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Monday, March 1, 2010

Ayurveda and Liver Health

The health of the liver is key to the health of the person. The liver is a complex, multipurpose, resilient organ that is essential to life[1][1]. The liver has hundreds of different functions and is connected with every part of the body. Every moment of every day, it is involved in manufacturing, processing, and supplying vast amounts of nutrients. These nutrients feed the 60 to 100 trillion cells of the body. In order for the cells to survive the liver must constantly make and supply them with nutrients, enzymes and hormones. The liver needs to be completely unobstructed in order to maintain a problem-free production line and smooth distribution system throughout the body[2][2].


Diagram A – location of liver Diagram B – hepatic lobule

The liver is a large, dark-red gland in the upper part of the abdomen on the right side, just beneath the diaphragm (Diagram A). Its manifold functions include storage and filtration of blood, secretion of bile, conversions of sugars into glycogen and many other metabolic activities[3][3].

It is the second largest organ in the human body, the largest being the endothelium (skin), but is the largest internal and solid organ and the largest gland. It weighs about 3.3 lbs and is divided into four unequal lobes[4][4]. Blood enters the liver through the hepatic artery (25%) and hepatic portal vein (75%). Arterial blood enters through the hepatic artery. The blood passing through the hepatic portal veins is venous blood draining from the spleen, gastrointestinal tract and the surrounding organs. Both sources provide oxygen to the liver, each portal about 50%.

Billions of liver cells (hepatocytes) make up the whole liver. Together they process nutrients, produce bile, destroy poisons and secret substances. The liver cells are organized into microscopic lobules. Each lobule has six corners (Diagram B). At each corner is a branch of the hepatic vein (nutrient rich blood), hepatic artery (oxygen rich blood) and bile duct[5][5].

It is this unique makeup that allows the liver to be so resilient to damage. The body can maintain normal function even if two thirds of the liver is lost. However, life is not possible without one[6][6].

FUNCTION – Western Science
The liver performs over 500 metabolic functions and supports every organ in the body. The hepatocytes are responsible for the chemical composition of the blood5. The functions include5 [7][7]:

Blood glucose regulation - Metabolize and store carbohydrates, which are manufactured as the source for the sugar in blood that red blood cells and the brain use
Fat metabolism - Synthesize, store and process fats, including fatty acids and cholesterol
Mineral storage – Iron and copper needed to make hemoglobin
Protein metabolism – converts excess amino acids to urea for elimination by kidneys, albumin and blood clotting factos
Bile production - bile acids to aid in the intestinal absorption of fats and fat-soluble vitamins (A,D,E AND K)
Hormone breakdown
Eliminates body waste - by metabolizing and/or secreting, the potentially harmful biochemical products produced by the body, such as bilirubin from the breakdown of old red blood cells and ammonia from the breakdown of proteins
Detoxification – Products as alcohol or have been inhaled or ingested are converted into harmless substances
Heat generation – With so much activity the liver generates a large amount of heat which is distributed around body by blood to keep the constant temperature

FUNCTION - Ayurveda
In Ayurveda the liver is governed by Pitta dosha which resides in the middle section of the torso[8][8]. Pitta means “that which digests things” and is responsible for all chemical and metabolic transformations in the body including such diverse roles as[9][9]:

thermal regulation
visual perception
emotional states
will power
converting rasa (clear plasma) to rakta (blood)[10][10]
maintain purity of blood by keeping ama (impurities) from mixing with it

Pitta contains the heat energy which helps digestion and the heat energy is agni[11][11]. Of the five Pitta sub-doshas, the liver (as well as spleen and stomach) is most associated with ranjaka pitta. Ranjaka means “that which colors”[12][12]. The substance that is tied to the liver is blood. Its red color, heat, health and being toxin-free are functions of ranjaka pitta.

Pachaka pitta is also associated with the liver due to its function in aiding digestion[13][13]. Pachaka originates from the word pachan which means “digestion”. It regulates how a person digests, assimilates and metabolizes food10.

Liver health is commonly measured through liver function tests (LFTs) which are done with a blood sample. LFTs are made up of a combination of biochemistry blood assays which include measurements of:

albumin – protein made by liver.
alanine transaminase (ALT) – enzyme present in hepatocytes. If hepatocytes are damaged ALT leaks into the blood. Specific for liver damage.
aspartate transaminase (AST) – enzyme present in liver, red blood cells, cardiac and skeletal muscles. Not specific to liver damage but ratio of ALT to AST may help differentiate between causes of liver damage.
alkaline phosphatase (ALP) – enzyme from cells lining the biliary ducts of the liver. Elevated in large bile duct obstruction, intrahepatic cholestatis or infiltrative diseases of the liver.
total bilirubin – breakdown product of heme (part of haemaglobin in red blood cells). Liver is responsible for clearing blood of bilirubin and if it cannot do so jaundice is the result.

