Twenty-five years ago, scientists were skeptical whether nonalcoholic fatty liver disease (NAFLD) was a clinical condition. However, after two decades, it became a global epidemic affecting around two billion people.
According to the American Liver Association, about 100 million individuals in the United States are estimated to have Nonalcoholic Fatty Liver Disease in 2023. It affects 25% of people in the US.
World Gastroenterology Organisation informs thatNAFLD also has reached epidemic proportions among populations typically considered at low risk, with a prevalence of 15% in China and 14% in Japan.
The liver is a critical organ for our survival. NAFLD is a high-risk disorder for people with insulin resistance, type II diabetes, obesity, and metabolic syndrome, which can worsen their metabolic condition.
Numerous friends, colleagues, and relatives were diagnosed with fatty liver. They initially felt awful. However, the good news is that most of them successfully reversed their condition or improved with healthy lifestyle habits and timely support from qualified healthcare professionals.
In this article, I introduce fatty liver disease at a high level, discussing its causes and symptoms and highlighting its importance for our overall health with impact and implications on individuals and society based on a comprehensive literature review. I provide seven practical tips gleaned from the scientific literature at the end.
Current Global Impact of Non-Alcoholic Fatty Liver Disease
Examining over 30 thousand records on non-alcoholic fatty liver disease indexed in PubMed is arduous.
However, The Lancet did the heavy work for us by publishing a meta-analysis in 2022 analyzing 28557 records and choosing 13577 from 72 publications, sampling over a million people from 17 countries.
“The overall prevalence of NAFLD worldwide was estimated to be 32.4%. Prevalence increased significantly over time, from 25.5% in or before 2005 to 37.8% in 2016 or later.
The overall incidence of NAFLD was estimated to be 46.9 cases per 1000 people annually. The prevalence of NAFLD was significantly higher in men than in women (39.7% vs 25.6%).”
The study noted considerable heterogeneity between studies of both NAFLD prevalence and incidence.
My Quick Calculation of the Global Impact
Some review papers mention two billion, and some sources like a YouTube video by Dr Kevn Berry mention even four billion people live with NAFLD.
As no single source of stats about the impact exists, I used Lancet’s meta-analysis to get a rough figure. To give you an idea, I quickly calculated based on this meta-analysis to understand an approximate global impact.
If we look at the current situation, 32.4% of 7.9 billion is approximately 2.56 billion people currently experiencing NAFLD worldwide. If 46.9 cases per 1000 per year, assuming a global population of approximately 7.9 billion, it indicates approximately 370 million new cases of NAFLD per year globally.
I only provide this info to give you an idea about the condition's prevalence. Now, more importantly, I’d like to introduce this disease's key points briefly so other sections of my story makes sense to you.
What is Fatty Liver Disease?
Based on my research and observations, I provide a high-level overview of non-alcoholic fatty liver disease. First, I’d like to highlight the importance of the liver for our health and well-being.
The liver is a critical organ. “All the blood leaving the stomach and intestines passes through the liver. The liver processes this blood, breaks down balances, creates the nutrients, and metabolizes drugs into either easier to use for the rest of the body or nontoxic forms.” [Source]
There are two types of fatty liver disease, alcoholic and non-alcoholic, breaking the balance of the liver. Alcoholic fatty liver disease (AFLD) is caused by excessive alcohol consumption, which I exclude in this article.
Non-alcoholic fatty liver disease (NAFLD), also known as hepatic steatosis, is a metabolic disorder mainly caused by lifestyle factors such as poor diet and sedentary life, particularly by excess calories the body cannot utilize and turn into fat stored in the liver.
Fatty liver disease means having too much fat in the liver. When the liver has more than 5% of its weight as fat, it’s called hepatic steatosis. While a small amount of fat in the liver is okay, storing too much fat in the liver can cause problems like chronic inflammation and liver damage.
While storing fat in the liver can be protective for a short time, keeping too much fat in the liver can cause metabolic problems and advanced forms of fatty liver disease, which later cause more complications.
NASH (Nonalcoholic Steatohepatitis) is an advanced form of NAFLD. In the NASH stage, fat accumulation in the liver causes inflammation and damage to liver cells. This inflammation and damage might lead to scarring and cirrhosis, resulting in liver failure.
An imbalance between the uptake, synthesis, and export of fatty acids causes fat accumulation in the liver. Insulin resistance is a key factor in the development of NAFLD.
