In recent years, Non-Alcoholic Fatty Liver Disease (NAFLD) has emerged as a silent epidemic, affecting approximately one in four individuals worldwide.(1) Despite its prevalence, most people with NAFLD remain unaware of their condition, as it often goes undetected for a prolonged period. This lack of awareness and early detection is alarming, given the severe consequences of the disease if left unchecked–including liver cancer and cirrhosis.

What Is NAFLD?

Non-Alcoholic Fatty Liver Disease (NAFLD) is a medical condition characterized by the accumulation of excess fat in the liver cells, not caused by heavy alcohol use. It’s one of the most common types of liver disease and is associated with obesity, type 2 diabetes, and other metabolic disorders influenced by insulin resistance.

NAFLD occurs when more than 5% of liver cells contain fat, hindering the liver’s over 500 vital functions, including toxin filtration and metabolism regulation. Without proper intervention, NAFLD can progress to Nonalcoholic Steatohepatitis (NASH), characterized by liver inflammation and fibrosis, ultimately leading to cirrhosis, liver cancer, and increased risk of cardiovascular diseases. (2)

In many cases, people with NAFLD are asymptomatic, especially in the early stages of the disease. This is why many cases are undiagnosed or discovered incidentally during tests for unrelated conditions. However, some individuals may experience subtle signs or symptoms that could indicate the presence of NAFLD, including fatigue, discomfort in the upper right abdomen, unexplained weight loss, and mild jaundice.

*It’s important to note that these symptoms are non-specific and can be associated with many other conditions.*

The prevalence of Non-Alcoholic Fatty Liver Disease (NAFLD) varies regionally, being higher in Western countries and amongst certain ethnic populations. It’s more prevalent in populations with increased rates of obesity, type 2 diabetes, and metabolic syndrome. (3) As these conditions become more common, the rates of NAFLD are also expected to rise. NAFLD commonly affects middle-aged and older individuals. However, it’s not just adults who are affected. NAFLD impacts up to 9.6% of American children, with rates soaring since 2020.(4)

NAFLD can be categorized into two main conditions:

Simple fatty liver (steatosis)—This is the initial stage of NAFLD, where there is excess fat in the liver but little or no inflammation or liver cell damage. This is the stage where fatty liver can be reversed through lifestyle modifications. 

Non-alcoholic steatohepatitis (NASH)—This is a more serious form of NAFLD. In addition to fat, there is also inflammation and damage to liver cells. This can lead to fibrosis, or scarring, of the liver and potentially progress to cirrhosis or liver cancer in severe cases.

The Role of Diet and Lifestyle in NAFLD

The surge in NAFLD cases is largely attributed to modern dietary habits and lifestyle changes. Excessive consumption of processed and sugary foods, coupled with a sedentary lifestyle, has led to hormonal imbalances and metabolic dysfunction. The Standard American Diet (SAD), characterized by high consumption of refined sugars, fats, and processed foods, plays a pivotal role in the development of NAFLD. This diet leads to an overload of the liver’s capacity to process fats and sugars, resulting in fat accumulation in the liver.(5) Contrary to popular belief, NAFLD is not caused by alcohol consumption but is closely linked to how the body manages blood sugar, especially concerning insulin resistance.

Metabolic Dysfunction and NAFLD Risk Factors

In 2023, the term Metabolic Associated Fatty Liver Disease (MAFLD) was proposed to better describe NAFLD’s relationship with metabolic conditions. This name change reflects a growing understanding that NAFLD is closely linked with metabolic disorders, such as obesity—more specifically, a high waist circumference (greater than 40” for men; 35” for women), high cholesterol, dyslipidemia (abnormal levels of lipids in the blood), and Type 2 diabetes.(6)The American Diabetes Association now recommends screening all Type 2 diabetes patients for fatty liver, as NAFLD is linked with a higher risk of difficult-to-treat Type 2 diabetes.(7) Furthermore, many patients with Polycystic Ovarian Syndrome (PCOS) also have fatty liver, often more severe due to insulin resistance.

So, how do these metabolic health risks affect the liver?

