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Mediterranean diet for NAFLD goes beyond just following a food list

April 28, 2022

3 min read

Shah reports no relevant financial disclosures.

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The Mediterranean diet, which may help reverse the early stages of nonalcoholic fatty liver disease, requires patience, practice and the development of new life skills, according to one expert dietician.

“As part of my role as a dietitian specializing in gastroenterology and liver nutrition, I have developed a webinar and a three-part series, along with handouts, for how to implement the Mediterranean diet in treatment for NAFLD,” Neha D. Shah MPH, RD, CNSC, CHES, a dietician at the University of California, San Francisco, and owner of Neha Shah Nutrition, told Healio. “The educational series will cover nutritional contributors to NAFLD as well as practical applications of how to implement the Mediterranean diet.”


Shah is one of many gastrointestinal health care professionals in the GI OnDEMAND network, an innovative virtual platform and collaboration between ACG and Gastro Girl Inc. that offers support, integrated care and a variety of interdisciplinary educational resources for patients and providers.

Healio spoke with Shah about the Mediterranean diet, its effectiveness in NAFLD and her advice for patients starting the diet.

Healio: Can you discuss treating NAFLD with the Mediterranean diet?

Shah: NAFLD comprises fat accumulation of at least 5% within the liver in a setting without significant alcohol intake of greater than 21 drinks in a week for men and 14 drinks a week for women, use of a medication or having a genetic disorder — that can all contribute to fat accumulation in the liver. With progression, NAFLD can lead to inflammation, injury and fibrosis of the liver.

Contributors to NAFLD include metabolic and lifestyle risk factors. Metabolic risk factors include diagnoses of obesity, diabetes, dyslipidemia, and metabolic syndrome, and lifestyle risk factors include diet. A diet high in saturated fat through animal protein and fructose through sweets has been implicated in the development of NAFLD. In addition, a diet low in mono/polyunsaturated fatty acids through fish, nuts, seeds, olive oil and dietary fiber through fruits, vegetables, whole grains and legumes may also contribute.

The Mediterranean diet reflects the eating patterns of individuals living alongside the Mediterranean Sea. The diet is high in dietary fiber, phytonutrients and mono/polyunsaturated fats, which provide a source of anti-inflammatory and antioxidant nutrients, and low in saturated fat, cholesterol and fructose. It is a framework to follow for which foods are to be eaten daily at most meals, which foods are to be eaten not daily but a few times in the week and which foods are to be eaten not even weekly.

As a primary focus, the foods that are to be consumed daily are:

fruits and vegetables, which provide a rich source of dietary fiber and phytonutrients. The Mediterranean diet recommends that each meal includes a fruit and a vegetable.

beans, lentils, and chickpeas, which are all legumes and provide a rich source of plant protein, dietary fiber and phytonutrients. The Mediterranean diet recommends including a legume several times a week; however, a legume can be included at least once a day or more to ensure there is plant protein as a part of a meal.

olive oil, nuts, and avocados, which are rich sources of plant monounsaturated fatty acids. Fats and oils from plants are consumed daily in the Mediterranean diet.

The foods to be consumed a few times a week are animal protein, such as poultry, fish, eggs and dairy. Foods to be eaten on occasion (not even weekly) are meat and sweets.

Healio: Is changing a NAFLD patient’s diet an effective way to treat the condition?

Shah: Yes, absolutely. Changing the diet to bring in higher amounts of dietary fiber and phytonutrients may reverse early stages of NAFLD, either by reducing the risk for diagnoses associated with NAFLD or lessening fat accumulation. A transition to a plant-based diet with less animal protein and less sweets is the goal. Daily consumption of fruits and vegetables as a source of dietary fiber has been shown to reduce risk for obesity, diabetes, dyslipidemia and high blood pressure, which are all associated with risk for NAFLD.

In addition, daily intake of phytonutrients through fruits and vegetables has been shown to reduce fat accumulation within the liver. Studies have shown that a high intake of legumes may reduce the risk for diabetes and improve blood glucose levels, which all may reduce the risk for NAFLD. Eating nuts daily has been associated with a reduced risk for obesity, diabetes, high blood pressure and metabolic syndrome. A small number of studies have shown that daily consumption of olive oil at meals has reduced fat accumulation in NAFLD.

Healio: What advice do you give NAFLD patients when first beginning a Mediterranean diet?

Shah: Add a fruit and vegetable, in 1/2-cup portions, to one meal in the day and build to adding to each meal in the day. Fruits and vegetables come in many forms, such as raw, cooked, blended, minced, mashed and chopped, and all count; they can be included as a side or snack or added into smoothies, soups and salads.

Practice is key to building a habit over time. Following the Mediterranean diet goes beyond a food list — it involves developing skills to implement and enjoying the diet in one’s lifestyle and culture. Skill development is the educational focus with how to build a balanced meal, how to do grocery shopping, how to do meal preparation and how to dine out while following the Mediterranean diet.