For the past 4 years, the Mediterranean diet has been named the “Best Overall Diet” by US News & World Report. The Mediterranean diet has been proven in multiple clinical studies to support the prevention and treatment of non-alcoholic fatty liver disease or NAFLD (1). In fact, the American Gastroenterology Association recommends that “adults with NAFLD should follow the Mediterranean diet.” (2)
While the Mediterranean Diet is often best known for its cardiovascular and heart health benefits, there is more and more evidence suggesting this healthy dietary pattern has positive effects on many health conditions including non-alcoholic fatty liver disease (NAFLD).
What is NAFLD?
NAFLD is an umbrella term that encompasses inflammatory liver conditions that occur in those who consume little or no alcohol, as opposed to alcohol related liver disease or ARLD where the cause of liver damage is from years of alcohol abuse. Unfortunately, NAFLD is increasingly prevalent worldwide especially in more developed nations, where approximately 25% of people worldwide and in the United States are affected by NAFLD and the incidence of this disease has more than doubled in the past twenty years. (3, 4, 5) When NAFLD further progresses and becomes severe, it progresses to non-alcoholic steatohepatitis (NASH), which is increased swelling of the liver leading to further liver damage. By 2030, experts predict that NASH will be the most frequent reason for liver transplants in the US. (3)
NAFLD is a progressive disease that can remain mild in nature and may require only routine monitoring, or it can be quite severe. In the beginning stages of NAFLD the liver starts to accumulate fat, often in the form of triglycerides (a type of fat that circulates in our blood). This extra fat build up can lead to inflammation and oxidative stress to the liver. These fat deposits can interfere with metabolic functions resulting in insulin resistance, steatosis, cellular damage, inflammation, and impair gut permeability. Late stage NAFLD can lead to more serious problems such as NASH (nonalcoholic steatohepatitis). Both NASH and NAFLD fall under the umbrella term NAFLD, however NASH is the more progressive form of liver disease when the inflammation starts to cause damage and scarring called fibrosis. This fibrosis can get worse over time resulting in cirrhosis and thus requiring liver transplant. Unfortunately, those with cirrhosis are at increased risk of developing liver failure and liver cancer.
Risk Factors for NAFLD and NASH
Unhealthy weight gain and obesity are major risk factors for the development of NAFLD. Type 2 diabetes and other conditions associated with insulin resistance such as PCOS (polycystic ovarian syndrome) and hyperlipidemia (particularly high triglycerides) are also known risk factors.
Treatment of NAFLD and NASH
At this time there are no medication or pharmaceutical therapies available for NAFLD.(7) The good news is that NAFLD is typically treatable via lifestyle intervention therapy. Lifestyle intervention including diet, exercise, and weight loss are considered the gold standards for the treatment of fatty liver disease. These modifiable lifestyle habits are proven treatment options that can help improve NAFLD and prevent the progression to the more dangerous forms of liver diseases.
Healthy eating habits and weight loss are proven steps towards prevention and treatment of liver disease. Even minimal weight loss can have a positive impact on NAFLD, and 7-10% weight loss has been shown to potentially reverse NAFLD and NASH: (9)
- 3-5% weight loss improves liver steatosis (infiltration of liver cells with fat).
- 5-7% weight loss improves inflammation and ballooning of the liver.
7-10% weight loss has shown to lead to NASH regression and fibrosis regression. (9)
How does the Mediterranean Diet improve NAFLD and NASH?
Adaptation to a Mediterranean diet can result in healthy weight loss and this supports the mounting evidence that the Mediterranean diet can prevent and reverse fatty liver disease. The Mediterranean diet is centered predominantly around vegetables, fruits, whole grains, beans, fish, seafood, olive, olive oil, nuts, and seeds, as well as smaller portions of dairy, poultry, and egg - all components of a healthy weight reduction plan. This diet limits ultra-processed foods, foods with added sugars, sugary beverages such as soda, refined carbohydrates, saturated fats, red meat, and other processed meats - all known to cause weight gain and inflammation. The Mediterranean diet is rich in polyunsaturated fats, antioxidants, vitamins, minerals, carotenoids, polyphenols, and fiber which have anti-inflammatory properties and support metabolic functions supportive of weight reduction.
