Non Alcoholic Fatty Liver – Yes, You SHOULD Worry!


If your doctor has told you that you have a fatty liver, you’re not alone. 

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease in the USA.  While you don’t need to panic, you must take it seriously.  Read on to find out what to do about it.


Some 65 million Americans have non-alcoholic fatty liver disease (NAFLD) and that number will reach 100 million by 2030, according to Scott Friedman, MD, of the Icahn School of Medicine at Mount Sinai Hospital in New York City.


NAFLD is defined as the presence of macrovascular steatosis in the presence of less than 20 gm of alcohol ingestion per day.  

It is most commonly associated with insulin resistance/type 2 diabetes mellitus and obesity. It is manifested by steatosis, steatohepatitis, cirrhosis, and, rarely, hepatocellular carcinoma.¹


My Mother’s Story

 My mother (who was not an alcoholic) had NAFLD for several years, which eventually progressed into cirrhosis of the liver.  Complications from cirrhosis eventually took her life.

It is not known why some patients progress to cirrhosis.

Here is a brief summary of what happened:

My mom’s very first sign of liver cirrhosis was edema – fluid buildup in the ankles, feet and legs.

Until that time, her fatty liver had been asymptomatic, and neither she nor her doctor were particularly worried about it.

If you have this, see your doctor and ask for a liver enzyme test!


She mentioned this numerous times to her physician, who prescribed diuretics (water pills) to help flush out the extra water. 

My mother was not a drinker, but she was overweight, sedentary and pre-diabetic with high lipids (sometimes called Metabolic Syndrome or Syndrome ‘X’).

Mom had been diagnosed with fatty liver some years before, but that is quite common, and had not set off any alarms.

At this point though, her doctor should have done a simple liver enzymes blood test, as chronic edema is considered one of the early signs of liver decompensation. 


But he didn’t.


I imagine he assumed the swollen feet and ankles were caused by other, more common, benign factors.

Mom suffered with uncomfortable and unsightly swollen legs for around five years before a much more serious symptom emerged…

Ascities – fluid buildup in the stomach.  In her case, the fluid was pushed by her diaphragm up into the lining around her lungs, and she began having a hard time getting a full breath of air.

When she saw the doctor for this, he sent her for a chest x-ray that day.  The x-ray indicated a problem, and mom was told to go to emergency immediately for more testing.  She was admitted briefly to the hospital for a battery of tests, which ultimately confirmed she had cirrhosis of the liver. 

At that point, her cirrhosis was considered advanced.

That was only the beginning of a two year nightmare, involving nearly all of the terrible symptoms of liver cirrhosis at some point or another. 

While there were some periods of time when her health would rally somewhat (my sister and I called these ‘reprieves’), the disease was unrelenting in its progression. 

Mom was in an out of the hospital, and eventually had a TIPS procedure to bypass the liver’s portal vein and help with the fluid buildup.  It only helped for a few months.

In the end, mom was admitted to hospice, where she suffered a  variceal bleed (internal bleeding caused by increased blood pressure in the portal vein system).


The presence of enlarged veins (varices) usually causes no symptoms … Until they bleed (called a variceal bleed).

Then, it becomes an emergency.


Sometimes a surgeon can tie off or cauterize the bleed.

In my mom’s situation, she was already so weak and ill that her body would not have survived any kind of invasive medical intervention. 

Her variceal bleed proved to be fatal.



Why I tell this story…


I tell this story so that anyone who has been told by their doctor that they have fatty liver, can be proactive and work to reverse it.

And believe me when I say you must reverse your fatty liver.

Because NAFLD can progress into nonalcoholic steatohepatitis (NASH), the next stage of liver disease. 

And if you develop NASH,  it means you have inflammation and liver cell damage, along with fat in your liver. 


Currently, 16.5 million people have the most serious subtype of NAFLD, non-alcoholic steatohepatitis (NASH), a number that will rise to 27 million, says Scott Friedman, MD, of the Icahn School of Medicine at Mount Sinai Hospital in New York City.


NASH is usually a silent disease with few or no symptoms.

Patients generally feel well in the early stages and only begin to have symptoms—such as fatigue, weight loss, and weakness—once the disease is more advanced or cirrhosis develops.



The progression of  can take years, even decades. The process can stop and, in some cases, reverse on its own without specific therapy.

Or NASH can develop quickly, eventually worsening, causing scarring or “fibrosis” to appear and accumulate in the liver.

As fibrosis worsens, cirrhosis develops; the liver becomes seriously scarred, hardened, and unable to function normally.