The liver is essential in all metabolic processes. It regulates blood sugar by converting excess glucose into glycogen and storing it. When necessary, it converts glycogen back to glucose. It also processes fats and proteins, ensuring amino acids are available for energy production.

Essentially, the liver acts as a “public works” system of the body, maintaining metabolic balance.

The liver also filters everything that enters the body, distinguishing between beneficial and harmful substances. Everything that we are exposed to–the foods we eat, the environment we live in and even what we put on our skin is sent to the liver to be broken down and metabolized. It truly is the workhorse of the body, constantly working to keep us in a state of homeostasis. When the liver is overburdened, we start experiencing other health issues in the body.  

NAFLD doesn’t just affect the liver. It can disrupt the function of other organs, leading to an increased risk for heart disease and major cardiovascular events like heart attacks and strokes. It’s also associated with increased risks of other cancers, like colon and breast cancer.(8)

Sort of like the chicken and the egg analogy, it’s challenging to pinpoint what comes first—does metabolic dysfunction lead to fatty liver disease, or does fatty liver disease trigger metabolic changes?

Both conditions are closely related and often coexist, exacerbating each other. Fatty liver can worsen metabolic syndrome components like insulin resistance, while metabolic syndrome increases the risk of fatty liver. Systemic, chronic inflammation from the liver can also impact digestive, heart, bone, reproductive, and mental health. (9)

Screening and Early Detection

Given the silent nature of NAFLD and its potential to remain undetected for years, regular screening is crucial, particularly for those with metabolic risk factors. Individuals struggling with insulin resistance, sleep apnea, consuming a high-sugar or processed diet, or with a family history of fatty liver disease should consider discussing NAFLD screening with their healthcare provider.

NAFLD is often initially suspected during routine health checks, which typically include annual blood tests such as a complete blood count, liver function test, HbA1c, and lipid panels. The liver function test measures enzymes like Alanine Aminotransferase (ALT), Aspartate Aminotransferase (AST), Alkaline Phosphatase (ALP), and Gamma-glutamyltransferase (GGT). Elevated levels of ALT and AST can indicate liver cell injury and inflammation, common in NAFLD. However, it’s noteworthy that liver enzyme levels can be within the normal range in some individuals with NAFLD, making these indicators part of a comprehensive evaluation process.

ALP and GGT are also significant enzymes measured in liver function tests. Elevated ALP levels can suggest bile duct issues or liver inflammation, while increased GGT levels are often associated with bile duct issues or liver damage. These enzymes provide additional insights into liver health and can help diagnose NAFLD and understand its underlying mechanisms.

If NAFLD is suspected, further diagnostic tests, such as ultrasound, FibroScan, or, in some cases, a liver biopsy, may be recommended. These tests provide a more detailed assessment of liver fat accumulation, inflammation, and potential liver damage. Ultrasound is a non-invasive imaging method that can reveal fat deposits in the liver, while FibroScan measures liver stiffness, indicating fibrosis or scarring. A liver biopsy, although more invasive, offers a detailed view of the liver tissue, helping to confirm the diagnosis and determine the disease’s severity.

Management of NAFLD often focuses on controlling risk factors, such as losing weight, controlling diabetes and cholesterol levels, and adopting a healthy diet and exercise routine. Currently, there are no specific medications approved for the treatment of NAFLD, although various drugs are being studied.

The Path to Reversal: Lifestyle Interventions and Nutritional Focus

Unlike many liver diseases, NAFLD is often treatable and reversible, especially in its early stages, thanks to the liver’s regenerative capabilities. (10) The focus should be on reducing the intake of refined sugars and carbohydrates and increasing the consumption of nutrient-dense foods. The goal is to reduce liver fat and inflammation and improve liver function. 

Here’s a guide on dietary adjustments and supplements that may help:

Foods to Limit or Avoid

Linoleic Acid—Found in many seed oils like sunflower, corn, soybean, and safflower oils, linoleic acid can contribute to inflammation and liver stress.

Processed Foods—Often high in unhealthy fats, sugars, and additives, these processed foods can exacerbate liver fat accumulation and worsen NAFLD.

