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To answer this question, we’re going to use Guyton’s Textbook of Medical Physiology on page 927. This is what it says:
Effect of insulin lack on causing a fatty liver
Strange as it may seem, though insulin lack causes the dissolution of the fat stores in adipose tissue, it causes a great increase in the amount of stored triglycerides in the liver, leading to a very fatty liver. The reason is the following: the excess of free fatty acids in the blood causes rapid diffusion of fatty acids into the liver cells.
So yes, keto can cause fatty liver or hepatic steatosis.
Now, what exactly does that mean, and is it something to be worried about?
In this article:
- What happens when you have a fatty liver?
- Why does the ketogenic diet cause fatty liver and how can you fix it
- Other Ways to Prevent Fatty Liver Disease
What happens when you have a fatty liver?
At it's most basic, fatty liver disease is when you have too much fat in your liver cells. That said, when people use the term “ fatty liver,” there are actually two conditions that they could be discussing: nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH).
This is an important distinction: NAFLD, on one hand, is largely benign and really common (it’s now thought to affect between 20-40% of the US population). It's usually caused by:
- Insulin resistance (caused by too much sugar or glucose)
- Oxidative stress
- High blood sugar (hyperglycemia), including prediabetes or type 2 diabetes
- High levels of fats (particularly triglycerides and saturated fat) in the blood
NASH liver disease, on the other hand, is essentially when NAFLD becomes problematic and starts to cause symptoms. This is more likely to happen to older people, people with diabetes, or individuals with a high concentration of body fat in the abdomen. It's much more serious and it implies both inflammation and damage to liver cells. It can also imply other health problems like heart disease.
Generally speaking, when we’re talking about keto-related fatty liver, we’re focusing on NAFLD (whew!). That said if you notice any concerning NASH liver disease symptoms like:
- Abdominal pain
- Weight loss
You should look into getting a biopsy or a liver function test to check your liver enzymes and see if you need any further treatment. This is really important. Undiagnosed NASH can lead to serious medical issues, including fibrosis (scarring of the liver), cirrhosis, and liver cancer.
Why does the ketogenic diet cause fatty liver and how can you fix it
Now you may be thinking that’s weird, I thought that the ketogenic diet was healthy? Now I have to worry about it causing fatty liver disease?
Well, not necessarily. It is healthy when done correctly, and it won't always lead to fatty liver disease or other "keto health problems" like keto flu or keto fatigue. In my videos, I never recommend a straight ketogenic diet. I always recommend adding a bunch of vegetables to your daily meals. Why? Well, like with any diet, there’s a healthy way to do it an unhealthy way. There are lots of vegetarians, for example, that eat pasta and bread-based diet (while others stick to legumes, leafy greens, and a wide range of fruit and plant-based proteins).
It’s the same thing with keto. See, the classic keto diet is really unspecific about where you’re getting your carbohydrates, your protein, and your fat from - it just says high fat, moderate protein, and low carbohydrates (below 20 g of carbs or at most 20-50 carbs). The latter be:
- A piece of bread
- An apple or some berries
- Crackers, chips, etc
This grey area leaves room for error and unhealthy choices. Many people, for example, just stick to bacon, nuts, and other high-fat foods without incorporating any vegetables or balancing meals. That’s why I’ve tightened up my keto rules a little bit more.
You Need Vegetables
What you want to do is beef up your vegetables. You want to do at least 7-10 cups of vegetables each day - and you can really have an unlimited amount (they don't count in those 20-50 grams of carbohydrates). This will:
- Help make sure that you get enough potassium and other vital nutrients
- Keep that liver flushed out
- Be anti-inflammatory and help you get the water you need in your diet
- Promote healthy weight loss
- Promote a healthy digestive tract, along with optimum hydration.
This is also the number 1 way to keep you from developing a fatty liver on the keto diet. Some of the top vegetables that you should incorporate include:
- Brussel sprouts
- Red radish
- Collard greens
- Sea Kelp
That said, here are some other tips and tricks to make sure you’re on track:
Other Ways to Prevent Fatty Liver Disease
This will decrease your body's overall fat content, increase muscle content, improve your circulation, and more.
Limit OTC medications
and make sure that you're taking the medication if you have diabetes, insulin resistance, or high triglyceride levels
Maintain a healthy weight:
Resolving fatty liver disease ultimately calls for weight loss (although that doesn't mean eating low-fat foods). Tackling that is a good place to start.
Cut back on carbs:
It may seem like the logical answer to resolving fatty liver disease is to cut down on fat - but that's usually not the source. Research shows that only about 16% of liver fat in people with NAFLD comes from dietary fat. Most of it usually comes from fatty acids in their blood. On top of that, about 26% of liver fat is formed from DNL (de novo lipogenesis) - and ultimately from excess carbs.
Include foods that promote liver fat loss:
This includes green tea, monounsaturated fats, whey protein, and soluble fiber.
Even if you don't have NASH, consuming alcohol can still be a problem. Avoid it if you can.
Incorporate choline and methionine:
These compounds have both been shown to correct or reverse NAFLD-related issues. Make sure that you consume foods that are high in both (things like egg yolk, liver, grass-fed dairy, beef, chicken, pork, nuts, and cruciferous vegetables). Alternatively, incorporate a choline supplement into your routine. We recommend 400-500 mg, though you can go as high as 3000 mg if you want.
Incorporate healthy supplements:
Like Omega-3 fatty acids and milk thistle.
Check out our entire liver-friendly keto diet plan here.