Tahlia Sage
- Oct 20, 2023
- 11 min read

Holistic Wellness Guide For Nonalcoholic Fatty Liver Disease (NAFLD)

I don’t drink but I have a fatty liver and my liver enzyme has been high for years. Why?

This puzzling question is the most common one I get asked when clients come to me for help with Non-alcoholic Fatty Liver Disease (NAFLD).

NAFLD is a disease that affects approximately 30% of the adult population and 10% of children in North America. It is a trend that’s increasing by 50% over the past 30 years for adults, and the prevalence for children has more than doubled in the past 20 years. You are not alone in experiencing this situation.

I want to empower you with the knowledge that you can learn about to support your body’s ability to regenerate and renew a healthy liver.

Root Cause

Nonalcoholic fatty liver is a condition where more than 5% of the liver (either by volume or by weight) is filled with fat. To understand why the liver accumulates more than a healthy amount of fat, we need to understand why the body turns on this maladaptive process.

1. Metabolic Syndrome

According to biopsy data from a large pool of data from liver donors and clinical biopsies, the prevalence of fatty liver increases with an individual’s BMI, especially when people are in the obese category.

For a person who is not athletically built, a BMI of 27 or higher is a good indicator of metabolic syndrome. However, the bar is much lower for different ethnicities that are more susceptible to metabolic syndrome (such as African American and East Asian groups). One or multiple changes below can be a sign of metabolic syndrome:

Increase in triglyceride level
Increase in high-density cholesterol
Increase in waist circumference
Increase in blood sugar
Increase in blood pressure

Metabolic disease is an important process to grasp. What it means is that it turns on a set of maladaptive switches in the body that prevents the body from properly burning fat and creating enough energy.

2. Insulin Resistance

Insulin resistance is a feature of metabolic syndrome. Insulin is an important hormonal signal that lets the body know how to spend or store energy. When the body becomes less responsive to this signal, cells become energy starved even though they are practically marinating in excess blood sugar. The body favours fat storage and slows down fat burning and muscle building. What's worse is that as insulin resistance progresses, energy starved cells signal the body to create sugar from dietary protein and free storage sugar from the liver. The excess sugar turns into fat deposits in liver cells. Over time, this vicious cycle leads to increased fat in the liver.

The thing is, insulin resistance is not a condition someone catches in a day; it is a gradual process that develops from cumulative effects of dietary choices, exercise habits, toxicity exposure, and mental and emotional stress.

3. Lipid congestion and Inflammatory Injury

When the body senses there is an inflammatory process going on, it likes to pitch in and create more fats to help patch up the injuries like a makeshift bandage. Individuals who have insulin resistance and metabolic syndrome have chronically increased inflammation in the body so the body has to always create more fat.

More fat in the blood deposits more fat to the liver, and these fatty deposits on the liver create inflammatory injury to the liver tissue injury creates more fat in response to the inflammatory injury, and the vicious cycle continues. Over time, this results in fatty liver even though alcohol doesn’t play any part in this inflammatory process.

Signs & Symptoms

These are some of the common signs and symptoms clients have shared with me.

1. Gastrointestinal Symptoms

This is a common first symptom for many people because the liver gallbladder system plays an important role in fat digestion, bowel movement, and gut microbiome balance by releasing bile. Liver cells produce bile and store concentrated bile in the gallbladder then released into the intestine to help emulsify fats, stimulate intestinal peristalsis, and inhibit bad gut bacteria growth. Insulin resistance makes bile run thicker and sticker, making it hard for the body to digest and absorb fats and fat-soluble nutrients, more gas, and bloating due to gut bacteria changes and IBS symptoms such as constipation and diarrhea.

Fatty Food Intolerance

Weakened digestion and decreased ability to enjoy rich fatty meals can be an early warning sign of the liver not functioning at its tip-top shape. If you try to avoid fried food or fatty meat because they can provoke nausea, heartburn, diarrhea, constipation, or make you feel like there is a rock sitting in your stomach, you may need to discuss these symptoms with a qualified health practitioner.

