The term ‘liver disease’ encompasses many different conditions including hepatitis, liver cancer, fatty liver disease and genetic conditions like hemochromatosis. Hopefully you’re still with me! Don’t worry, today we’ll only be reviewing non-alcoholic fatty liver disease (NAFLD), a liver condition that appears to be on the rise. In fact, NAFLD affects over 7 million people here in Canada, making it the most common liver disease in the country!
What is NAFLD & NASH?
Non-alcoholic fatty liver disease (NAFLD) is a condition in which fat is inappropriately stored in the cells of the liver. As the name implies, this particular type of fatty liver disease occurs in people who drink little to no alcohol – while there is also fatty liver that can result from excessive alcohol consumption. Often in practice, it’s not cut and dry – you may drink moderately, as well as have nutrition and lifestyle habits which can contribute to fatty liver disease. Regardless of the cause, lifestyle changes are typically the first intervention.
If left undiagnosed or untreated, having NAFLD could also increase a person’s risk of developing a more advanced form of liver disease, called non-alcoholic steatohepatitis (NASH). 30% of those with NAFLD progress to developing NASH. So, what’s the difference? In NAFLD, there are fatty deposits throughout the liver, but little to no inflammation or liver cell damage. NASH on the other hand, is characterized by fatty deposits in the liver PLUS inflammation and liver cell damage, fibrosis (hardening of the liver) and can even lead to permanent scarring in the liver, called cirrhosis. In other words, it is more permanent and irreversible than normal NAFLD – but can still be managed with lifestyle, diet, and/or medications.
What causes fatty tissue to build up in the liver in these individuals that aren’t drinking excess alcohol? There are a few risk factors that are associated with developing NAFLD and NASH including:
- Having characteristics of metabolic syndrome – this includes factors such as high blood pressure, high cholesterol, diabetes mellitus or insulin resistance, and large waist circumference
- Rapid weight loss
- Excessive intake of energy, in particular fat and sugar, and overall lack of balance in the diet
- Genetic risk factors
This list is certainly not exhaustive – there are many reasons a person could develop NAFLD and we still have a lot to learn about the pathways in which people develop this complex condition!
What are the symptoms of NAFLD?
One of the most challenging aspects of NAFLD and NASH is that they often go undetected, particularly in the early stages in which many people get little to no symptoms at all. If individuals do present with symptoms, they generally experience one or more of the following things:
- Pain/discomfort in the upper right abdomen (where the liver is located)
- Unexplained weight loss
- General feeling of unwell
In the more extreme cases, where liver cirrhosis and scar tissue develop, people may experience fluid buildup called edema or ascites, and yellowing of the skin and eyes called jaundice. However, this is unlikely to occur in the beginning stages of NAFLD and NASH.
Because this condition is difficult to detect with physical symptoms, it is key to manage your health by seeing your doctor regularly and having routine blood work – usually annually or every couple of years unless you are at higher risk. This is especially important for anyone with a personal history or family history of liver issues, diabetes mellitus (particularly type 2), or any of the other risk factors listed above.
How is NAFLD diagnosed?
As mentioned above, routine medical check-ups play a big role in detecting liver disease. This can involve physical examination, blood work, and imaging tests. In many cases, the first signs of NAFLD pop up in blood tests. Doctors will commonly include a check for liver enzyme levels including alanine aminotransferase (ALT) and aspartate aminotransferase (AST). If these are elevated, your doctor may want to investigate fatty liver disease.
Other tests for diagnosing NAFLD & NASH include imaging tests such as abdominal ultrasounds, fibro scans, and CT scans to view the liver and detect fatty tissue. In some cases, people that undergo abdominal ultrasounds for other reasons (like heart issues or kidney problems) may discover they have NAFLD without actually being investigated for it – again, it’s often a very “under the radar” sort of condition!
A combination of blood tests and imaging is typically enough to determine if someone has NAFLD, but your healthcare team may decide to do additional testing to identify the severity of your condition such as a liver biopsy or additional blood testing.
What are the treatment options?
You might be thinking: “If I don’t have symptoms of NAFLD, what’s the big deal? Should I even worry about it?” And sure – you might not feel unwell right NOW, but it is very important to manage both NAFLD and NASH to avoid long-term complications. Poorly managed fatty liver disease can ultimately lead to cirrhosis and increased risk of liver cancer. I’d imagine that is something most people would like to prevent if at all possible!
Treatment of NAFLD involves a combination of lifestyle and medication management, although not everyone needs pharmacological therapy to improve their liver outcomes.
Should I lose weight if I have NAFLD?
