Fatty Liver Disease is often described as a “silent killer,” meaning patients rarely show early symptoms. Late symptoms of Fatty Liver Disease include fatigue and pain in the upper right side of your abdomen. When fat builds up in your liver, Fatty Liver Disease can develop, causing inflammation and dysfunction. The two types of Fatty Liver Disease are alcoholic Fatty Liver Disease (caused by excess alcohol use) and nonalcoholic Fatty Liver Disease (caused by many factors unrelated to alcohol). Weight loss is the main treatment for nonalcoholic Fatty Liver Disease, but restoring insulin sensitivity by following a low carbohydrate diet like the keto diet may also offer treatment.
Understanding Fatty Liver Disease
Fatty Liver Disease is broken down into two types: alcoholic Fatty Liver Disease and nonalcoholic Fatty Liver Disease (NAFLD). Alcoholic Fatty Liver Disease is caused by excessive alcohol use, which causes cellular damage. Over time, alcohol irritates the liver lining, causing inflammation. This inflammation and irritation can lead to liver dysfunction and elevated liver enzymes. NAFLD is more complex because many factors can contribute to its development. While researchers are still trying to understand it, obesity is the largest associated risk factor.
Other risk factors include:
- Type 2 diabetes
- Being middle-aged (in your 40s or 50s) or older
- High cholesterol
- High blood pressure
- Metabolic syndrome
- Hepatitis C
- Hispanic or non-Hispanic white ethnicities
These risk factors can promote fat collection and storage in the liver. Sometimes, excess fat in the liver causes inflammation, leading to a more aggressive form of NAFLD called nonalcoholic steatohepatitis (NASH). If Fatty Liver Disease is left untreated, regardless of the cause, cirrhosis (excess liver scarring as it attempts to heal itself) and subsequent liver failure can occur. Variceal bleeding, which causes bleeding into the GI system, is another complication. Abdominal swelling (ascites) and brain swelling (encephalopathy) can also occur when fatty liver is not identified or treated.
Doctors are worried about an increasingly common condition called nonalcoholic fatty liver disease, or NAFLD, in which extra fat builds up in the liver. Hugo Rosen, a liver disease specialist and chair of medicine at the Keck School of Medicine of USC, has seen an increase in the proportion of patients with fatty liver disease. In NASH, the liver becomes inflamed and damaged, which can cause scarring and higher risk of cancer or liver failure. Rosen said patients worried about NALFD or NASH should request liver blood tests and imaging tests like an MRI or ultrasound.
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The Silent Progression of Fatty Liver Disease
Since Fatty Liver Disease doesn’t usually show early symptoms, detecting it early is key. With early detection, treatment can begin sooner, and more severe symptoms may be avoided. Many people don’t know they have a fatty liver, leading to its reputation as a “silent killer.” It usually causes no pain or other symptoms. For those at risk of alcoholic or non-alcoholic Fatty Liver Disease, a routine full-body scan can be beneficial. At Ezra, a full-body scan looks at up to 13 organs, including the liver.
Treatment Approaches for Fatty Liver Disease
Once someone reduces or stops their alcohol use, alcoholic Fatty Liver Disease can often be reversed. Weight loss techniques can look different depending on a person’s genetics, abilities, and preferences. Sometimes, simply reducing calorie intake isn’t enough or isn’t sustainable long term. This has led to exploring different dietary avenues to reduce fat in the liver. Nonalcoholic fatty liver disease (NAFLD) is emerging globally, while no therapeutic medication has been approved as an effective treatment to date, lifestyle intervention through dietary modification and physical exercise plays a critical role in NAFLD management. In terms of dietary modification, Mediterranean diet is the most studied dietary pattern and is recommended in many guidelines, however, it may not be feasible and affordable for many patients.
Recently, a ketogenic diet and intermittent fasting have gained public attention and have been studied in the role of weight management. Generally, clinical practice guidelines of major international hepatology associations concordantly recommend weight reduction ≥7-10% in overweight or obese patients with NAFLD via hypocaloric diet, in combination with more physical exercise. Notably, successful weight reduction is associated with a reduction in liver enzyme levels and an improvement in histological findings related to liver steatosis, inflammation, and fibrosis. However, a 7-10% weight loss is not easily achievable or sustainable even in the context of clinical trials. Moreover, one-fifth of patients with NAFLD were classified as lean and 40% were non-obese; hypocaloric diet may not be the most appropriate treatment for such patients.
The Ketogenic Diet: A Potential Treatment?
More research shows that the keto diet can not only assist in weight loss, but that it can also help prevent Fatty Liver Disease and reverse fatty liver damage. But before we discuss why a keto diet can help with Fatty Liver Disease, let’s review what it is. The ketogenic diet consists of a very low carbohydrate diet, typically between 5-10 percent of total calories for the day. The aim of this paper is to present a review of the available publications and the current state of knowledge of the effect of the KD on NAFLD.