At first glance health issues that are associated with liver disease are those that show dramatic changes to the liver such as hepatitis and cirrhosis. ‘Hepat-’ is Greek for anything pertaining to the liver and ‘-itis’ means inflammation. Infectious hepatitis has plagued human kind for millennia. The first reference to it was in 400 BC in the writings of Hippocrates and in ancient Chinese medical texts[14][14]. Cirrhosis is interstitial inflammation of an organ, usually the liver[15][15], is used to describe hardened liver tissue.

To rely on LFTs to monitor the health of the liver is a disadvantage. The liver is a very resilient organ and will continue to work hard even when impeded in its capacity. It can lose 60% of its efficiency and still operate ‘normally’ as measured by the blood tests. By the time the LFT levels a substantial amount of damage has already been done[16][16].

The main impediment to a healthy fully functioning liver is the formation of gallstones in the liver which may referred to as intrahepatic stones. Some gallstones are formed in the gallbladder but the majority are formed in the liver. These stones vary in size from tiny to golf balls like obstructions. They clog up the channels (srotas) of the liver and reduce the efficiency of its operations. Thought the liver maybe full of gallstones it is mostly undetected by blood tests, ultrasounds or x-rays until the condition is very severe16.

There are many symptoms of the presence of gallstones in the liver, some of the mild symptoms are:
Food cravings
High cholesterol
Angry personality
Puffy eyes
Liver spots on back of hands and facial area
Dizziness and fainting spells
Difficulty breathing

The presence of these diseases also indicate gallstones in the liver:
Liver cirrhosis
Heart disease
Brain disorders
Duodenal ulcers
Prostate diseases

This is by no means a comprehensive list but some of the indicators that an obstructed liver is the source of the illness. The liver is responsible for so many functions in the body and should some of these functions not work at optimum vikriti (disease) will follow.

Digestive System
The Ayurvedic perspective is that “we are not what we eat, we are what we digest”. It is of utmost importance to have a strong agni (digestive fire) in order to digest our food well. Undigested or improperly digested food becomes ama (toxins) and is the cause of disease. Digestion is a function of all three dosha – vata, pitta and kapha. Vata moves the food, pitta governs agni and the metabolic processes necessary for absorption of nutrients, while kapha is responsible for the digestive fluids[17][17].

Agni governs all metabolic processes of which most occur in the liver. The liver produces bile which is its most important function. Roughly 1 to 1.5 quarts are produced a day. Without sufficient bile, most commonly eaten foods remain undigested or partially digested, which results in the formation of ama. Bile is viscous, yellow, brown or green fluid, alkaline and has a bitter taste[18][18].

Bile would usually be stored in the gallbladder. If the bile ducts are obstructed the full volume of bile needed for digestion is not released. The liver will drop production of bile to cope, leading to even worse digestion. Even with the lowered production there may still be excess bile and in severe cases jaundice may result[19][19].

Here is one example of improper digestion leading to disease. The small intestine needs bile to digest and absorb fats and calcium from food. If there is insufficient bile undigested food remains in the intestinal tract. Some of the fats are excrete in stools. If the fats are not absorbed, calcium is not absorbed either leaving blood in deficit. The blood (rasa) then takes the calcium it needs from the bones (asthi) resulting in osteoperosis18.

The Heart
The liver is designed to protect the heart. A healthy liver detoxifies and purifies the blood. It breaks down alcohol, toxins produced by microbes and kills bacteria and parasites. It creates urea which is the nitrogenous portion of amino acid which is not required for forming new proteins. Urea is then excreted in urine[20][20]. There are five quarts of blood in the human body, one quart is filtered by the liver every minute[21][21]. The only waste left in the blood after liver filtration is carbon dioxide which is eliminated through the lungs.

As gallstones impact the liver kinks are developed in the structure of the lobules. This reduces the internal blood supply and harmful cellular debris is not filtered correctly and enters the bloodstream. The venous blood from the liver feeds into the right side of the heart. As the liver congests the heart pumps stronger to move the blood through the obstructions. Over time this can lead to heart palpitations or even heart attacks20.

Gallstone Formation
The gallstones are formed due to changes that effect bile. Bile is made from water, mucus, bile pigments (bilirubin), bile salts, cholesterol, enzymes and good bacteria. Abnormal changes to the composition of bile changes the solubility of the individual components which result in the formation of gallstones.

