Non-alcoholic fatty liver disease is the most common chronic liver disease in North America, and its incidence is rising dramatically. In this article, I will highlight the underlying reasons for the NAFLD epidemic, and how powerful each and every one of us is to reverse it.
What is Non-Alcoholic Fatty Liver Disease (NAFLD)
NAFLD is the term for a condition where there is a build-up of fat in the liver. It is most commonly associated with other metabolic conditions, such as being overweight, having diabetes, high cholesterol, hypothyroidism, and polycystic ovarian syndrome (PCOS.)
NAFLD occurs when there is a surplus of nutrients – calories, carbohydrates, and especially fructose (a type of sugar in fruit and highly processed foods) that the body is unable to use for energy. The liver processes these extra nutrients to store them for future use. Most of the surplus is stored in fat cells, but some is stored by the liver as well. When this surplus accumulates over time the liver becomes congested with fat, and a diagnosis of non-alcoholic fatty liver disease is made.
Symptoms of NAFLD
Rarely do the early stages of NAFLD have any symptoms. Symptoms usually occur when fatty liver has progressed to further stages. The symptoms that may occur include:
- A dull or aching pain in the upper right abdomen
- Tiredness and fatigue
- Weight loss
- Yellowing of the skin or eyes
- Itchy skin
- Swelling in the legs, ankles, or feet
Diagnosis of NAFLD
Most often NAFLD is diagnosed by ultrasound. For some the fatty liver is found incidentally while looking at other organs (such as the uterus, stomach, pancreas, or gallbladder.) Blood tests with abnormal liver function results may indicate a need for an abdominal ultrasound, however only 20% of people diagnosed with NAFLD have abnormal blood tests at the time of their diagnosis.
Other lab tests can indicate a need to assess for NAFLD.
- Abnormal cholesterol panels (high triglycerides, high LHD, and low HDL)
- Elevated CRP
- Elevated ESR
- Abnormal blood sugar levels (high HbA1C or high fasting glucose)
For my patients, I also suggest we follow up a diagnosis of NAFLD with additional testing. In particular I recommend testing for copper, zinc, vitamin A, vitamin D, and fasting serum insulin, in addition to the tests listed above.
Stages of NAFLD
Early stage NAFLD may have few to no symptoms, but if left unchecked it can lead to serious liver damage. This is why early diagnosis and management is important. The four stages of NAFLD are:
- Fatty liver – also known as steatosis – a build-up of fat in the liver that is typically found incidentally while testing for other concerns
- Non-alcoholic steatohepatitis (NASH) – a more serious form of NAFLD in which there is inflammation in the liver, leading to liver damage
- Liver fibrosis – persistent inflammation causes scar tissue to form in the liver and surrounding blood vessels. In liver fibrosis the liver is still able to function, but under strain.
- Liver cirrhosis – the most severe form of liver damage, cirrhosis occurs after years of inflammation. This can cause the liver to shrink, be deformed, scarred, and lumpy. This damage is permanent and can lead to liver failure.
You do not need to progress through all four phases of NAFLD. We can stop the progression, and if caught early enough, completely reverse the accumulation of fat around the liver.
Understanding WTF is Happening in NAFLD
It is one thing to understand how fatty liver disease is diagnosed, but it is an entirely different thing to understand HOW it happens. I’m going to present a simplified explanation here, because I think that when we understand how we developed a condition, we can more actively engage in the process of reversing it.
When we consume food our body has two options: burn the fuel to create energy, or store it for later use. In our modern diets we are overconsuming nutrients, especially carbohydrates, causing a surplus that our body stores for future use. The liver is involved in this storage process by taking the excess nutrients and packing them up to be stored in our fat cells. And the liver holds on to some of these fat cells for quick access (how efficient!), but if it stores too many the liver starts to become overwhelmed by them – and this is how fatty liver disease starts.
This is often why we see NAFLD develop in people who are overweight, who have diabetes, or who have high cholesterol. The elevated cholesterol is often the result of the same process – the liver moving excess calories into fat storage in the form of triglycerides and low density lipoproteins (LDL.) In fact, half of people with high cholesterol are expected to have some degree of fatty liver.
Naturopathic Treatment Options for NAFLD
Fatty liver is a condition that reminds us what a powerful force our diet is on our health – for good or for bad. And the cornerstone of treating NAFLD is optimizing the diet and lifestyle. We also must look at the underlying risk factors for fatty liver, and address those as well. And of course, there are some supportive nutritional and supplemental options that can be used in individuals to help improve their outcomes and increase the odds that they will be able to reverse the fatty liver disease, or prevent further progression.
