Fatty liver disease and keto: 5 things to know

Once a rare disorder, nonalcoholic fatty liver disease, or NAFLD, has now become all too common. It’s estimated to affect about 25% of the population in most Western countries, and as many as 1 billion people worldwide.1 Even children are now being affected.2
 
Although NAFLD can have dire consequences, it can potentially be improved — and in some cases even reversed — with a keto or low-carb approach. In this guide, we’ll tell you how.

Key takeaways

Keto diets are potentially beneficial for people with NAFLD because they can:

  1. Reduce liver fat
  2. Decrease insulin levels
  3. Help reverse the disease process
  4. Suppress appetite, promote weight loss, and improve heart health markers
  5. Provide a healthy, satisfying way of eating that can be maintained long term

 

What is nonalcoholic fatty liver disease (NAFLD)?

In nonalcoholic fatty liver disease (NAFLD), too much fat is stored in the liver. Although everyone has a little fat in their liver, fat makes up more than 5% of the liver in people with fatty liver disease. 3
In the past, fatty liver was seen almost exclusively in people who regularly consumed large amounts of alcohol, but today factors other than alcohol are the leading cause, hence the name NAFLD. One of the criteria for NAFLD is having a fatty liver but averaging less than two alcoholic beverages (20-30 grams of alcohol) per day.4
Nonalcoholic hepatic steatosis, known more simply as nonalcoholic fatty liver, is the earliest stage of NAFLD. In some people, the disease remains at this stage and never progresses. Although they experience metabolic issues related to excess liver fat, they don’t sustain significant liver damage.

But in 25-30% of all cases, fatty liver progresses to a more serious condition known as non-alcoholic steatohepatitis (NASH), in which the liver cells become inflamed and injured. When the liver attempts to repair these damaged cells, scar tissue forms, resulting in a condition called fibrosis.5

Eventually, about 20% of NASH cases may progress to cirrhosis — end-stage, irreversible liver disease that usually results in liver failure.

While only a portion of all NAFLD cases progress to NASH and then cirrhosis, non-progressing NAFLD can still be a health problem. NAFLD has been linked to increased risk of heart disease and type 2 diabetes.6

Unfortunately, many people aren’t aware they have NAFLD because symptoms like abdominal swelling, loss of appetite, and jaundice usually don’t develop until the disease is well advanced.

What causes NAFLD?

Several things can contribute to the development of NAFLD. These include:

  • Excess energy intake: Eating more calories than needed may lead to excess fat accumulation in the liver — and research suggests this can happen no matter what type of food is over consumed.7
  • Too many refined carbs: Consuming more carbohydrates than your body is able to handle can drive liver fat storage via a process known as de novo lipogenesis (literally “making new fat”).8 This typically happens when both carb and calorie intake are high.
    In one study, when overweight adults ate 1,000 extra calories as refined carbs, they experienced a 27% increase in liver fat after just three weeks.9
  • Too much sugar: When it comes to excess carbs, sweets and sugar-sweetened beverages may be especially problematic. These items are high in fructose, which has been shown to increase liver fat when consumed in large amounts.10 Some researchers believe that high fructose intake is a major contributor to NAFLD.11
  • Sedentary lifestyle: Observational research suggests that spending too much time sitting rather than moving may promote excess liver fat storage.12 However, this is hard to differentiate from other potential contributing lifestyle factors.

Risk factors for NAFLD

Not everyone who consumes a lot of refined carbs and gets little exercise will end up developing NAFLD. So who is most likely to get it?

Here are some things that increase the likelihood of developing NAFLD:

  • Insulin resistance: People with insulin-resistant conditions like type 2 diabetes and metabolic syndrome are at higher risk for NAFLD. Although the exact mechanism isn’t completely understood, insulin resistance and high insulin levels are known to drive excessive storage of liver fat.13
  • Carrying too much weight around the middle: Because it’s so strongly linked to high insulin levels, large waist size places people at increased risk for NAFLD, even if their BMI is in the “normal” range.14
  • Genetics: Some people are more likely to develop NAFLD because they’ve inherited certain gene variants that increase their risk for the disease. However, further research in this area is needed.15

How to know if you have NAFLD

NAFLD is diagnosed by lab tests, a liver ultrasound or a CT scan, and sometimes a liver biopsy. In blood tests, in addition to high triglycerides and insulin levels, certain liver enzymes are elevated, especially GGT and ALT. An ultrasound or CT scan will show excess fat or other changes in the liver.

Using a formula that calculates the combined effects of triglycerides, GGT, waist size and BMI, the Fatty Liver Index has been shown to help predict the likelihood that someone has NAFLD. However, in at least one study, waist size alone was found to similarly predict this risk.16

If you think you may have NAFLD, follow up with your doctor for further testing.