Not every person with NAFLD develops NASH, and not everyone with NASH develops cirrhosis,


but –


Once serious scarring or cirrhosis is present, few treatments can halt the progression.

A person with cirrhosis experiences fluid retention, muscle wasting, bleeding from the intestines, and liver failure.

Liver transplantation is the only treatment for advanced cirrhosis with liver failure, and transplantation is increasingly performed in people with NASH.



Causes of Non-Alcoholic Fatty Liver Disease

NASH most often occurs in persons who are middle-aged and overweight or obese.  But not always.  Below are the known causes of NASH.



Nutritional Drugs
 Starvation Glucocorticoids
Obesity* Tamoxifen
 Bariatric surgery Amiodarone
 Parenteral nutrition Valproic acid
 Celiac disease Zidovudine
Metabolic Didanosine
Insulin resistance*† Other
Inflammatory bowel disease
 Fatty liver of pregnancy Halogenated hydrocarbons
Toxic Mushrooms
*Most common causes.


Dyslipidemia is an abnormal amount of lipids (e.g. triglycerides, cholesterol and/or fat phospholipids) in the blood. In developed countries, most dyslipidemias are hyperlipidemias; that is, an elevation of lipids in the blood. This is often due to diet and lifestyle.


Insulin Resistance refers to a diminished ability of cells to respond to the action of insulin in transporting glucose (sugar) from the bloodstream into muscle and other tissues. Insulin resistance typically develops with obesity and heralds the onset of type 2 diabetes.



Risks Associated with Non Alcoholic Fatty Liver Disease (NAFLD)



Liver ailments are not the only outcome of NAFLD, according to Mary Rinella, MD, of Northwestern University’s Feinberg School of Medicine in Chicago. She lists a series of adverse outcomes, including:


  • Premature death from all causes; one study found that 10-year survival of people with NAFLD was 77%, significantly lower than the 87% expected rate
  • From 12% to 38% of people with NASH, depending on the study, die of cardiovascular causes
  • Malignancy other than hepatocellular carcinoma (non-liver cancers)



NAFLD Raises Mortality Risk From All Causes

Research reports that patients with advanced non-alcoholic fatty liver disease (NAFLD) faced a greater overall burden of cardiovascular disease and all-cause mortality

All-cause mortality was higher in non-alcoholic steatohepatitis (NASH) than NAFLD (22.1% versus 14.5%, P=0.025) during the 14-year study period, reported Jake Mann, MD, from the University of Cambridge, and colleagues.

Also over the 14-year study period, all-cause mortality was higher in patients with cirrhosis than those with NAFLD (53.1% versus 14.5%, P<0.001), the group stated at the European Association for the Study of the Liver (EASL) annual meeting.

“Non alcoholic fatty liver disease is recognized as a risk factor for cardiovascular disease,” Mann said at an EASL press conference. “Our results suggest that non-alcoholic steatohepatitis conveys an even greater risk. This study provides important new insights into mortality and burden of cardiovascular disease in patients across the non-alcoholic fatty liver disease spectrum.”


When observing incidence of cardiovascular disease, the authors found increasing rates of heart disease as patients progressed along the fatty liver spectrum:


  • Congestive cardiac failure was seen in 3.8% of patients with NAFLD, in 9% of patients with NASH (P=0.01), and in 6.6% of patients with cirrhosis (P<0.05).
  • Atrial fibrillation was observed in 4.9% of patients with NAFLD, in 8.2% of patients with NASH, and in 8.3% of patients with cirrhosis (P<00001).


 “We knew that patients with fatty liver disease were at risk of heart disease, but we didn’t know if that risk became greater as fatty liver disease progressed,” he said.

He added:


“this is the largest U.K. study of its kind, and we have shown an increasing trend and an increasing association between cardiovascular morbidity across the non-alcoholic fatty liver disease spectrum.”


He suggested that abnormalities in blood clotting and other factors that drive fatty liver disease are similar to those that are associated with heart disease.

“It is possible that what we are describing is the natural history of diseases of these patients who are afflicted by multiple comorbidities,” Mann said. “The implication of this is that patients across the spectrum of fatty liver disease have a very high risk of cardiac disease and kidney disease that the physician should be aware of.”


EASL press conference moderator Laurent Castera, MD, PhD, vice-secretary of EASL and head of hepatology at Hospital Beaujon at University of Paris-VII said:


“It is therefore imperative that we identify people in the early stages of non-alcoholic fatty liver disease so they can be treated through diet and lifestyle interventions before their condition becomes potentially deadly.”


