World Journal of Nutrition and Health
ISSN (Print): 2379-7819 ISSN (Online): 2379-7827 Website: Editor-in-chief: Srinivas NAMMI
Open Access
Journal Browser
World Journal of Nutrition and Health. 2018, 6(1), 11-22
DOI: 10.12691/jnh-6-1-2
Open AccessArticle

Dietary Intervention in Clinical Improvement of Nonalcoholic Fatty Liver Patients

Aliaa Abdel Moneim1, , Dalia I Tayel1, Ahmed Zeid2, Olfat Darwish1, Khaled Matrawy3 and Mohamed Eid4

1Nutrition Department, High Institute of Public Health, Alexandria University, Egypt

2Hepatobilliary Unit, Faculty of Medicine Alexandria University, Egypt

3Radiodiagnosis Department, Institute of Medical Research, Alexandria University, Egypt

4Radiology Department, Faculty of Medicine, Alexandria University, Egypt

Pub. Date: November 01, 2018

Cite this paper:
Aliaa Abdel Moneim, Dalia I Tayel, Ahmed Zeid, Olfat Darwish, Khaled Matrawy and Mohamed Eid. Dietary Intervention in Clinical Improvement of Nonalcoholic Fatty Liver Patients. World Journal of Nutrition and Health. 2018; 6(1):11-22. doi: 10.12691/jnh-6-1-2


Nonalcoholic fatty liver disease (NAFLD) is related to lifestyle practices including dietary intake and sedentary lifestyle. The common treatment is directed towards weight loss, which is usually difficult to be achieved or maintained. Therefore, a nutritional intervention program aiming at improving the metabolic health not only focusing on weight loss was conducted. Total of 110 patients referred to the hepatology outpatient clinic in the Main Alexandria University Hospital were selected based on ultrasound examination. Data about dietary intake, habits, and practices, and lifestyle practices were collected. Body composition measurements, laboratory investigations, clinical examination and measuring liver fat by ultrasound were assessed. A Mediterranean diet reduced in total carbohydrates, very low in refined sugars, rich in vegetables, moderate in fruits and low fat dairy, with more incorporation of fish, legumes, olive oil, nuts and seeds; was used for 12 weeks and different exercise advices were provided to patients. A significant reduction in the amount of liver fat, together with improvement in lipid profile, liver enzymes, blood pressure, fasting blood glucose and waist circumference were reported. The criteria of metabolic syndrome and gastrointestinal tract symptoms were improved among the majority of patients, with moderate reduction in body weight 5-6%. Liver fat content estimated by ultrasound was associated with the amount of dietary fat and carbohydrate intake, eating meals at irregular times, and unhealthy cooking methods. Nutrition intervention with Mediterranean diet has significant positive impact on metabolic health of NAFLD patients.

NAFLD Mediterranean diet liver enzymes exercise metabolic health lifestyle carbohydrates follow up study

