What lifestyle changes are needed for steatosis (fatty liver disease)?

Lifestyle Changes for Steatosis (Fatty Liver Disease)

All patients with hepatic steatosis should adopt a Mediterranean diet, achieve 5-10% weight loss through caloric restriction, engage in 150-300 minutes of moderate-intensity exercise weekly, and eliminate or severely restrict alcohol consumption. 1

Weight Loss Strategy

Target weight loss of 5-10% of total body weight is essential for meaningful improvement. 1, 2

• 5% weight loss reduces hepatic steatosis 1
• 7% weight loss can lead to resolution of steatohepatitis 1
• 10% weight loss results in fibrosis regression or stability 1
• Even 3-5% weight loss provides benefit for normal-weight patients (BMI ≤25 kg/m² non-Asian, ≤23 kg/m² Asian) 1

Achieve this through a hypocaloric diet of 1200-1500 kcal/day or reduce baseline intake by 500-1000 kcal/day. 1 Weight loss should be gradual at maximum 1 kg/week, as rapid weight loss may paradoxically worsen liver disease. 2, 3

Dietary Modifications

Follow a Mediterranean diet pattern as the primary dietary approach. 1

What to Eat Daily:

• Fresh vegetables and fruits 1
• Unsweetened whole grains rich in fiber 1
• Fish or white meat 1
• Olive oil, nuts, and seeds as primary fat sources 1
• Legumes 1

What to Strictly Limit or Avoid:

• Red meat: Maximum 0.33 portions/day (2.3 portions/week) 1
• Processed meat: Maximum 0.10 portions/day (0.7 portions/week) 1
• Sugar-sweetened beverages: Eliminate completely due to fructose content 1
• High-fructose corn syrup: Avoid in all forms 1
• Simple sugars and ultra-processed foods 1

Important caveat: Fructose from whole fruits is NOT associated with NAFLD and should not be restricted. 1

The Mediterranean diet reduces hepatic steatosis even without weight loss by improving insulin sensitivity. 1 Recent evidence shows every standard deviation increase in Mediterranean Diet Score decreases odds of fatty liver by 26%. 1

Physical Activity Requirements

Engage in 150-300 minutes of moderate-intensity OR 75-150 minutes of vigorous-intensity aerobic exercise per week. 1

• Moderate-intensity = 3-6 metabolic equivalents (brisk walking, stationary biking) 1
• Vigorous-intensity = >6 metabolic equivalents 1
• Resistance training can complement aerobic exercise and has independent benefits on NAFLD 1
• Exercise reduces hepatic fat even without significant weight loss by improving insulin sensitivity and decreasing hepatic de novo lipogenesis 1

Walking more than 3 hours per week specifically decreases cirrhosis-related deaths and hepatocellular carcinoma risk. 1

Alcohol Restriction

Restrict or eliminate alcohol consumption entirely. 1, 2

Recent high-quality prospective evidence demonstrates that even low alcohol intake (9-20 g daily) doubles the risk of adverse liver-related outcomes in NAFLD patients compared to lifetime abstainers. 1 This contradicts older cross-sectional studies suggesting benefit from low-moderate intake. 1 The 2021 AGA guidelines now recommend restricting alcohol to reduce liver-related events, with many experts advocating complete abstinence. 1

Management of Metabolic Comorbidities

Aggressively treat coexisting conditions as cardiovascular disease is the main driver of mortality in NAFLD before cirrhosis develops. 1, 2

• Diabetes: Consider GLP-1 receptor agonists (semaglutide, liraglutide) or SGLT2 inhibitors, which improve both glycemic control and liver histology 2, 3, 4
• Dyslipidemia: Statins are safe and recommended; they may reduce hepatocellular carcinoma risk by 37% 2, 3, 4
• Hypertension: Optimize blood pressure control 1
• Avoid sulfonylureas and insulin when possible as they may increase hepatocellular carcinoma risk 2, 3

Common Pitfalls to Avoid

• Do not pursue rapid weight loss: Maximum 1 kg/week to avoid worsening liver disease 2, 3
• Do not restrict fruit intake: Despite fructose content, whole fruits are not associated with NAFLD 1
• Avoid hepatotoxic medications: Corticosteroids, amiodarone, methotrexate, tamoxifen, estrogens, tetracyclines, valproic acid 3, 4
• Do not use metformin specifically for liver disease: It has no significant effect on liver histology 2, 3

Special Considerations for Normal-Weight Patients

Even patients with normal BMI who have steatosis benefit from lifestyle intervention with lower weight loss thresholds of 3-5%, achieving 50% NAFLD resolution at this level and 70% resolution at 7-10% weight loss. 1 These patients typically have visceral adiposity and insulin resistance despite normal weight. 1