Read time: 11 minutes

• Type 2 diabetes and nonalcoholic fatty liver disease are closely linked. Insulin resistance is the common factor between them. 
• People with fatty liver disease rarely experience symptoms, so consistent checkups with your healthcare team are crucial for early detection.
• The best way to reverse fatty liver disease is through weight loss and specific lifestyle changes such as following the Mediterranean style of eating.

Type 2 diabetes and nonalcoholic fatty liver disease (NAFLD) can be thought of as two sides of the same coin. People living with type 2 diabetes are twice as likely to develop fatty liver disease, and people with fatty liver disease are twice as likely to develop type 2 diabetes. 

What’s the common factor between these conditions? 

It’s insulin resistance. In both obese and non-obese people, research shows that high insulin resistance is the most significant factor in predicting NAFLD.

“The relationship with insulin resistance and fatty liver disease is bidirectional,” explains Alexa Stelzer, RDN, LD, CDCES, and clinical health coach at One Drop. “Insulin resistance can cause fat to build up in the liver and then the fat itself makes the body more insulin resistant.”

This unfortunate phenomenon is affecting more and more people around the world, particularly in the U.S. Roughly 24% of American adults live with NAFLD today. By 2040, it’s estimated that NAFLD will likely impact more than half the U.S. adult population. 

Read on to understand the science behind this common condition, the connection of fatty liver disease with insulin resistance and diabetes, and steps you can take to reverse fatty liver disease. 

The Connection Between Insulin Resistance and Fatty Liver Disease 

To understand the connection between insulin resistance and fatty liver disease, let’s take a step back and look at the role insulin plays in the body.

Insulin is a hormone made by the pancreas that helps the body use glucose (a.k.a. sugar) for energy. All cells need glucose for energy, but glucose can’t enter them directly. Insulin “unlocks” cells, allowing glucose to enter them and provide this energy.

Insulin resistance happens when your cells don’t respond well to insulin and they can’t easily absorb the energy from glucose. The cells literally “resist” the insulin. As a result, the glucose that can’t enter our cells sits in our bloodstream. This causes high blood sugar (hyperglycemia). Glucose is then stored as fat rather than utilized for producing energy.

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Additionally, when the body becomes insulin resistant, the pancreas produces more insulin to compensate. This extra insulin tells the liver to produce more fat than it can get rid of, leading to fat accumulation in the liver cells. 

Accumulating fat in the liver means it can’t do its primary jobs. Located in the upper right part of your abdomen, the liver is one of the largest and most vital organs in the body. Mostly made up of cells called hepatocytes, the liver plays an important role in processing nutrients absorbed in the gut and the regulation of glucose levels in the bloodstream. 

Most importantly, the liver acts as a filter that removes harmful substances and toxins from the blood, so they can be eliminated. 

What Are the Stages of Fatty Liver Disease?

Fatty liver disease is progressive, meaning that if nothing is done, the condition can get worse over time and cause life-threatening problems. At the early stages, when there’s a buildup of fat in your liver, but no damage yet, the condition is called nonalcoholic fatty liver disease (NAFLD). 

If left untreated, the fat buildup can hurt the liver cells (hepatocytes), causing them to swell and start to die. When this happens, inflammation arises and it’s called nonalcoholic steatohepatitis (NASH). As collagen fibers replace the dead hepatocytes, scarring (fibrosis) occurs. 

When scar tissue builds up over years or decades, the liver becomes harder and has a tough time functioning. This condition is called cirrhosis and can lead to liver failure as well as increase the risk of liver cancer.

Other Risk Factors for Fatty Liver Disease

Besides insulin resistance and type 2 diabetes, lifestyle factors such as a diet high in fructose or sitting for more than three hours per day play a big role in NAFLD. 