Pain & Discomfort In The Upper Right Side

The liver gallbladder sits in the upper right side of the abdomen. This pain can sometimes feel sudden and sharp, or dull and full due to liver gallbladder inflammation and spasm. Many people feel no pain at all because it can take some time to sense this symptom.

2. Headache

The liver is a place where toxins are processed and removed from the body. Fatty liver is often associated with suboptimal lipid levels (cholesterol, triglycerides, LDL), inflammation, and congestion due to the thick and sticky bile slowing natural detoxification. The backlog of toxic load can lead to headaches, migraines, or lack of mental clarity.

3. Irritability

According to Traditional Chinese Medicine Energetics, the liver processes anger. So as this energetic channel becomes congested, liver fire builds up resulting in frustration, irritability, and lack of patience.

4. Dull Skin and loss of Sparkle In The Eye

The liver is the generator of the master detoxifier & antioxidant in the body: glutathione. This powerful molecule cleanses the body of toxins and supports repair and regeneration. When people have fatty liver, the liver generates less glutathione. The glow of the skin will be reduced and the eyes will also lose their sparkle when our internal environment is filled with unprocessed toxins.

Lab Work & Diagnostic Process

Conventional testing

Liver biopsy is the conventional test that helps confirm fatty liver which requires the extraction of a tiny amount of liver tissue. Other image testing such as MRI and ultrasound can show fatty deposits on the liver. However, less invasive testing such as liver enzymes from blood tests has strongly correlated with the presence of fatty liver.

Laboratories Ranges

In non-alcoholic fatty liver disease, different liver enzymes can be in the high normal standard range or only slightly elevated compared to the standard range. NAFLD was significantly associated with higher alanine aminotransferase (ALT) and gamma-glutamyl transferase (GGT). In people with type 2 diabetes, the prevalence of fatty liver is 70-95%, because of the presence of insulin resistance. Please consider referring to the optimal range if your goal is to be proactive about your liver health.

ALT (alanine aminotransferase) is a liver enzyme found in the liver and it is a strong biomarker for liver damage.
- The reference range is 4 to 36 IU/L. Ideal ALT should be 10.00 - 26.00 IU/L. The presence of fatty liver for ALT can be observed as low as 28 IU/L in people with metabolic syndrome.
GGT (Gamma-glutamyl transferase) is an enzyme localized in the liver, kidney, and pancreas tissues and it is a biomarker for congestion in the liver and gallbladder. An increase can be a sign of depletion of antioxidant storage (glutathione) and congestion in the liver gallbladder.
- The standard range is 6-50 IU/L. The optimal range is 10-17 U/L

Holistic Dietary Considerations

Diet is a powerful tool when it comes to improving non-alcoholic fatty liver (NAFLD). The following strategies can provide support to promote liver repair via five key mechanisms.

1. Decongest The Liver

Lipotropic nutrients

Lipotropic nutrients work by pushing stuck fat out of the liver by making bile. Bile production is the body’s natural process to remove and upcycle fats. Bile serves as a crucial digestive factor: emulsifying fatty foods, inhibiting pathogenic bacteria found in food and our intestine, and promoting regularity. This group of nutrients has been shown to improve bile flow and fat burning- in a way, flushing fats out of the body. These nutrients are usually from the B vitamin family or in a synergistic relationship with the B vitamin family. These nutrients are: Vitamin B1, Vitamin B2, Vitamin B3, Vitamin B5, Vitamin B6, Vitamin B9, Vitamin B12 Inositol, Choline, Methionine. Deficiencies I observe it’s not only from a lack of intake, but worsened by imbalance of gut biome. Our gut bacteria produces and activates many of these B vitamins, without this symbiosis, we cannot fully get the B vitamins from our food.

My favorite high-concentration food form of lipotropic nutrients is liver pate (grass-fed and pasture-raised) which contains all of these nutrients because a healthy liver needs these lipotropic nutrients to carry about its metabolic function. Other foods that will contribute lipotropic nutrients include dark leafy greens (eg. kale, collards, swiss chards, romaine lettuce, red leafy lettuce, green leaf lettuce), beetroot, egg yolk, nuts & seeds, and legumes.