Why a keto or low-carb diet can improve NAFLD

Because many people with NAFLD are overweight, they often receive recommendations to eat low-calorie or low-fat diets. However, besides being difficult to stick with long term, these diets may do little to address the root causes of NAFLD.17

Recently, keto eating has been shown to improve NAFLD in a number of ways.

Keto and low-carb diets can help people with NAFLD because they:

  1. Decrease liver fat: Since eating too many carbs can increase liver fat storage, it makes sense that cutting back on carbs can have the opposite effect. And studies have confirmed that this is exactly what occurs.
    In an eight-week randomized controlled trial (RCT) of 106 people with NAFLD, those who ate a low-carb diet had greater reductions in liver fat and less abdominal fat than those who ate a low-fat diet.18 Several smaller trials have also shown a decrease in liver fat with a low-carb approach.19
  2. Reduce insulin levels and insulin resistance: A very-low-carb diet can dramatically improve insulin sensitivity in people with NAFLD — and often very quickly.
    In one study, people with NAFLD who ate a keto diet for six days had a 58% decrease in insulin resistance and a 53% decrease in insulin levels. According to the researchers, the lower insulin levels allowed liver fat to be broken down and converted into ketones.20
  3. May help reverse the disease process: Several small studies have shown that in addition to preventing the progression of NAFLD, keto eating may actually reverse the disease.
    In a 12-week study of people with metabolic syndrome and NAFLD who followed a Spanish Mediterranean ketogenic diet, 13 of 14 people had a decrease in liver fat levels, and three had a complete resolution of NAFLD.21
    In another small trial, patients with NAFLD ate a diet that limited carbs to 20 grams per day for six months. By the end of the study, fatty liver, inflammation, and fibrosis had improved in four of the five patients.22
    And in the analysis of one-year data from Virta Health’s large ongoing study in people with type 2 diabetes, most participants with NAFLD who followed a very-low-carb diet had reductions in liver fat and fibrosis scores.23
  4. Suppress appetite, promote abdominal fat loss, and improve heart health markers: Ketogenic diets have been shown to help reduce appetite in several studies, including a meta-analysis of RCTs, which is considered the strongest, highest-quality evidence.24
    In several trials, people with NAFLD who followed a keto or low-carb diet ended up eating less and losing abdominal fat without intentionally restricting calories.25
    Other benefits of low-carb eating include reductions in heart disease risks factors, such as lower blood triglycerides, blood sugar, and blood pressure.26
  5. Provide a healthy, satisfying way of eating that can be maintained long term: Low-carb and keto diets have been shown to be effective and sustainable in the long run.27

Getting started with low carb or keto for NAFLD

After getting the OK from your doctor, you can learn the basics of low-carb eating in our keto and low-carb diet guides.

Although a very-low-carb approach seems to produce the most dramatic reduction in liver fat, if you’d rather reduce carbs more gradually, read Eating better: Six steps down the carb mountain to get started.

In addition to paying attention to carb intake, make sure to get enough protein. Higher protein intake has been found to reduce liver fat in people with NAFLD, as well as those with type 2 diabetes.28 Use our target protein ranges chart to figure out how much you need.

Other lifestyle changes that may improve NAFLD

Besides eating low carb, a few other changes might also be helpful:

  • Exercise regularly: Being more physically active can help reduce insulin resistance and liver fat. Which type of exercise is best? In a review of 12 trials, performing either aerobic exercise or resistance training for 40-45 minutes three times a week was found to be beneficial for NAFLD.29
    So choose the type of exercise you prefer and will stick to. Or better yet, aim for a combination of both, if you can.
  • Include fatty fish in your diet: Try to eat salmon, sardines, mackerel, or anchovies at least twice a week. These fish are high in omega-3 fats, which have been shown to reduce liver fat, GGT, and triglycerides in people with NAFLD.30
  • Consider turmeric or curcumin: You may know turmeric as the bright-yellow, pungent spice used in Indian and Asian curries and other dishes. Studies suggest that turmeric or its active component curcumin may help reduce liver fat in those with NAFLD.31
    Curcumin has also been shown to produce slight weight loss and reduce waist size in people who are overweight or have metabolic syndrome.32
    Try increasing the amount of turmeric in curries and other recipes that call for it, like our Keto coconut curry chicken or Pork tenderloin with curry sauce. Another option is to take a supplement containing 600 mg of curcumin.

    Note: If you take blood thinners, do not take curcumin or turmeric before speaking with your doctor or pharmacist.

Summary

Fatty liver disease occurs due to a combination of lifestyle and genetic factors. If allowed to progress from simple fatty liver, it can sometimes lead to more serious liver disease.

The good news is that a low-carb or keto diet can lead to a dramatic loss of liver fat and may potentially reverse the disease. The time to start is now, so you can begin living your healthiest, best life.