Other risk factors for fatty liver disease include:

• A genetic predisposition

• Abnormal levels of cholesterol
• Imbalanced gut microbiome
• Being overweight or obese

Symptoms of Fatty Liver Disease

Like hypertension, NAFLD is often “silent.” This means that there aren’t a lot of noticeable symptoms. But when symptoms are present, they can include:

• General fatigue or mental confusion
• Sharp or dull pain in the upper right side of the abdomen

If NAFLD has progressed to NASH, then you might also experience these symptoms: 

• Swollen abdomen and legs (edema)
• Enlarged blood vessels
• Yellow-tinted skin and whites of the eyes (jaundice)
• Red palms
• Enlarged spleen

If you’re living with any of the risk factors for fatty liver disease, your doctor is likely also checking for signs of fatty liver disease even if you’re not experiencing symptoms. If any of these symptoms are present, be sure to get in touch with your healthcare team right away to prevent fatty liver disease from progressing to something more serious. 

How is Fatty Liver Disease Diagnosed?

Fatty liver disease is diagnosed when more than 5% of liver cells contain liver fat. Doctors use blood tests, imaging scans, and liver biopsies to diagnose fatty liver disease.  

A blood test can detect certain markers that could mean fatty liver disease:

• Elevated alanine aminotransferase (ALT) can indicate liver inflammation. Doctors disagree on exactly what ALT level indicates NAFLD, but different studies have suggested a value between 26 and 66 IU/L.
• Aspartate aminotransferase (AST) is the other liver enzyme that can be used to gauge liver function. Many doctors use the AST to ASL ratio to detect fibrosis in the liver. 

If the blood test shows elevated levels of ALT or AST, an ultrasound or MRI scan might be ordered to confirm it. These imaging tests can help the doctor spot fat deposits and scar tissue in the liver.

The gold standard for diagnosing NAFLD is the liver biopsy, which is a procedure in which your doctor takes a small portion of your liver tissue and a pathologist examines it for signs of disease. 

There are three kinds of liver biopsy: percutaneous liver biopsy (a needle is inserted through your skin above the kidney area), transjugular liver biopsy (a needle is inserted into the jugular vein located in your neck and passed through the veins to take a small piece of tissue), and a surgical liver biopsy (if you’re receiving surgery for another reason, the doctor captures a small piece of tissue at the same time).

Is There Medication for Fatty Liver Disease?

Currently, no medications have been approved to treat either NAFLD or NASH, but there are many different companies currently exploring options. 

“One of the most promising solutions is an oral medication called Lanifibranor,” says Stelzer. “This medication, being developed by Inventiva Pharma, has shown promising results in studies thus far.”

Another type of medication being investigated for its ability to treat NASH are a class of medications called GLP-1 receptor agonists (GLP-1 RAs). You may have heard of Ozempic, Rybelsus, or Trulicity—they’ve been generating a lot of attention as celebrities have been using them as an appetite suppressant and quick-fix weight loss medication, causing shortages among people with type 2 diabetes. 

Trials with semaglutide, a GLP-1 RA approved to treat diabetes and obesity, have shown promising results in slowing the progression of NASH. Studies are also being done on a variety of other medications that impact liver physiology.

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How to Reverse Fatty Liver Disease

The good news about fatty liver disease is that it’s reversible if caught early enough and before permanent damage has been done to the liver. This is why consistent screening is so critical for people living with insulin resistance, type 2 diabetes, or another risk factor. 

“Being diagnosed with fatty liver disease early on is an opportunity to take action and reduce the risk of symptoms,” says Stelzer. “A positive aspect is that the key lifestyle modifications for managing fatty liver disease are very much aligned with how you might already be trying to work on obesity, type 2 diabetes, or another metabolic condition.”

Lose excess weight

The number one way to reverse fatty liver disease is through weight loss. An important research study showed that losing 10% of body weight improved markers for fatty liver disease, but losing 5% has also been shown to reduce fat buildup in the liver. Every little bit of weight loss counts. 

Of course, there are many different approaches that you can take to lose weight, but some of the best research when it comes to fatty liver in particular suggest exercising regularly and following the Mediterranean diet.

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Try the Mediterranean style of eating

This eating pattern emphasizes heart-healthy foods prevalent in countries that border the Mediterranean Sea. The Mediterranean diet has been shown to improve signs of fatty liver disease even when it doesn’t cause weight loss. 

When eating this way, you’ll want to reduce overall carbohydrate intake, especially sugars and refined carbs, and increase monounsaturated and omega-3 fatty acid intake. To get started, focus on plant-based foods, lean protein, nuts, fish, and olive oil while limiting red meat, butter, and added sugar. 