NAFLD is a Predictor of Heart Disease



According to Clinical Gastroenterology and Hepatology, non alcoholic fatty liver disease (NAFLD) and cardiovascular diseases (CVDs) have common metabolic risk factors, and NAFLD is associated independently with an increased risk of cardiovascular diseases, primarily carotid atherosclerosis (narrowing or constriction of any part of the carotid arteries).


Two studies presented at the annual meeting of  the European Association for the Study of the Liver, went further, stating that:



 Non alcoholic fatty liver disease (NAFLD) is an independent predictor of carotid atherosclerosis. 



NAFLD and Type 2 Diabetes



A 2017 study² reviewed in the Journal of Clinical Endocrinology & Metabolism found:
There is a strong and independent association between NAFLD with both diabetes and pre-diabetes.



NAFLD Increases Risk of Several Cancers



A recent study published in the Journal of Hepatology found that non alcoholic fatty liver disease (NAFLD) was tied to an increased risk of hepatocellular carcinoma (HCC – liver cancer), colorectal cancer in men, and breast cancer in women.
“These findings suggest that patients with NAFLD require multidisciplinary evaluation with attention given to the development of malignancy,” the researchers wrote.


NAFLD and Hypertension (High Blood Pressure)



According to a 2015 study in the journal PLoS One, non alcoholic fatty liver disease (NAFLD),  may be an independent risk factor for hypertension, according to a study of more than 1,500 Korean adults.
The study found that NAFLD was positively associated with baseline blood pressure,  insulin resistance, urinary albumin/creatinine excretion, and high sensitivity C-reactive protein.



 “Our findings suggest that fatty liver index, a simple surrogate indicator of fatty liver disease, might be useful for identifying subjects at high risk for incident hypertension in clinical practice,” the authors wrote.

Diagnosing Non Alcoholic Fatty Liver Disease


Because nonalcoholic fatty liver disease causes no symptoms in most cases, it frequently comes to medical attention when tests done for other reasons point to a liver problem. This can happen if your liver looks unusual on ultrasound or if you have an abnormal liver enzyme test.


While many people with a fatty liver are unaware that they have a liver problem, there are some symptoms which may be experienced:

  • Weight excess in the abdominal area
  • Elevated cholesterol and triglyceride levels
  • Tiredness and fatigue
  • Nausea
  • Gallstones
  • Overheating of the body
  • Excessive sweating
  • Red itchy eyes


Tests done to pinpoint the diagnosis and determine disease severity include

  • blood tests,
  • imaging procedures and
  • liver tissue examination.


Reversing Non Alcoholic Fatty Liver Disease


Lifestyle Choices to Heal Your Fatty Liver



Lose Weight

Clinicians have long recommended weight loss to fatty liver patients on the assumption that it could be very helpful. But only recently have studies begun to demonstrate just how powerful losing weight can be, said Dr. Amy Kim, a hepatologist and assistant professor at Johns Hopkins School of Medicine.

In a recent study published in the journal Gastroenterology, scientists recruited 293 patients and looked at what happened when they followed exercise and diet programs for a year. The patients all had an advanced form of fatty liver disease in which the liver becomes scarred and inflamed, known as nonalcoholic steatohepatitis, or NASH.


Among those who lost 10 percent or more of their body weight, “90 percent had resolution of NASH, and 45 percent had regression of fibrosis,” or scarring, the authors reported.


“In clinic, we always say weight loss,” Dr. Kim said. “But this was a large prospective trial that confirmed that.”

“The more weight loss there is, the better the improvement,” she added.

Some people choose to follow specific diet plans. As someone who has done much research on liver disease, I recommend the Mediterranean diet  because of its  anti-inflammatory properties and the level of satisfaction it offers (but any healthy diet which works for you is fine).


Example: The Mediterranean Diet Weight Loss Solution – The 28 Day Kickstart Plan for Lasting Weight Loss



Proven, Beneficial Foods and Herbs



A study in Advanced Biomedical Research found that garlic powder supplements appear to help reduce body weight and fat in people with fatty liver disease.

You can add garlic powder to your cooking or take a garlic supplement.


Omega-3 Fatty Acids



A review of current research suggests that omega-3 fatty acids improve liver fat levels and HDL cholesterol levels in people with fatty liver disease.

More research is needed to confirm this, but eating foods high in omega-3 fatty acids may help lower liver fat. These foods include salmon, sardines, walnuts, and flaxseed.  You can also take an omega-3 fatty acid supplement.


Milk Thistle (Silymarin)



The effect of Silymarin on NAFL has been investigated in several studies.  A 2013 study published in the World Journal of Hepatology found that

“Silymarin appears to be effective to reduce the biochemical, inflammatory and ultrasonic indices of hepatic steatosis. Some parameters indicative of early stage of atherosclerosis were also lowered”.