Amino Acids

Amino acids are protein building blocks that serve as sorting bags that neutralize internal and external wastes and toxins in the last step of liver detoxification. This step is a rate-limiting step because if there are not enough of these sorting bags freely available, toxins and wastes could backflow into blood circulation causing inflammatory damage. The key issue I observe is the poor digestion and absorption of protein from digestive issues which is a common challenge experienced by clients who have fatty liver. Another common challenge for people with fatty liver is the nausea and ingestion that deters them from consuming high-quality animal protein that contains the full spectrum of amino acids.

Sulfur

Stinky sulfur (the wafting scent from hard-boiled eggs and steamed broccoli) is an active participant in liver detox and it is the raw material needed for many of the amino acids required to sort and neutralize toxins such as taurine and cysteine. Sulfur-containing foods increase glutathione, the master detoxifier and regenerator produced inside the liver.

Allium family vegetables (onion, garlic, leek, green onions) and cruciferous family vegetables (cabbage, radish, kale, arugula, broccoli, cauliflower) as well as eggs contain sulfur. In clients with fatty liver, sulfur-containing food can interact with an imbalanced gut microbiome and cause gas and discomfort creating a dietary deficiency of sulfur.

Bitters

Plant bitters decongest the liver by stimulating bile flow and encouraging fat purging through bile production. Some traditional medicinal bitters also provide added benefits of encouraging digestive juice production and bowel regularity. The bitter foods that I like for the liver include arugula, endives, frisée, radicchio, dandelion greens, and different types of radishes. From my own experience and talking with clients, we certainly don’t have these foods as much and as often as needed to provide the liver the encouragement that it needs.

2. Reduce Inflammation

Antioxidants serve as a shield that can protect liver cells from free radicals and promote liver repair. Antioxidants work in synergistic networks with each other to strengthen the shield and enhance the reduction of inflammatory insults on the liver. Dietary antioxidants come from a variety of fresh vegetables and fruits. The more types of fresh produce one can acquire, the stronger protective effect one will get from this tightly knitted network of antioxidants.

A challenge I see is the temptation to favor fruits over vegetables. A randomized clinical trial from 2022 has demonstrated that more than 4 servings of fruits per day can worsen fatty liver. Modern hybridization of fruits selectively increases fructose content in fruits. Fructose has been shown to increase fat production in the liver.

3. Promote Regularity

Now that the body pushes out the stuck fat with lipotropic nutrients and flushes the fat out of the liver with the help of bitters, there is still one more catch. Without a daily refreshing and cleansing bowel movement, this eliminated fatty waste gets reabsorbed into the bloodstream from the large intestine, creating a backlog of inflammatory fatty waste and adding to the burden of the liver. The normal range of time from mouth to anus is 14 hours to 58 hours but a good poop under 24 hours is ideal. Slow transit time has been associated with more inflammatory fat around the organs. Hydration and fiber and the two important factors because a hydrated poop is more slippery and 65% of poop is water and fiber can add bulk which makes the poop travel faster.

4. Reduce Insulin Resistance

Insulin resistance leads to more inflammatory fat production and accumulation in the liver and slows fat burning. This is why insulin resistance is a major contributing factor to non-alcoholic fatty liver. Blood sugar balancing strategies such as increasing organic vegetable intake for a diversified profile of fiber, minimizing refined carbohydrates (eg. white rice, pasta, baked goods, heavily sweetened products such as granola, cereal, juices, and even some protein bars), and replace them with complex carbohydrates such as root vegetables (carrots, rutabaga, beets, turnip), cruciferous vegetables (broccoli, cauliflower, cabbage) and ancient/heritage grains such as wild rice, farro, black rice, etc, and make sure you get sufficient protein. In my approach, I don’t shy away from animal protein such as salmon, eggs pasture-raised chicken and grass-fed elk, venison, and beef. Lastly, please consider healthy fats from high antioxidant sources as long as it doesn’t worsen your symptoms such as pain, constipation or diarrhea. These fats help to turn down inflammatory signals in the body. Some examples include brazil nuts, almonds, hazelnuts, sunflower seeds, pumpkin seeds, avocado, salmon, cod liver and organic olive oil. Grass Fed organic butter and other animal fats only in moderation depending on the individual's genetics.