There are two types of gallstones: cholesterol and pigment stones. Cholesterol stones are more common and are usually green sometimes white or yellow in color. They composed of 80% cholesterol (Diagram C). Pigment stones are brown or black (Diagram D). The dark color comes from the high concentration of bilirubin and calcium salts found in bile, but can still have up to 20% cholesterol. They are harder than cholesterol stones. Cholesterol stones can also become hard but calcified stones only develop in the gallbladder[22][22].

Diagram C – Cholesterol stones Diagram D – Pigment stones

When bile is normal the dissolving action of bile salts accompanied by large quantities of water keep cholesterol in liquid form. When abnormal components are introduced gallstones form. The changes which cause gallstones are:
Increased amount of cholesterol in bile overwhelms the dissolving capacity of bile salts
Decrease in bile salts
Increase in bile pigments and bilirubin

As a Pitta organ the liver is the origin of many systemic inflammatory, digestive disorders and fiery emotions when it is out of balance. When working towards a healthy liver there are general daily practices to maintain optimum health, actions towards pacifying the pitta dosha and specific activities for targeting the liver[23][23].

To have and maintain a health liver is a multi-step approach beginning with a liver cleanse. Gallstones in the liver are present for all people, even those with a healthy diet and lifestyle. The only way to evacuate the stones is to perform a liver cleanse.

Detailed instructions for the liver and gallbladder flush is available in –
Andreas Moritz, ‘The Amazing Liver and Gallbladder Flush’.

The basic instruction is to start drinking apple juice to soften the gallstones. In the evening, Epson salts (magnesium sulfate) and warm water is sipped for its laxative effects. Extra virgin cold pressed olive oil is mixed with grapefruit juice then drunk. After drinking the mixture the person goes straight to bed and lies down for 20 minutes propped up by pillows before going to sleep. The oil goes to work and can be heard gurgling down the digestive tract. The next morning more Epson salts and warm water is sipped to facilitate the evacuation of the gallstones. In addition to moving gallstones out of the liver, the digestive tract is also flushed moving debris out of the body. This should be done at least twice a year or if possible monthly in case of major disease[24][24].

Depending on the dosha of the patient, the liver cleanse should be timed for their seasonal change: kapha in spring, pitta in summer and vata in fall. The cleanse works best on a Sunday (day of the liver) and during a full or new moon.

When the liver is out of balance the symptoms that arise are those governed by pitta dosha. It is not enough to only treat the liver, the pitta dosha must be pacified. The elements of pitta are water and fire, with fire being dominant. The qualities of pitta dosha are: oily, sharp, hot, light, acidic, moving and liquid. Like qualities increase like, so these are the qualities in food to avoid creating more pitta. The pitta person has a tendency to overheat so cooling qualities are encouraged[25][25].

The pitta diet should encourage foods with sweet, bitter and astringent tastes and avoid salty, sour and pungent tastes. The challenge is if the body is out of balance it may crave the foods that would aggrevate it. Pittas should avoid meat, alcohol and fried foods, eating more salads and cooling herbs and spices.

Pitta Pacifying Diet Guide[26][26]

Favor – Sweet Bitter Astringents, Cooling

Reduce – Salty Sour Pungent, Heating
White rice (jasmine, basmati), barley couscous, quinoa
Corn, millet, buckwheat, brown rice
Melons, pears, mangoes, apples, coconuts, figs
Sour fruits - Grapefruit, pineapple, berries
Cucumber, kale, broccoli, zucchini, potatoes, squash
Spinach, mustard greens, tomatoes, radish, garlic
Mung beans, lentils, chickpeas, split peas
Fermented soy bean products and tempeh
Pumpkin seeds, blanched almonds (small amounts), sunflower
Nuts and Seeds
Peanuts, cashews, pistachios and all salted nuts
Organic milk, butter, ghee, cottage cheese, panir, unsalted cheese
Yoghurt, salted cheese, ice cream
Require less oil - ghee, sunflower and coconut oil
Oils and Fats
Almond, corn, safflower and sesame
Jaggary, maple suger, small amounts of honey
Molasses, brown sugar
Lots of water, apple juice, mint tea, coconut water
White meats, fresh water fish
Red meat, salt water fish, shellfish, egg yolks

Herbs that benefit Pitta dosha are: cilantro, cumin, tumeric, mint, saffron and fennel. Avoid any heating or hot spices allspice, basil, curry powder, garlic, ginger and especially any chilies[27][27].

Herbs that are promote liver health are:
Guduchi – The best rasayana (rejuvenative). Can strengthen digestive fire without causing it to burn too bright and there are no complications from long term use. Bitter and sweet, it can clear and strengthen simultaneously.

