Diabetes and NAFLD

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Diabetes and NAFLD

If you have diabetes, you’re likely aware of the risk of certain complications, such as heart disease, nerve damage, and kidney problems. What you may not be aware of is another complication: non-alcoholic fatty liver disease. Learn more about this lesser-known diabetes complication, along with steps that you can take to avoid or even reverse it.

Liver 101

The liver is amazing, considering everything it does to keep the body healthy and running smoothly. Sitting in the upper right abdomen, it’s one of the largest organs in the body. Here’s a brief rundown of what the liver does:

  • Detoxifies drugs, alcohol, and poisonous chemicals
  • Produces proteins that help blood to clot
  • Breaks down fat for energy
  • Makes bile (which is needed for fat breakdown)
  • Stores glucose in the form of glycogen to be used for energy
  • Metabolizes protein
  • Stores vitamins and minerals

It’s thought that the liver has about 500 jobs to do — no wonder this organ is so important!

Fatty liver disease

Fatty liver disease (technically, non-alcoholic fatty liver disease, or NAFLD, for short) is a condition in which extra fat builds up in liver cells. As the name implies, it’s not due to drinking alcohol (that’s a whole other issue). The liver normally contains some fat, but if more than 5% to 10% of the liver’s weight is due to fat, you’ve got a fatty liver.

Between 7% and 30% of people with NAFLD can develop a more damaging form of liver disease, called nonalcoholic steatohepatitis (NASH). With NASH, the liver becomes inflamed. This inflammation leads to fibrosis, or scarring, of the liver, which can progress to cirrhosis. Over time, a person with NASH can develop liver failure, requiring a liver transplant for survival.

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Who gets NAFLD?

According to the American Liver Foundation, NAFLD is the most common chronic liver condition in the U.S., affecting about 25% of adults, although other data points to up to 45% of adults having NAFLD. The exact cause of NAFLD isn’t entirely clear, but it’s more common in people who:

In addition, NAFLD can run in the family, and it’s more likely to occur in older people (but younger adults and children can get it, too), and people with fat that is concentrated in the abdomen (belly fat, in other words). It may also be caused by certain medicines, such as tamoxifen, estrogen, methotrexate, and glucocorticoids, and infections such as hepatitis C.

People who have type 2 diabetes and heart disease are more likely to have NAFLD. Likewise, people with NAFLD are more like to have heart disease and/or type 2 diabetes.

NAFLD symptoms

You may not have any symptoms in the early stages of NAFLD. But symptoms can occur as the disease progresses and include pain or discomfort in the upper right abdomen and fatigue.

If the disease progresses to NASH, you may have yellowing of the skin and eyes, itching, a swollen belly (ascites), sleepiness, and confusion. Liver cancer is another side effect of advanced liver disease.

NAFLD diagnosis

Since NAFLD rarely causes symptoms early on, your health care provider may suspect an issue with your liver during a regular physical exam. For example, your provider may notice that your liver is enlarged when they palpate (press on) your abdomen. A blood test may show that your liver enzymes, or liver function tests (LFTs) are high. Specifically, these LFTs are ALT (alanine aminotransferase) and AST (aspartate aminotransferase). Your provider might order other blood work to check for chronic viral hepatitis, celiac disease, a lipid profile, and a hemoglobin A1C.

Imaging tests, such as ultrasound, MRI or CT scan, magnetic resonance elastography (MRE), or transient elastography, which measures liver “stiffness,” might be ordered.

If these tests don’t indicate an issue, you may have a liver biopsy. This involves taking a sample of your liver tissue to look for inflammation and scarring. If the tissue shows fat without inflammation or damage, the diagnosis is NAFLD. But fat, inflammation, and scarring likely indicates NASH.


At this time, there are no medications to treat NAFLD, although Actos (pioglitazone) has been shown to reduce fat in the liver. Pioglitazone has been used off-label, but the downside of this medication is weight gain. The American Liver Foundation notes that “Currently, there are no FDA-approved medications to treat nonalcoholic fatty liver disease, although a few are being studied with promising results.”

While there may not be approved medical treatments at this time, it doesn’t mean that you can’t help your liver and reduce liver fat. Here’s what you can do:

  • Aim to gradually lose weight. Losing 10% of your body weight is ideal, but losing even 5% of your weight can help. Weight loss is one of the most important steps you can take to prevent NAFLD from worsening. Work on cutting back on portions, eating a diet that emphasizes vegetables, lean protein foods, and healthy fats, and cutting back on refined carbs, especially sugar-sweetened drinks. A Mediterranean-style eating plan can be a good choice. Ask your provider for a referral to a dietitian who can help you with a weight-loss eating plan. Avoid fad diets that cause you to lose weight too quickly, as rapid weight loss can actually be harmful to your liver.
  • Increase your physical activity. Try to be active most days of the week, building up to 30 minutes a day (you don’t have to do all 30 minutes at one time, either!).
  • Take care of your diabetes. Try to keep your blood sugars and A1C levels within your target range. Take diabetes medications as prescribed.
  • Pay attention to your cholesterol and triglycerides. If they’re above a safe level, cut back on saturated fat and talk with your provider about taking cholesterol-lowering medication.
  • Avoid drinking alcohol.
  • Take prescription and over-the-counter medicines as directed. Also, check with your provider before taking dietary or herbal supplements, since some can be harmful to your liver.
  • Get vaccinated for hepatitis B. The hepatitis vaccine is recommended for all people with diabetes. Ask your provider if you should be vaccinated for hepatitis A, too.

For more information about NAFLD and NASH, check out the following resources:

Want to learn more about protecting your liver? Read “Preventing Fatty Liver (NAFLD).”

Originally Published July 27, 2021
Amy Campbell, MS, RD, LDN, CDCES

Amy Campbell, MS, RD, LDN, CDCES

Amy Campbell, MS, RD, LDN, CDCES on social media

A Registered Dietitian and Certified Diabetes Educator at Good Measures, LLC, where she is a CDE manager for a virtual diabetes program. Campbell is the author of Staying Healthy with Diabetes: Nutrition & Meal Planning, a co-author of 16 Myths of a Diabetic Diet, and has written for  publications including Diabetes Self-Management, Diabetes Spectrum, Clinical Diabetes, the Diabetes Research & Wellness Foundation’s newsletter, DiabeticConnect.com, and CDiabetes.com

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