to do something about this.

The two paths

What to do next

• Check the page below for availability.
• Take one capsule each morning, with food, not on an empty stomach.
• Do not judge it in the first fortnight.
• Ask your GP to repeat your liver function tests at around 12 weeks. You are entitled to ask, and a number is worth more than a feeling.
• Keep doing whatever you were already doing that was sensible.

Dr James Whitmore,

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