6 Insights: Vegetarian Diets for Reducing NAFLD Risk

In the quest to tackle Non-Alcoholic Fatty Liver Disease (NAFLD) and Cardiovascular Disease (CVD), vegetarian diets emerge as a promising solution.

This article delves into the multifaceted benefits of plant-based nutrition for liver health.

We explore how vegetarian eating, by reducing fatty liver disease, plays a crucial role in NAFLD management.

Emphasizing a lifestyle shift, we highlight the effectiveness of a vegetarian regimen in preventing NAFLD and its broader implications for liver disease risk reduction.

This introduction sets the stage for an in-depth look at the transformative impact of vegetarian diets on liver health and NAFLD prevention.

Main Findings

• Mediterranean Diet: Reduces NAFLD and CVD risks, improves metabolism, and decreases liver steatosis.
• Low-Fat Diet: Aids in weight loss, unclear effect on NAFLD.
• DASH Diet: Lowers CVD, diabetes, and cancer risks, and may prevent NAFLD.
• Vegetarian Diets: Less NAFLD risk, improves metabolic health.
• Low-Carb Ketogenic Diet: Effective for weight loss, potential NAFLD benefits.
• Intermittent Fasting: Improves liver health in NAFLD patients.

Introduction

Explaining the Link Between Diet, Heart Health, and Liver Disease

Plant-Based Diets and NAFLD: A Path to Liver Health

Non-alcoholic fatty liver disease (NAFLD) is a leading cause of chronic liver problems, ranging from mild conditions like non-alcoholic steatohepatitis to more severe issues such as cirrhosis and even liver cancer ¹.

It is closely linked with factors like obesity, dyslipidemia, and diabetes ².

NAFLD occurs when insulin resistance, impaired lipid metabolism, inflammation, and oxidative stress disrupt the balance of liver cells, leading to their damage and death.

Subsequently, the body initiates a repair process involving immune cells, sinusoidal endothelium, astrocytes, and ductal cells, resulting in fibrogenesis and remodeling of the affected liver area ³.

Genetic factors also play a significant role in NAFLD, with certain genetic variations impacting hepatic steatosis, cancer risk, and lipid content in liver cells ^{4 5}.

While the specific nutrigenomic effects of diets on these genes require further research, they present an intriguing avenue for future studies.

While this review primarily focuses on diet, it’s essential to acknowledge that other environmental factors can influence NAFLD.

Lifestyle choices, such as diet, sleep patterns, and eating habits, can shape the gut microbiota, which in turn affects body weight and liver health ^{6 7 8}.

The Complex Connection between CVD and NAFLD

The relationship between NAFLD and cardiovascular disease (CVD) is intricate and involves various environmental factors like sedentary lifestyles, diets high in saturated fats, sleep disorders, increased visceral fat, and obesity.

Although some genetic factors are associated with NAFLD, they also impact triglyceride and cholesterol levels, as well as atherosclerosis risk ⁹.

NAFLD is characterized by elevated levels of antagonists of nitric oxide synthase ¹⁰ and a procoagulant state ¹¹, increasing the risk of CVD.

Both NAFLD and atherosclerotic disease share risk factors such as alterations in glucose metabolism and insulin resistance ¹².

Managing NAFLD typically involves lifestyle changes like weight loss and increased physical activity ¹³.

However, pharmacotherapies are also under evaluation ¹⁴.

These include statins, metformin ¹⁵, thiazolidinediones, omega-3 ¹⁶, and novel therapies ^{17 18 19 20}, such as Acetyl-CoA inhibitors, Peroxisome Proliferator-Activated-Receptor agonists, Glucagon-Like Peptide 1 Agonists, Caspase inhibitors, and Sodium-Glucose Cotransporter-2 Inhibitors.

Clinical Practice Guidelines for Dietary NAFLD Treatment

The American Association of Clinical Endocrinology’s Clinical Practice Guidelines emphasize weight loss through a low-calorie diet, reduced intake of saturated fats, starch, and carbohydrates, improved eating patterns, and exercise as the primary treatment for NAFLD.

