Fatty liver is the condition when an abnormal amount of fat starts accumulating in the liver, leading to inflammation, oxidative stress, scar tissue deposits, and cell death. These can progressively lead to conditions called NAFLD, NASH, liver fibrosis, liver cirrhosis, liver cancer, and liver failure.
The liver has an amazing ability to regenerate itself. With proper lifestyle and diet changes, and supplementation, one can slow down, stop, or partially reverse the damage.
Milk Thistle: 500 mg a day;
Turmeric: 500 mg of curcumin a day;
Omega-3 oils: 1,000 mg a day of (EPA+DHA);
Chromium: Take a natural-source multimineral;
Licorice: 2 g a day of licorice root.
Vitamin E: 800 IU a day;
BCAAs: Whey protein 20 to 40 g a day (in advanced stages of the disease).
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The liver is one of the largest internal organs in the body. While heart attacks carry shock value, the health of the liver should be our bigger concern given its myriad roles in keeping us healthy.
When the fat starts accumulating in the liver, its functioning worsens progressively. In this article, we will discuss supplementation strategies for controlling or reversing such fatty liver. We will also discuss the role of the liver in our health, how fatty liver develops, and potential complications.
The liver performs many tasks that are essential for life:
- Makes enzymes and other proteins needed in body functions;
- Makes substances called clotting factors that help in, well, blood clotting and wound healing;
- Stores and regulates the supply of minerals such as iron and vitamins such as vitamin A;
- Produces bile that helps in fat digestion;
- Helps control blood glucose and cholesterol levels;
- Makes substances called immune factors that help in fighting infections;
- Filters bacteria and toxic chemicals from the blood.
As you can guess, a weakened liver function makes one vulnerable to many disorders.
How Fatty Liver Develops
The liver has some fat stored in it during normal times. However, under certain conditions, it starts hoarding more fat. When the fat crosses five percent of the liver’s weight, its functioning start getting hampered.
Fatty Liver Disease (FLD)
When an organ starts retaining fat abnormally, it is called steatosis. Steato means ‘pertaining to fat’. Steatosis means fatty changes in an organ. If that happens in a liver, it is called fatty liver disease (FLD) or to sound more impressive, hepatic steatosis. Hepatic means ‘pertaining to the liver’.
FLD has two varieties based on its causes:
Alcoholic Fatty Liver Disease
This condition is caused due to excessive alcohol drinking for a long period of time. When alcohol is metabolised (broken down) in the liver, a toxic compound called acetaldehyde is formed. It can damage liver cells and cause inflammation or swelling.
In fact, every time you drink alcohol, some liver cells die. But the liver has an amazing ability to regenerate itself. So new liver cells are formed to replace those dead cells. However, if one drinks excessively—more than two drinks a day in the case of men and more than one drink a day in the case of women—this regeneration is not enough to repair the damage caused by alcohol and the liver worsens.
By the way, one alcoholic drink has 14 g of alcohol in it. Since different drinks have different alcohol content by weight percentage, the type of drink will decide how much of it constitutes a single drink. Exhibit 1 below gives a ready reckoner.
Non-Alcoholic Fatty Liver Disease (NAFLD)
This condition is caused when excess fat is deposited in the liver cells in people who drink no or little alcohol. Nearly one-third of all people and about three-fourths of obese people in the world suffer from NAFLD. Since it is so common, it is worth knowing about.
NAFLD has various risk factors that can cause it. But it is most commonly found in people who have insulin resistance. Here is a layperson’s explanation of how fat deposition increases in the liver when one develops insulin resistance.
How Insulin Resistance Causes Fatty Liver
After a meal, the carbohydrates in it are absorbed in the blood as glucose. This increases blood glucose levels. The body signals the pancreas to release insulin when it senses high blood glucose levels. In general, the more the blood glucose, the more will be the release of insulin.
Insulin helps most of the body cells to take up glucose from the blood to use it as fuel. Insulin also tells the liver to store some glucose in the form of a compound called glycogen. When insulin levels are very high, which can happen when one has eaten a lot of carbohydrates in the meal, the liver converts some of the blood glucose into free fatty acids. These fats flow through the bloodstream and get stored in fat cells. Some of this fat also gets stored in the liver.
