What should be avoided in patients with fatty liver disease?

What to Avoid with Fatty Liver Disease

Patients with fatty liver disease must completely eliminate or severely restrict alcohol consumption, as even low intake (9-20g daily) doubles the risk of adverse liver-related outcomes compared to lifetime abstainers. 1, 2

Alcohol: The Most Critical Avoidance

• Complete alcohol abstinence is strongly recommended for all patients with NAFLD, as a large prospective study of 8,345 patients demonstrated that 9-20g of daily general alcohol use or 0-9g of daily non-wine alcohol use doubled the risk for adverse liver-related outcomes compared with lifetime abstainers 1
• Current or former smokers with NAFLD should avoid alcohol entirely, as only never-smokers showed any potential cardiovascular benefit from alcohol use 1
• Alcohol exhibits synergistic pathological effects with obesity, meaning the hepatotoxicity threshold is significantly lower in obese individuals with fatty liver 2
• Even "light to moderate" alcohol consumption increases hepatocellular carcinoma incidence by 1.2-2.1 times in NAFLD patients 2

Dietary Components to Avoid

• Simple sugars and added sugars should be minimized, as they contribute to hepatic de novo lipogenesis 1, 3
• Red meat and processed meats should be restricted, as the Mediterranean diet pattern that limits these foods is associated with decreased hepatic steatosis 1, 3
• Ultra-processed foods should be avoided due to their contribution to metabolic dysfunction 3
• Omega-3 fatty acid supplements should not be used as specific treatment for NAFLD or NASH, though they may be considered for hypertriglyceridemia management 1
• Ursodeoxycholic acid (UDCA) is not recommended for treatment of NAFLD or NASH 1

Medications to Avoid or Use with Caution

• Corticosteroids should be avoided as they may worsen steatosis 3
• Amiodarone should be avoided due to potential worsening of hepatic steatosis 3
• Methotrexate should be avoided as it can exacerbate liver disease 3
• Tamoxifen should be avoided due to hepatotoxic potential 3
• Vitamin E in high doses may be associated with increased risks of prostate cancer and all-cause mortality, limiting its routine use 1
• For diabetic patients, avoid sulfonylureas and insulin when possible, as these increase hepatocellular carcinoma risk compared to metformin 3

Lifestyle Behaviors to Avoid

• Sedentary lifestyle must be avoided—patients need 150-300 minutes of moderate-intensity or 75-150 minutes of vigorous-intensity aerobic exercise weekly 1, 3
• Smoking must be stopped immediately, as it increases hepatocellular carcinoma risk by 1.5-1.8 times and is associated with liver fibrosis progression 3
• Weight gain or maintenance of obesity should be avoided—target 7-10% body weight reduction to improve steatohepatitis and fibrosis 1, 3

Common Clinical Pitfalls to Avoid

• Do not tell patients "moderate alcohol is acceptable"—the evidence clearly shows even low levels double adverse outcomes in NAFLD patients 1, 2
• Do not discontinue statins in NAFLD patients with dyslipidemia—statins are safe and reduce hepatocellular carcinoma risk by 37% 2, 3
• Do not ignore cardiovascular risk factors—cardiovascular disease is the main driver of mortality in NAFLD before cirrhosis develops 3
• Do not fail to address all components of metabolic syndrome—isolated treatment of liver disease without managing diabetes, hypertension, and dyslipidemia worsens outcomes 3
• Do not initiate or continue pioglitazone if ALT exceeds 2.5 times the upper limit of normal, and discontinue if ALT exceeds 3 times the upper limit of normal 4

Monitoring Considerations

• Avoid neglecting regular liver enzyme monitoring when using medications like pioglitazone—check ALT prior to initiation and periodically thereafter 4
• For female patients on pioglitazone, avoid overlooking fracture risk assessment, as bone fracture incidence increases to 5.1% versus 2.5% with placebo 4
• Avoid missing macular edema screening in diabetic patients, particularly those on thiazolidinediones—ensure regular ophthalmologic examinations 4