The Best Diet for Fatty Liver Disease: Does Keto Really Beat Out the Mediterranean Diet?

You walked into your doctor’s appointment feeling fine, then walked out with a fatty liver diagnosis. The problem with a sudden diagnosis, though, is often not knowing where to start to make a change. You scour the web for the best fatty liver diet, but see conflicting results. Is there really one eating plan that can help reverse nonalcoholic fatty liver disease (NAFLD), now known as metabolic dysfunction-associated steatotic liver disease (MASLD)? New research on the keto diet and fatty liver may just surprise you. 

What is fatty liver disease? 

“A fatty liver is exactly what it sounds like—too much fat has accumulated in the liver,” says Catherine Metzgar, PhD, RD, director of coaching at Virta Health. “Some liver fat is normal, but too much can affect how well the liver works and may eventually lead to inflammation and scarring.”

Fatty liver is closely connected to insulin resistance, which can cause more fat to travel to the liver. The liver then turns excess carbs into fat, explains Metzgar. That connection with insulin resistance is why fatty liver is especially common in people with:

• Prediabetes
• Obesity
• Type 2 diabetes 

“Alcohol, medications, genetics and other health conditions can also contribute to the development of fatty liver,” she adds. 

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What research shows on the keto diet for fatty liver

“A ketogenic diet significantly reduces carbohydrates, includes a moderate amount of protein and uses fat as the primary source of energy,” explains Metzgar. “The right amount of carbohydrate varies, but it is often between 30 and 60 grams per day.”

When the amount of carbs you consume is reduced, the body relies on fat for fuel, using less insulin, says Metzgar. “The liver turns some of that fat into ketones, which the body and brain can use for energy,” she adds. “This natural state is called nutritional ketosis.”

In a new Cell Metabolism study conducted by WashU researchers, more than 50 adults with obesity, prediabetes and liver fat were assigned to follow either the keto diet, Mediterranean diet or a low-fat plant-forward diet for about five months. They found that liver fat decreased by 67 percent in the keto group compared to only 45 percent in the Mediterranean group. An added bonus: 50 percent of the keto diet group reversed prediabetes compared to only 29 percent of the Mediterranean group and seven percent of the low-fat group.

So why did keto excel when it came to liver health and blood sugar? “When eating fewer carbohydrates, participants had less glucose to manage, so their pancreases did not need to release as much insulin to bring glucose back down,” explains Metzgar. “The liver also had less excess glucose available to turn into fat, while lower insulin levels allowed the body to use more fat for energy.”

Is keto really the best diet for fatty liver?

“A well-formulated ketogenic diet can be a very effective strategy for reducing liver fat, especially for someone who also has insulin resistance, prediabetes or type 2 diabetes,” says Metzgar. 

But Metzgar says the best approach for combatting fatty liver and supporting your metabolic health more generally is the one that provides enough nutritional value and is sustainable for you. “For some people, that may be a ketogenic diet,” she says. “For others, a Mediterranean or less restrictive lower-carbohydrate approach may be a better fit.”

Metzgar also says some people may be a better fit for keto than others. Those who may benefit include people with:

• Obesity
• Prediabetes or type 2 diabetes
• Insulin resistance 
• Certain seizure disorders

People who may not be a good fit for keto and should seek medical guidance first include those with:

• Type 1 diabetes 
• An eating disorder 
• Kidney, liver or pancreatic disease
• Pregnant or breastfeeding 
• An SGLT2 inhibitor such as Jardiance or Farxiga

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How to give the keto diet for fatty liver a try

Your first step should be talking with a healthcare professional about the keto diet, especially if you take high blood pressure or diabetes medication, says Metzgar. “These conditions can improve quickly when carbohydrates are reduced, so medication may need to be adjusted,” she adds. 

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Metzgar also shares four tips to help you get started after you’ve gotten your doctor’s go-ahead:

• Prioritize protein: Aim to include fish, eggs, meat, poultry, tofu or another protein at each meal, recommends Metzgar. “Protein supports fullness and muscle health, but you do not need excessive amounts,” she adds. 
• Focus on whole foods and non-starchy veggies: Center your meals around foods that are minimally processed and non-starchy vegetables such as leafy greens, cauliflower, zucchini, peppers and broccoli, says Metzgar. 
• Try carb-lowering strategies: Metzgar recommends swapping a higher carb food for a lower carb food such as cauliflower instead of potatoes, reducing your carb portion or trying to consume it less often and paying attention to refined and hidden carbs in sauces and drinks. 
• Stay hydrated and prioritize electrolytes: Metzgar says fluids and electrolytes are especially important when on the keto diet, as the body releases more sodium and water when fewer carbs are consumed. Drink plenty of water (at least eight, 8-oz. cups daily), and consider an electrolyte supplement such as Create Creatine + Electrolytes Classic Lemonade. 

The bottom line on keto for fatty liver

With so many diet plans available all promising to help reverse health issues like fatty liver disease, it’s hard to know where to truly start. But research and our experts agree the keto diet can be helpful for reducing liver fat content if it’s a good fit for you. And remember: When it comes to reversing a fatty liver diagnosis or managing any health diagnosis, the truth is there’s rarely one answer. So don’t forget to give things like brisk walking, strength training and managing any underlying health conditions a try too.

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