When cells become insulin resistant, they cannot manage glucose effectively, leading to high blood sugar levels. This triggers more insulin release, stimulating the liver to produce more fatty acids. These fatty acids are then stored in the liver, leading to the development of NAFLD.
The medical reports I reviewed indicate that non-alcoholic fatty liver disease might not show noticeable symptoms. Therefore, accurate diagnosis is made through analysis, including blood tests, ultrasounds, and CT or an MRI scan of the lipids in the liver.
However, some papers mentioned symptoms such as fatigue, itchy skin, abdominal pain, swelling of the abdominal area and legs, confusion, yellow skin, enlargement of breasts in men, and overall body weakness.
The papers I reviewed highlighted excessive calories turning into fat molecules as being the main cause. However, while high triglyceride levels are commonly seen in patients with NAFLD, not everyone with high triglycerides will develop the disease.
Studies indicated that NAFLD is closely associated with obesity, high blood sugar, insulin resistance, type II diabetes, metabolic syndrome, high blood pressure, and hyperlipidemia (high triglycerides and LDL). NAFLD can also make these conditions worse.
While the above-mentioned risk factors are strongly associated with NAFLD, the exact mechanisms by which they contribute to the development of the condition are still being studied.
This paper in JAMA Pediatrics states that “Nonalcoholic fatty liver disease is the hepatic manifestation of the metabolic syndrome and is considered the most common form of chronic liver disease in children.”
The paper mentions that “several factors contribute to NAFLD development, including race/ethnicity, genetic factors, environmental exposures, and alterations in the gut microbiome.”
A meta-analysis in JAMA Network identified that 66% of patients older than 50 with diabetes or obesity are thought to have nonalcoholic steatohepatitis with advanced fibrosis.
Therefore, the paper concluded that primary care physicians, endocrinologists, and other specialists must be aware of the scope and long-term effects of the disease.
Medical doctor Mary Rinella (the paper's author) highlighted that “early identification of patients with nonalcoholic steatohepatitis may help improve patient outcomes through treatment intervention, including transplantation for those with decompensated cirrhosis.”
The review by Dr. Rinella made the following two important conclusions. One is about the treatment methods, and the other is about the condition causing more complex health issues if not resolved.
1 — “Lifestyle modification is the foundation of treatment for patients with nonalcoholic steatosis. Available treatments with proven benefits include vitamin E, pioglitazone, and obeticholic acid; however, the effect size is modest (<50%). Food and Drug Administration approves none.”
2 — “The association between nonalcoholic steatohepatitis and cardiovascular disease is clear, though causality remains to be proven in well-controlled prospective studies. The incidence of nonalcoholic fatty liver disease–related hepatocellular carcinoma is increasing, and up to 50% of cases may occur in the absence of cirrhosis.”
This paper in the World Journal of Gastroenterology points out, "Patients with NAFLD have an increased risk of premature cardiovascular as well as of liver-related mortality. Of concern, up to 50% of cases, NAFLD-HCC may occur without cirrhosis, a circumstance which will often worsen the outcome.”
As the liver plays a significant cleansing role in maintaining our health, the entire body might face severe health conditions if it gets sick.
As this paper on Hepatology concludes, “the analysis quantifies the enormity of the clinical and economic burdens of NAFLD, which will likely increase as the incidence of NAFLD continues to rise.”
Is there hope for not getting it or reversing it?
The short answer is yes, to lower the risks and reverse the condition.
Like many researchers and practitioners, I am optimistic and want to pass this valuable information on to those who experience this condition or those whose children have it.
Even though there are no approved drugs for the fatty liver or well-established treatment methods globally, treatment methods used for other metabolic disorders and relevant lifestyle modifications look effective.
The good news is, as informed by these medical doctors, several drugs are in advanced stages of development. They might be available soon.
The most effective intervention is dietary changes such as cutting refined carbs, sugary drinks, condensed fruit juices, junk food, and alcohol.
Even though total calories are believed to be a cause, the main culprit seems to be calories from sugar, as articulated by Dr. Leonid Kim in this YouTube video.
Until 2020, there were no randomized trials specifically comparing diets. The importance of low-carb diets in managing NAFLD is still in dispute.
However, The University of Alabama conducted a pilot randomized trial in 2020. I won’t go into the methodical details of the study as medical doctor Kevin Berry explained it in a short YouTube video that you might watch and learn from his clinical insights.