Jill Wallentin in the kitchen

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  1. The Journal of Clinical and Translational Hepatology 2020: Non-alcoholic fatty liver disease: Growing burden, adverse outcomes and associations [overview article; ungraded]

  2. European Journal of Pediatrics 2014: Pediatric non-alcoholic fatty liver disease: an increasing public health issue [overview article; ungraded]

  3. Clinical Liver Disease 2012: Nonalcoholic fatty liver disease: Definitions, risk factors, and workup [overview article; ungraded]

  4. The Journal of Clinical and Translational Hepatology 2020: Non-alcoholic fatty liver disease: Growing burden, adverse outcomes and associations [overview article; ungraded]

  5. World Journal of Gastroenterology 2016: Metabolic aspects of adult patients with nonalcoholic fatty liver disease [overview article; ungraded]

  6. Journal of Hepatology 2016: Non-alcoholic fatty liver disease and cardiovascular risk: Pathophysiological mechanisms and implications[overview article; ungraded]

    Diabetes Care 2018: Nonalcoholic fatty liver disease and risk of incident type 2 diabetes: A meta-analysis [systematic review of observational studies with HR >2; weak evidence]

  7. Medicine 2016: Nonalcoholic fatty liver disease is associated with excessive calorie intake rather than a distinctive dietary pattern [observational cohort very weak evidence]

    Journal of Investigative Medicine 2017: Influence of dietary macronutrients on liver fat accumulation and metabolism [overview article; ungraded]

  8. American Journal fo Clinical Nutrition 2003: Hepatic de novo lipogenesis in normoinsulinemic and hyperinsulinemic subjects consuming high-fat, low-carbohydrate and low-fat, high-carbohydrate isoenergetic diets [nonrandomized study, weak evidence]

  9. The American Journal of Clinical Nutrition 2012: Effect of short-term carbohydrate overfeeding and long-term weight loss on liver fat in overweight humans [non-controlled study; weak evidence]

  10. In one trial, overweight people were randomly assigned to consume 1 liter (about 32 ounces) of either sugar-sweetened beverages, milk, diet soda, or water every day for six months. By the end of the trial, liver fat had increased significantly more in the sugar-sweetened beverages group compared to the other groups:

    The American Journal of Clinical Nutrition 2012: Sucrose-sweetened beverages increase fat storage in the liver, muscle, and visceral fat depot: A 6-mo randomized intervention study [randomized trial; moderate evidence]

    Similar results were seen in a shorter trial in normal-weight men:

    The Journal of Clinical Endocrinology & Metabolism 2015: Effect of a high-fructose weight-maintaining diet on lipogenesis and liver fat [non-randomized study; weak evidence]

  11. Hepatobiliary Surgery and Nutrition 2015: Carbohydrate intake and nonalcoholic fatty liver disease: fructose as a weapon of mass destruction [overview article; ungraded]
    Nutrients 2017: Fructose consumption, lipogenesis, and non-alcoholic fatty liver disease [overview article; ungraded]

  12. Hepatology 2020: Inadequate physical activity and sedentary behavior are independent predictors of nonalcoholic fatty liver disease [observational study; very weak evidence]

    Journal of Applied Physiology 2011: Does physical inactivity cause nonalcoholic fatty liver disease? [overview article; ungraded]

  13. Nutrients 2017: Nonalcoholic fatty liver disease and insulin resistance: New insights and potential new treatments [overview article; ungraded]

  14. World Journal of Gastroenterology 2015: Central obesity and nonalcoholic fatty liver disease risk after adjusting for body mass index[pooled obervational studies with OR >2; weak evidence]

  15. Nature Reviews Gastroenterology & Hepatology 2019: Genetic contributions to NAFLD: Leveraging shared genetics to uncover systems biology [overview article; ungraded]

  16. World Journal of Gastroenterology 2016: Fatty liver index vs waist circumference for predicting non-alcoholic fatty liver disease [observational study; very weak evidence]

  17. In fact, in one intervention trial, a low-fat diet performed worse than a low-carb or Mediterranean diet for treating NAFLD:

    Journal of Hepatology 2019: The beneficial effects of Mediterranean diet over low-fat diet may be mediated by decreasing hepatic fat content [randomized trial; moderate evidence]

  18. Hepatology Research 2018: Comparison of efficacy of low-carbohydrate and low-fat diet education programs in non-alcoholic fatty liver disease: A randomized controlled study [randomized trial; moderate evidence]

  19. Journal of Hepatology 2019: The beneficial effects of Mediterranean diet over low-fat diet may be mediated by decreasing hepatic fat content [randomized trial; moderate evidence]

    The American Journal of Clinical Nutrition 2011: Short-term weight loss and hepatic triglyceride reduction: Evidence of a metabolic advantage with dietary carbohydrate restriction [non-controlled study; weak evidence]