Creative CommonsThis work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit


[1]  Byrne CD, Targher G. NAFLD: A multisystem disease. J Hepatol. 2015; 62 : S47-S64.
[2]  Federico A, Zulli C, de Sio I, Prete AD, Dallio M, et al. Focus on emerging drugs for the treatment of patients with non-alcoholic fatty liver disease. WJG. 2014; 20 (45): 16841-57.
[3]  Amini M, Esmailzadeh A, Shafaeizadeh S, Behrooz J, Zare M. Relationship between major dietary patterns and metabolic syndrome among individuals with impaired glucose tolerance. Nutr J. 2010; 26: 986-92.
[4]  El-Zanaty and Associates (Egypt), ICF International. 2015. Egypt Health Issues Survey 2015. Ministry of Health and Population (Egypt), Cairo, Egypt and Rockville, Maryland, USA: Ministry of Health and Population and ICF International.
[5]  Galal OM. The nutrition transition in Egypt: obesity, undernutrition and the food consumption context. Public Health Nutr. 2002; 5(1A): 141-8.
[6]  Lazo M, Hernaez R, Eberhardt MS, Bonekamp S, Kamel I, Guallar E, et al. Prevalence of Nonachololic fatty liver disease in the United States. The Third National Health and Nutrition Examination Survey, 1988-1994. Am J Epimeiol 2013; 178(1): 38-45.
[7]  Ratziu V, Cadranel JF, Serfaty L, Denis J, Renou C, Delassalle P, et al. A survey of patterns of practice and perception of NAFLD in a large sample of practicing gastroenterologists in France. J Hepatol. 2012; 57: 376-83.
[8]  Leung CM, Lai LS, Wong WH, Chan KH, Luk YW, Lai JY, et al. Non-alcoholic fatty liver disease: an expanding problem with low levels of awareness in Hong Kong. J Gastroenterol Hepatol. 2009; 24: 1786-90.
[9]  Lazo M, Solga SF, Horska A, Bonekamp S, Diehl AM, Brancati FL, et al. Effect of a 12-month intensive lifestyle intervention on hepatic steatosis in adults with type 2 diabetes. Diabetes Care. 2010; 33: 2156-63.
[10]  Fock KM, Khoo J. Diet and exercise in management of obesity and overweight. J Gastroenterol Hepatol. 2013; 28: 59-63.
[11]  Valtuena S, Pellegrini N, Ardigo D, Rio DD, Numeroso F, Scazzina F, et al. Dietary glycemic index and liver steatosis. Am J Clin Nutr. 2006; 84: 136-42.
[12]  Gill HK, Wu GY. Non-alcoholic fatty liver disease and the metabolic syndrome: effects of weight loss and a review of popular diets. Are low carbohydrate diets the answer?. WJG. 2006; 12: 345-53.
[13]  Koopman KE, Caan MWA, Nederveen AJ, Pels A, Ackermans MT, Fliers E, et al. Hypercaloric diets with increased meal frequency, but not meal size, increase intrahepatic triglycerides: a randomized controlled trial. J Hepatol. 2014; 60: 545-53.
[14]  Michalsen A, Li C. Fasting therapy for treating and preventing disease - current state of evidence. Forsch Komplementmed. 2013; 20(6): 444-53.
[15]  Abenavoli L, Greco M, Nazionale I, et al. Effects of Mediterranean diet supplemented with silybin-vitamin E-phospholipid complex in overweight patients with non-alcoholic fatty liver disease. Exp Rev Gastroenterol Hepatol. 2015; 9: 519-27.
[16]  Sofi F, Casini A. Mediterranean diet and non-alcoholic fatty liver disease: New therapeutic option around the corner? WJG. 2014; 20(23): 7339-46.
[17]  Hammond KA. Assessment: dietary and clinical data. In: Mahan LK, Escott-Stumps S, editors. Krause's food and nutrition therapy. 12th ed. Missouri: Elsevier Saunders; 2012.p.383-410.
[18]  Willett W. Nutritional epidemiology. 2nd ed. New York, Oxford. Oxford University Press, 1998.
[19]  National Nutrition Institute. Food Composition Tables for Egypt. 2nd ed. Cairo, ARE; 2006.
[20]  Gibson RS. Principle of nutritional assessment. 2nd ed. Oxford: Oxford University Press; 2005.