You may also read the paper “Effects of a carbohydrate-restricted diet on hepatic lipid content in adolescents with non-alcoholic fatty liver disease: A pilot, randomized trial.” It is published in the Journal of Pediatric Obesity.
The key point of this important research is the value of low-carb diets in treating NAFLD or lowering its risks.
This stringently controlled story showed that adolescents with non-alcoholic fatty liver disease who followed relatively lower carb and higher fat diets lost much more liver fat than the control group.
Both groups ate whole foods, refrained from junk food, and did not get calorie restrictions.
Carbs, especially glucose and fructose, have long been known as the primary cause of liver fat.
For example, this 2009 clinical trial published in The American Journal of Clinical Nutrition concluded that:
“A 7-day high-fructose diet increased ectopic lipid deposition in liver and muscle and fasting VLDL-triacylglycerols and decreased hepatic insulin sensitivity. People with type II diabetes may be more prone to developing dyslipidemia when challenged by high fructose intakes.”
What can we do?
We can do a lot.
I met many people who reversed their nonalcoholic fatty liver disease, both NAFLD and NASH (the inflammatory version), with healthy lifestyle habits and professional support.
For example, I documented a friend’s case in a story titled Here’s How David Reversed Fatty Liver Disease After 65 with Lifestyle Changes.
Here are seven steps and helpful tips to defeat Non-Alcoholic Fatty Liver Disease sustainably.
7 Steps and Helpful Tips to Defeat NAFLD
The following steps and tips are not health advice but information and awareness for improving lifestyle choices. Patients with NAFLD must consult qualified healthcare professionals to obtain timely treatment.
1 — Refrain from refined carbs and junk foods.
Refined carbs and junk food are high in sugar, unhealthy fats, and excessive calories. Some healthy fats like omega-3s can be beneficial. Avoiding these foods and consuming adequate calories and nutrients from whole foods can reduce the amount of fat accumulating in the liver, improving liver function.
2 — Move the body joyfully and do regular exercises.
Movement and regular exercise can reduce fat accumulation in the liver, decrease insulin resistance, and improve metabolic function. Physical activity can also reduce inflammation in the long run, reducing the chance of getting NAFLD or recovering. Try at least 150 minutes of weekly exercise, which can help with other conditions too.
3 — Consider cutting snacks and eating your foods in a specific window.
Eating snacks randomly and frequent meals throughout the day can cause insulin spikes, increasing the risk of NAFLD. Limiting snacking and eating within a specific window (time-restricted eating) can increase insulin and leptin sensitivity and reduce the risk of developing or recovering NAFLD. The primary goal of time-restricted eating is not to reduce calories but to give the body a chance to rest. When we don’t consume food for a while, the digestive system, including the liver, focuses on other vital functions that digest and metabolize food.
4 — Manage stress and maintain a healthy weight.
Obesity and oxidative stress can lead to the overproduction of cortisol, which can cause insulin resistance and chronic inflammation, two indicators of NAFLD and NASH. Managing stress and maintaining a healthy weight via a healthy diet, regular exercise, and restorative sleep can reduce the risk of developing or recovering from NAFLD.
5 — Manage chronic conditions.
Chronic conditions like obesity, insulin resistance, metabolic syndrome, type 2 diabetes, and high blood pressure can increase the risk of developing NAFLD. Chronic inflammation might lead to NASH. Proper management of these conditions with professional support can reduce the risk of developing NAFLD, leading to NASH, and might reverse these conditions with healthy lifestyle habits.
6 — Lower alcohol consumption.
Ethanol contains refined carbs. Therefore, excessive alcohol use not only causes AFLD but also can lead to fat accumulation in the liver and inflammation, leading to NAFLD. Lowering alcohol consumption can prevent the development of both alcoholic and non-alcoholic fatty liver disease. It is a low-hanging fruit.
7 — Get checked and obtain timely professional support.
Regular check-ups and timely professional support can help us detect and treat NAFLD before it progresses to severe forms. Getting checked and obtaining timely professional support can create awareness and improve the chances of successfully treating NAFLD and not experiencing it again.
Early detection and intervention of NAFLD and NASH can provide better outcomes. I hope this story serves as a wake-up call for those who may carry this risk.
Thank you for reading my perspectives. I wish you a healthy and happy life.
If you found this story helpful, you may also check out my other articles on NewsBreak. I write important life lessons based on my decades of research and experience in cognitive, metabolic, and mental health as a postdoctoral researcher and executive consultant.
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