Focus on Unsaturated Fats
Replacing saturated fats found in high fat dairy including butter, tropical oils including coconut, and red meat with polyunsaturated fats may help reduce liver fat. The Mediterranean diet focuses on unsaturated fats such as olive oil, nuts, seeds, avocado, and olives. These healthy fats are rich in monounsaturated fats and omega-3 polyunsaturated fats due to the high intake of fish, seafood, and walnuts. (9) An added bonus of making the switch to these heart healthy unsaturated fats is a risk reduction of cardiovascular disease and improved cholesterol levels. Saturated fats promote oxidative stress which can lead to inflammation of the liver. The healthy fats emphasized on the Mediterranean diet can actually help reduce liver fat deposits and liver inflammation. (10)
Emphasis on Plants
It is encouraged to replace refined starches and processed carbohydrates (think sugary cereals, white breads, crackers, and white rice) with whole grain breads, cereals, and intact grains including brown rice, quinoa, oats. (9) The Mediterranean diet is rich in plant-based fibers secondary to high intake of fruits, vegetables, whole grains, and beans. Increased fiber intake has numerous health benefits. Fiber rich foods promote satiety, that feeling of fullness, with less calories helping to promote weight loss. Many plant-based fibers contain fermentable fibers which help fuel our gut bacteria and promote the production of SCFA (short chain fatty acids). SCFA has many health benefits including lower risk of developing insulin resistance, suppression of inflammatory bacteria and improved gut health.
Polyphenols are also found in fruits and vegetables, and they too are super stars of the Mediterranean diet. Polyphenols have been shown to help reduce liver fat accumulation, decrease inflammatory markers and liver enzymes levels based on laboratory reports.
The Mediterranean diet is plant-centric and limits animal protein and emphasizes protein sources from fish, seafood, tofu, poultry, and beans. Aiming for meatless meals is not only good for the planet, but also your liver.(9)
Reduction of Simple Sugars
There is some limited data that high fructose consumed in excess, not the typical amount consumed in a whole food diet that includes natural fructose containing foods such as fruit, but from refined added sugars increase risk factors for NAFLD. The Mediterranean diet does not contain many added sugars as it limits foods and beverages with added refined sugar such sugar, high fructose corn syrup, dextrose, glucose, etc. These simple sugars are often found in sweet beverages such as soda, lemonade juice, sweet tea, fruit juices, candy, baked goods, and other sweet treats. If you often read the food label you will notice that sugar is added to so many of our food products! With recent label changes you cannot identify how many grams of added sugar are added to your foods. (9)
Increased levels of physical activity are essential for the management of NAFLD. It is recommended to engage in physical activity for 150 minutes per week to help reduce the risk of Type 2 diabetes and cardiovascular disease. There is strong evidence to support 250-300 minutes of exercise per week for long-term weight reduction. One large Korean study showed that exercising five - six times or more per week showed the greatest benefit in the prevention and treatment of NAFLD. Based on these facts, it would be helpful to aim for a minimum 150 minutes per week with a goal of 300 minutes per week for the best results. Exercise can be broken into several small segments dispersed over the day and includes a wide variety of activities including, walking, biking, swimming, weight training, pilates, yoga, and more. The most important factor is finding an activity you enjoy and making it a priority in your day. (11, 12)
Regular coffee intake has shown to help reduce risk of developing NAFLD. Low, moderate, and high coffee drinkers are all less likely to develop liver cirrhosis in comparison to non-coffee drinkers. I would like to raise a cup to that! Coffee is rich in polyphenols; this specific nutrient may be the contributing factor for its positive health benefits. (13)
Heavy drinking (defined as more than 14 drinks a week for men and 7 drinks a week for women) should be discouraged for those with active liver disease including NAFLD. Unfortunately, there is lack of evidence on light alcohol intake and NAFLD. While the Mediterranean diet does include small amounts of wine it would be best to discuss this topic with your healthcare professional.
The Mediterranean diet is a healthy, highly esteemed, sustainable eating pattern focused on olive oil, fruits and vegetables, whole grains, nuts, seeds, seafood, and fish while limiting processed foods, sugars, and animal proteins which are consistent with the nutrition recommendations for NAFLD. The main staples of the Mediterranean diet have proven to improve one’s health, promote healthy weight status and in recent years shown to help reduce risk and progression of NAFLD.