A >5% weight loss can yield cardiometabolic benefits and reduce liver fat.

More substantial weight loss (10%) may even reverse steatohepatitis or liver fibrosis ²¹.

Several societies, including the European Association for the Study of the Liver, the European Association for the Study of Diabetes, the European Association for the Study of Obesity ²², the European Society for Clinical Nutrition and Metabolism ²³, the Asian Pacific Association for the Study of the Liver ²⁴, and the American Gastroenterological Association ²⁵, specifically recommend the Mediterranean diet for individuals with NAFLD.

Some of these guidelines ^{26 27} also offer recommendations regarding macronutrient composition, such as restricting simple and high glycemic carbohydrates or reducing total and saturated fat intake while increasing monounsaturated fatty acids (MUFAs) and omega-3 polyunsaturated fatty acids (n-3 PUFAs).

These recommendations are rooted in evidence showing that these macronutrients improve metabolic parameters, reduce liver enzyme levels, and decrease steatosis in NAFLD beyond the benefits of weight loss alone ²⁸.

Exploring Diet Types for Liver Health

Harnessing the Power of Vegetarian Diets to Safeguard Your Liver

Non-alcoholic fatty liver disease (NAFLD) is a complex liver condition influenced by a web of genetic and environmental factors ^{29 30}.

Central to NAFLD’s development and progression is insulin resistance, a critical player in liver health ³¹.

Insulin resistance leads to increased fat production in the liver, reduced control over fat breakdown in adipose tissue, and higher transport of fatty acids to the liver.

These metabolic shifts result in adipose tissue dysfunction and the production of inflammatory cytokines, causing elevated free fatty acid levels and heightened oxidative stress.

Another contributing factor is the gut microbiota, which can impact free fatty acid absorption and the production of inflammatory cytokines ^{32 33 34}.

Mediterranean Diet and NAFLD: A Match Made in Health Heaven

The Mediterranean diet, characterized by a rich blend of fruits, vegetables, legumes, cereals, white meat, fish, and olive oil as the primary fat source, is celebrated worldwide for its health benefits ^{35 36 37 38 39 40 41 42}.

In particular, two landmark studies underscore its effectiveness in cardiovascular disease prevention.

The PREDIMED study demonstrated the Mediterranean diet’s superiority in primary cardiovascular disease prevention compared to a control diet ⁴³.

Meanwhile, the CORDIOPREV study revealed that the Mediterranean diet outperformed a low-fat diet in preventing major cardiovascular events among coronary heart disease patients ⁴⁴.

Beyond cardiovascular health, recent years have seen a surge in interest regarding the Mediterranean diet’s impact on NAFLD.

Observational studies and clinical trials provide substantial support for the notion that this dietary pattern can ward off NAFLD.

Observational data shows that adherence to the Mediterranean diet is linked to lower insulin resistance and less liver steatosis in NAFLD patients ⁴⁵.

A cross-sectional analysis of two independent studies with nearly 14,000 participants reported that higher adherence to the Mediterranean diet corresponds to a reduced prevalence of hepatic steatosis, assessed through ultrasound ⁴⁶.

Another study involving over 500 individuals with cardio-metabolic risk factors demonstrated an inverse correlation between NAFLD and Mediterranean diet adherence, with higher adherence also associated with lower insulin resistance ⁴⁷.

In the ATTICA prospective cohort study, researchers discovered that the Mediterranean diet not only protected against diabetes and cardiovascular disease in NAFLD patients but also exhibited an inverse association with NAFLD itself ⁴⁸.

Clinical trials have further examined the Mediterranean diet’s impact on NAFLD.

In one study, overweight participants were divided into three groups, with two receiving a low-calorie Mediterranean diet for six months.

These participants saw improvements in anthropometric parameters, lipid profiles, and reduced hepatic fat, along with enhanced insulin sensitivity when supplemented with antioxidants ⁴⁹.