[21]  Michael L. Bishop, Edward P, Fody MD, Larry E. Schoeff, editors. Clinical chemistry: principles, techniques, and correlations. 7th ed. USA. Lippincott Williams & Wilkins; 2013.
[22]  Marshall RH, Eissa M, Bluth EI, Gulotta PM, Davis NK. Hepatorenal Index as an accurate, simple, and effective tool in screening for steatosis. AJR Am J Roentgenol. 2012; 1999: 997-1002.
[23]  Escott-Stump S, Earl R. Guidelines for dietary planning. In: Mahan LK, Escott-Stumps S, editors. Krause's food and nutrition therapy. 12th ed. Missouri: Elsevier Saunders; 2012. p.337-380.
[24]  Mifflin MD, St Jeor ST, Hill LA, Scott BJ, Daugherty SA, Koh YO. A new predictive equation for resting energy expenditure in healthy individuals. Am J Clin Nutr. 1990; 51: 241-7.
[25]  Frankenfield D, Roth-Yousey L, Compher C. Comparison of predictive equations for resting metabolic rate in healthy non-obese and obese adults: a systematic review. J Am Diet Assoc. 2005; 105: 775-89.
[26]  Esco MR. Resistance training for health and fitness. American College of Sport Medicine ACSM. ACSM’s consumer information committee. 2013. Available at: Accessed 20 March 2017.
[27]  Alberti KG, Zimmet P, Shaw J. Metabolic syndrome--a new world-wide definition. A Consensus Statement from the International Diabetes Federation. Diabet Med. 2006; 23:469-80.
[28]  Willett WC. The Mediterranean diet: science and practice. Public Health Nutr. 2006; 9(1A):105-10.
[29]  Georgoulis M, Kontogianni MD, Margariti A, Tiniakos D, Fragopoulou E, Zafiropoulou R, Papatheodoridis G. Associations between dietary intake and the presence of the metabolic syndrome in patients with non-alcoholic fatty liver disease. J Hum Nutr Diet. 2015; 28(4): 409-15.
[30]  Kontogianni MD, Tileli N, Margariti A, Georgoulis M, Deutsch M, Tiniakos D, et al. Adherence to the Mediterranean diet is associated with the severity of non-alcoholic fatty liver disease. Clin Nutr. 2013; 1-6.
[31]  Barbaro B, Toietta G, Maggio R, Arciello M, Tarocchi M, Galli A, Balsano C. Effects of the Olive-Derived Polyphenol Oleuropein on Human Health. Int J Mol Sci. 2014; 5: 18508-24.
[32]  Gupta V, Mah XJ, Garcia MC, Antonypillai C, van der Poorten D. Oily fish, coffee and walnuts: dietary treatment for nonalcoholic fatty liver disease. WJG. 2015; 21(37): 10621-35.
[33]  Ryan MC, Itsiopoulos C, Thodis T,Ward G, Trost N, Hofferberth S, et al. The Mediterranean diet improves hepatic steatosis and insulin sensitivity in individuals with non-alcoholic fatty liver disease. J Hepatol. 2013; 59: 138-43.
[34]  Zhang L, Pagoto S, May C, Olendzki B, Tucker KL, Ruiz C, et al. Effect of AHA dietary counselling on added sugar intake among participants with metabolic syndrome. Eur J Nutr. 2017; Mar 28.
[35]  Misciagna G, Díaz MDP, Caramia1 DV, Bonfiglio C, Franco I, Noviello MR, et al. Effect of a low glycemic index Mediterranean diet on non-alcoholic fatty liver disease. A randomized controlled clinical trial. J Nutr Health Aging. 2017; 21(4): 404-12.
[36]  Chalasani N, Younossi Z, Lavine JE, Diehl AM, Brunt EM, et al. The diagnosis and management of non-alcoholic fatty liver disease: practice guideline by the American Gastroenterological Association, American Association for the Study of Liver Diseases, and American College of Gastroenterology. Gastroenterology. 2012; 142: 1592-609.
[37]  U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th Edition, Washington, DC: U.S. Government Printing Office, December 2010. Available at:
[38]  Kang H, Greenson JK, Omo JO, Chao C, Peterman D, Anderson L, et al. Metabolic syndrome is associated with greater histologic severity, higher carbohydrate, and lower fat diet in patients with NAFLD. Am J Gastroenterol. 2006; 101: 2247-53.
