A new article in Systematic Reviews paints a mixed picture for the use of diabetes medications to help those with non-alcoholic fatty liver disease (NAFLD).
The researchers identified 18 trials investigating whether diabetes medications meaningfully improved signs of NAFLD. The most promising drug was the GLP-1 agonist liraglutide, which improved liver parameters and helped with weight loss. Another diabetes drug, pioglitazone, improved liver function and amount of liver fat, although it also stimulated weight gain which caused the authors to question if it is truly a reasonable long-term solution. Metformin, on the other hand, improved weight and glucose control but had no beneficial effect on NAFLD.
This study highlights how drugs may not be the best approach for fixing the damage caused by metabolic disease and over-consumption of simple carbohydrates. As the authors mention, lifestyle change remains first-line therapy for the treatment of fatty liver disease. But how do we know which lifestyle is best? The authors did not mention specifics, thus leaving us to wonder.
Fortunately, we have emerging evidence that low-carb and ketogenic diets improve fatty liver while also helping with glycemic control and weight loss, an impressive combination rarely seen with medications. As we reported earlier, studies have shown that carbohydrate restriction changes liver metabolism, stimulating the breakdown of liver fat. Another study mentioned in the same post showed that when children substitute sugar for more complex forms of starch, they experience reduced amounts of liver fat.
Yet another impressive study found that despite equal weight loss, a low-carb Mediterranean diet was better than a low-fat diet for reversing liver fat and signs of NAFLD. And finally, Virta Health published a subset of its data showing that one year on a ketogenic diet improved non-invasive tests for NAFLD and liver scarring.
Do we need more evidence that carbohydrate restriction benefits fatty liver? I certainly don't think so. It seems clear to me that carbohydrate restriction should be first-line therapy. While national guidelines and contemporary medical practice will likely call for more studies, in the meantime, millions of patients need help. These are real people suffering with a dangerous medical condition that could lead to liver failure.
Why wouldn't doctors everywhere suggest carbohydrate restriction? If you are a medical provider, please consider this even without societal guidelines. And if you're a patient suffering from NAFLD, bring this up with your doctor to see if a low-carb or keto diet is an appropriate treatment to consider.
Thanks for reading,
Bret Scher, MD FACC