Refined Carbohydrates and Sugars—Can lead to weight gain, poor blood sugar control, and increased liver fat.

Alcohol—Even though NAFLD is not caused by alcohol, it can exacerbate liver problems. It is advisable to limit your consumption or, better yet, avoid it entirely. 

Liver-Loving Foods To Add to Your Diet

High-Fibre Foods—Helps digestion, controls blood sugar levels, and aids in weight management.

Healthy FatsOlive oil, avocados, nuts (especially walnuts), and seeds (like flaxseeds and chia seeds) are all great for heart health, help reduce inflammation, and are beneficial for overall liver health.

Antioxidant-Rich Foods—Blueberries, strawberries, dark leafy greens (spinach, kale), beets, and kiwis all help to protect the body from oxidative stress and support liver health. (11)

Dark Chocolate—The darker, the better. Look for cacao content of 74% or higher. Dark chocolate contains flavonoids that help to reduce inflammation and have even been found to reduce fibrosis in the liver. (12)

Cruciferous Vegetables—Cauliflower, broccoli, brussels sprouts, cabbage, and kale these vegetables boast high amounts of indole-3 carbinol and sulforaphane, which help to support liver detoxification. (13)

Coffee—Rich in bioactive compounds and antioxidants, many studies support coffee as beneficial to liver health. (14) Of course, this doesn’t mean a sugar-laden mocha frappuccino, but black coffee (both caffeinated and decaffeinated) can help detoxify the liver. One study showed that coffee can even counteract the impact of alcohol consumption. (15) Enjoy up to 2 cups of black coffee each day.

Beneficial Nutrients for NAFLD Prevention and Management

While there is no specific pharmacological cure for NAFLD, increasing certain nutrients in your diet can aid in managing Non-Alcoholic Fatty Liver Disease. Key nutrients to include are:

  • Omega-3 Fatty Acids—These essential fatty acids are known for their anti-inflammatory properties and ability to improve heart health. In the context of NAFLD, Omega-3s help reduce liver fat and inflammation. Foods rich in Omega-3 include fish like salmon and mackerel, flaxseeds, and walnuts.
  • Choline—Essential for healthy liver function, choline helps in fat removal from the liver, maintains cell membrane integrity, and regulates cholesterol metabolism. (16) Foods rich in choline, like organic egg yolks, grass-fed beef liver, wild-caught salmon, and krill oil, are recommended. Arugula is another good source.
  • Niacinamide (Nicotinamide)—A precursor to Nicotinamide Adenine Dinucleotide (NAD+), a crucial molecule for longevity, niacinamide reduces oxidative stress and can prevent fatty liver disease. (17) It can be found in poultry, mushrooms, and green peas.
  • Vitamin B12 and Folic Acid—These nutrients are believed to help slow down the progression of Non-Alcoholic Steatohepatitis (NASH), a severe form of NAFLD. B12 can be found in fish, meat, poultry and eggs, and folic acid is highest in leafy green vegetables.
  • Vitamin E—Recognized for its antioxidant properties, Vitamin E can be beneficial for those with NAFLD, especially in reducing liver inflammation and damage. (18) It’s found in foods like almonds, sunflower seeds, and spinach.
  • N-acetylcysteine (NAC)—Necessary for the production of glutathione, a vital antioxidant, NAC supplementation is beneficial for liver health, especially in NAFLD patients.
  • Probiotics—Beneficial bacteria that can improve gut health, probiotics may also play a role in managing NAFLD. They help balance the gut microbiome, which is linked to liver health. Probiotics can be found in fermented foods like yogurt, kefir, and sauerkraut.
  • CoQ10 (Ubiquinol)—Important for mitochondrial health and ATP production, CoQ10 supplementation can improve NAFLD symptoms by reducing oxidative stress and inflammation. (19)
  • Milk Thistle—Containing antioxidants like silymarin and silybin, milk thistle supports liver health by protecting against toxins and aiding in liver cell regeneration. (20)

Lifestyle Habits

As with many other metabolic health concerns, adjustments to activity levels and weight management can go a long way in reducing the risk of NAFLD.