Another study assessed the effect of a low glycemic index Mediterranean diet on the NAFLD score, measured through liver ultrasonography, and observed a significant decrease ⁵⁰.

Additionally, a randomized, cross-over study involving non-diabetic subjects with biopsy-proven NAFLD found that the Mediterranean diet reduced liver steatosis and improved insulin sensitivity compared to a low-fat, high-carbohydrate diet ⁵¹.

Support from reviews and meta-analyses aligns with these findings.

A recent meta-analysis indicated an inverse relationship between Mediterranean diet consumption and liver steatosis, likely attributed to improvements in factors like body mass index, triglyceride levels, and insulin resistance ⁵².

Another meta-analysis by Haigh et al. explored the effects of the Mediterranean diet and calorie restriction on NAFLD biomarkers, revealing that these dietary interventions reduce alanine aminotransferase, aspartate aminotransferase, fatty liver index, and liver steatosis ⁵³.

A third meta-analysis highlighted the Mediterranean diet’s role in reducing fatty liver index and insulin resistance in NAFLD patients ⁵⁴.

These findings underscore the Mediterranean diet’s potential as a beneficial nutritional approach for NAFLD patients, a sentiment echoed in guidelines from various scientific societies ^{55 56 57 58}.

Low-Fat Diet and NAFLD: A Contender for Liver Health

Low-fat diets limit daily calorie intake from fat sources to no more than 30% of total calories ⁵⁹.

These diets have undergone extensive scrutiny regarding their effectiveness in weight loss and associated improvements ^{60 61}.

Low-fat plans have also demonstrated their ability to mitigate risk factors for metabolic syndrome ⁶².

However, their efficacy in treating NAFLD remains uncertain.

One trial found that hepatic triglyceride content decreased by 25% after 12 weeks of a low-fat diet in NAFLD participants, independent of body weight loss or caloric intake ⁶³.

Another study, which compared a low-fat diet to a Mediterranean/low-carbohydrate diet in a weight-loss trial involving participants with abdominal obesity and dyslipidemia, revealed a 3.8% reduction in hepatic fat content in the low-fat diet group over 18 months ⁶⁴.

Interestingly, this study also noted a greater reduction in liver fat content in the Mediterranean/low-carbohydrate group.

The DASH Diet: A Dash of Hope for NAFLD

The Dietary Approaches to Stop Hypertension (DASH) diet has primarily been recommended for hypertension prevention and management ^{65 66}.

It emphasizes a low-saturated-fat, high-protein, high-fiber, low-sodium dietary approach ⁶⁷.

The DASH eating plan centers on fruits, vegetables, low-fat dairy products, fish, whole grains, poultry, nuts, seeds, legumes, while reducing fat, red meat, and added sugar intake ⁶⁸.

DASH has shown effectiveness in reducing mortality from various causes, including cardiovascular disease, diabetes, and cancer ⁶⁹.

The connection between NAFLD and the DASH diet has gained attention due to compelling evidence from observational studies and one clinical trial suggesting its potential as a preventive measure.

One study revealed an inverse relationship between DASH diet adherence and NAFLD risk, with participants in the highest quartile of DASH Diet Score experiencing a 30% reduction in NAFLD risk ⁷⁰.

Another long-term study, spanning two decades with a large cohort, found that being in the highest tertile of DASH diet adherence was associated with a lower risk of NAFLD ⁷¹.

Additional studies reinforce the benefits of the DASH diet for NAFLD.

The Multiethnic Cohort reported an inverse association between DASH scores and NAFLD risk ⁷².

A subgroup analysis of the HELENA trial found that DASH scores correlated inversely with liver fat content ⁷³.

A recent report even proposed the DASH diet as an effective tool for managing NAFLD ⁷⁴.

Clinical trial evidence remains limited.

In a trial involving 60 overweight and obese NAFLD patients, participants were randomly assigned to follow either the DASH diet or a control diet for eight weeks.

Those on the DASH diet experienced favorable changes in weight, body mass index, liver enzymes, triglycerides, insulin resistance, and inflammatory markers ⁷⁵.