So in normal people, very high consumption of carbohydrates on a regular basis can cause storage of fats in fat cells (obesity) and in liver cells (fatty liver).
In some people, due to various reasons, the cells of the body can become resistant to the action of insulin. That is, they are not able to take in as much glucose as they would in normal conditions. This reduces blood glucose absorption and keeps it high longer.
The body does not understand that blood glucose is now high because of the reduced efficacy of insulin. It wrongly thinks that it is because of excessive ingestion of carbohydrates in the meal. So it pushes the pancreas to produce even more insulin. This condition is called insulin resistance.
Insulin-resistant people end up with too much insulin in their blood for the same levels of blood glucose. This excessive insulin condition is called hyperinsulinemia. Hyper means ‘more than normal’.
The excessive insulin in the blood forces the liver to make more and more fats from the blood glucose. In a normal person, this fat generation needs a lot of consumption of carbohydrates. But in an insulin-resistant person, normal consumption of carbohydrates also creates fats.
As a result, in an insulin-resistant person, normal consumption of foods causes excess fat storage in the liver cells (fatty liver) and fat cells around the body (obesity). In fact, these persistent, high insulin production demands fatigue out the cells of the pancreas causing them to die. This causes chronically high levels of blood glucose, which is type 2 diabetes. No wonder most people with fatty liver also have abdominal obesity and often, type 2 diabetes.
Interestingly, eating a lot of carbohydrates can cause fatty liver but eating a lot of fats is not shown to cause fatty liver.
NAFLD may have fat deposits in liver cells but there may be no inflammation or swelling of the liver cells. In that case, NAFLD or hepatic steatosis just stays as simple fatty liver disease, with no further liver damage or complications. This stage is reversible and considered non-progressive if its causes such as insulin resistance are reduced or removed.
However, in some patients, fatty liver progresses further. Both the alcoholic and non-alcoholic forms of fatty liver proceed in roughly the same manner. So I will stick to describing the non-alcoholic version. Keep in mind that the alcoholic form also progresses the same way, except for a few differences that I will mention later in the article.
Non-Alcoholic Steatohepatitis (NASH)
When the fat deposits inside the liver cells increase in size, they start pushing the cell nuclei away from the center. The fat blobs coalesce causing small, irreversible sacs of fats inside the liver cells.
The cells start developing inflammation. This swelling in the liver cells is called hepatitis. Hepato means ‘pertaining to the liver’; —itis is an appendage signifying inflammation. Hepatitis is ‘swelling in the liver’.
This condition is called non-alcoholic steatohepatitis or NASH. So we have progressed from hepatic steatosis (fatty changes in the liver) to steatohepatitis (fatty-changes-induced liver inflammation).
NAFLD with extensive inflammation and a lot of fatty deposits leads to more severe forms of the disease.
The excess fat, which accumulates inside the liver cells, leads to a condition called lipotoxicity. The liver’s capacity to use and store fats goes for a toss. There is an increase in the free radical generation, leading to oxidative stress that damages cell membranes. This leads to cell death and more inflammation. That alters the action of insulin in the liver causing a further increase in insulin resistance. Lipo means ‘fat’; lipotoxicity occurs when excess fat turns toxic to the organ.
Lipotoxicity causes increasing amounts of liver cell deaths, which triggers the deposition of collagen outside of those liver cells. This increases fibrous scar tissue inside the liver. These are permanent deposits and the condition is called liver fibrosis.
Liver fibrosis is the first stage of liver scarring. Over a period of time, more and more scar tissue gets deposited all over the liver, leading to a serious condition called liver cirrhosis. A cirrhotic liver is woefully inadequate in performing its tasks because the scar tissue cannot perform the role of liver cells.
Exhibit 2 shows the progression of fatty liver disease through the fatty liver, liver fibrosis, and liver cirrhosis.
Liver cirrhosis takes ten to thirty years to develop. All along this process, there is extensive damage inside the liver cells. As mentioned earlier, the liver is an amazing organ, which tries to regenerate itself all the time. However, when the liver tries to heal the damage by producing new cells for all those years, those cells have a higher chance of developing mutations that can cause cancer.