The most common type of keto diet consists of a high fat intake and low carbohydrate intake diet with an unrestricted total calorie intake. Tracking macronutrient levels are key to the keto diet. The goal of the keto diet is to achieve ketosis, or ketogenesis. Ketogenesis happens when your body uses fat instead of carbohydrates for energy. During ketogenesis, ketone bodies are formed - these are water-soluble molecules produced by the liver from fatty acids. Ketone bodies assist with weight loss thanks to their ability to induce satiety - or the sensation of fullness. This can lead to eating smaller portions without feeling hungry.
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Additional benefits of the keto diet include a reduction in triglycerides, abdominal fat, and risk for Metabolic Syndrome. As you work towards ketosis by reducing your carb intake, you will eat more foods that have a low-glycemic index like vegetables and certain fruits. These foods have less of an impact on your blood glucose levels than high-glycemic foods. A diet rich in low-glycemic index foods helps reduce insulin resistance and keep a steady blood sugar level.
How Keto Combats Fatty Liver
Keto doesn’t only offer weight loss and insulin level improvement to combat fatty liver. The diet also reduces lipogenesis. Lipogenesis is the process of converting carbohydrates into fatty acids, thus turning them into fat. This fat tends to end up in tissue around the midsection and the liver. By reducing the fat conversion process, less fat may be stored in the liver. Not only does a low-carb diet reduce insulin levels and lipogenesis - it can increase the rate fatty acids are broken down, or their oxidation rate. Reducing oxidative stress helps reduce inflammation and irritation in the liver.
Scientific Evidence Supporting Keto for Fatty Liver
It may seem counterintuitive to eat a high-fat diet to manage fatty liver. But more research highlights the beneficial effects of a high-fat, low-carbohydrate diet on Fatty Liver Disease. A 2018 study evaluated the effects of carbohydrate-restricted induced ketosis in 262 obese or overweight patients. After one year, participants had improved their blood sugar parameters, reduced their cardiovascular risk factors, and reduced the need for medications to manage high blood pressure and diabetes. Liver enzymes (ALT) used to measure liver health also improved in this trial. Participants also had sustained weight loss during this trial.
Another noteworthy result was a reduction in the diabetes lab test HbA1c, which related to improved liver enzyme levels regardless of weight loss. This highlights the role insulin sensitivity and blood glucose management can play in reducing the risk and worsening of fatty liver. A 2020 meta-analysis of 154 articles reviewed the benefits of the keto diet on Fatty Liver Disease. The authors concluded, in addition to caloric restriction, macronutrient distribution also plays a role in NAFLD treatment. This means high-fat keto diets had a greater and faster impact on liver fat content than only restricting carbohydrates. The meta-analysis also notes the role ketosis plays in liver fat reduction due to fatty acid oxidation.
Detecting Fatty Liver Early
Since fatty liver is a silent disease in its early stages, it can easily be missed without proper surveillance. Lab tests evaluating liver enzymes, including ALT and AST, can help identify fatty liver, but only after damage to liver health and function has begun. A liver biopsy is another way to determine if someone has Fatty Liver Disease, but it is invasive and carries risks such as bleeding and infection. The ezra Full Body scans up to 13 organs, including the liver.
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Cautions and Considerations
The ketogenic or keto diet is a high fat, low-carbohydrate eating plan. While some early studies suggest that keto may improve liver function in certain conditions like nonalcoholic fatty liver disease (NAFLD), its effects on advanced liver damage, such as cirrhosis, are less clear and potentially concerning. Liver cirrhosis is the final stage of chronic liver damage, where healthy tissue is replaced with scar tissue, impairing liver function. Diet plays a critical role in managing cirrhosis, and healthcare professionals often advise people to follow a balanced diet that supports liver health and prevents further complications.
However, several animal studies suggest that the keto diet may worsen liver injury in the context of fibrosis or cirrhosis. A 2021 study in mice found that a high fat ketogenic diet increased cholesterol buildup in the liver. It also noted that the keto diet increased liver inflammation and markers of scarring. These findings suggest that in cases of existing liver damage, a keto diet may accelerate liver dysfunction rather than improve it. However, in some short-term human studies, results are more promising. A 2020 study showed that a 6-day controlled ketogenic diet in adults with nonalcoholic fatty liver disease showed rapid reductions in liver fat and better insulin resistance. A 2025 review of very-low-calorie keto diets (VLCKD) showed substantial reductions in liver fat, improved insulin sensitivity, and lower liver enzyme levels.
However, it noted that long-term safety data, especially in cirrhosis, are still limited. These studies suggest short-term benefits in reducing fat and inflammation in early liver disease, but they involved people with fatty liver before cirrhosis developed. Cirrhosis represents advanced, irreversible liver damage. Most keto studies exclude patients with cirrhosis, and animal data warn of possible harm from increased fibrosis and inflammation. While ketogenic diets may help reverse liver fat and early fibrosis, there is no strong evidence supporting their safety or benefit in established cirrhosis.