The Power of Plant-Based Diets in Shielding Your Liver from NAFLD

Limited but promising research suggests that adopting a vegetarian diet may offer protection against non-alcoholic fatty liver disease (NAFLD).

While more extensive studies are needed, the existing evidence hints at the potential benefits of plant-based eating for liver health.

A Promising Path: Vegetarian Diets and NAFLD

Research into the effects of vegetarian diets on liver biochemistry and histology in NAFLD patients remains relatively limited.

However, early findings from cross-sectional studies and short-term clinical trials are encouraging.

One cross-sectional study involving 1,273 vegetarians and 2,127 non-vegetarians revealed that vegetarians had a significantly lower risk of developing NAFLD than their non-vegetarian counterparts ⁷⁶.

Even after adjusting for factors like gender, age, smoking, and alcohol consumption, vegetarians maintained this advantage, with an odds ratio of 0.79 (p < 0.05).

Non-vegetarians, on the other hand, exhibited higher fibrosis scores.

The beneficial effects of vegetarian diets may be attributed to their rich polyphenol content.

Polyphenols are compounds found in plant-based foods that have been linked to reduced insulin resistance, oxidative stress, and inflammation, all of which play roles in NAFLD development ⁷⁷.

Another study demonstrated a connection between vegetarian diets and improved metabolic parameters.

This dietary approach was associated with reductions in fasting glucose, insulin resistance, body mass index, total cholesterol, and LDL cholesterol (all p < 0.05).

Additionally, there was a remarkable 57% decrease in the new onset of fatty liver disease among those following a vegetarian diet ⁷⁸.

These results suggest that plant-based diets may not only help manage existing NAFLD but also prevent its development.

In a three-month randomized clinical trial, 75 overweight or obese NAFLD patients followed a lacto-ovo-vegetarian diet.

This intervention led to significant improvements in various health indicators, including body mass index, waist circumference, liver enzymes, fasting blood glucose, insulin resistance, lipid profile, systolic blood pressure, and NAFLD.

In fact, 67% of patients on the lacto-ovo-vegetarian diet experienced significant NAFLD improvement, compared to only 21% of those on a standard weight loss diet ⁷⁹.

While these findings are promising, it’s crucial to emphasize the need for further research to evaluate the specific impact of vegetarian diets on liver histology in NAFLD patients.

Low/Very Low-Carbohydrate Ketogenic Diet and NAFLD

A recent meta-analysis indicates that low-carbohydrate and very low-carbohydrate diets may not necessarily be superior to low-fat diets in improving liver fat or transaminase levels in NAFLD patients ⁸⁰.

Beyond the macronutrient distribution, the type of calories consumed may also play a crucial role in NAFLD management.

One factor of interest is the glycemic index, which measures the post-meal glycemic response to carbohydrates.

Some studies have explored low glycemic index diets and their potential impact on liver fat composition ^{81 82}.

Research has suggested that ketogenic low-carbohydrate diets could effectively reduce hepatic triglyceride concentrations in obese individuals, apart from promoting weight reduction.

These diets may exert positive effects on liver disease by decreasing insulin levels, lipogenesis, and fatty acid oxidation ⁸³.

In a 12-week randomized controlled trial involving obese participants with polycystic ovarian syndrome, the ketogenic diet outperformed a control diet in lowering liver enzymes and improving liver fat content, along with other health parameters ⁸⁴.

However, it’s essential to note that these results may not be directly transferable to other populations due to the unique pathogenic mechanisms involved in polycystic ovarian syndrome.

Another trial revealed that obese patients following a ketogenic diet for two months experienced more significant reductions in body weight, visceral fat, and hepatic fat compared to those on a traditional low-calorie diet ⁸⁵.

Swift weight loss and rapid mobilization of liver fat could offer an alternative approach to NAFLD treatment, as suggested by these findings.

Intermittent Fasting and NAFLD

Intermittent fasting, a dietary strategy that involves restricting eating periods, has demonstrated potential to reduce NAFLD.