Exercise regularly

Even a small amount of exercise can greatly improve fatty liver disease. 

Incorporating both aerobic and resistance training in your routine has been shown to be most effective. Generally, it’s recommended that you aim for 150 minutes of moderate-intensity aerobic exercise per week along with strength endurance training at least two to three times a week. HIIT workouts are a great option for people pressed for time.

The key to creating a sustainable workout routine is to start small and do something you enjoy. If you’re feeling overwhelmed, you could begin by standing up and going for a short walk if you tend to sit for long stretches of time. Gradually, you can add more strenuous activities and build up to the recommended amount of exercise. Remember, every moment of movement makes a difference.

Other Factors that Could Improve Fatty Liver Disease

Besides losing weight, eating healthy, and getting exercise, new research has revealed some other interesting factors that could help reverse fatty liver disease.

Limit exposure to phthalates

Phthalates are chemicals that make plastics more durable. They’re found in numerous everyday products including vinyl flooring, lubricating oils, soaps, shampoos, and hairsprays. Research shows that they mimic naturally occurring hormones like estrogens and androgens which can in turn interfere with the endocrine system. A research study from 2020 reports that “there is sufficient evidence that links metabolic disorders development through phthalates exposure.” For more information, check out this guide to limiting phthalate exposure from the Environmental Working Group. 

Cut back on fructose

Fructose is often added into artificially sweetened drinks and other sweet foods. Eating a lot of fructose has been associated with increased risk of fatty liver, fibrosis, obesity, and insulin resistance. To cut back on eating fructose, check labels for these ingredients: fructose, high-fructose corn syrup, honey, agave syrup, invert sugar, maple-flavored syrup, molasses, palm or coconut sugar, or sorghum.

Consider intermittent fasting

While this style of eating is not appropriate for everyone, if you’re able to tolerate not eating for an extended period of time (i.e. a typical intermittent fast consists of 16 hours of not eating and eight hours of eating per day), research shows that intermittent fasting regimens may be a promising approach to losing weight and improving overall metabolic health. Always speak with your healthcare team before trying a new approach to eating like intermittent fasting.

What About Supplements for Fatty Liver Disease?

No supplements have been proven to cure NAFLD. Some people experience benefits from supplementing with certain nutrients such as choline, but it’s best to proceed with caution if you’re considering supplementation. 

“It's not that none of these supplements work,” explains Stelzer. “It's just that we don't have adequate evidence to be able to recommend a specific dosage and to know in which populations these supplements could be helpful versus harmful. Supplements can have interactions with other medications or unwanted side effects. They’re also an added expense.”

Instead of supplements, it’s generally recommended to focus on whole food. Many of the studies that look at nutrients like choline have been looking at the overall diet, so we can’t be sure that you can isolate these nutrients and have the same effect. There could be a symbiotic effect that comes from eating the nutrient in a whole food. 

The Bottom Line on Fatty Liver Disease

Fatty liver disease is a progressive condition often without symptoms that is intricately linked with insulin resistance. If caught early enough, you can reverse fatty liver disease through losing weight and making lifestyle changes. 

“If you’re diagnosed with fatty liver disease and insulin resistance, rather than feeling like you have to do all these additional things to manage both, you can really double down and just focus on eating healthy and exercising more,” says Stelzer. “These two things can have a really big impact across the board for all of your health conditions.”

Making the lifestyle changes necessary to reverse fatty liver disease takes time and patience, but it’s absolutely doable. By starting small, building habit loops into your day, and leaning on family, friends, and your healthcare team, you can make changes that last. 

Finding the right social support is critical in improving your health. Consider connecting with a One Drop clinical health coach with a 14-day free trial to One Drop Premium. All One Drop clinical health coaches are certified diabetes care and education specialists with years of experience supporting people in making long-term changes for better health and a more fulfilling life. If you’re looking to reverse fatty liver disease or improve your overall health, you don’t have to go it alone. Reach out today.

This article has been clinically reviewed by Hanna Rifkin, RD, CDCES, clinical health coach at One Drop.