Diet and Exercise in NAFLD/NASH: Beyond the Obvious

Georg Semmler; Christian Datz; Thomas Reiberger; Michael Trauner


Liver International. 2021;41(10):2249-2268. 

In This Article

Abstract and Introduction


Lifestyle represents the most relevant factor for non-alcoholic fatty liver disease (NAFLD) as the hepatic manifestation of the metabolic syndrome. Although a tremendous body of clinical and preclinical data on the effectiveness of dietary and lifestyle interventions exist, the complexity of this topic makes firm and evidence-based clinical recommendations for nutrition and exercise in NAFLD difficult. The aim of this review is to guide readers through the labyrinth of recent scientific findings on diet and exercise in NAFLD and non-alcoholic steatohepatitis (NASH), summarizing "obvious" findings in a holistic manner and simultaneously highlighting stimulating aspects of clinical and translational research "beyond the obvious". Specifically, the importance of calorie restriction regardless of dietary composition and evidence from low-carbohydrate diets to target the incidence and severity of NAFLD are discussed. The aspect of ketogenesis—potentially achieved via intermittent calorie restriction—seems to be a central aspect of these diets warranting further investigation. Interactions of diet and exercise with the gut microbiota and the individual genetic background need to be comprehensively understood in order to develop personalized dietary concepts and exercise strategies for patients with NAFLD/NASH.


Non-alcoholic fatty liver disease (NAFLD) may present as "simple" steatosis or with a potentially progressive inflammatory phenotype of non-alcoholic steatohepatitis (NASH) that can progress to cirrhosis and/or hepatocellular cancer, thus being expected to become the leading cause of liver-related morbidity and mortality.[1] Since no drug has yet been approved specifically for the treatment of NASH and/or associated cirrhosis,[2] dietary interventions and physical activity (PA) and exercise are generally regarded the cornerstones of NAFLD/NASH treatment. These interventions might be specifically effective to target the "triple hit" of modern-day lifestyle (ie sedentary behaviour, low PA and poor diet) that contributes to the "multiple-hit" pathogenesis of NAFLD.[3,4] The aim of this review is to provide an overview of recent research findings covering diet and PA "beyond the obvious", thereby presenting stimulating aspects of this topic complimentary to state-of-the-art reviews (eg Refs.[5–7]).