This approach encompasses various methods of energy restriction, ranging from alternating eating and fasting periods to complete fasting or very low-calorie consumption ⁸⁶.

A prospective observational trial involving 697 participants with or without type 2 diabetes found that periodic fasting reduced NAFLD.

After intermittent fasting, improvements were observed in fasting glucose, glycated hemoglobin, body mass index, and liver enzymes.

Notably, the number of fasting days correlated positively with improvements in the fatty liver index.

Furthermore, 50% of subjects with a baseline fatty liver index over 60 (indicating NAFLD) transitioned to intermediate or low fatty liver index categories, indicating potential regression of liver disease ⁸⁷.

In another controlled trial, seventy NAFLD patients were assigned to either an intermittent calorie restriction diet, a low-carbohydrate diet, or general lifestyle advice for three months.

Participants following the intermittent calorie restriction diet experienced reductions in body weight and liver steatosis compared to those receiving lifestyle advice ⁸⁸.

The low-carbohydrate diet also led to a reduction in hepatic fat content ⁸⁹.

Two additional trials investigated alternated-day fasting and established associations between these intermittent fasting methods and reductions in liver fat and fibrosis scores ⁹⁰⁹¹.

A recent meta-analysis involving 417 NAFLD participants across six trials supported the positive effects of intermittent fasting on liver tests ⁹².

