Nonalcoholic Fatty Liver Disease: What You Need to Know

Diseases of the liver are often traced to heavy alcohol consumption, but non-drinkers may develop a condition known as nonalcoholic fatty liver disease, or NAFLD. It’s usually seen in people with metabolic syndrome: obesity plus diabetes or prediabetes, high cholesterol and high blood pressure.

There are two types of NAFLD:

• NAFL, involving fat in the liver without significant inflammation or liver cell damage; and
• NASH, or nonalcoholic steatohepatitis, a far more serious condition marked by fat, inflammation and liver cell damage. NASH can cause long-term injury to the liver in the form of fibrosis (scarring) or even cirrhosis.

The great news about NAFLD, says Dr. Danielle Brandman, Medical Director of the Center for Liver Disease and Transplantation at Weill Cornell Medicine, is that it can get better and even be completely reversible through changes in eating habits and exercise, and the weight loss resulting from these changes.

However, if a patient’s liver damage from NAFLD progresses to cirrhosis, with its extensive scarring and damage, that is much more difficult to reverse, she says. Having cirrhosis increases the risk of liver failure or liver cancer—especially hepatocellular carcinoma (HCC), the most common type of liver cancer. Liver failure and liver cancer may result in the need for a life-saving liver transplant.

To screen or not to screen

While the American Association for the Study of Liver Diseases (AASLD) does not officially recommend routine screening for NAFLD, the organization does recommend that doctors actively check their at-risk patients for NAFLD.  Because patients with diabetes and metabolic syndrome are considered at higher-than-usual risk for NASH and potentially rapid progression to cirrhosis, screening may be beneficial.

Primary care providers (PCPs) can screen for NAFLD via a blood test to assess a patient’s liver enzymes and order an abdominal ultrasound, if needed. If NAFLD is suspected, PCPs can check your platelets to help determine if there’s significant damage. If that turns out to be the case, it’s time to make an appointment with a hepatologist. 

Signs and symptoms

“Most patients with NAFLD have no symptoms,” says Dr. Brandman. “When they do, the most common ones are fatigue and right-sided abdominal pain.

“Those with cirrhosis and resulting liver failure may experience jaundice—yellowing of the skin or eyes—along with fluid retention, bleeding and confusion,” she adds.

Toward a healthy liver

Losing weight can be challenging, but it’s the best treatment on offer for NAFLD.

Dr. Brandman shares the following weight-loss guidelines:

Diet and nutrition

• To improve or resolve NASH, aim to lose 7 percent of your starting weight.
• To improve liver fibrosis, set your goal higher and aim to lose 10 percent of your starting weight.
• Don’t drink your calories. Stay away from sugar-sweetened beverages like soda or energy drinks.
• Try to get protein from leaner sources such as poultry and fish rather than red meat.

Exercise

• Adopt a long-term goal of getting 30 minutes per day of moderate-to-vigorous exercise, 5 days per week. That’s 150 minutes per week.
• Start slow. Try 5 minutes a day 5 days per week, and gradually work up to your goal of 30 minutes a day.
• Find an activity you enjoy and will stick with.
• Weight and resistance training combined with bodyweight exercises like push-ups (regular or modified) can also improve liver health and lead to sustained weight loss.
• Structured weight management programs are also helpful in promoting and sustaining weight loss.

Supplements and medications

“Vitamin E and pioglitazone (an older diabetes drug) can reduce fat and inflammation in the liver, but they may not be effective in reversing liver fibrosis,” Dr. Brandman says. “And because pioglitazone has the potential side effect of weight gain, there are good reasons to avoid this drug. Several other diabetes and weight-loss drugs have shown promise in improving NAFLD, but none are FDA-approved yet for the condition.

“Still,” she continues, “there are many clinical trials in progress. There are good reasons to be optimistic.”

Weight-loss procedures

Bariatric procedures—either surgical or endoscopic—are good options for producing the weight loss needed to improve NAFLD, including reversal of liver fibrosis, Dr. Brandman says. “These procedures are not approved specifically for NAFLD management, but they may be appropriate options if patients meet the criteria for weight-loss surgery.”  

Alcohol: How much is too much?

People with healthy livers should avoid drinking more than 1 drink a day for women and 2 drinks a day for men.

Alcohol, even in small amounts, can add to liver damage in patients with NAFLD, so it should be avoided. 

Patients with cirrhosis should never drink alcohol. Ever. 

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