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Fatty Liver Disease Common in Diabetes: Prevention, Treatment

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©2016 by David Leonard, M.Ag.,Nutrition Educator (retired), University of NH Cooperative Extension


Fatty Liver Disease Common in Type-2 Diabetes: Prevention, Treatment

Non-alcoholic fatty liver disease (NAFLD) in its mildest form is called simple fatty liver disease or hepatic steatosis and has no symptoms. It can potentially progress to NASH (non-alcoholic steatohepatitis) which causes liver inflammation.

NASH also has no symptoms initially but can lead to increased fibrosis (scarring) and cirrhosis (scar tissue replaces normal liver tissue and educes proper function), increased risk of liver cancer, and even liver failure. Some later-stage symptoms of NASH are fatigue, unexplained weight loss, and an ache in the upper right part of the abdomen (www.webmd.com/digestive-disorders/tc/nonalcoholic-steatohepatitis-nash-overview).


Risk Factors

  • NAFLD is strongly linked to too much sugar & saturated fat, lack of exercise, and excessive body fat (especially deep abdominal or visceral fat found beneath the stomach muscles and associated with an "apple" shape). Visceral fat releases harmful amounts of fatty acids into the bloodstream which can lower good HDL cholesterol and increase, blood pressure, triglycerides, blood sugar, and insulin resistance (your body’s natural insulin doesn’t work as well). The same for excess liver fat.
  • Obesity raises NAFLD risk by over 4 fold. One study found that NAFLD patients averaged a 42” waistline (typically an "apple" shape, meaning more risky visceral fat) vs. 37.5” for those without NAFLD.
  • NAFLD is very common in type 2 diabetes: In a study of 100 type-2 patients (average diabetes duration 8.5 years), liver imaging revealed a NAFLD incidence of 79% (under age 58), 68% (ages 58-65), and 47% (over age 65). What’s more, the advanced fibrosis rate was 3% (under age 58), 6% (ages 58-65) and 13% (over age 65) (Alimentary Pharmacology and Therapeutics, e-pub 9/15/15).

Diagnosing NAFLD: Experts recommend that all people with type 2 diabetes be routinely screened. Those with several risk factors should be referred to a liver specialist (hepatologist) for further tests.


Treating NAFLD

  • A healthy diet low in saturated fat, cholesterol, sweetened beverages, and other added-sugar foods. Sugar from whole fruit is fine, but go easy on 100% juices.
  • Weight loss (when needed) and exercise can rapidly reverse NAFLD, along with the possible use of cholesterol meds and oral diabetes meds like metformin that reduce insulin resistance [Nutr Reviews, 6/07;Mayo Clinic Health Letter, 9/06; Pediatrics, 10/06, Br J Diabetes Vasc Dis. 2006;6(6):251-260].

A 52-week Cuban trial encouraged 261 overweight or obese adults with NASH to lose weight by diet (750 fewer cals./day) & exercise (200 minutes weekly walking). Among the 29 who lost at least 10% of their body weight, all had NASH improvement, 26 (90%) became free of NASH, and 13 (45%) had reduced liver fibrosis (the other 16 saw no worsening). Among those with a less than 5% weight loss, 32% improved, 10% became free of NASH, and 16% had reduced fibrosis, 63% stabilized it, and 21% saw a worsening (Gastroenterology 2015;14:367-78).

Another study with 109 severely obese adults with NASH found that bariatric surgery resolved mild NASH in 94% and severe NASH in 74% after 12 months (Gastroenterology 2015;14:379-88).