Author [Ref.]	Study Design	Health Status	Type of Intervention/Diet Evaluated	Main Findings
Kontogianni et al. [93 ]	Observational	Recent NAFLD diagnosis	MedDiet	MedDiet negatively correlated with liver enzymes (p = 0.03), insulin resistance (p = 0.001) and severity of steatosis (p = 0.006).
Khalatbari-Soltani et al. [94 ]	Cross-sectional	Two adult populations (Fenland and CoLaus cohorts)	MedDiet	Greater adherence to MedDiet was associated with lower liver steatosis [0.86 (CI: 0.81–0.90)].
Baratta et al. [95 ]	Observational	Healthy adults	MedDiet	Higher adherence to MedDiet was associated with lover IR (OR: 0.801; p = 0.018) and NAFLD (high adherence vs. low OR: 0.093; p = 0.030).
Kouvari et al. [96 ]	Observational	NAFLD	MedDiet	Higher MedDiet score was inversely associated with NAFLD [0.53 CI: 0.29–0.95)].
Abenavoli et al. [97 ]	Randomized trial	Patients with overweight and NAFLD	A.MedDiet	MedDiet alone or with antioxidant improves insulin sensivity (p = 0.045), HOMAR-IR (p = 0.021), Tryglicerides index (p = 0.020) and fatty-liver index (p = 0.017) and anthropometric parameters (all p = 0.001).
Misciagna et al. [98 ]	Randomized controlled trial	Moderate to severe NAFLD	Low glycemic index Mediterranean diet	Low glycemic index Mediterranean diet decreases NAFLD score [OR: 0.07 (CI: 0.02–0.12; p < 0.05)]
Properzi et al. [99 ]	Randomized controlled trial	NAFLD with cardiometabolic risk factors	MedDiet	Both diets improve liver steatosis (p < 0.01) without difference betweens both groups (p = 0.32)
Ryan et al. [100 ]	Randomized controlled trial	NAFLD patients with obesity	MedDiet	MedDiet reduces liver steatosis (39 ± 4% vs. 7 ± 3%; p = 0.012).
Akhlaghi et al. [101 ]	Meta-analysis	NAFLD patients	MedDiet	A trend for the improvement of NAFLD was observed for MedDiet [0.95 (CI: 0.9–1); p = 0.05].
Kawaguchi et al. [102 ]	Meta-analysis	NAFLD patients	MedDiet	MedDiet improved liver steatosis (CI: −0956 to −0.237; p = 0.001) and IR (CI: −0.713 to −0.003; p = 0.048).
Haigh et al. [103 ]	Meta-analysis	NAFLD patients	MedDiet with calorie restriction	MedDiet reduced ALT (p < 0.001), AST (p = 0.004), fatty liver index (p < 0.001) and liver steatosis (p = 0.02).
Gepner et al. [104 ]	Randomized controlled trial	Patients with obesity/dyslipidemia	Low fat	Liver fat content reduction in all groups (- 4%compared to baseline, p < 0.001). Greater in the MedDiet/Low-carbohydrate group (p = 0.036) was observed.
Hekmatdoost et al. [105 ]	Case-control	NAFLD patients	DASH diet	Inverse relationship between the DASH diet and NAFLD risk (OR: 0.70; p < 0.05).
Park et al. [106 ]	Observational	Multiethnic Cohort	DASH diet	High DASH scores are associated with a reduction in NAFLD risk (OR: 0.78; p < 0.001).
Watzinger et al. [107 ]	Cross-sectional	NAFLD patients	DASH diet and MedDiet	Diet quality scores was inversely associated with liver fat content (OR: 4.41; p = 0.04 for MedDiet score and OR: 4.41; p = 0.05 for DASH score).
Razavi Zade et al. [108 ]	Randomized controlled trial	Overweigh and obese patients with NAFLD	DASH diet	DASH diet reduced body max index (p = 0.06), liver enzymes (p < 0.05), triglycerides (p = 0.04), insulin resistance (p = 0.01) and inflammatory markers (p < 0.05).
Chiu et al. [109 ]	Cross-sectional	Non-vegetarians and vegetarians	Vegetarian diets	Vegetarian diets may be inversely associated with NAFLD (OR: 0.79; p < 0.05).
Jin et al. [110 ]	Observational	Vegetarians	Vegetarian diet	Vegetarian diet, was associated with lower odds of NAFLD [OR: 0.43 (CI: 0.32–0.87); p = 0.013] and cardiometabolic risk factors(Body max index, LDL cholesterol, fasting glucose and insulin resistance, all p < 0.05).
Garousi et al. [111 ]	Randomized controlled trial	Overweight/obese adults with NAFLD	Lacto-ovo-vegetarian diet.	Lacto-ovo-vegetarian diet reduced grade of NAFLD compared to Standard weight-loss diet (67% vs. 21%; p = 0.01)
Ramon-Krauel et al. [112 ]	Randomized controlled trial	Obese children	Low-glycemic load	Both diets improved liver steatosis (without differences between the two diets)
Ahn et al. [113 ]	Meta-analysis	Heterogeneus population with NAFLD	Low-carbohidrate diet	No differences between Low-carbohidrate and Low-fat diet
Li et al. [114 ]	Randomized controlled trial	Polycystic ovary syndrome	Ketogenic diet	Ketogenic diet improved menstrual cycle, body weight, blood glucose and liver function test (all p < 0.05) at 12 weeks. Ketogenic diet group reduced liver function test compared to control group (p < 0.05).
Cunha et al. [115 ]	Randomized controlled trial	Healthy participants	Very low-calorie ketogenic diet	Very low-calorie ketogenic diet reduced weigh (−9.7 kg vs−1.67 kg; p < 0.0001) and liver fat (4.77 vs. 0.79; p < 0.005) compared to low-calorie diet.
Drinda et al. [116 ]	Observational	T2DM and non-T2DM participants	Periodic fasting	Periodic fasting with weigh reduction rapid improved fatty liver index (Non-T2DM participants: −14.02 compared to baseline; p < 0.0001 and T2DM participants −19.15; p < 0.001 compared to baseline. Additionally, greater changes in T2DM participants p < 0.002 T2DM vs. non-T2DM).
Cai et al. [117 ]	Randomized controlled trial	NAFLD patients	Alternate-day fasting	Changes in fat free mass, lipids, fasting insulin, blood pressure and liver stiffness in both groups compared to baseline without differences between the two groups.
Holmer et al. [118 ]	Randomized controlled trial	NAFLD patients	Interminent calorie restriction and low-carbohydrate high-fat diet	Intermintent calorie restriction diet reduced hepatic fat content (−2.6%; CI: −5 to −0.2). Low-carbohidrate high fat diet reduce hepatic fat (−3.9%; CI: −6.3 to −1.4)
Yin et al. 119 ]	Meta-analysis	NAFLD patients	Intermittent fasting	Intermittent fasting improved weigh (−2.45%, CI: −3.98 to −0.91; p < 0.05) and liver enzymes (ALT: −10.54, CI: −14.01 to −7.08; p < 0.05 and ALT: −11.31, CI: −14.3 to −8.32; p < 0.05).