A vast majority of the recommendations that exist regarding nutrition for NAFLD are focused on reducing overall weight as a means for improving liver biomarkers. However, a systematic review from 2003 revealed that a vast majority of the studies that analyzed the connection between weight reduction and NAFLD had flawed methods, making it difficult to truly connect the dots between weight loss and NAFLD, predominantly because weight loss if often not permanent, and weight cycling appears to be a possible risk factor for worsening NAFLD and progression to NASH or cirrhosis.
So, what does this all mean? Weight loss COULD improve NAFLD outcomes, but we always want to put health first. Pursuing weight loss does not always mean someone is healthy! And keep in mind – rapid weight loss is actually a risk factor for the development and worsening of NAFLD, so we want to ensure any weight changes are sustainable and realistic – so NO crash diets! At Ignite Nutrition, we work with our fatty liver patients to improve health behaviours first, regardless of whether weight changes or not.
There is no standard “NAFLD diet”, but there are some key dietary concepts that are linked to better outcomes in those with non-alcoholic fatty liver. The main strategies include:
- Reducing saturated fat intake – saturated fat is primarily found in animal products, particularly beef, pork, creamy sauces, cheese, and other high fat dairy. It is also in coconut and palm oil.
- Reducing intake of simple carbohydrates, especially fructose – high consumption of simple sugars such as those found in pop, juice, baked goods, candy and highly processed grains can contribute to excess fat being deposited in the liver. Avoiding these foods is recommended, but it doesn’t need to be all or nothing! Enjoy these foods occasionally and continue to eat natural sugars from fruits, vegetables, and dairy.
- Increasing consumption of unsaturated fats such as omega-3s – Omega-3 fatty acids have been shown to help with reducing inflammation and fat synthesis in the liver. Foods high in omega-3 fatty acids include fish (particularly salmon, trout, tuna, mackerel & sardines), nut, seeds, plant oils and fortified foods like omega-3 eggs.
- Increasing fibre consumption – getting enough fibre in the diet can actually help to reduce the amount of fat we uptake into our bloodstream and carry to the liver. Fibre, particularly soluble fibre, binds to fat in the digestive track and helps us to evacuate it naturally if you know what I mean – yes, that’s right, we poop it out! Fibre also plays a key role in regulating blood sugars and gut health, both factors implicated in the development of NAFLD.
- Reducing or eliminating alcohol intake – like mentioned at the beginning, we often see those with moderate alcohol intake diagnosed with NAFLD. Alcohol is very hard on the liver, so reducing intake or entirely is helpful.
- Exercise – getting moving is a key component of reducing fat deposits in the liver. While our dietitians are not exercise specialists, we can help you find exercise that works for you, that you actually enjoy!
As a way of encompassing all of the above recommendations, we often recommend following a Mediterranean-style eating plan with an emphasis on lots of plant-based foods (veggies, fruit, and whole grains) PLUS leaner cuts of meat like chicken, turkey, and fish. Along with this, consuming 1-2 meatless meals per week that include pulses like beans, chickpeas, and lentils is a great way of displacing intake of foods higher in saturated fat, plus an excellent source of fibre.
Working with a dietitian is also highly recommended if you have NAFLD, as each case is very unique. This is especially true if you also have other conditions like diabetes or high blood pressure for example! Registered dietitians are trained to work WITH you to determine the best diet plan for your body, your health history, and your schedule.
There are numerous drugs that have been studied for NAFLD – almost too many to count! Generally speaking, medications used for the treatment of NAFLD mainly target the underlying cause (or suspected cause) of NAFLD. In particular, medications that aid in cholesterol reduction and blood sugar management are a mainstay of care for individuals with NAFLD, as these conditions are commonly linked to the development of this disease.
Additionally, we commonly get asked about herbal supplements for NAFLD, but in general there are not high-quality research studies to support their use. It is best to ask your health care team about the use of these sorts of products before purchasing them, as there may be more evidence-based lifestyle and medical options for you to try instead.
Although you may not feel unwell with NAFLD, it is still very important to manage this condition with diet, exercise, and medications if necessary, to prevent long-term complications. If you have been diagnosed with NAFLD, working with a dietitian to incorporate a balanced diet that will help to reduce fatty deposits in your liver is highly recommended!
Discuss all your treatment options with your physician, particularly if you have comorbidities that may complicate your condition.
And finally, many health professionals encourage weight loss to treat NAFLD. While this may be appropriate, please remember that weight loss without a focus on sustainable behaviours and long-term health can actually worsen NAFLD, particularly rapid weight loss. There are many other factors in addition to weight that ultimately lead us to our healthiest selves!