Not all cirrhosis patients develop liver cancer and not all liver cancer patients have cirrhosis. But some have both of them.
A malfunctioning liver, either with cirrhosis or cancer, can go into failure. When the liver fails, the only option is liver transplant to revive the person.
Alcoholic Versus Non-Alcoholic Fatty Liver
Both the alcoholic (AFLD) and non-alcoholic (NAFLD) fatty liver disease conditions progress the same way except for a few differences.
Nearly 20% of patients with AFLD progress to cirrhosis, while the number for NAFLD is 1 to 2%. Also, the cause of death in AFLD patients is direct liver damage and alcohol; while NAFLD patients die mainly from heart disease and cancer, which are indirect causes.
AFLD develops due to regular heavy consumption of alcohol. NAFLD develops due to regular heavy consumption of calories mainly in the form of carbohydrates and saturated fats.
Scientists have found that periodic binge drinking is less problematic compared to daily heavy drinking for developing AFLD. Is that good news for those who indulge in the former?
The liver is the only organ in our abdominal cavity, which has the capacity to regenerate itself. Even if half of its original mass is damaged or missing, it can regenerate to its full size.
It is important to note that the liver can regenerate its mass but not its shape. The remaining liver mass becomes larger to compensate for the lost functionality of the damaged part. This is vital because even if your liver regenerates, it will not go back to its original shape. Don’t be under a false impression that liver regeneration means you can be back to your original pristine self.
The process of liver regeneration goes through three magical steps:
- When some liver mass is surgically removed (as in liver cancer) or scarred (as in cirrhosis), the liver regeneration mechanism is triggered. Hundreds of genes are activated, and certain chemicals called growth factors are released inside the liver.
- The existing healthy liver cells start multiplying with millions of new cells produced. Interestingly, if the present crop of liver cells is not that good, the cells of the inner lining of the bile duct turn themselves into liver cells and the process continues. The bile duct is the tube that carries bile from the liver to the duodenum—the part that connects the stomach to the small intestines.
- Once enough liver cells are produced, certain chemicals are released, which stop the production of growth factors.
The whole process takes about fifteen days to reach the original liver mass. In another fifteen days, the newly formed liver cells adjust in size so much that the new liver tissue becomes indistinguishable from the original healthy one. Certain terms and conditions apply though.
Even at the liver cirrhosis stage, some cell regeneration is possible. What is vital is certain chemicals that are the end-products of inflammatory processes happening inside the liver are no more present. So if it is AFLD, one has to stop drinking alcohol completely. If it is NAFLD, one has to go on a strict diet and lifestyle control—exercise, no processed foods, preserved meats, and fatty dairy products, and more antioxidants and essential amino acids to improve immunity and better tissue repair.
Symptoms of Fatty Liver
A good authoritative website will tell you all about the signs, symptoms, and diagnosis of fatty liver disease. I have given a few links for the same towards the end of this article. But I want to cover certain points that need additional attention.
Unfortunately, fatty liver disease often shows no symptoms until it progresses to liver cirrhosis. I have used the word ‘unfortunately’ because signs and symptoms of a condition give us an early warning and force us to investigate and get treated. In the absence of any symptoms, one-third of the people around the world carry on with their fatty liver without knowing about it, until it is too late to reverse the damage.
Some ‘lucky’ people get the following symptoms:
- Pain in the abdomen;
- A feeling of heaviness or fullness in the top right corner of the abdomen;
- Sickly yellow skin;
- Swelling in the abdomen or legs;
- Loss of appetite and weight loss;
- Extreme fatigue; and
- Mental confusion.
Diagnosis of Fatty Liver
I often get asked about how one should know if one has fatty liver. This is because there are usually no symptoms but one in every three people has fatty liver. So here are a few comments:
- Usually, fatty liver is detected accidentally when people get a liver profile blood test done or undergo an abdominal ultrasound examination for some other reason. But there is no certainty that these blood chemicals (called markers or indicators) would be elevated in fatty liver.
- In fatty liver disease, two liver enzymes—AST (SGOT) and ALT (SGPT) have a mild to moderate increase (2 to 4 times the normal) in their levels. These two enzymes leak into the blood when liver cells are damaged. Unfortunately, in some fatty liver patients, these and the other liver-related blood markers are normal. So you cannot use them to rule out the fatty liver.
