You may think it’s strange to fight fat with fat but there’s evidence to show that omega 3s benefit non-alcoholic fatty liver disease (NAFLD) [1]. For those of you who are new to NAFLD, it is the most common cause of liver disease in developed countries and burdens healthcare systems [2]. NAFLD is a spectrum of disorders of fat accumulation in the liver not caused by alcohol [3]. The severity of NAFLD can range from non-alcoholic fatty liver (NAFLD) to non-alcoholic steatohepatitis (NASH) with or without fibrosis to cirrhosis (scarring of the liver) [1]. In 4-27% of people with NASH and cirrhosis, this can progress to hepatocellular carcinoma (liver cancer) [4].
In NAFLD, >5% of liver cells have fat infiltration [2]. The most commonly used imaging method for diagnosis is an abdominal ultrasound and the gold standard for determining the degree of fat infiltration is a liver biopsy [2]. The cause of NAFLD has yet to be determined but its development and progression may be associated with both oxidative stress and insulin resistance, which means that your cells don’t take up sugar in response to insulin [5]. As such NAFLD is associated with metabolic syndrome and type II diabetes [2]. Other risk factors include obesity (BMI >30), dyslipidemia (elevated lipids in the blood) and disturbances in the balance of gut microbes [1][2]. In most cases, an individual will not experience symptoms but there could be fatigue, malaise and right upper abdominal pain [3].
NAFLD is often thought to be a condition that affects adults, but rates in children have been growing. The average prevalence is around 8% [6] and in obese children, it’s been reported to be as high as 38% [7]. In adults residing in developed countries, 20% to 30% have NAFLD, 2% to 5% have NASH, and 1% to 2% have liver cirrhosis [8]. Despite this high prevalence, there are no drugs currently approved for NAFLD and both diet and exercise remain first line treatments [1].
Image modified and re-created from Reference {2]
Omega 3s for Non-Alcoholic Fatty Liver Disease
The body can’t make omega 3s and as essential fats these need to be obtained from one’s diet. There are 3 types of omega 3s: eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are found in fatty fish, whereas alpha-linolenic acid (ALA) is found mostly in plants including flaxseeds and walnuts [9]. ALA needs to be converted by your body into EPA and DHA which is an inefficient process as only approximately 8-20% gets converted to EPA and 0.5-9% to DHA [10].
The omega 3 long chain polyunsaturated fatty acids (n-3 LC-PUFAs), specifically EPA and DHA, are what have been shown to benefit NAFLD in adults and children. A 2018 systematic review and meta-analysis of 18 clinical studies found that supplementation with omega 3s resulted in significant improvements in cardiometabolic risk factors (total cholesterol, LDL-C, HDL-C, triglycerides and insulin resistance), the levels of liver enzymes (ALT and GGT), liver fat content and steatosis score [1].
EPA and DHA are beneficial because they modulate gene expression in the liver, promoting fatty acid oxidation and inhibiting fatty acid synthesis and storage. More specifically, omega 3s supress the sterol regulatory element-binding protein 1 (SREBP-1) involved in fatty acid synthesis and storage, whilst stimulating PPAR- α to increase fatty acid oxidation and PPAR-y to increase insulin sensitivity. This gene modulation results in an overall decrease in fat accumulation [1].
Although beneficial, omega-3 consumption should be encouraged as one facet of a treatment plan that also involves a healthy diet and regular exercise (150 to 200 minutes of moderate to vigorous activity per week) [1][3]. In terms of healthy eating, the Mediterranean diet has been shown to be particularly helpful for NAFLD. This diet is not only great for heart health but also decreases insulin resistance and the severity of disease in those with NAFLD [11]. A Mediterranean diet emphasizes fish, fruits, vegetables, beans, whole grains, nuts, seeds and olive oil, while eating dairy, eggs and poultry in low to moderate amounts and limiting red meat and sweets [12][13]. Although wine consumption is encouraged on the Mediterranean diet, this should be avoided especially in those with cirrhosis as this increases the risk of hepatocellular carcinoma development [14]. Other dietary measures for NAFLD include drinking coffee every day, which can reduce liver fibrosis progression [15] [16]. However, more is not better as caffeine can increase anxiety in those who are predisposed and may keep you up at night!
