Between 30 and 40% of adults in the United States have non-alcoholic fatty liver disease, making it a fairly common problem.  In this article, I’ll share a brief refresher on the characteristic features of non-alcoholic fatty liver disease (NAFLD), and specifically non-alcoholic steatohepatitis (NASH), and I’ll share a few elements of a lifestyle-based approach that you can utilize to help your patients support optimal liver health.
What are non-alcoholic steatohepatitis (NASH) and non-alcoholic fatty liver disease (NAFLD)?
Non-alcoholic fatty liver disease, also referred to as NAFLD, is an umbrella term for a group of liver conditions that are not associated with alcohol use or abuse. NAFLD is characterized by an abundance of fat being stored in the cells that comprise the liver.
There are two types of NAFLD: (1) simple fatty liver and (2) non-alcoholic steatohepatitis, also known as NASH. Simple fatty liver is characterized by an increase in fat in the liver cells; however, there tends to be little to no inflammation present. Non-alcoholic steatohepatitis or NASH, on the other hand, is a type of NAFLD that is characterized by liver inflammation and liver cell damage due to fat build-up in the liver.
Simple fatty liver is not usually associated with liver cell damage or long-term complications, whereas NASH is frequently accompanied by inflammation and liver cell damage that can progress to fibrosis or scarring of the liver. Potential complications of NASH include liver cirrhosis and hepatic cancer.
What is the underlying cause of NAFLD?
The cause(s) of NAFLD and NASH are still somewhat unclear; however, it is clear that diet- and lifestyle-related conditions like insulin resistance, being overweight or obese, diabetes, hyperlipidemia, large waist circumfrence, and other metabolic syndrome-related conditions significantly increase our risk of being diagnosed with these conditions.
We also know that obesity (especially with large waist circumference), hypertension, hyperlipidemia, hyperglycemia, and metabolic syndrome increase our risk of developing NASH, as opposed to simple fatty liver. 
Although less common, the following factors and states of being may also increase our patients’ risk of developing NAFLD and NASH:
Rapid weight loss
Hepatitis C and other infections
History of cholecystectomy
Fat storage disorders
Medications such as amiodarone, diltiazem, glucocorticoids, highly active antiretroviral therapy, methotrexate, synthetic estrogens, tamoxifen, and valproic acid
An approach to addressing NAFLD and NASH
The treatment for NAFLD and NASH includes addressing known risk factors like hypertension and insulin resistance. I have found a comprehensive approach that addresses each aspect of metabolic syndrome (if present) and includes sustainable weight loss, if indicated, to be an extremely effective means of normalizing elevated liver enzymes, if applicable, and addressing NAFLD and NASH.
Here are three of the interventions I’ve found to be helpful in addressing NAFLD:
1. Emphasize healthy movement
Just as exercise is an essential part of maintaining a healthy weight and blood sugar, it’s also an important part of addressing NAFLD (including NASH). [2,3] In fact, recent research suggests that exercise has beneficial effects on NAFLD through multiple mechanisms, including through enhancing lipid metabolism and insulin sensitivity and through facilitating beneficial changes to the gut microbiome.
2. Enhance insulin sensitivity and normalize blood sugar
Optimizing blood sugar levels has an extremely beneficial effect on NAFLD as well. I have found adopting a varied mostly plant-based diet and implementing various forms of intermittent fasting to be extremely beneficial in addressing NAFLD and optimizing liver health. Research suggests that intermittent fasting with concomitant weight reduction has been associated with rapid improvements in both diabetic and non-diabetic individuals with fatty liver disease.
3. Support optimal liver health using beneficial herbs and nutrients
Research supports the intelligent use of a variety of herbs and herbal extracts in the treatment of NAFLD. Herbs and active herbal constituents that have been demonstrated to be beneficial in addressing this condition tend to fall into three different categories:
Hepatoprotective herbs like Silybum marianum (Milk thistle seed)
Anti-inflammatory herbs like Zingiber officinalis (Ginger rhizome)
Hypoglycemic herbs like berberine-containing herbs**
Hypolipidemic herbs like Allium sativum (Ginger)
Additionally, research suggests that antioxidants like omega-3 fatty acids  and glutathione  may be effective means of addressing NAFLD, particularly in the early stages in the case of omega-3 fatty acids.