What Influences Our Food Choices?

Understanding How Lifestyle and Culture Shape Dietary Choices

People’s dietary preferences are influenced by various factors, including lifestyle, culture, and individual circumstances ¹²⁰.

These factors can range from health issues and physical changes to economic status and social surroundings, making it challenging for individuals to adopt a balanced and nutritious diet that meets their specific needs ¹²¹.

The Impact of Socioeconomic Status

One of the significant determinants of dietary habits is a person’s socioeconomic status ¹²².

This status encompasses factors like education, financial stability, and one’s perception of their social position.

Research suggests that countries with higher incomes often correlate with higher socioeconomic status, leading to healthier food choices and increased consumption of fruits and vegetables ¹²³.

In contrast, lower socioeconomic status groups tend to consume fewer dairy products and more saturated fats, carbohydrates, and calorie-dense foods ¹²⁴.

This discrepancy is primarily due to the affordability and accessibility of high-fat and high-carbohydrate foods, which are often more budget-friendly, making them a preferred choice for individuals with limited resources.

Age, Marital Status, and Eating Habits

Age and marital status can also play a significant role in shaping eating habits.

Research has shown a strong connection between being unmarried and a higher risk of cardiovascular disease-related mortality ¹²⁵.

This relationship is attributed to changes in dietary patterns resulting from social isolation, leading to reduced consumption of fruits and vegetables and increased intake of fats and carbohydrates.

These effects tend to be more pronounced in older individuals.

The Power of Nutrition Knowledge

Nutrition knowledge is another crucial factor influencing dietary choices.

Reports indicate that educating adults about nutrition can lead to positive outcomes, including weight loss, shifts in eating patterns, and reduced fat intake ¹²⁶.

This underscores the importance of awareness and education in promoting healthier diets.

Looking Ahead

What’s Next in Nutrition and Liver Health Research?

Ongoing Research to Confirm Dietary Benefits for NAFLD

While available human studies have demonstrated the positive impact of various dietary patterns on NAFLD, more randomized controlled trials are needed to substantiate these findings.

Currently, numerous clinical trials are underway to assess the advantages of dietary interventions in individuals with NAFLD.

Although this review is not a systematic analysis, it sought relevant trials on ClinicalTrial.gov and EudraCT databases, focusing on trials actively recruiting participants (Table below).

The upcoming trials encompass a wide range of diets, including the Mediterranean diet, low-calorie diets, ketogenic diets, and fat-restricted diets.

Some trials also explore combinations of the Mediterranean diet with different antidiabetic medications.

These studies target diverse populations, including overweight and obese individuals, those with prediabetes, and patients with type 2 diabetes mellitus (T2DM).

These ongoing investigations aim to provide further insights into the efficacy of specific dietary interventions for managing NAFLD.