[39]  Zelber-Sagi1 S, Nitzan-Kaluski D, Goldsmith R, Webb M, Blendis L, Zamir Halpern Z, Oren R. Long term nutritional intake and the risk for non-alcoholic fatty liver disease (NAFLD): a population based study. J Hepatol. 2007; 47 : 711-7.
[40]  Mohamed AA, Shousha WG, Shaker O, Mady MS. Ibrahim EMA, et al. Insulin resistance in Egyptian nonalcoholic fatty liver disease patients. BJMMR. 2015; 6(5): 463-73.
[41]  Kirk E, Reeds DN, Finck BN, Mayurranjan MS, Patterson BW, Klein S. Dietary fat and carbohydrates differentially alter insulin sensitivity during caloric restriction. Gastroenterology. 2009; 136: 1552-60.
[42]  Adams LA, Angulo P. Treatment of non-alcoholic fatty liver disease. Postgrad Med J. 2006; 82: 315-22.
[43]  Okita M, Hayashi M, Sasagawa T, Takagi K, Suzuki K, Shingo Kinoyama S, et al. Effect of a moderately energy-restricted diet on obese patients with fatty liver. Nutr J. 2001; 17: 542-7.
[44]  Chowdhury EA, Richardson JD, Holman GD, Tsintzas K, Thompson D, Betts JA. The causal role of breakfast in energy balance and health: a randomized controlled trial in obese adults. Am J Clin Nutr. 2016; 103: 747–56.
[45]  Hassan NE, El Shebini SM, Ahmed NH. Association between dietary patterns, breakfast skipping and familial obesity among a sample of Egyptian families. J Med Sc. 2016; 15; 4(2): 213-21.
[46]  Chandler-Laney1 PC, Morrison SA, Goree LLT, Ellis AC, Casazza K, Desmond R, Gower BA. Return of hunger following a relatively high carbohydrate breakfast is associated with earlier recorded glucose peak and nadir. Appetite. 2014; 80: 236-41.
[47]  Farshchi HR, Taylor MA & Macdonald IA. Regular meal frequency creates more appropriate insulin sensitivity and lipid profiles compared with irregular meal frequency in healthy lean women. Eur J Clin Nutr. 2004; 58: 1071-7.
[48]  Farshchi HR, Taylor MA & Macdonald IA. Beneficial metabolic effects of regular meal frequency on dietary thermogenesis, insulin sensitivity, and fasting lipid profiles in healthy obese women. Am J Clin Nutr. 2005; 81: 16-24.
[49]  Pot GK, Hardy R,Stephen AM. Irregularity of energy intake at meals: prospective associations with the metabolic syndrome in adults of the 1946 British birth cohort. Br J Nutr. 2016; 115, 315-23.
[50]  Dam-Larsen S, Becker U, Franzmann MB, Larsen K, Christoffersen P, Bendtsen F. Final results of a long-term, clinical follow-up in fatty liver patients. Scand J Gastroenterol. 2009; 44: 1236-43.
[51]  Bookman ID, J Pham, M Guindi, E J Heathcote. Distinguishing nonalcoholic steatohepatitis from fatty liver: serum-free fatty acids, insulin resistance, and serum lipoproteins. Liver Int. 2006; 26(5): 561-71.
[52]  Fabbrini E, Sullivan S, Klein S. Obesity and nonalcoholic fatty liver disease: biochemical, metabolic, and clinical implications. J Hepatol. 2010; 51(2): 679-89.
[53]  Wasfy EA, Elwan NM, Bayomi SL , El- Sheikh TF , El-yamani SA, Talha BE. Study of risk factors involved in the progression of nonalcoholic fatty liver disease in Egyptian patients. J Am Sci. 2010; 6(12): 588-96.
[54]  Dunn SL, Siu W, Freund J, Boutcher SH. The effect of a lifestyle intervention on metabolic health in young women. Diabetes Metab Syndr Obes. 2014:7 437-44.
[55]  Halmos EP, Power VA, Shepherd SJ, Gibson PR, Muir JG. A diet low in FODMAPs reduces symptoms of irritable bowel syndrome. Gastroenterol. 2014; 146(1): 67-75.e5.
[56]  Zito FP, Polese B,Vozzella L, Gala A, Genovese D, Verlezza V, et al. Good adherence to Mediterranean diet can prevent gastrointestinal symptoms: a survey from Southern Italy. W J Gastrointest Pharmacol Ther. 2016; 7(4): 564-71.
