What is the treatment for fatty liver disease?

Treatment of Fatty Liver Disease

The cornerstone of fatty liver disease treatment is achieving 7-10% weight loss through Mediterranean diet and regular exercise, which improves liver inflammation and can reverse fibrosis. 1, 2

Dietary Management

Adopt a Mediterranean diet pattern as the primary dietary intervention, which reduces liver fat even without weight loss and provides cardiovascular benefits. 3, 1, 2 This includes:

• Daily consumption of vegetables, fresh fruits, fiber-rich whole grains, legumes, nuts, fish or white meat, and olive oil as the principal fat source 3, 1, 2
• Minimal intake of simple sugars, red meat, and processed meats 3, 1
• Create a caloric deficit of 500-1000 kcal/day (typically 1,200-1,500 kcal/day for women; 1,500-1,800 kcal/day for men) to achieve gradual weight loss of 500-1000g per week maximum 1, 2

Eliminate fructose-containing beverages and processed foods, as added fructose is strongly associated with NAFLD development. 1, 2

Replace saturated fats with monounsaturated and polyunsaturated fats, especially omega-3 fatty acids from fish and olive oil. 3, 1, 2

Critical Dietary Pitfall

Never pursue rapid weight loss exceeding 1kg per week, as this can precipitate acute hepatic failure and worsen liver disease. 1, 4, 2

Exercise Requirements

Prescribe 150-300 minutes of moderate-intensity aerobic exercise per week OR 75-150 minutes of vigorous-intensity exercise. 1, 2 The evidence shows:

• Vigorous-intensity exercise (≥6 METs) provides greater benefit than moderate exercise for improving NASH severity and fibrosis 4
• Both aerobic and resistance training effectively reduce liver fat 1, 2
• Exercise improves liver health even without weight loss by enhancing insulin sensitivity 1

Weight Loss Targets Based on Disease Severity

The amount of weight loss needed depends on your treatment goals:

• 5% weight loss: Improves steatosis (fat accumulation) alone 2
• 7-10% weight loss: Required to improve hepatic inflammation, achieve NASH resolution, and potentially reverse fibrosis 1, 4, 2

Management Algorithm by Risk Stratification

Low-Risk Patients (FIB-4 <1.3, no significant fibrosis)

Focus exclusively on lifestyle modifications without pharmacotherapy. 3, 1

• Implement Mediterranean diet and exercise program 3, 1
• Address cardiometabolic risk factors (diabetes, hypertension, dyslipidemia) 3, 1
• Monitor annually with non-invasive testing 3

High-Risk Patients (NASH with fibrosis on biopsy)

Implement aggressive lifestyle modifications PLUS consider pharmacological treatment. 3, 1, 4

Pharmacological options for biopsy-proven NASH with fibrosis:

• Vitamin E 800 IU daily for patients without diabetes or cirrhosis 4
• Pioglitazone 30 mg daily for patients without cirrhosis, with or without diabetes (treats both diabetes and NASH simultaneously) 4
• Statins for all patients with dyslipidemia, as they are safe in liver disease and reduce hepatocellular carcinoma risk by 37% 2
• GLP-1 agonists for diabetes management, which promote NASH recovery 2

Important caveat: No pharmacotherapy has been approved by regulatory agencies specifically for NAFLD treatment—all current options are off-label. 1, 4

Patients with Cirrhosis

Refer for liver transplantation evaluation when the first major complication occurs or hepatic dysfunction develops. 4

• Perform ultrasound screening for hepatocellular carcinoma every 6 months 1, 4
• Screen for esophageal varices with EGD 1, 4
• Continue gradual weight loss (<1kg/week) if compensated 4

Bariatric Surgery Consideration

Consider bariatric surgery for patients with severe obesity meeting national eligibility criteria, as it resolves NASH in 85% of patients at 1 year and improves all histological features. 2

Medications to Avoid

Discontinue medications that worsen steatosis when possible: corticosteroids, amiodarone, methotrexate, tamoxifen, estrogens, tetracyclines, and valproic acid. 1

Do not use metformin as specific treatment for NAFLD histology—while it helps with diabetes management, it has no significant effect on liver histology. 1, 4

Critical Monitoring Priority

Cardiovascular disease is the main driver of morbidity and mortality in NAFLD patients before cirrhosis develops, not liver-related complications. 3, 2 Therefore:

• Aggressively manage all metabolic risk factors (diabetes, hypertension, dyslipidemia) 3, 1, 2
• Assess lipid profile, fasting glucose/HbA1c, waist circumference, and BMI regularly 1, 2
• Use statins liberally for cardiovascular protection 2