If you are looking for an easy way to implement this diet via Mediterranean diet food delivery, please visit us at ModifyHealth and explore our new Mediterranean diet meal delivery services. Our Mediterranean meal delivery provides fully prepared, healthy, liver friendly, plant-based meals right to your doorstep. With ModifyHealth, we can help you achieve better health one delicious bite at a time along with dietitian coaching and support. We hope that you too are convinced that adapting a Mediterranean diet will yield better health. Let us help reduce your risk of fatty liver disease, achieve healthy weight loss if recommended by a healthcare professional, and adapt to a healthy eating plan for the long-term.
To learn more, please visit https://modifyhealth.com/collections/mediterranean-plan.
Vanessa Vargas is a registered dietitian living in Bend, Oregon. She has many years of experience working as an outpatient dietitian specializing in weight management, bariatric surgery, diabetes, and cardiovascular disease. After discovering the low FODMAP diet to help manage her own IBS in 2016 she has expanded her practice to GI nutrition with a focus on irritable bowel syndrome, small intestinal bacteria overgrowth, inflammatory bowel diseases, and celiac disease. Vanessa is a Monash trained FODMAP dietitian and has been contributor of FODMAP related articles and grocery lists. Vanessa is available for in person nutrition counseling at Summit Health in Bend, OR and also offers a virtual nutrition practice with a focus on the low FODMAP diet. During her free time you will find her exploring the beautiful landscape of Central Oregon on her mountain bike, running, swimming, skiing, and hiking the nearby mountains.
- Anania C, Perla FM, Olivero F, Pacifico L, Chiesa C. Mediterranean diet and nonalcoholic fatty liver disease. World J Gastroenterol. 2018;24(19):2083-2094. doi:10.3748/wjg.v24.i19.2083
- Younossi ZM, Koenig AB, Abdelatif D, Fazel Y, Henry L, Wymer M. Global epidemiology of nonalcoholic fatty liver disease-Meta-analytic assessment of prevalence, incidence, and outcomes. Hepatology. 2016 Jul;64(1):73-84. doi: 10.1002/hep.28431. Epub 2016 Feb 22. PMID: 26707365.
- National Institutes of Diabetes and Digestive and Kidney Diseases,“Definition & Facts of NAFLD & NASH.”Nov. 2017. Retrieved from: https://www.niddk.nih.gov/health-information/liver-disease/nafld-nash/definition-facts. Accessed on June 8, 2017.
- Yoo ER, Sallam S, Perumpail BJ, Iqbal U, Shah ND, Kwong W, Cholankeril G, Kim D, Ahmed A. When to Initiate Weight Loss Medications in the NAFLD Population. Diseases. 2018 Sep 30;6(4):91. doi: 10.3390/diseases6040091. PMID: 30274326; PMCID: PMC6313489.
- Manu V. Chakravarthy, Thomas Waddell, Rajarshi Banerjee, Nicola Guess, Nutrition and Nonalcoholic Fatty Liver Disease: Current Perspectives, Gastroenterology Clinics of North America,Volume 49, Issue 1,2020,Pages 63-94
- Lu W, Li S, Li J, et al. Effects of Omega-3 Fatty Acid in Nonalcoholic Fatty Liver Disease: A Meta-Analysis. Gastroenterol Res Pract. 2016;2016:1459790. doi:10.1155/2016/1459790
- van der Windt DJ, Sud V, Zhang H, Tsung A, Huang H. The Effects of Physical Exercise on Fatty Liver Disease. Gene Expr. 2018;18(2):89-101. doi:10.3727/105221617X15124844266408
- Hayat U, Siddiqui AA, Okut H, Afroz S, Tasleem S, Haris A. The effect of coffee consumption on the non-alcoholic fatty liver disease and liver fibrosis: A meta-analysis of 11 epidemiological studies. Ann Hepatol. 2021 Jan-Feb;20:100254. doi: 10.1016/j.aohep.2020.08.071. Epub 2020 Sep 10. PMID: 32920163.
- Yaskolka Meir A, Rinott E, Tsaban G, et alEffect of green-Mediterranean diet on intrahepatic fat: the DIRECT PLUS randomised controlled trialGut Published Online First: 18 January 2021. doi: 10.1136/gutjnl-2020-323106
- Mokhtari E, Farhadnejad H, Salehi-Sahlabadi A, Najibi N, Azadi M, Teymoori F, Mirmiran P. Spinach consumption and nonalcoholic fatty liver disease among adults: a case-control study. BMC Gastroenterol. 2021 May 1;21(1):196. doi: 10.1186/s12876-021-01784-8. PMID: 33933019; PMCID: PMC8088717