In closing, NAFLD is an umbrella term for a fairly common group of conditions that can be aggravated by diet- and lifestyle-related conditions. The most successful and generally accepted means of addressing NAFLD involves addressing the metabolic conditions that increase risk and severity of NAFLD. I’ve found a comprehensive approach that emphasizes healthy movement, optimizing diet, employing therapeutic fasting, and supplementing with beneficial herbs and nutrients to be an effective means of addressing NAFLD.
**Please note contraindications and only use or recommend if you are aware of contraindications and trained in the safe use of this herbal medicine.
 Diehl, A. M., MD, & Tetri, B. A., MD. (2016, November 1). Nonalcoholic Fatty Liver Disease & NASH. Retrieved January 14, 2021, from https://www.niddk.nih.gov/health-information/liver-disease/nafld-nash/
 Oh, S., So, R., Shida, T., Matsuo, T., Kim, B., Akiyama, K., Isobe, T., Okamoto, Y., Tanaka, K., & Shoda, J. (2017). High-Intensity Aerobic Exercise Improves Both Hepatic Fat Content and Stiffness in Sedentary Obese Men with Nonalcoholic Fatty Liver Disease. Scientific reports, 7, 43029. https://doi.org/10.1038/srep43029
 Rezende, R. E., Duarte, S. M., Stefano, J. T., Roschel, H., Gualano, B., de Sá Pinto, A. L., Vezozzo, D. C., Carrilho, F. J., & Oliveira, C. P. (2016). Randomized clinical trial: benefits of aerobic physical activity for 24 weeks in postmenopausal women with nonalcoholic fatty liver disease. Menopause (New York, N.Y.), 23(8), 876–883. https://doi.org/10.1097/GME.0000000000000647
 Houttu, V., Boulund, U., Grefhorst, A., Soeters, M. R., Pinto-Sietsma, S. J., Nieuwdorp, M., & Holleboom, A. G. (2020). The role of the gut microbiome and exercise in non-alcoholic fatty liver disease. Therapeutic advances in gastroenterology, 13, 1756284820941745. https://doi.org/10.1177/1756284820941745
 Drinda, S., Grundler, F., Neumann, T., Lehmann, T., Steckhan, N., Michalsen, A., & Wilhelmi de Toledo, F. (2019). Effects of Periodic Fasting on Fatty Liver Index-A Prospective Observational Study. Nutrients, 11(11), 2601. https://doi.org/10.3390/nu11112601
 Xu, Y., Guo, W., Zhang, C., Chen, F., Tan, H. Y., Li, S., Wang, N., & Feng, Y. (2020). Herbal Medicine in the Treatment of Non-Alcoholic Fatty Liver Diseases-Efficacy, Action Mechanism, and Clinical Application. Frontiers in pharmacology, 11, 601. https://doi.org/10.3389/fphar.2020.00601
 Yang, J., Fernández-Galilea, M., Martínez-Fernández, L., González-Muniesa, P., Pérez-Chávez, A., Martínez, J. A., & Moreno-Aliaga, M. J. (2019). Oxidative Stress and Non-Alcoholic Fatty Liver Disease: Effects of Omega-3 Fatty Acid Supplementation. Nutrients, 11(4), 872. https://doi.org/10.3390/nu11040872
 Honda, Y., Kessoku, T., Sumida, Y., Kobayashi, T., Kato, T., Ogawa, Y., Tomeno, W., Imajo, K., Fujita, K., Yoneda, M., Kataoka, K., Taguri, M., Yamanaka, T., Seko, Y., Tanaka, S., Saito, S., Ono, M., Oeda, S., Eguchi, Y., Aoi, W., … Nakajima, A. (2017). Efficacy of glutathione for the treatment of nonalcoholic fatty liver disease: an open-label, single-arm, multicenter, pilot study. BMC gastroenterology, 17(1), 96. https://doi.org/10.1186/s12876-017-0652-3