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Mascaró, C.M.; Bouzas Velasco, C.; Tur, J. Non-Alcoholic Fatty Liver Disease and Mediterranean Lifestyle. Encyclopedia. Available online: https://encyclopedia.pub/entry/22234 (accessed on 17 July 2025).
Mascaró CM, Bouzas Velasco C, Tur J. Non-Alcoholic Fatty Liver Disease and Mediterranean Lifestyle. Encyclopedia. Available at: https://encyclopedia.pub/entry/22234. Accessed July 17, 2025.
Mascaró, Catalina Maria, Cristina Bouzas Velasco, Josep Tur. "Non-Alcoholic Fatty Liver Disease and Mediterranean Lifestyle" Encyclopedia, https://encyclopedia.pub/entry/22234 (accessed July 17, 2025).
Mascaró, C.M., Bouzas Velasco, C., & Tur, J. (2022, April 25). Non-Alcoholic Fatty Liver Disease and Mediterranean Lifestyle. In Encyclopedia. https://encyclopedia.pub/entry/22234
Mascaró, Catalina Maria, et al. "Non-Alcoholic Fatty Liver Disease and Mediterranean Lifestyle." Encyclopedia. Web. 25 April, 2022.
Non-Alcoholic Fatty Liver Disease and Mediterranean Lifestyle
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This entry is adapted from the peer-reviewed paper 10.3390/nu14010049

Non-alcoholic fatty liver disease (NAFLD) is defined as the accumulation of excessive fat in the liver not linked to alcohol abuse. A Mediterranean diet has many healthy components: it decreases the risk of cardiovascular disease, MetS, cancer, and overall mortality. The benefits of following a Mediterranean diet on NAFLD have also been described because it provides antioxidants and anti-inflammatory nutrients useful in slowing the development of hepatic steatosis. A high adherence to a Mediterranean diet improves liver fat content, fibrosis, and insulin sensitivity.

non-alcoholic fatty liver disease mediterranean diet physical activity mediterranean lifestyle metabolic syndrome