Example: Nature’s Bounty Milk Thistle






Drinking coffee is a morning ritual for many people, but there may be more to it than a quick pick me up.

As a report in Annals of Hepatology pointed out, coffee contains chlorogenic acid, which is a potent compound known to have antioxidant and anti-inflammatory properties, which appear to help protect the body from non alcoholic liver disease.  It also helps to reduce cholesterol and hypertension.


A 2016 meta‐analysis published in Alimentary Pharmacology and Therapeutics shows that an increase in daily coffee consumption of two cups is associated with a near halving of the risk of cirrhosis.


This is a large effect compared to many medications used for the prevention of disease. For example, statin therapy reduces the risk of cardiovascular disease by 25%.

Furthermore, unlike many medications, coffee is generally well tolerated (and enjoyed!),  and has an excellent safety profile.






Eating a variety of whole vegetables is helpful for fatty liver disease, but broccoli could be particularly helpful. 

An article in the Journal of Nutrition found that long-term consumption of broccoli helped prevent the buildup of fat in the liver of mice. Researchers still need to conduct more studies on humans, but this early evidence looks very promising.

Of course, if you don’t like broccoli, there’s a supplement for that, too!



Tea (Especially Green Tea)



Using tea for medicinal purposes is a practice that goes back thousands of years.

As recent research in the World Journal of Gastroenterology suggests, green tea especially may help reduce body fat percentage and fat in the blood. The higher antioxidant levels in green tea may be helpful for the liver, as well. 

You can drink green tea, or take a green tea supplement for a more concentrated dose.






While tree nuts are a great addition to any diet plan, walnuts are especially high in omega-3s.


A report from 2015 found that eating walnuts improved liver function tests in people with non-alcoholic fatty liver disease.






Avocados are rich in healthful fats but also contain anti-inflammatory nutrients and soluble fiber, which can help reduce blood sugar and oxidative stress in the body.



Soy Protein and Whey Protein



As a review in the Journal of Gastroenterology and Hepatology noted, some proteins can help protect the body from fatty liver disease.

Soy protein and whey protein appear to help balance the effects of simple carbohydrate intake and can reduce blood sugar levels. They also help the body retain muscle mass and reduce overall weight.


Exercise and Be More Active



Exercise will help you to lose weight and maintain a healthy weight.  It’s also good for your cardiovascular fitness. 

Aim for at least 30 minutes of exercise most days of the week. If you’re trying to lose weight, you might find that more exercise is helpful. But if you don’t already exercise regularly, get your doctor’s OK first and start slowly.

I find walking to be the perfect exercise; it’s pleasant and easy on the joints.  I use a treadmill at home when the weather doesn’t allow for an outside walk.  I feel that my treadmill has been a real boon for my fitness and weight loss efforts (and saved my sanity on many a day).

Do whichever exercise works best for you, but make it a regular part of your lifestyle.



Control Your Diabetes (if applicable)



Follow your doctor’s instructions to stay in control of your diabetes. Take your medications as directed and closely monitor your blood sugar.  Be vigilant.


Lower Your Cholesterol (if applicable)



Follow your doctor’s advice and take any prescribed medications to keep your cholesterol and your triglycerides at healthy levels.





Recommended:  Skinny Liver – A Proven Program to Prevent and Reverse the New Silent Epidemic – Fatty Liver Disease by  Kristin Kirkpatrick, MS, RD,LD and
Ibrahim Hanouneh, MD


Skinny Liver – A Cleveland Clinic dietician and a renowned liver disorder specialist offer a plan for optimal liver health, with tools to treat and prevent liver diseases, including NAFLD

Final Thoughts

If you are living with fatty liver disease, learn as much as you can about your condition, and do all you can to heal your liver and reverse the condition.  Work closely with your doctor.

Since many medications can harm your liver, always let all your health care providers know about any medications you are taking. These include OTC drugs, dietary supplements, and vitamins.

What to Read Next


¹Source Reference: Mann J, et al, “The burden of cardiovascular disease and mortality across a spectrum of non-alcoholic fatty liver disease: A 14-year follow-up population study of 929,465 individuals” EASL 2015; Abstract G12.

²Source Reference: Yao He et. al. “Association of NAFLD with diabetes and the impact of BMI changes: a 5 years’ cohort study based on 18507 elderly.” J Clin Endocrinol Metab online Jan. 16, 2017.

Other Sources:
US National Library of Medicine National Institutes of Health
MedPage Today


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