Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in the world, and rates are continuing to rise with the obesity epidemic. In fact, while some estimate that NAFLD affects almost two billion people globally, most are unaware it exists, let alone that they may be affected by it. Health experts around the world believe that the rates of NAFLD will continue to grow in the coming decades and will compromise individual health as well as cause substantial economic hardships.
While the relationship between diet and heart health is well known, nutrition and weight can have a big impact on liver health as well. This is because many of the risk factors related to NAFLD have a connection to dietary and other lifestyle factors. Risk factors for NAFLD include excess body weight, elevated LDL cholesterol, diabetes or prediabetes, high blood pressure and metabolic syndrome. This article examines these risk factors and highlights evidence-based lifestyle interventions that you can share with your clients that can help reverse this increasingly common disease.
Nonalcoholic Fatty Liver Disease: The Basics
Fatty liver disease involves the accumulation of fat in the liver. If left untreated, NAFLD can worsen and become nonalcoholic steatohepatitis (NASH), which includes both an accumulation of fat in the liver and inflammation and liver damage. Eventually, NASH can lead to cirrhosis of the liver, which is characterized by scarring and permanent hardening of the liver, or liver cancer. The rising rates of NAFLD in recent years is concerning to researchers “because NAFLD is often a progressive disease that can be associated with significant complications such as liver cirrhosis, hepatocellular carcinoma, and an increase in liver-related and overall mortality.”
There is good news, however. Early diagnosis combined with lifestyle intervention can reverse NAFLD.
How is NAFLD Diagnosed?
Diagnostic tests for NAFLD include blood tests, liver biopsy and imaging tests. Blood tests are specifically testing for the liver enzymes AST and ALT. Further testing can be done with imaging tests and may include ultrasound, CT or MRI to check for fat in the liver. People with NAFLD often don’t experience any symptoms, which is why it’s crucial to have annual physicals and regular blood work.
Lifestyle Intervention is the Treatment for NAFLD
There is currently no pharmacological treatment available for NAFLD. The recommended treatment is weight loss and lifestyle change, which can reverse fatty liver disease and prevent further complications.
Early diagnosis is key to being able to reverse the course of the disease. It’s important to encourage clients to get annual physicals including blood work, to become aware of any risk for NAFLD as well as other chronic diseases.
While the condition is reversible, it should be noted that people with NAFLD “also have an increased risk for type 2 diabetes, atherosclerosis, cardiovascular disease, and chronic kidney disease and consequently, they have a shorter lifespan and may experience a lower quality of life.” The diagnosis should be taken seriously, and you should encourage your clients to maintain close contact with their medical care team to monitor labs and disease progression.
A client experiencing NAFLD and/or other medical complications may have a medical team consisting of a primary care provider, gastroenterologist and registered dietitian. Depending on the client’s comorbidities, they may be working with additional specialists. Be sure to look to your client’s medical care team for specific recommendations or guidelines regarding nutrition and exercise.
While a client may feel discouraged to learn they have elevated liver enzymes or NAFLD, it is possible to change course and reverse NAFLD with weight loss and lifestyle change. As a health and exercise professional, you can play a key role in putting the recommendations from the provider into practice, thus helping clients with NAFLD improve their condition, prevent further complications and make lasting changes that enhance overall health and well-being.
Evidence-based Lifestyle Changes to Treat Fatty Liver Disease
Best practices for treating NAFLD include moderate weight loss, improving nutrition and increasing exercise, which can all help to normalize liver enzyme levels.
People experiencing NAFLD need support in making lasting behavior changes. They may be experiencing other health issues, and making lifestyle changes can help improve both their liver health and other comorbidities as well. A meta-analysis published in 2021 found that a 7 to 10% reduction in weight was sufficient to improve or treat NAFLD. The best approach to achieving this level of moderate weight loss is through sustainable dietary changes and increased physical activity.
The progression of NAFLD is specifically related to diets that are high in sugar, calories and saturated fat, and low in fiber, unsaturated fat and micronutrients. Helping your clients make the following diet-related changes can support the management of liver enzymes and overall health:
- Decrease ultra-processed food consumption in favor of less-processed foods, specifically fruits, vegetables, lean meats, whole grains, nuts and seeds. Ultra-processed foods like chips, crackers, cookies, fast food, etc., are typically high in fat or sugar and more calorically dense than nutrient dense and are not satisfying.
- If an individual has diabetes, they must monitor and control their glucose levels.
- Reduce added-sugar intake from food and drinks as much as possible. If a client drinks a lot of soda or other sugary drinks, switching to no-sugar-added beverages can be helpful in minimizing sugar intake.
- Incorporating high-fiber foods like fruits and vegetables can keep clients satiated without a lot of calories.