    Cell Metabolism 2018: An integrated understanding of the rapid metabolic benefits of a carbohydrate-restricted diet on hepatic steatosis in humans[non-controlled study; weak evidence]

  20. Proceedings of the National Academy of Sciences of the United States of America 2020: Effect of a ketogenic diet on hepatic steatosis and hepatic mitochondrial metabolism in nonalcoholic fatty liver disease [non-controlled study; weak evidence]

  21. Journal of Medicinal Food 2011: The effect of the Spanish Ketogenic Mediterranean diet on nonalcoholic fatty liver disease: A pilot study [non-controlled study; weak evidence]

  22. Digestive Diseases and Sciences 2007: The effect of a low-carbohydrate, ketogenic diet on nonalcoholic fatty liver disease: a pilot study [non-controlled study; weak evidence]

  23. BMJ Open 2019: Post hoc analyses of surrogate markers of non-alcoholic fatty liver disease (NAFLD) and liver fibrosis in patients with type 2 diabetes in a digitally supported continuous care intervention: an open-label, non-randomised controlled study [non-controlled study; weak evidence]

  24. Obesity Reviews 2015: Do ketogenic diets really suppress appetite? A systematic review and meta-analysis [strong evidence]

  25. Hepatology Research 2018: Comparison of efficacy of low-carbohydrate and low-fat diet education programs in non-alcoholic fatty liver disease: A randomized controlled study [randomized trial; moderate evidence]

    The American Journal of Clinical Nutrition 2011: Short-term weight loss and hepatic triglyceride reduction: evidence of a metabolic advantage with dietary carbohydrate restriction [non-controlled study; weak evidence]

    Journal of Medicinal Food 2011: The effect of the Spanish Ketogenic Mediterranean diet on nonalcoholic fatty liver disease: A pilot study [non-controlled study; weak evidence]

  26. All participants in the Spanish Mediterranean diet trial had such impressive improvements in these health markers that by the end of the study, they no longer met the criteria for metabolic syndrome:

    Journal of Medicinal Food 2011: The effect of the Spanish Ketogenic Mediterranean diet on nonalcoholic fatty liver disease: A pilot study [non-controlled study; weak evidence]

    Similar improvements have been seen in other trials:

    Journal of Hepatology 2019: The beneficial effects of Mediterranean diet over low-fat diet may be mediated by decreasing hepatic fat content [randomized trial; moderate evidence]

    Cell Metabolism 2018: An integrated understanding of the rapid metabolic benefits of a carbohydrate-restricted diet on hepatic steatosis in humans [non-controlled study; weak evidence]

  27. PLoS One 2015: Dietary intervention for overweight and obese adults: Comparison of low-carbohydrate and low-fat diets. A meta-analysis [strong evidence]

    The British Journal of Nutrition 2016: Effects of low-carbohydrate diets v. low-fat diets on body weight and cardiovascular risk factors: a meta-analysis of randomised controlled trials [strong evidence]

    Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 2019: Diet, diabetes status, and personal experiences of individuals with type 2 diabetes who self-selected and followed a low carbohydrate high fat diet [non-controlled study; weak evidence]

  28. Nutrición Hospitalaria 2014: Hypocaloric high-protein diet improves clinical and biochemical markers in patients with nonalcoholic fatty liver disease (NAFLD) [non-controlled study; weak evidence]

    Cell Metabolism 2018: An integrated understanding of the rapid metabolic benefits of a carbohydrate-restricted diet on hepatic steatosis in humans [non-controlled study; weak evidence]

    Diabetologia 2019: A carbohydrate-reduced high-protein diet improves HbA1c and liver fat content in weight stable participants with type 2 diabetes: a randomised controlled trial. [randomized controlled trial; moderate evidence]

    Gastroenterology 2017: Isocaloric diets high in animal or plant protein reduce liver fat and inflammation in individuals with type 2 diabetes [randomized controlled trial; moderate evidence]

  29. Journal of Hepatology 2017: Aerobic vs. resistance exercise in non-alcoholic fatty liver disease: A systematic review [systematic review of randomized trials; strong evidence]

  30. Gastroenterology Research and Practice 2016: Effects of omega-3 fatty acid in nonalcoholic fatty liver disease: A meta-analysis [systematic review of randomized trials; strong evidence]

  31. Integrative Medicine Research 2019: Efficacy of curcumin/turmeric on liver enzymes in patients with non-alcoholic fatty liver disease: A systematic review of randomized controlled trials [systematic review of randomized trials; strong evidence]

  32. Frontiers in Pharmacology 2019: The effects of curcumin on weight loss among patients with metabolic syndrome and related disorders: a systematic review and meta-analysis of randomized controlled trials [strong evidence]

    Critical Reviews in Food Science & Nutrition 2018: The effects of curcumin supplementation on body weight, body mass index and waist circumference: a systematic review and dose-response meta-analysis of randomized controlled trials [strong evidence]