5. Periodic Liver Cleanses

No one can live in a perfect bubble where all food is untouched by chemicals, all stress doesn’t exist, and every meal is meticulously balanced. Life is too short to not enjoy yourself in moderation while you are on holiday. Therefore, I think it is good to refer to ancient wisdom, a time when people lived more in sync with nature.

According to Traditional Chinese Medicine, the liver houses the soul and generates vitality and endurance, therefore a healthy liver is something to be worked on to support long-term health. TCM recommends supporting the natural purging and cleansing process twice a year, in early spring and late summer.

This means intentionally incorporating these concepts during spring and late summer to support liver health.

Herbal Considerations

1. Milk thistle

Milk thistle has been shown to have liver protective effects. Antioxidants found in milk thistle are called silymarin, which protects liver cells from damage by inflammatory fats and toxins.

Silymarin can also promote liver tissue repair and regeneration, and slow and even reverse fibrosis of the liver.

Dosage that has been documented:

Tinctures: 4-9 g dried equivalent, per day (1:1, 4-9 ml)

Capsules: Standardized extract of 80% 3 - 6, 175 mg capsules daily

2. Artichoke Leaves

Artichoke leaves encourage toxin and fat purging from the liver by stimulating bile production and bile flow. Artichoke extract has been shown to lower total cholesterol and LDL cholesterol.

Dosage that has been documented:

Tinctures: 3-8ml 1:2 extract per day

Capsules:

320mg standardized extract 4-6 times per day

1-4g dried leaves per day

3. Dandelion Root

Dandelion roots help to reduce inflammation in the liver and help promote bile flow and blood sugar health.

Dosage that has been documented:

Tinctures:1:5 extract 3-5ml 3 times per day

Capsules: dry herb equivalent 4-10g per day

4. Schisandra

Shisandra has been shown to decrease oxidative stress on liver cells and improve liver detoxification and liver function

Dosage that has been documented:

Tinctures: 1:2 extract 1-3ml 3 times per day

Capsules: dry herb equivalent 250mg 3 times per day

Supplement Considerations

1. N-acetyl-cysteine (NAC)

NAC is a precursor to glutathione, the master repair and detox antioxidant produced by the liver. Fatty liver is associated with ramped-up oxidative damage to liver cells but failure to produce enough glutathione from injured liver cells resulting in a buildup of inflammatory damage. Vitamin C helps to recycle glutathione so supplementing food forms of vitamin C is going to help maintain good glutathione levels.

NAC at 600 mg twice per day or reduced glutathione at 300mg once per day has been shown in clinical trials to reduce liver enzyme levels.

2. Lipotropic Nutrients & Methylation Support

Supplementing with active forms of B6, folate, B12, and choline can help give the fat-purging process a boost. Studies have shown B12 and folate supplementation can help reduce the progression of NAFLD and low choline is linked with fat accumulation in the liver. B6 is an active cofactor in glutathione synthesis.

A typically high dose of choline is close to 500 mg daily, B6 (P-5-P) 50mg, methylated B12 300mg, and folate (methyltetrahydrofolate) 300mg.

3. Vitamin E

Vitamin E has been shown to help cells from being damaged by fat-soluble free radicals. When there are more inflammatory fats in the liver, vitamin E serves to protect liver cells from damage.

400-600 IU vitamin E has been used in clinical trials to help prevent liver damage from fatty liver. Keep in mind vitamin E can be derived from GMO soy so it is best to consider your sources and diversify the intake of food sources of vitamin E such as organic wheat germ, organic olive oil that has high-phenol content, sunflower seeds, and almonds.