[57]  Feinle-Bisset C, Azpiroz F. Dietary and lifestyle factors in functional dyspepsia. Nat Rev Gastroenterol Hepatol. 2013; 10: 150-7.
[58]  Lee SH, Kim KN, Kim KM, Joo NS. Irritable bowel syndrome may be associated with elevated alanine aminotransferase and metabolic syndrome. Yonsei Med J. 2016; 57(1): 146-52.
[59]  Chan YK, Estaki M, Gibson DL. Clinical consequences of diet-induced dysbiosis. Ann Nutr Metab. 2013; 63(suppl 2): 28-40.
[60]  Bellentani S, Grave RD, Suppini A, Marchecini A. Behavior therapy for nonalcoholic fatty liver disease: the need for a multidisciplinary approach. J Hepatol. 2007; 47(2): 746-54.
[61]  Prati D, Taioli E, Zanella A, Torre ED, Butelli S, Vecchio ED, et al. Updated definitions of healthy ranges for serum alanine aminotransferase levels. Ann Intern Med. 2002; 137: 1-9.
[62]  Shechter A, Grander MA, St-Onge MP. The role of sleep in the control of food intake. Am J Lifestyle Med. 2014; 8(6): 371-4.
[63]  Bambha K, Wilson LA, Unalp A, et al. Coffee consumption in NAFLD patients with lower insulin resistance is associated with lower risk of severe fibrosis. Liver Int. 2014; 34: 1250-8.
[64]  Anty R, Marjoux S, Iannelli A, Patouraux S, Schneck AS, Bonnafous S. Regular coffee but not espresso drinking is protective against fibrosis in a cohort mainly composed of morbidly obese European women with NAFLD undergoing bariatric surgery. J Hepatol. 2012; 57(5): 1090-6.
[65]  St George A, Bauman A, Johnston A, Farrell G, Chey T, George J. Independent effects of physical activity in patients with nonalcoholic fatty liver disease. J Hepatol. 2009; 50: 68-76.
[66]  Baba CS, Alexander G, Kalyani B, Pandey R, Rastogi S, Pandey A, Choudhuri G. Effect of exercise and dietary modification on serum aminotransferase levels in patients with nonalcoholic steatohepatitis. J Gastroenterol Hepatol. 2006; 21:191-8.
[67]  Bloue NG, Kenny GP, Wells GA, Sigal RJ. Effect of exercise on glycemic control and body mass in type 2 diabetes mellitus: a meta-analysis of controlled clinical trials. JAMA. 2001; 286: 1218-27.
[68]  Tamura Y, Tanaka Y, Sato F, Choi JB, Watada J, Niwa M, et al. Effects of diet and exercise on muscle and liver intracellular lipid contents and insulin sensitivity in type 2 diabetic patients. J Clin Endocrinol Metab. 2005; 90: 3191-6.
[69]  Tsuzuku A, Kajioka T, Endo H, Abbott RD, Curb JD, Yano K. Favorable effects on non-instrumental resistance training on fat distribution and metabolic profiles in healthy elderly people. Eur J Appl Physiol. 2007; 99: 549-55.
[70]  Sabinicz A, Maciejewska D, Kaczorowska M, Ryterska K, Jamioł-Milc D, Wyszomirska-Raszeja J. Reduction of sitting time has a positive effect on the decrease of insulin resistance in patients with non-alcoholic fatty liver disease. Prz Gastroenterol. 2016; 11(4): 257-62.
[71]  Newton JL. Systemic symptoms in non-alcoholic fatty liver disease. Dig Dis. 2010; 28: 214-9.
[72]  Khov N, Sharma A, Riley TR. Bedside ultrasound in the diagnosis of nonalcoholic fatty liver disease. WJG.2014; 20(22): 6821-25.
[73]  Jeong WK, Lim HL, Lee HK, Jo JM, Kim Y. Principles and clinical application of ultrasound elastography for diffuse liver disease. Ultrasonography. 2014; 33(3): 149-60.
[74]  Webb M, Yeshua H, Zelber-Sagi S, Santo E, Brazovski E, Ore R. Diagnostic value of a computerized hepatorenal index for sonographic quantification of liver steatosis. Am J Roentgenol. 2009; 192: 909-14.
[75]  Xia MF, Yan HM, He WY, Li XM, Li CL, Yao XZ, et al. Standardized ultrasound hepatic/renal ratio and hepatic attenuation rate to quantify liver fat content: an improvement method. J Obes. 2011; 20: 444-452.