1. Mediterranean Diet and Non-Alcoholic Fatty Liver Disease (NAFLD)

It was highlighted the benefits of a Mediterranean diet on metabolic diseases such as metabolic syndrome (MetS), type 2 diabetes mellitus, and cardiovascular disease, thanks to its components rich in antioxidants, monounsaturated fatty acids, saturated fatty acids, animal protein, and fiber [1]. To understand how a Mediterranean diet can improve MetS, it is necessary to know that MetS is the expression of three or more metabolic disruptions: abdominal obesity, high triglyceridemia, hypertension, high fasting glycemia, and low high-density lipoprotein (HDL)-cholesterol. So, a Mediterranean diet can improve MetS status because it is able to curtail some or all the disorders associated with MetS [2]. The cluster of these individual alterations also carries a risk for the development of type 2 diabetes mellitus and cardiovascular disease. A Mediterranean diet benefits MetS, type 2 diabetes mellitus, and cardiovascular disease because it improves the parameters that cause these three major pathologies. It decreases hypertension, obesity, and hypercholesterolemia, thus preventing or improving coronary risk. It also decreases lipidemia as well as glycemia, protects against type 2 diabetes mellitus, and then improves MetS. A Mediterranean diet achieves this effect thanks to its anti-inflammatory and antioxidant components, from foods such as olive oil, whole grains, fruits, vegetables, and fish [3].
Polyphenols are another component of a Mediterranean diet that have very positive effects on human health. They are found in foods typical of this diet, such as olive oil, walnuts, and red wine, with the latter always consumed in moderation. Their beneficial effects take place because they act by regulating genes and signaling pathways that intervene on oxidative stress, inflammation, atherosclerosis, and mitochondrial function, keeping in mind that mitochondrial dysfunction is directly related to obesity. Thus, some were showed that the consumption of polyphenols induces an increase of messenger RNA of those genes involved in pathways that regulate obesity, type 2 diabetes mellitus, and dyslipidemia. They have a positive influence on obesity because they reduce the accumulation of intracellular triglycerides and down-regulate the expression of genes linked to adipogenesis and adipocyte proliferation, resulting in less tissue accumulation. Benefits associated with type 2 diabetes mellitus lie in better glucose tolerance, which reduces insulin resistance. Polyphenols reduce plasma glucose levels and, therefore, insulin secretion. Regarding dyslipidemia, in addition to decreasing circulating triglyceride levels, they also decrease the oxidation of LDL-cholesterol. This oxidation produces an imbalance in the levels of lipoproteins that lead to MetS, which is why its reduction is important. On the other hand, polyphenols are also involved in the regulation of inflammatory response and in the expression of genes involved with atherosclerosis, reducing the expression of these genes. They counteract the signaling of the cascade that forms atherogenic plaque, which is also beneficial for cardiovascular disease. It is through these mechanisms that a Mediterranean diet manages to reduce the main complications of MetS [4].
The dietary approaches to stop hypertension (DASH) are based on the consumption of whole grains, fruits and vegetables, and foods low in fat, especially saturated fatty acids and cholesterol. DASH has beneficial effects on NAFLD parameters such as triglyceridemia, insulin markers, and liver enzymes. It was recommended that participants maintain their physical activity routines, but no guidelines were given and no physical activity intervention was undertaken [5]. The current one [6] that recommended a Mediterranean dietary pattern to participants, based on foods such as fruit, vegetables, whole grains, legumes, fish, and other foods poor in saturated fatty acids. It demonstrates the improvement of NAFLD after a Mediterranean diet is followed, although it also recommended performing physical activity. Although the diets have different names, it is obvious that they have a very similar basis in food consumption and nutrient contents. Hence, similar results were obtained, supporting the importance of diet to improve NAFLD.
As noted previously, people with a high probability of developing NAFLD are those with obesity and MetS, so all benefits that a Mediterranean diet achieves over MetS are directly related to those over NAFLD [7].
A Mediterranean diet, thanks to its compounds, reduces weight, body mass index, waist circumference, fasting insulin levels, homeostasis model assessment-insulin resistance, fatty liver indexes, triacylglycerides, fasting plasma glucose, and serum alanine aminotransferase. A few were showed trends to decrease AST levels. Therefore, the beneficial effects of a Mediterranean diet could explain the improvement of NAFLD [8]. Moreover, it has been shown that there is a direct association between reduced insulin resistance and less severity in NAFLD [9]. All of these benefits are also evident, showing that compliance with a Mediterranean diet is associated with a lower probability of having NAFLD [10][11][12][13][14][15][16].
Another positive effect of a Mediterranean diet is that it has been shown to reduce intrahepatic lipids. The monounsaturated fatty acids of a Mediterranean diet, present for example in olive oil, improve lipid profile, insulin sensitivity, glycemic control, and blood pressure, producing an improvement in NAFLD. [9]. In fact, the findings show this relationship between a Mediterranean diet, the above benefits, and the improvement in NAFLD [6][11][14][15][16].