Amalaki – pacifies all doshas especially pitta. It is nutritive and rejuvanative to all dhatus (tissues). Can be found in Chyavanprash (medical jam).
Aloe vera - Aloe gel can direct can act as a vehicle or “anupan” to carry or direct herbs to the liver organ. Aloe gel can easily be combined with Tumeric or coriander and taken along with Guduchi and Amalaki. The bitter and demulcent nature of aloe gel can assist in clearing and healing inflammatory conditions and compliments the actions of both Guduchi and Amalaki[28][28].
Katuka – Useful for treating jaundice, liver problems and cleansing liver & gallbladder of stones. It is the most commonly used bitter tonic.
Ayurveda promotes having a daily routine to improve the health of the body, mind and spirit. Pitta doshas have ‘fiery’ natures and need to release their aggression, frustration, anger, self-criticism and intensity. Having a pitta pacifying daily routine would help to cool and calm the pitta mind, body and with it the liver.

Eating: Do not over eat! The greatest cause of gallstones is overindulging of food. Eating more than the stomach can handle makes the liver over time producing more cholesterol to secrete into the bile, forming gallstones.

Eat on at regular times each day favoring leafy greens instead of oily meats. Pitta fire tends to run hot and when hungry the body’s need for food is demanding. Pitta people do not do well missing meals.

Regular fasting (ideally once a week) is beneficial for the liver. Fasting on a liquid diet consisting of: vegetable soups, fruit juice, vegetable juice, herbal teas and water gives the liver a break from processing complex foods[29][29].

When eating, do so in a welcoming environment and calm state of mind. Do not eat when upset as the liver is already ‘hot’ from the emotional state.

Sleep: Getting enough sleep is important to general health including liver health. Ideally a person should go to sleep before 2nd kapha time (10pm – 2am) as it is the most restorative time of rest and rise with the sun before the 1st kapha time (6am – 10am).

Water: Drink plenty of water. If possible drink ionized water that has been boiled. Ionized water has a cleansing effect on all the tissues of the body. If the body is dehydrated, the fluids of the body are thicker and the organs have to work harder to move them. It also reduces the amount of water available for toxin removing activities and to flush toxins out in waste.

Massage: abhyanga (whole body massage) with snehana (oleation) releases stress (especially for the driven pittas), nourishes and rejuvenates the whole body. They are the least likely to massage themselves but benefit from regular moderate pressure massages with skilled professionals.

Coconut oil is preferred for its cooling and calming effects. If the skin is inflamed sunflower oil would be beneficial.

Aromatherapy: Smells are the direct pathway to the brain. Sweet and cooling essential oils like jasmine, lotus, lemongrass, gardenia, sandalwood, mint, rose and cinnamon work to pacifiy the pitta mind producing calmer more restful thoughts[30][30].

Exercise: The Pitta aggressive nature can be calmed with the correct dose of exercise. Having a competitive nature, Pittas can go overboard with physical pursuits and add more heat to their already fiery body. Walking near water or with a breeze is cooling for their dosha. Water sports also cool and calm their nature.

Yoga therapy is beneficial to the pitta person if they keep in mind that it is not a competition. They should practice in moderation, avoid pushing or bouncing poses and remember that “less is more”. To cool the blood and the liver, aid to release pitta in the mid region of the spine.

Asanas (postures) that can cool pittas are forward bends and spinal twists release the heat and tension in the mid region which also fuels the mind. Twisting postions performed in a lunge, seated or lying down are very soothing for Pittas. Yoga coupled with pranayama (breathing) can worked to reconnect the cooled body and mind.

Yoga asanas that are recommended:
Shoulder stand (sarvangasana) – digestive organs are gently massaged to loosen ama
Seated forward bend (paschimottanasana) – cooling pose, reduces high blood pressure
Standing open leg forward bend (padottanasana) – deep forward bend releasing back tension
Seated spinal twist (ardha matsyendrasana) – classic spinal twist which is great for pachaka pitta and liver. Enhances venous blood to liver from other digestive organs.

Meditation and Pranayama (breathing): Cooling pranayama such as shitali or left-nostril breathing will cool the hot quality of Pitta. Before meditation internal heat must be released from the body.

After pranayama some peaceful meditation will quiet the active pitta mind releasing anger and allowing the sense of control to dissipate. With regular meditation the pitta mind, body and spirit will be cool and calm[31][31].
The goal of Ayurveda is to allow the body to heal itself. Cleansing the liver is not a cure all for disease, but sets the body back into a state to heal itself. Combined with an appropriate daily routine, a healthy life free of disease is easily obtainable.

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