Hugo Rosen, a liver disease specialist at the Keck School of Medicine of USC, said that’s why poor eating habits and fad diets that boost fat intake are particularly worrisome. Keto is attractive to many people because “you can eat a lot of tasty stuff - butter, red meat, cheese,” he said. “But you’re basically consuming 80% of your caloric intake from fat. Don’t overdo it on fats, Rosen recommends, especially from processed foods. Fructose and other sugars are a major concern as well, especially in sodas, candy, sugary cereals, sweetened juices and fast food. Instead, he suggests eating a well-balanced diet that features high-fiber foods, vegetables, fruits, fish, lean meats, nuts, eggs, seeds and unrefined oils. That’s one problem with fad diets, Rosen said - they can be difficult to stick with, especially if they cut out tasty items entirely. “Rapid weight loss is not recommended because it’s rarely sustainable,” he said.
The Importance of Professional Guidance
Anyone with liver disease who is considering a major dietary change like the keto diet should do so only under the close guidance of a hepatologist or clinical nutrition specialist. Beyond consulting with a doctor or nutritionist about their dietary habits, Rosen said people with NAFLD or NASH should consider moderate exercise to avoid a condition called sarcopenia, or low muscle mass and strength. Another concern is alcohol. Rosen said even moderate alcohol consumption (10 to 20 grams for women and 10 to 30 grams for men per day) can cause issues, citing a recent study that followed 60,000 Koreans with NAFLD. He also called on health providers to learn more about liver issues like NAFLD. “There definitely needs to be enhanced education of primary care providers to think of NAFLD and how frequently it occurs,” Rosen said.
Ketogenic Diet and Intermittent Fasting
In recent years, there has been a paramount interest in two dietary patterns, ketogenic diets and intermittent fasting (IF), and their benefits in the management of various health conditions have been evaluated. In this review, we focus on the role of the aforementioned dietary patterns on liver-related outcomes in patients with NAFLD.
IF refers to a period of voluntary abstinence from food and/or drink for caloric restriction, or no caloric intake over a specified period of time. There are three types of IF, alternate-day fasting (ADF), periodic fasting, and time-restricted fasting (TRF). The most well-known periodic fasting schedule is 5:2, which means having a regular diet for 5 days a week and fasting or near fasting for 2 days a week. The most well-known TRF schedule is 16:8, which means fasting for 16 h and eating for 8 h a day . IF has gained attention as an effective strategy for weight loss in people with NAFLD, given that weight loss is the mainstay of NAFLD management for fat content and fibrosis extent reduction. Generally, people following IF have approximately 10% or 300 kcal less energy intake than people taking normal diets or in non-fasting periods .
Potential Therapeutic Mechanisms of Ketogenic Diet in MAFLD
Reduction in Insulin Resistance
It is known that insulin resistance is one of the main factors underlying MAFLD development, which has been confirmed in numerous publications. Insulin resistance occurs as a result of prolonged, elevated blood glucose levels and fatty liver itself. Insulin resistance impairs glucose disposal and leads to hyperinsulinemia in a vicious cycle. Then, fatty liver degeneration starts to occur through increased de novo synthesis of fatty acids in the liver, inflow of fatty acids from the adipose tissue (absence of lipolysis inhibition), and increased production of proinflammatory adipokines and cytokines in the adipose tissue. All this is actually stimulated by hyperinsulinemia and leads to the progressive deposition of triglycerides (TG) in the liver parenchyma and MAFLD development.
One of the benefits of the ketogenic diet is the reduction in insulin and glucose concentrations in the blood, thus improving sensitivity of cells to insulin action. A number of publications demonstrate that KD decreases concentrations of insulin, glucose, and glycated hemoglobin (HbA1c) through numerous mechanisms of action. The first of them is body weight reduction (owing to the nature of the ketogenic diet, achieving a calorie deficit is extremely easy and intuitive, with no need to count calories). This, in turn, is associated with an improvement in insulin sensitivity (including as a result of the mechanism of increasing the level of adiponectin (the concentration of which is lower in obese people and increases during the reduction in fat tissue), which has anti-inflammatory effects and improves insulin sensitivity), reduction in glycaemia and insulin concentration values, and, consequently, with an improvement in MAFLD. It is one of the key mechanisms, although not the only one, since low-carb diets have been found to improve the sensitivity to insulin, even in the absence of major weight loss.
The second mechanism of action is associated with the absence of monosaccharides (and significant reduction in the total amount of carbohydrates to <50 g daily) in the ketogenic diet, which directly prevents excessive fluctuations of glucose levels and insulin spikes . The stabilization of glycaemia and insulin concentration contributes to an improvement in the MAFLD condition. The third mechanism consists of the fact that a ketogenic diet almost entirely eliminates fructose (present, among others, in fruit juices, high-fructose syrups, or fruits), which can disturb insulin signaling in the liver (including as a result of mechanisms such as promoting de novo lipogenesis (DNL), inducing endoplasmic reticulum (ER) stress, impairing fatty acid oxidation (FAO), and inducing hepatitis). An elimination of that component would, thus, exert a favorable effect on insulin sensitivity.