Regular Physical Activity—Aim for at least 150 minutes of moderate exercise per week. Helps to reduce liver fat and improves overall health.

Weight Loss—If you are overweight or have a high waist circumference, reducing your body weight by even 5-10% can significantly reduce liver fat and improve liver function. Aim for gradual weight loss (1-2 lbs/week).

Adequate Sleep—Sleep is vital for metabolic health and hormone regulation. The goal is to get 7-9 hours of quality sleep per night.

By focusing on a healthy diet, key nutrients, regular exercise, and maintaining a healthy weight, you can significantly reduce your risk of developing this disease. Your liver is a remarkable organ with the ability to regenerate and heal, given the right conditions. So, let this be a call to action. Whether you’re at risk, currently battling NAFLD, or simply aiming to maintain good health, the time to act is now. In the journey to health, every step counts. Let’s make those steps count towards a healthier, happier you.

In-Text References

  1. Cotter TG, Rinella M. Nonalcoholic Fatty Liver Disease 2020: The State of the Disease. Gastroenterology. 2020 May;158(7):1851-1864. doi: 10.1053/j.gastro.2020.01.052. Epub 2020 Feb 13. PMID: 32061595.
  2. Pouwels S, Sakran N, Graham Y, Leal A, Pintar T, Yang W, Kassir R, Singhal R, Mahawar K, Ramnarain D. Non-alcoholic fatty liver disease (NAFLD): a review of pathophysiology, clinical management and effects of weight loss. BMC Endocr Disord. 2022 Mar 14;22(1):63. doi: 10.1186/s12902-022-00980-1. PMID: 35287643; PMCID: PMC8919523.
  3. Riazi K, Swain MG, Congly SE, Kaplan GG, Shaheen AA. Race and Ethnicity in Non-Alcoholic Fatty Liver Disease (NAFLD): A Narrative Review. Nutrients. 2022 Oct 28;14(21):4556. doi: 10.3390/nu14214556. PMID: 36364818; PMCID: PMC9658200.
  4. Le Garf S, Nègre V, Anty R, Gual P. Metabolic Fatty Liver Disease in Children: A Growing Public Health Problem. Biomedicines. 2021 Dec 14;9(12):1915. doi: 10.3390/biomedicines9121915. PMID: 34944730; PMCID: PMC8698722.
  5. Mirmiran P, Amirhamidi Z, Ejtahed HS, Bahadoran Z, Azizi F. Relationship between Diet and Non-alcoholic Fatty Liver Disease: A Review Article. Iran J Public Health. 2017 Aug;46(8):1007-1017. PMID: 28894701; PMCID: PMC5575379.
  6. Paschos P, Paletas K. Non-alcoholic fatty liver disease and metabolic syndrome. Hippokratia. 2009 Jan;13(1):9-19. PMID: 19240815; PMCID: PMC2633261.
  7. https://www2.diabetes.org/newsroom/press-releases/2023/american-diabetes-association-releases-guideline-update-NAFLD-diabetes
  8. Liu C, Liu T, Zhang Q, et al. New-Onset Age of Nonalcoholic Fatty Liver Disease and Cancer Risk. JAMA Netw Open. 2023;6(9):e2335511. doi:10.1001/jamanetworkopen.2023.35511
  9. Chen L, Deng H, Cui H, Fang J, Zuo Z, Deng J, Li Y, Wang X, Zhao L. Inflammatory responses and inflammation-associated diseases in organs. Oncotarget. 2017 Dec 14;9(6):7204-7218. doi: 10.18632/oncotarget.23208. PMID: 29467962; PMCID: PMC5805548.
  10. Kudaravalli P, John S. Nonalcoholic Fatty Liver. [Updated 2023 Apr 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK541033/