Naturopathic Doctors can help you with diet and other preventative measures. This is only a small snapshot of what a holistic plan for NAFLD looks like. For more dietary and supplement advice and if you’re interested in learning more about bettering your health, contact me at annemarie@drlacroixnd.com to book a consult.
DISCLAIMER: This post is for educational purposes only and should not replace expert medical advice from your ND or MD. Omega 3s may not be for every individual with NAFLD and medication/supplement interactions should be assessed.
References:
1. Musa-Veloso, K. et al. 2018. Systematic review and meta-analysis of controlled intervention studies on the effectiveness of long-chain omega-3 fatty acids in patients with nonalcoholic fatty liver disease. Nutrition Reviews. 76(8): 581-602. https://pubmed.ncbi.nlm.nih.gov/29917092/
2. Huang, T.DS., Behary, J. and Zekry, A. 2019. Non-alcoholic fatty liver disease (NAFLD): a review of epidemiology, risk factors, diagnosis and management. 10.1111/imj.14709. https://www.ncbi.nlm.nih.gov/pubmed/31760676
3. Family practice notebook. 2019. Nonalcoholic Fatty Liver. https://fpnotebook.com/GI/Lvr/NnlchlcFtyLvr.htm
4. Dhamija, E. et al. 2019. Non-alcoholic fatty liver disease associated with hepatocellular carcinoma: An increasing concern. Indian Journal of Medical Research. 149(1): 9-17. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6507546/
5. Kitade, H. et al. 2017. Nonalcoholic Fatty Liver Disease and Insulin Resistance: New Insights and Potential New Treatments. Nutrients. 9(4):387. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5409726/
6. Anderson, E.L. et al. 2015. The Prevalence of Non-Alcoholic Fatty Liver Disease In Children and Adolescents: A Systematic Review and Meta-Analysis. PLoS One. 10(10):e0140908. https://pubmed.ncbi.nlm.nih.gov/26512983/
7. Schwimmer, J.B. 2006. Prevalence of fatty liver in children and adolescents. Pediatrics. 118(4)1388-1393. https://pubmed.ncbi.nlm.nih.gov/17015527/
8. Neuschwander-Tetri, B.A. 2017. Non-alcoholic fatty liver disease. BMC Med. 15(1):45. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5330146/
9. Harvard T.H. Chan. Omega 3 Fatty Acids: An Essential Contribution. Accessed from: https://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/fats-and-cholesterol/types-of-fat/omega-3-fats/
10. Stark, A. H. et al. 2008. Update on alpha-linolenic acid. Nutrition Reviews. 66(6): 326-332. https://pubmed.ncbi.nlm.nih.gov/18522621/
11. Kontogianni, M.D. 2014. Adherence to the Mediterranean diet is associated with the severity of non-alcoholic fatty liver disease. 33(4). 678-683. https://pubmed.ncbi.nlm.nih.gov/24064253/
12. American Heart Association. What is the Mediterranean diet? Accessed from: https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/nutrition-basics/mediterranean-diet
13. Mayo Clinic. Mediterranean diet: A heart-healthy eating plan. Accessed from: https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/mediterranean-diet/art-20047801
14. Romero-Gomez, M. et al. 2017. Treatment of NAFLD with diet, physical activity and exercise. Journal of Hepatology. 67(4):829-846. https://pubmed.ncbi.nlm.nih.gov/28545937/
15. Heath, R. D. et al. 2017. Coffee: The magical bean for liver diseases. World Journal of Hepatology. 9(15): 689-696. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5440772/
16. Shen, H. et al. 2016. Association between caffeine consumption and nonalcoholic fatty liver disease: a systemic review and meta-analysis. 9(1): 113-120. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4699270/