Ketosis and Fatty Liver

piece of steak on a fork
Bite of steak on a fork (Image: vengerof/iStock/Getty Images)

Fatty liver is usually associated with alcohol abuse, but even people who don't drink can develop nonalcoholic fatty liver disease, or NAFLD. NAFLD includes asymptomatic steatosis, meaning simple fatty liver, which can progress to steatohepatitis, meaning inflamed fatty liver. Later, the disease can cause fibrosis, or scarring, and ultimately cirrhosis, which is permanent. Alcoholic fatty liver can only be treated by abstaining from alcohol in the early stages of the disease. But, because NAFLD is likely diet-related, it might be reversible by substantially reducing carbohydrate intake by means of a ketogenic diet.

Understanding NAFLD

NAFLD is associated with obesity -- especially abdominal, insulin resistance, elevated blood sugar, inflammation and high serum triglycerides. These are all signs of metabolic syndrome, considered the precurser to Type 2 diabetes. When the body cannot use sugar properly, some of it is converted to fat -- triglycerides -- by the liver, where it can accumulate. A 2009 study conducted at the Center for Human Nutrition and Atkins Center of Excellence in Obesity Medicine found that excess liver fat is probably the major culprit behind the health issues often associated with obesity.

The Ketogenic Diet

The ketogenic diet is a high-protein, high-fat, carbohydrate-restricted diet usually used for weight loss. Reducing or eliminating dietary carbohydrate forces the body to rely on stored fat for energy. However, the body metabolizes fat differently in the absence of carbohydrates, resulting in a condition called ketosis. Incompletely metabolized fat forms molecules called ketones, which accumulate in the blood and urine. Ketones have limited value as an energy source in the absence of carbohydrate, mainly for the brain, but most are excreted in the urine and breath.

Effects of Ketosis on Fatty Liver

Ketosis by itself does not reverse NAFLD. It is most likely the dietary carbohydrate restriction that has the potential to reduce the synthesis of fat by the liver. One of the first studies of the ketogenic diet’s effect on NAFLD, conducted at Duke University in 2007, reported that the carbohydrate depletion seems to reverse or slow the progression of NAFLD. There might be other mechanisms at work as well. For example, some research has looked at the vitaminlike nutrient choline for its role in preventing fatty liver. Choline is abundant in meat and other animal proteins, which is the mainstay of the ketogenic diet.


The ketogenic diet is generally not suitable for a very long duration. It can promote uric acid accumulation in the tissues, osteoporosis, mineral imbalances, nutrient deficiencies and muscle protein loss over time. Another side effect is a fruity odor of acetone on the breath, as this is one route the body uses to excrete ketones. However, fatty liver disease is potentially very serious if it is allowed to progress and should be addressed. A trial ketogenic diet under medical supervision, combined with lifestyle changes that can be maintained in the long run, might be an effective treatment.

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