Diet and Lifestyle for NAFLD
Reduce carbohydrates, especially fructose
The World Health Organization recommends that sugar accounts for less than 10% of our daily calories, however the Standard American Diet (SAD) contains around three times this amount. Fructose – found predominantly in fruit, and heavily processed foods, including high fructose corn syrup, is especially harmful on the liver as it is processed exclusively by the liver and not the digestive tract. One of the most profound ways you can support your liver is to cut out all processed sugars, added sugars, and reduce your fruit intake to no more than one serving per day.
Carbohydrates in the forms of grains can also add to your overall daily sugar burden. As most people eat a wheat-based grain (bread, pasta, crackers, bagels, muffins, etc) at every meal and every snack, cutting back on grains can be essential to improving liver metabolism of carbohydrates. Reduce your grains to one serving per day (1/2 cup of a cooked grain or two slices of bread) and opt for unprocessed whole grains (barley, quinoa, brown rice, millet) whenever possible.
Consider a Mediterranean diet
The Mediterranean diet, one of the best researched diets in the world, has been found to reduce the risks of developing heart disease, diabetes, cancer, and other chronic diseases.
Based on a predominantly plant-based diet, the Meditteranean diet also emphasizes healthy fats from nuts, seeds, olives and olive oils, and reduces animal products by limiting dairy and meats to just a few servings per week maximum. Learn more here: https://fullscript.com/blog/mediterranean-diet and here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7996886/
Healthy fats, NOT low fat
The instinctive response many people have to a diagnosis of fatty liver is to dramatically cut fat from their diets. However, that is not going to help! We need healthy fats to enable our body to metabolize and clear the fats that are accumulated around the liver.
In the typical Standard American Diet (SAD) we consume 25 times more omega 6s (pro-inflammatory fatty acids from dairy, red meats, and industrial processed seed oils) than omega 3s (ant-inflammatory fatty acids from nuts, seeds, and fatty fish.) Increasing our consumption of omega 3 fatty acids through hemp seeds, walnuts and walnut oil, flax and flax oils, fatty fish (like mackerel, sardines, and salmon) and supplements can be very supportive for NAFLD.
Have a coffee or tea
Yes, there are health benefits to drinking coffee. Drinking 2 cups of coffee per day provides an abundance of polyphenols which have been found in the research to reduce the progression of fatty liver to cirrhosis. BUT – you can’t add dairy or sugar to your coffee. You have to drink it black, or with a bit of oat or almond milk, to get the benefits.
Green tea, another abundant source of antioxidants and bioactive compounds, can improve metabolism, support the production of bile acids by the liver, improve insulin resistance, and help balance cholesterol levels. One or two cups a day can go a long way towards supporting your fatty liver!
Cut out alcohol
Non-alcoholic fatty liver disease is not caused by alcohol. But drinking can make it worse by putting more strain on the liver. It is highly recommended to reduce or totally eliminate alcohol from your lifestyle if you’ve been diagnosed with fatty liver.
You’ve got to move it, move it
Of course exercise is important. We know that. So why are over half of us not engaging in regular physical activity??
For weight loss, cholesterol improvement, and fatty liver disease the experts have reached a consensus that 150 minutes per week of moderate or vigorous exercise is the minimum that is needed to have positive results. This works out to around 20-30 minutes per day. From weight training, to walking, cycling, dancing, or HIIT exercises, there is something for everyone. The important thing is to get started – showing up is the most important step.
Supplements to Support NAFLD
There are over 200 different supplements that impact blood sugar stability, and a vast number that directly impact cholesterol synthesis and liver health. I’ll be highlighting some of the most impactful for fatty liver disease.
Vitamin A
A fat soluble vitamin, vitamin A is essential for vision, immune function, and metabolism of carbohydrates and fat. The liver plays an essential role in vitamin A metabolism, and up to 95% of vitamin A is stored in the liver. Any condition impacting the liver is going to impact vitamin A function. Unfortunately, low vitamin A can cause high blood sugar levels, and reduce the ability of the pancreas to produce insulin, leading to a vicious cycle of further liver damage. While vitamin A may not treat fatty liver disease directly, providing patients with NAFLD with vitamin A support is important for overall health and well being.
Vitamin D
Another fat-soluble vitamin, vitamin D is involved in immune system function, and control of insulin secretion (in addition to hunders of other activities.) Studies have reported an association between vitamin D deficiency and a diagnosis of NAFLD – with vitamin D deficiency occurring in up to 75% of patients with fatty liver. Additionally problematic is the finding that the severity of liver damage in NASH is higher in patients with deficient vitamin D. Living in Canada is a major risk factor for vitamin D deficiency as we are unable to make vitamin D from sun exposure between October and April. As a result, all Canadians require supplementation – either seasonally or year-round depending on your vitamin D levels.
