Fatty liver disease is a growing epidemic in the United States, now affecting an estimated 20-30% of the adult population. Fatty liver occurs in the early stages of liver damage and is the result of triglyceride and fatty acid deposits on the liver. It is most commonly caused by alcohol consumption or the typical Western diet high in sugar, processed foods and saturated fats. When not caused by alcohol, we call this non-alcoholic fatty liver disease (NAFLD). NAFLD is commonly found in conjunction with other metabolic syndromes. If NAFLD is left untreated, it can progress to non-alcoholic steatohepatitis (NASH), which is an inflammatory condition of the liver. NASH can progress to fibrosis, then cirrhosis and ultimately liver failure and liver cancer. It is fast becoming the most common cause of liver failure and the most common indication for liver transplantation. It is also the most frequent cause of chronic liver disease in our children. The diagnosis of fatty liver disease is usually made when your doctor discovers elevated liver enzymes (AST and ALT) on routine lab work. Once other causes for liver disease are ruled out, an abdominal ultrasound is obtained, which will often reveal fatty deposition in the liver.
There is good news. Food is one of our best medicines to combat NAFLD. We can reverse the disease and return the liver to a normal, healthy structure by changing how we eat and how we move our body. What to eat if you have fatty liver disease The simple answer is a Mediterranean diet. Here are the essential points: Eat more plants: Think about fruits and vegetables filling half of every plate of food you make. For me, the hardest meal to fill with vegetables used to be breakfast until I started my morning smoothie routine. Packing a smoothie with antioxidant-rich fruits and veggies (like berries and broccoli) is a great place to start!
Eat fish or plant-based proteins: We rarely see Americans NOT getting enough protein. In fact, our diets have an excess of animal-based proteins, which have been linked to fatty liver disease. For healthy protein, focus on either fish (fresh or canned—a great source of omega-3s) or plant-based sources such as black beans, pinto beans, garbanzo beans, lentils, split peas, quinoa, soy and tofu. Quinoa, hemp, chia and soy are all complete proteins (containing all essential amino acids). However, even if you do not eat a “complete protein,” you can get all the essential amino acids by eating a variety of plants. Limit animal-based proteins: Dairy, cheese, butter, eggs, beef and pork all contain high amounts of saturated fat, which has been linked to high cholesterol, heart disease and fatty liver disease. Red meat, particularly cooked at high temperatures (such as when grilled), is associated with a fatty liver. So how can we get our daily dose of protein with plants? It's much simpler than you think.
A 145-pound woman needs 52 grams of protein per day (0.8g/kg protein per day):
A 200-pound man needs 72 grams of protein per day:
Eat healthy fats: A low-fat diet is helpful for temporarily cutting calories and losing weight, but it is hard to sustain. This is, of course, because fat adds flavor to foods and helps you feel satiated. Instead, I encourage my patients to eat healthy fats in moderation for a delicious and healthy diet. This means cooking with olive oil, eating nuts for snacks, putting chia or flax seeds in your smoothie and eating fish twice a week or taking a fish oil supplement daily (with 250-500mg of DHA-EPA). Extra virgin olive oil (EVOO) is even more beneficial than regular olive oil. This is because EVOO contains higher levels of antioxidants and polyphenols, which can be lost when the oil is refined or heated. Many studies suggest that adding an additional tablespoon of EVOO to a Mediterranean diet has added health benefits (including dramatically decreased rates of cardiovascular disease). A wonderful way to achieve this is to make your own salad dressing to top your salad, steamed broccoli, asparagus, roasted eggplants, sliced tomatoes, boiled beets or another vegetable of your choice. Just blend one part vinegar (I like red wine or champagne vinegar) to three parts EVOO. Add a pinch of salt and pepper to taste. (Make a large batch and refrigerate for up to two weeks.) Eat whole grains: Whole grains include old-fashioned oats, barley, wheat berries, farro, freekeh, brown rice, black rice and quinoa. These grains are high in fiber, high in protein and have a low glycemic load compared to other carbohydrates. They also act somewhat like “prebiotics” for our gut, promoting a healthy gut microbiome. Whole grains are versatile and can be made for breakfast, cooked in soups, mixed in salads or accompany fish for dinner. I find my pressure cooker is a great way to cook whole grains quickly and in big batches to mix into various meals all week long. You can also find microwaveable bowls of brown/wild rice online and in many grocery stores so you can have a whole grain in 90 seconds. Limit white bread, white rice and pasta. These simple carbohydrates have a high glycemic load and therefore quickly become sugar once in your body. The resulting spikes in sugar contribute to insulin resistance, promote de novo lipogenesis (fat creation) and initiate an inflammatory cascade that contributes to damage in fatty liver disease.
Avoid alcohol: Zero alcohol is best if you have fatty liver. Alcohol is toxic to the already-damaged liver, and our goal is to protect the liver from any further injury. Try sparkling water with lemon or lime for something different. Physical activity: Regular exercise has been proven to reverse fatty liver disease, even in the absence of weight loss. The exercise goal for people with fatty liver disease is at least 200 minutes of moderate-intensity exercise per week. It is also okay to achieve this in two-three shorter sessions each day as long as each session is at least 10 minutes long. Any amount of exercise is good for your health, but to maximize the benefits, we want a sustained effort and heart rate elevation. The goal with moderate aerobic exercise is for your heart rate to reach 50-70% of your peak heart rate (you can calculate yours here). There is no perfect type of exercise, so pick what you enjoy. Start with 10 minutes a day and work your way up to reach your goal! Some of the most common moderate-intensity exercises include water jogging, brisk walks, cycling, elliptical machine, dancing, doubles tennis and gardening. In summary
Eat more plants. Aim to make vegetables the main attraction on your plate at every meal.
Eat fish and/or plant-based proteins. Limit red meat consumption.
Eat healthy fats. Use EVOO liberally.
Eat whole grains. The abundance of fiber and protein in whole grains results in a lower glycemic burden to the body.
Alcohol is toxic to our livers. Avoid alcohol if you already have a diagnosis of fatty liver disease. Try alternatives to alcohol.
Engage in physical activity.
Resources
Benedict M, Zhang X. Non-alcoholic fatty liver disease: An expanded review. World J Hepatol. 2017 Jun 8; 9(16): 715–732.
Bush H, Golabi P, Younossi ZM. Pediatric Non-Alcoholic Fatty Liver Disease. Children (Basel). 2017 Jun 9; 4(6).
Della Pepa G, Vetrani C, Lombardi G, Bozzetto L. Isocaloric Dietary Changes and Non-Alcoholic Fatty Liver Disease in HIgh Cardiometabolic Risk Individuals. Nutrients. 2017 Oct 9; 9(10): 1065.
Van der Windt DJ1, Sud V1, Zhang H1, Tsung A1, Huang H1. The Effects of Physical Exercise on Fatty Liver Disease. Gene Expr. 2018 May 18;18(2):89-101.
Zelber-Sagi S., Salomone F., Mlynarsky L. The Mediterranean dietary pattern as the diet of choice for non-alcoholic fatty liver disease: Evidence and plausible mechanisms. Liver Int. 2017; 37:936–949. doi: 10.1111/liv.13435.
Sara Bowling, MD
Sara Bowling, MD, is a family physician and home cook on a mission to inspire her patients to cook more delicious food at home for better health. To find more healthy tips and lots of plant-based recipe ideas, check out drbowlingskitchen.com or follow her on Instagram @drbowlingskitchen.
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