Identifier	Study Design	Population Health Status	Sample Size	Duration	Type of Intervention	Liver Endpoint
NCT05309642	Parallel control trial	36 BMI >25 kg/m2 and 36 BMI < 25 kg/m2	72	12 weeks	Very low calories ketogenic diet	Change on liver steatosis by MRI
NCT05275608	Parallel control trial	BMI > 30–40 kg/m2 NAFLD T2DM	20	90 days	Very low calories ketogenic diet	Change in liver enzymes as secondary outcome
NCT04440540	Parallel control trial	Obese patients	40	1 year	Lifestyle program (diet not specified)	Change of intrahepatic triglycerides content in NAFLD
NCT05200585	Parallel	NAFLD	30	6 months	Behavioral: Healthy Liver/Hígado Sano program	MRI liver steatosis change
NCT04383951	Parallel	NAFLD	40	16 weeks	Ketogenic diet	MRI liver steatosis change
NCT05268042	Randomized controlled trial	Obese adolescents with NALF	80	6 months	Moderately carbohydrate-restricted diet	MRI liver steatosis change
EudraCT:2021-000152-19	Randomized controlled trial	NAFLD and prediabetes patients	390	18 months	1.Med diet + metformin placebo pioglitazone placebo 2. Med diet + metformin + pioglitazone placebo 3. Med diet + metformin + pioglitazone	Evaluated witch model induce a greater regression of NAFLD

Practical Tips

Simple Dietary Changes for Better Liver and Heart Health

• Moderate Calorie Restriction:

Reducing total energy intake through moderate calorie restriction (500–1000 kcal/day) achieved through approaches like intermittent fasting or low-carbohydrate diets can significantly improve NAFLD.

Patients with NAFLD should aim to shed 5–10% of their body weight over six months.

• Embrace Mediterranean or DASH Diets:

Opting for a Mediterranean-style or DASH (Dietary Approaches to Stop Hypertension) diet can be highly beneficial.

The Mediterranean diet emphasizes fruits, vegetables, whole grains, legumes, nuts, fish, and olive oil while minimizing red and processed meat, refined carbohydrates, and saturated fat.

This dietary pattern is strongly linked to a reduced risk of NAFLD and its associated complications.

• Limit Added Sugars and Refined Carbohydrates:

High consumption of added sugars and refined carbohydrates elevates the risk of NAFLD.

Patients should steer clear of or minimize their intake of sugar-sweetened beverages, sweets, and high-calorie snacks.

• Avoid Excessive Alcohol:

Alcohol is a hepatotoxin that can exacerbate liver damage in NAFLD patients.

Those with NAFLD should abstain from alcohol altogether or restrict their consumption to no more than one drink per day for women and two drinks per day for men.

These practical dietary recommendations offer a sound foundation for managing and mitigating the impact of NAFLD.

Final Thoughts

In this comprehensive review, we’ve synthesized the latest insights into Non-Alcoholic Fatty Liver Disease (NAFLD) and its management, offering valuable information for healthcare professionals, researchers, and anyone interested in promoting liver health.

• Understanding the NAFLD Challenge:

NAFLD has emerged as a pressing global health issue, affecting individuals across the age spectrum.

Its prevalence is expected to rise, primarily due to its links with obesity, diabetes, metabolic syndrome, cirrhosis, liver cancer, and cardiovascular disease.

This review delves into various nutritional therapies that have proven effective or shown promise in addressing NAFLD.

• Weight Loss as a Priority:

Among these therapies, weight loss takes precedence, especially in individuals grappling with overweight or obesity.

Shedding excess pounds remains a critical focus.

However, in cases where dietary interventions alone prove insufficient or in advanced NAFLD stages, a combination of pharmacological therapy and dietary changes can be pivotal.

• Tailoring Diets for Long-Term Success:

A significant challenge in NAFLD management is ensuring long-term adherence to a personalized diet, potentially for life.

This emphasizes the need for clinicians and nutritionists to collaborate closely with patients, exploring various dietary patterns.

The goal is to establish a tailored dietary plan that aligns with individual preferences and leverages the proven benefits of different diets, such as improved insulin sensitivity and enhanced antioxidant capacity.

• The Diet Diversity:

While the Mediterranean Diet holds a prominent place in scientific society reports on NAFLD management, our review uncovers promising evidence related to other dietary approaches.

These include low-fat diets, vegetarian diets, and dietary interventions centered on eating patterns, such as intermittent fasting.

While the evidence for some of these diets may be limited, their potential as alternatives for NAFLD treatment is worth exploring ^127128129130.

Review date not set.