2. Mediterranean Diet, Physical Activity and NAFLD

Many were showed that the importance of regular physical activity for better health. A physical activity intervention can improve and normalize obesity, lipid disorders (lowering triglyceridemia and raising HDL-cholesterol), hypertension, and other MetS-related parameters. One of the major effects is on the normalization of insulin resistance. However, a physical activity intervention alone is not enough; it demands other elements such as cardiorespiratory fitness and an adequate diet. Cardiorespiratory fitness is the maximum ability of systems involved in exercise (mainly respiratory and cardiovascular) to supply oxygen to the skeletal muscles, and then to improve the activity. Thus, increasing regular physical activity and stimulating cardiorespiratory fitness may have a greater impact on health. It has been seen that an intervention of 3 to 12 months of exercise can improve levels of cardiorespiratory fitness and, consequently, reduce cardiovascular risk [7]. Although there was a possibility that these benefits were useful in slowing the progression of NAFLD, no specify details were given [7][10][13]. Following a Mediterranean diet improves MetS parameters and is directly associated with improved NAFLD [10][13]. For this reason, physical activity and Mediterranean diet go hand in hand.
Others highlighted the importance of physical activity and resistance training in achieving benefits with NAFLD. Physical activity provides benefits with NAFLD because it improves metabolic condition; however, the type and intensity of physical activity needed to achieve this effect is unclear [8]. The need for dietary intervention has been mentioned, as well as the importance of adding antioxidants into a Mediterranean diet to achieve beneficial effects with NAFLD [9]. However, it remains unclear which type of diet is the most appropriate [17]. It is important to realize that not just any diet achieves beneficial effects and it is necessary to determine which type of diet is best. Currently, it was showed that a Mediterranean diet is the most appropriate to decrease all risk factors for NAFLD and hence to improve this illness, since it is already rich in antioxidants and other healthy nutrients. However, it was agreed that the beneficial effects of a Mediterranean diet are greater when dietary intervention is combined with the practice of regular physical activity [6][11][12][14][15][16][18][19][20]. Several were showed that the effects of Mediterranean lifestyle would be obvious after one year of follow-up. It has also been reported that the intensity of physical activity is adaptable to each person’s physical condition and needs, in order to have a greater effect [6]. The ideal exercise would be an expenditure of 400 kcal for a person who weighs 70 kg for three days a week [6].
It were described obesity as an independent risk factor for NAFLD. Weight, BMI, and, therefore, obesity, are directly related to a higher probability of developing NAFLD [21]. The results show that this is not always sufficient, and that one can be obese without NAFLD, or vice versa [10][11]. Presently, it was showed that the possibility of developing NAFLD increases with the expression of three or more MetS alterations. As mentioned, one of the MetS alterations is being overweight or obese, but it also includes others such as low HDL-cholesterol, hypertriglyceridemia, and high fasting glycemia, which further increase the possibility of the development and/or progression of NAFLD [6][10][11][12][13][14][15][16][18][19][20][22][23].
Recently, it was supported lifestyle change to treat NAFLD, including dietary intervention and physical activity, but also bariatric surgery if necessary [24]. The current one was showed that it is not necessary to put patients through the stress of surgery, since a properly applied Mediterranean diet is able to decrease weight and body mass index [12][14][15]. In fact, one of the consequences of any type of stress, including surgery, is an increase in oxidative stress with the production of reactive oxygen spices (ROS). They damage fatty acids and induce the lipid peroxidation chain reaction, which favors the development of NAFLD. This effect is counterproductive to the benefits sought with a Mediterranean lifestyle that seeks to reduce said stress with the contribution of antioxidants in a Mediterranean diet [25].
NAFLD not only affects adults, but there are also children with this pathology [26]. There is no clear therapy for treatment and pediatricians rely on dietary modification and/or physical activity [27]. Several diets were studied, all low in fat, but none based on a Mediterranean diet. They argued that there is insufficient evidence to recommend a single weight-loss method, although such weight loss improves NAFLD parameters. Accordingly, it supports the lack of therapies for NAFLD. However, it also supports the evidence that an effective treatment to improve NAFLD is to follow a Mediterranean diet together with physical activity, as part of a Mediterranean lifestyle. Both a Mediterranean diet and physical activity are considered equally important for the management of NAFLD.
Recently, it was carried out in times of a pandemic, confirms the evidence from this. A large group of obese people, and a smaller group with diagnosed NAFLD, were interviewed about their lifestyle and anthropometric measurements during a month of confinement by COVID-19. It was found that weight had increased in more than half of the subjects, who confessed that they did not engage in physical activity and had a low adherence to a Mediterranean diet. Furthermore, 70% of the NAFLD group also gained significant weight and thus did not receive any improvement in NAFLD. This confirms that situations where a Mediterranean lifestyle is not followed is a risk factor for metabolic diseases. At the same time, it confirms the results that both physical activity and Mediterranean diet are equally important in acting as a protective factor against this type of disease, including NAFLD [28].

References

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Catalina Maria Mascaró
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