Inositol
Inositol is a compound made in our bodies that is essential for our cells to respond to signals from our hormones, including insulin. Studies have found that a deficiency of inositol in animals is associated with an increased risk of fatty liver disease. As well, when given inositol, animal studies showed a reduction in triglyceride levels and accumulation of fat around the liver. Inositol is a very safe supplement, and is typically well tolerated with occasional digestive upset being the most common side effect. Doses range from 500mg up to 4g daily (in divided doses.)
CoQ10
An important antioxidant, Coenzyme Q10, or just CoQ10 for short, is especially active in the heart, muscles, and liver. Recent studies have found that taking 100mg per day of CoQ10, for as little as three weeks (!!) resulted in reduced liver enzymes, inflammation, and degree of NAFLD. Additionally, CoQ10 is well known to help balance the cholesterol patterns typically associated with NAFLD. CoQ10 has a very high safety profile and doesn’t interact with medications, making it an ideal option for people who are taking other medications for conditions associated with fatty liver, such as blood pressure medications, diabetes medications, or statins.
Resveratrol
Found in red wine, grapes, berries, and nuts, resveratrol helps to improve insulin sensitivity and tolerance to glucose, while also helping to reduce cholesterol levels and inflammation. Multiple studies have shown improvements in liver enzymes and cholesterol levels with supplementation, but not ultrasound findings. It can be a helpful addition to a NAFLD plan, but further research might be needed to determine who will best benefit from resveratrol, or if other treatment options may be superior.
Berberine
Found in a variety of different plants, berberine is well-known for its ability to lower cholesterol and improve blood sugar levels by improving the body’s sensitivity to insulin. A meta-analysis found that berberine taken for 2-4 months improved cholesterol levels, insulin resistance, liver enzymes, and degree of fatty liver in patients with NAFLD. Doses range from 500-1500mg per day, and digestive discomfort can be a common side effect. You’ll want to discuss with your ND what your optimal dosage is.
Milk Thistle
The active polyphenol in milk thistle, silymarin, reduces inflammation and fibrosis in the liver, while stimulating liver regeneration and exerting powerful antioxidant activity. It is a powerhouse liver support, and studies have shown significant benefit in treatment of fatty liver.
Studies of milk thistle, on its own or in combination with vitamin E, have shown improvements in liver enzymes, reduced insulin resistance, and improvements of fat accumulation on ultrasound. One study also found that when combined with diet and exercise, those taking the milk thistle had further benefits, showing how a well-rounded approach can lead to optimal benefits. Dose of milk thistle is typically standardized to silymarin content, and doses range from 180mg to 500mg daily.
Curcumin
One of the most powerful anti-inflammatories comes from the spice turmeric. Curcumin has been found in multiple studies to improve many important markers for NAFLD. It has been found to reduce fat accumulation around the liver (steatosis), reduction in liver enzymes, reduction in body weight and waist circumference (which is not commonly seen with supplements!) Doses need to be based on the active curcumin levels in the supplement, and not all supplements are created equal. Because absorption of curcumin varies significantly, some concentrated supplements may have much better performance than others.
Probiotics
Most of us are now aware of the benefits of probiotics for human health, but few have awareness of the immense power they have for the treatment of non-alcoholic fatty liver disease. In 2019 a meta-analysis of the available research on probiotics for fatty liver found that they could significantly improve liver damage, reduce liver enzymes, improve triglycerides and cholesterol levels, reduce insulin resistance, and decrease liver stiffness. The only thing the probiotics didn’t improve was weight loss. Supplements containing Lactobacillus, Bifidobacterium and Streptococcus strains performed the best in studies, compared to single strain supplements. Discuss your options with your ND.
Omega 3 Fatty Acids
Classified as essential fatty acids, they are just that essential. We cannot make our own omega 3s so we must consume them in our diet. Eating more omega 3s (or taking omega 3 rich supplements) helps to shift our body’s focus from lipogenesis (making new fat) towards fatty acid oxidation (breaking down fats). This is very important for managing fatty liver. Additionally, omega 3s are powerful anti-inflammatories and can also help to improve insulin sensitivity. Win win!
Several studies have looked at omega 3s for fatty liver disease, and have shown reduced serum triglycerides, lowered liver enzymes, and improvements on ultrasound in both children and adults with fatty liver. Doses range, discuss your optimal dose with your naturopathic doctor.
Putting it All Together
The most important thing for fatty liver disease is to recognize how powerful you are in addressing this condition. The choices you make now can either positively impact your liver, or negatively. So there is no better time than now to begin treating your liver with love.
But you don’t have to do it alone. In this article I discussed ten different supplements that are helpful for non-alcoholic fatty liver disease, but no one needs to take all ten! Making decisions on which ones will be most impactful for you, and will help improve your results when combined with appropriate diet and lifestyle should be done with the support of a qualified health care provider. If you need support, don’t hesitate to get in touch.
In health,
Dr. Lisa
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