  11. Chen M, Chen X, Wang K, Cai L, Liu N, Zhou D, Jia W, Gong P, Liu N, Sun Y. Effects of kiwi fruit (Actinidia chinensis) polysaccharides on metabolites and gut microbiota of acrylamide-induced mice. Front Nutr. 2023 Feb 6;10:1080825. doi: 10.3389/fnut.2023.1080825. PMID: 36814509; PMCID: PMC9939636.
  12. Magrone T, Russo MA, Jirillo E. Cocoa and Dark Chocolate Polyphenols: From Biology to Clinical Applications. Front Immunol. 2017 Jun 9;8:677. doi: 10.3389/fimmu.2017.00677. PMID: 28649251; PMCID: PMC5465250.
  13. Syed RU, Moni SS, Break MKB, Khojali WMA, Jafar M, Alshammari MD, Abdelsalam K, Taymour S, Alreshidi KSM, Elhassan Taha MM, Mohan S. Broccoli: A Multi-Faceted Vegetable for Health: An In-Depth Review of Its Nutritional Attributes, Antimicrobial Abilities, and Anti-inflammatory Properties. Antibiotics (Basel). 2023 Jul 7;12(7):1157. doi: 10.3390/antibiotics12071157. PMID: 37508253; PMCID: PMC10376324.
  14. Poole R, Kennedy OJ, Roderick P, Fallowfield JA, Hayes PC, Parkes J. Coffee consumption and health: umbrella review of meta-analyses of multiple health outcomes. BMJ. 2017 Nov 22;359:j5024. doi: 10.1136/bmj.j5024. Erratum in: BMJ. 2018 Jan 12;360:k194. PMID: 29167102; PMCID: PMC5696634.
  15. Yaya I, Marcellin F, Costa M, Morlat P, Protopopescu C, Pialoux G, Santos ME, Wittkop L, Esterle L, Gervais A, Sogni P, Salmon-Ceron D, Carrieri MP; ANRS CO13-HEPAVIH Cohort Study Group. Impact of Alcohol and Coffee Intake on the Risk of Advanced Liver Fibrosis: A Longitudinal Analysis in HIV-HCV Coinfected Patients (ANRS HEPAVIH CO-13 Cohort). Nutrients. 2018 May 31;10(6):705. doi: 10.3390/nu10060705. PMID: 29857547; PMCID: PMC6024311.
  16. Mehedint MG, Zeisel SH. Choline’s role in maintaining liver function: new evidence for epigenetic mechanisms. Curr Opin Clin Nutr Metab Care. 2013 May;16(3):339-45. doi: 10.1097/MCO.0b013e3283600d46. PMID: 23493015; PMCID: PMC3729018.
  17. Mehmel M, Jovanovi? N, Spitz U. Nicotinamide Riboside-The Current State of Research and Therapeutic Uses. Nutrients. 2020 May 31;12(6):1616. doi: 10.3390/nu12061616. PMID: 32486488; PMCID: PMC7352172.
  18. El Hadi H, Vettor R, Rossato M. Vitamin E as a Treatment for Nonalcoholic Fatty Liver Disease: Reality or Myth? Antioxidants (Basel). 2018 Jan 16;7(1):12. doi: 10.3390/antiox7010012. PMID: 29337849; PMCID: PMC5789322.
  19. Gutierrez-Mariscal FM, Arenas-de Larriva AP, Limia-Perez L, Romero-Cabrera JL, Yubero-Serrano EM, López-Miranda J. Coenzyme Q10 Supplementation for the Reduction of Oxidative Stress: Clinical Implications in the Treatment of Chronic Diseases. Int J Mol Sci. 2020 Oct 23;21(21):7870. doi: 10.3390/ijms21217870. PMID: 33114148; PMCID: PMC7660335.
  20. Mulrow C, Lawrence V, Jacobs B, et al. Milk Thistle: Effects on Liver Disease and Cirrhosis and Clinical Adverse Effects: Summary. 2000. In: AHRQ Evidence Report Summaries. Rockville (MD): Agency for Healthcare Research and Quality (US); 1998-2005. 21. Available from: https://www.ncbi.nlm.nih.gov/books/NBK11896/
LiverUnveiling the Silent Epidemic: Understanding Non-Alcoholic Fatty Liver Disease (NAFLD)