- Abdominal ultrasound is a safe, non-invasive technique to check for fatty liver. But it cannot be used for very obese patients (as the liver cannot be seen under a thick layer of fat). It also cannot tell you the severity of inflammation or fibrosis in the liver. It cannot detect FLD when the fat is less than thirty percent of the liver. Note that more than five percent fat infiltration in the liver is called FLD. But you have to wait till it crosses thirty percent to make a confirmed diagnosis with ultrasound.
- A recent technique called Vibration-controlled Transient Elastography or Fibroscan helps measure the severity of scarring. So it is useful in the liver fibrosis stage but does not help in the diagnosis at the earlier stages.
- The gold standard for diagnosis of fatty liver disease is still liver biopsy. A thin needle is pushed through your abdomen into your liver and a small piece of it is extracted and studied under a microscope. That is the only way to ascertain the amount of cell death, inflammation, and deposition of fat, iron, or copper in the liver. But it is a painful and bloody process with its risks and high costs. So unless there is a high degree of suspicion, it is not resorted to.
All in all, we don’t have a good way to make a confirmed diagnosis of the fatty liver before it gets bad and partly irreversible. So my opinion is to act assuming you have fatty liver if you have diabetes or abdominal obesity.
Remember, one out of every third person in the world has fatty liver; so even if you don’t have obesity and diabetes, you may be a victim of fatty liver. Preventive strategies are really important.
Supplementation Strategies for Fatty Liver
There are very few large trials on the management of fatty liver with supplements. As mentioned earlier, most people find out that they have fatty liver only by accident or by luck. It is not easy to find such a person who knows that he has fatty liver and is not doing anything about it to be roped in for a clinical trial. So the supplementation for fatty liver disease relies on results from laboratory experiments (in vitro or in a petri dish) instead of from patients (in vivo or in living beings).
The supplementation strategies rest on five pillars:
- Reducing insulin resistance;
- Reducing oxidative stress with antioxidants;
- Reducing lipotoxicity and liver inflammation;
- Reducing scarring or fibrous material deposition; and
- Helping liver cell regeneration.
You may have realised by now that oxidative stress, lipotoxicity, and liver inflammation are parts of the same vicious circle. They feed on one another, progressing together. So I will lump the supplements for 2 and 3 in the same basket.
In the advanced stages of fatty liver, the liver is not able to function properly. That can lead to infections (due to reduced immune factors), bleeding (due to reduced clotting factors), and brain damage (due to the liver not being able to remove toxins from the blood). While there are supplements that can help in such cases, I would stay away from them and let the doctors manage them with medicines since some of these are serious and acute problems.
Fatty liver disease is not a condition that one should treat on one’s own. Consult a good doctor and take medicines prescribed by her. The supplementation strategies are for two types of people:
- Those who don’t have symptoms or are diagnosed with fatty liver yet but want to stay safe and prevent it;
- Those who are already taking treatment for fatty liver and want to add complementary and natural interventions.
Supplements for Reducing Insulin Resistance
- Chromium: Decreases insulin resistance. Reduces blood glucose levels. Typically, 200 to 1000 µg/day of chromium picolinate helps in controlling blood glucose levels. Take from a plant-based source. The bioavailability of chromium from a plant-based source is much higher than from a chemical-based chromium salt. Best to take chromium through a multimineral supplement.
- Vitamin D: Reduces insulin resistance. Ideal levels of vitamin D in the blood are 60 ng/mL. Aim for at least 2,000 IU of vitamin D a day. A supplement that also contains vitamin K2 is ideal, to protect against calcium deposition in soft tissues of the body such as heart arteries (heart attacks) and kidneys (kidney stones).
- Gymnema: Reduces insulin resistance and carbohydrate absorption in the intestines.
- Ginger: Blocks the enzymes that metabolise carbohydrates in the intestines and reduces insulin resistance.
Supplements for Reducing Oxidative Stress, Lipotoxicity, and Liver Inflammation
- Milk Thistle: Silymarin is the active compound in milk thistle plant extract. Milk thistle has been used for 2,000 years for liver disorders. It stabilises liver cell membranes, helps detoxify the liver, and stops the growth of and destroys liver cancer cells. Strong antioxidant, reduces inflammation. Take 400 mg a day.