- Reducing or eliminating alcohol intake can also be beneficial for liver health in addition to reducing calories consumed.
- Because weight loss is crucial for improving liver health, utilizing a method of self-monitoring can help to track caloric intake. While there are many methods for tracking intake, such as written food logs, tracking apps, calorie counting or photo journaling, focus on what’s best for the client and their personal relationship with food.
The benefits of physical activity for those with NAFLD go beyond weight loss due to its impact on liver enzyme markers. Cardiorespiratory training or a combination of cardiorespiratory and muscular training is recommended for improving liver enzymes. The recommendations related to physical activity to reverse NAFLD mirror those for the general population:
- Increase physical activity, which is key to helping to achieve weight loss, as well as improving liver enzymes, cholesterol and triglycerides. Individuals with NAFLD should aim for the recommended 150 minutes of moderate physical activity per week unless otherwise instructed by their medical care team.
- In addition to participating in physical activity, urge your clients to increase their movement throughout the day. Decreasing sedentary behavior through regular movement has been proven to be supportive of not only losing weight but also maintaining weight loss. Taking brief walking breaks throughout the day can be a convenient way to increase overall movement.
- Encourage your clients to find physical activities that they enjoy, which can help keep them motivated to regularly incorporate movement into their daily routines.
Open-ended Questions to Tap Into Client Motivation
- What do you think needs to change to meet your goal?
- On a scale of 0 to 10, how ready are you to make changes with your exercise habits?
- How would you like your health to be different?
- What do you think will happen if your weight doesn’t change?
- What have you tried in the past that has worked?
Case Study: How to Use Motivational Interviewing to Help a Client Who is Feeling Overwhelmed by a Chronic Disease Diagnosis
A 56-year-old client is meeting with a health coach for the first time. They inform the coach that their last physical revealed that their liver enzymes were elevated, and they have been diagnosed with both NAFLD and prediabetes. Their doctor recommends losing 25 pounds. They have no limitations related to exercise, but they are feeling discouraged about this new diagnosis.
Coach: Thanks for filling out your health-history forms. I saw your note about the recent diagnosis. I appreciate your willingness to share. Is there anything else you want me to know?
Client: It just feels hopeless. I want to lose this weight, but I’ve tried so many programs and diets. It doesn’t feel possible.
Coach: Tell me more about what you’ve tried before.
Client: I was good about exercise in the past. I walked quite a bit and enjoyed it and began lifting weights for a while. But I was never very regimented with my diet for very long. I’d do well for a while—maybe even a month or two. Then I’d have too many cheat days, or something would come up like a vacation and I’d fall off the wagon. But my doc said this liver issue could worsen. I already have prediabetes and feel like I have got to make a change before things get even worse.
Coach: I’m hearing you say that you enjoyed walking and lifting weights, and you think now is the time to make a change. And maybe changing the approach to nutrition could help you to stick with the changes longer. Is that right? What do you think would be helpful this time around?
Client: Yes, I have to make a change now, but I need something I can stick with. In the past, everything I’ve tried has had a lot of “off-limit foods.” I felt hungry and just craved junk food.
Coach: That’s understandable. So, you think a less restrictive plan, with room for some favorite foods, would be easier for you to stick with it?
Client: Yes, I can do the vegetables and all that. I just like to have ice cream or a donut, too. I can go without for a few weeks, but then I end up eating half a dozen donuts at once.
Coach: O.K., good to know. Let’s make a plan together that feels doable for you. We can always adjust it, but planning with the long-term in mind means we want to take small steps we can stick with. What are your hopes for the future if you’re able to become healthier?
Client: Well, my wife recently lost quite a bit of weight. She likes walking and I feel like I can’t keep up right now. I’d like to be able to take a trip with my family and not be the one sitting on the bench out of breath.
When clients feel hopeless, rather than offering advice or immediately suggesting a program or plan, take the time to just listen to them. Listen to their concerns, get clear on what they want for their future, and understand what they may have already tried. Ask questions to understand what they think could help. Following the client’s lead on what they are open to trying can lead to them taking action, and even the smallest actions can lead the client to no longer feel “stuck” or discouraged.
Clients who have NAFLD or other chronic diseases may already have many people in their lives playing the “expert” role, including doctors, dietitians, specialists and possibly concerned family members who may have a lot of opinions as well. Allowing the client to be the expert in their own life (which of course, they are) is key to a successful coaching relationship and can allow for better client outcomes in the long run.
As a health and exercise professional, you play an important role in providing support for lasting behavior change for clients with NAFLD and all chronic diseases. Supporting the medical team while following the client’s lead and tapping into their motivation are key factors in engaging clients in long-term change and promoting lasting health habits.