  • Fish oil, especially its DHA, appears beneficial for NASH treatment (J. of Nutr., e-pub, 2/5/13; PLOS ONE 2013; 8(12). A 6-month randomized trial with 40 adult patients, found that 50% of those receiving 2 g/day actual EPA/DHA from fish oil (along with a healthy diet) had a regression of the disease (complete regression in 33.4%). In the placebo group (healthy diet, no fish oil), 27% had some reversal but none achieved complete remission [Dig Liver Disease 12/2/07 E-pub ahead of print]. Two other studies also obtained positive results (Alimentary Pharmacol Ther., 2006; 23(8): 1143-51; Clin Endocrinol Metab, 2009 Jul 21 [Epub ahead of print]). DHA appears more effective than EPA based on a lab animal study (J. of Nutr, e-pub 2/5/13). See my 3/1/15 post on EPA & DHA in the Healthy RVers Group Forum at www.rvillage.com/groups/topic/view/group_id/80/topic_id/3847?query=P3RpdGxlPSZwYWdlPTI= . Check with your doctor before taking this relatively high dosage of fish oil.
  • Cinnamon: A 12-week trial with 50 NAFLD patients randomized them to placebo or 1.5 mg cinnamon (750 mg twice a day). Average LDL dropped significantly in both groups but markedly more so in the cinnamon group (from 95.5 to 90.3 for placebo vs. from 74.8 to 55.8 for treatment group). Moreover, the treated group saw significant improvements in liver enzymes (serum ALT & AST markedly improved), insulin resistance, fasting blood sugar, hs-CRP, total cholesterol, and triglycerides. HDL levels were unchanged in both groups (Nutr Research, e-pub 12/6/13). Cinnamon caution!: See my 12/27/15 post on cinnamon in the Healthy Diabetes Living group (http://www.rvillage.com/group/878/diabetes-healthy-living) on RVillage.com for possible adverse effects.
  • Milk thistle’s silybin & silymarin compounds may help treat NAFLD due to their anti-inflammatory effect and other properties, but more research is needed. Adverse effects are usually minor, but it should be avoided by those with ragweed allergy. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3924972/ , http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3226378/, both full text articles.)
  • Probiotics & prebiotics look promising as an add-on NAFLD treatment to improve the gut microbiome (intestinal bacteria) to help reduce inflammation plus other benefits (Heptatology, 6/09). In a 28-week randomized trial with 52 newly diagnosed NAFLD patients, a formulation containing 7 strains of beneficial bacteria was significantly superior to lifestyle changes alone re several markers of liver health such as alanine aminotransferase, aspartate aminotransferase, inflammatory markers and reduced fibrosis (Am J Clin Nutr 2014;99: 425-26 & 535-42).

Lifeway kefir (a yogurt-type milk drink) has 5 of the bacteria types used (the Evolve brand has 4) but not necessarily the exact strains. They may still be worth a try at around ½ cup twice a day; Lifeway is gluten free. Evolve contains 20 billion organisms per cup vs. 7-10 billion for Lifeway. Yogurt has fewer beneficial types of bacteria.

Some research-proven prebiotics (they promote the growth of “good” gut bacteria) are walnuts, almonds, pistachios, apples, oats, and barley.

  • High-dose vitamin E is often used for progressive, biopsy-confirmed NAFLD in non-diabetic patients, but metformin may be preferred for diabetics and is safer (Dig Dis 2014; 32(5):597-604; World J Gastroenterol. 2014 Oct 21; 20(39):14219-14229, free full text). Vitamin E caution!! 400 IU or more daily is associated with increased prostate cancer risk in some studies [JAMA 2011; 306:1549-56], and 600 IU daily was linked with higher lung cancer risk in smokers (Tufts Univ. Health & Nutrition Letter, 6/08).
  • The type-2 diabetes drug liraglutide resolved NASH in 9 of the 26 patients randomized to receive it (vs. 2 out of 26 in the placebo group) in a 48-week trial. Only 2 patients in the treated group progressed to liver fibrosis (scarring) vs. 9 in the placebo group, and the treated group lost more weight (11.6 lbs. vs. 1.3 lbs.) during treatment, but over half of it was regained in the 3 months after stopping treatment (Lancet, e-pub 11/19/15).


  • The info presented here should not replace professional medical or dietary advice, diagnosis or treatment.
  • Always consult your registered dietitian or physician before making any significant changes in diet or exercise
  • Don't ignore professional medical advice due to the info presented here.
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