- Turmeric: Curcumin is the active compound (3 to 5% by weight) of turmeric. It has strong anti-inflammatory, antioxidant, and anticancer properties, all of which are helpful in liver damage. Take 500 to 1,000 mg of curcumin a day.
- Dandelion: This is a herb whose dried extract has many anti-inflammatory, antioxidant, and antihyperglycemic properties. It allows a good flow of bile out of the liver helping it detox. Also useful for reducing lipotoxicity.
- Licorice: Glycyrrhizin is the active component (6 to 10% by weight) of licorice. It has anti-inflammatory and antioxidant actions in the liver.
- Omega-3 oils: Omega-3 oils (EPA, DHA, and ALA) reduce liver inflammation and lipotoxicity. They also help reduce liver fat in obese children and adults. Take 1,000 mg of (EPA+DHA) oils a day in the form of fish oil or algal oil. Usually, fish and algal oils have 30% of their weight in (EPA+DHA) oils. For in-depth coverage, read on this website: Omega–3 oils: A complete guide.
- Green tea extract: ECGC is the active compound of green tea that helps reduce lipotoxicity and inflammation in the liver. Take 500 mg of extract a day.
Supplements for Reducing Fibrous Deposition
The following micronutrients have anti-fibrotic actions in the liver:
- Vitamin D
- Vitamin E: Has anti-fat-deposition, anti-inflammatory, and antifibrotic effects. Take 800 IU a day.
- Carotenoids: These are precursors to vitamin A. For a comprehensive coverage, read on this website: Vitamin A: A complete guide.
Supplements for Helping Liver Cell Regeneration
Various antioxidants and essential amino acids support healthy immune function and efficient tissue repair.
- Milk Thistle
- Branched Chain Amino Acids (BCAAs): People with the advanced liver disease get muscle loss and malnutrition. BCAAs are found to help rebuild muscle mass in such people. The best source of BCAAs is a whey protein supplement.
- Essential Amino Acids: The body needs various amino acids for efficient liver tissue repair. There are nine amino acids that it cannot produce. So they need to be taken from foods or supplements. BCAAs constitute three of these nine amino acids. One may need to get the remaining six, too, in the supplementation form. The only food sources with optimal ratios of these amino acids are meats, dairy, and soybean products. A good whey protein supplement offers all the nine essential amino acids. Take 20 to 40 g a day.
Complications of Fatty Liver
If NAFLD and NASH are allowed to progress, it can lead to liver fibrosis, liver cirrhosis, liver cancer, and liver failure. About ten percent of NASH patients get cirrhosis, which can lead to other serious complications:
- Ascites: Fluid accumulation in the abdomen;
- Hepatic encephalopathy: Loss of brain function due to the non-removal of toxins in the blood by the damaged liver;
- Esophageal varices: Abnormal, swollen veins in the food pipe (esophagus) that can rupture and bleed.
To Read More
- MedlinePlus.gov: Fatty Liver Disease
- Cleveland Clinic: Fatty Liver Disease
- Mayo Clinic: Non-Alcoholic Fatty Liver Disease
- Johns Hopkins Medicine: Non-Alcoholic Fatty Liver Disease
- Betterhealth.vic.gov.au: Liver – fatty liver disease
- FattyLiverDisease: Alcoholic Fatty Liver Disease: Can the Liver Regenerate?
- MedicineNewsToday: Do liver supplements work?
- Healthline: The 10 Best Herbs for Liver Health: Benefits and Precautions
- Wikipedia: Liver Regeneration
Articles in Supplementation Series
- Supplements for Various Age Groups
- Supplements for Type 2 Diabetes
- Supplements for Osteoarthritis
- Supplements for Hair Loss
- Supplements for Fatty Liver
- Supplements for Anemia
- Supplements for Prostate Enlargement
- Supplements for Macular Degeneration
- Supplements for PCOS
- Supplements for Parkinson’s Disease
- Supplements for Gout
- Supplements for Eczema
First published on: 8th May 2022
Image credit: Plus size photo created by shurkin_son – www.freepik.com
Last updated on: 9th May 2022