Protecting Your Liver When You Have Diabetes
By Hope Warshaw
Diabetes that is not optimally managed puts you at risk of liver disease. Learn about the relationship between type 2 diabetes and certain liver conditions, plus steps you can take to lower your risk of diabetes-related liver complications.
Nonalcoholic fatty liver disease (NAFLD) impacts much of the general population. NAFLD is estimated to affect as many as one-quarter of people worldwide and is becoming the most common causes of chronic liver disease.
People with type 2 diabetes are even more likely to live with the condition. That association between type 2 diabetes and certain types of liver disease is on the rise. Since the 1980s, the number of people with type 2 diabetes who are diagnosed with a form of liver disease not related to alcohol consumption has increased steadily.
To address this, the American Diabetes Association (ADA) published last year’s Standards of Care with its first-ever recommendations for how to prevent, diagnose, and manage liver disease, and expanded those recommendations for treating liver disease in 2023.
The good news is that you can act to prevent or better manage liver damage. Read on to understand the connection between liver damage and both type 1 and type 2 diabetes and get the latest information on screening options, self-care behaviors, and current treatments to reduce your risk of diabetes-related liver damage.
Liver disease as it relates to diabetes
Because the liver is a key organ that filters blood, helps produce nutrients the body needs for health, and breaks down certain medications, it’s vital to maintain the health of the liver.
“Liver disease, as a complication of diabetes, is underdiagnosed and underappreciated,” Dr. Robert Gabbay, ADA’s chief science and medical officer, said. Gabbay explained that the ADA has been working to raise awareness among people with diabetes as well as healthcare professionals to diagnose and treat liver disease as it becomes more common.
Types of liver disease
NAFLD refers to a group of conditions in which fat builds up in the liver.
“Nonalcoholic fatty liver disease serves as an umbrella term for a range of liver diseases that progress if no diagnosis is made or interventions initiated,” said Dr. Kenneth Cusi, chief of the Division of Endocrinology, Diabetes & Metabolism at the University of Florida and author on the first-ever American Association of Clinical Endocrinology (AACE) guidelines for the diagnosis and care of NAFLD.
The condition is defined as having at least 5 percent fat in the liver, but without inflammation or changes to the liver cells, according to Colleen Dawkins, a family nurse practitioner and registered dietitian at Big Sky Medical Wellness in Lakeside, Montana.
Nonalcoholic steatohepatitis (NASH)
If NAFLD is not diagnosed and managed, it can then progress to NASH.
“NASH is defined as at least 5 percent fat in the liver, with inflammation and changes to the cells in the liver including fibrosis [scar tissue that forms in the liver],” Dawkins said.
With treatment to reduce the inflammation, which typically includes weight loss and medication, NASH can revert back to NAFLD. Being older, having excess weight around the midsection, type 2 diabetes, and high blood pressure are all associated with increasing amounts of fibrosis or scar tissue.
Without adequate treatment, NASH can actually progress to cirrhosis or liver failure. It has also become the leading cause of liver cancer and the leading reason people need a liver transplant.
NASH can progress to cirrhosis, a condition in which scar tissue replaces healthy liver tissue, permanently damaging the liver and preventing it from working normally. Cirrhosis is linked with liver cancer and can cause liver failure.
Getting screened for liver disease
Assessing NAFLD risk with the FIB-4 index
When your healthcare provider checks for diabetes-related eye or kidney disease, ask about calculating your score on the Fibrosis-4 index for liver fibrosis (FIB-4). This index can calculate your risk for NAFLD.
“Screening should include your medical history, a physical exam, and the FIB-4 risk calculation,” Cusi said.
FIB-4 includes four numbers: a person’s age, liver enzyme results (ALT and AST), and blood platelet level. The calculation gives a single number that indicates the risk of advanced fibrosis.
People with a FIB-4 score below 1.3 are thought to be at low risk; those with a score above 2.67 are at high risk for NAFLD. If your FIB-4 index indicates a high risk for NAFLD, your healthcare provider may refer you to a gastroenterologist or hepatologist (liver expert) for further evaluation and treatment.
People at intermediate risk – meaning anyone with a FIB-4 score between 1.3-2.67 – may need additional tests, including one or more of these listed below by Dawkins.
How is nonalcoholic liver disease diagnosed?
One indicator can be a blood test that includes measurements of two liver enzymes that show how the liver is functioning. Other indicators include:
Ultrasound of the abdomen (sometimes this can miss liver fat).
Vibration-controlled transient elastography, called a FibroScan, is an ultrasound that can more accurately measure fat in the liver.
An MRI or CT scan.
A liver biopsy, which considered the gold standard to determine if there is fat in the liver and whether the tissue is fibrotic, or hardened.
Signs and symptoms of potential liver damage
Unfortunately, there are very few signs or symptoms associated with liver disease, which makes detection and diagnosis a challenge.
Cusi and Dawkins both agree that some, but not all, people may experience pain on the right side of their abdomen. Dawkins added that feeling fatigued or experiencing unexplained weight loss may also be telltale signs.
Diabetes medications that may help prevent liver disease
While studies with certain glucose-lowering medications and other new medications are ongoing, there are currently no specific medications for diabetes-related liver disease.
Cusi currently recommends using one of the newer glucose-lowering medications, a GLP-1 receptor agonist, primarily because they assist with weight loss. The other class of glucose-lowering medication he recommends is SGLT-2 inhibitors. According to Cusi, these medications offer benefits for NASH as well as the prevention of heart and blood vessel diseases and kidney disease.
A downside of GLP-1s and SGLT-2s is that these medications can be quite expensive. If they are out of reach, Cusi points to an older glucose-lowering medication, pioglitazone, as being more affordable and accessible. While it will not result in the weight loss a GLP-1 receptor agonist or SGLT-2 inhibitor can offer, it can improve glucose, reduce fat in the liver and improve NASH.
Can vitamin E supplements help treat NAFLD or NASH?
You may hear and read about the use of vitamin E supplements to treat liver disease. The ADA Standards note that while vitamin E may be helpful for people without diabetes, it is not helpful for people with diabetes. Both Cusi and Dawkins agree that this supplement should not be used if you have diabetes.
Risk factors for nonalcoholic liver disease
Since early detection offers the best chance of reversing the progression of liver disease, knowing your individual risk level is crucial. The following are all risk factors for nonalcoholic liver disease:
Carrying excess weight
Having high glucose levels
Having abnormal blood lipid levels such as low HDL cholesterol, high LDL cholesterol, and high triglycerides
Dealing with high blood pressure
The prevalence of NAFLD is often undetected because clinicians do not consistently implement appropriate screening tests. If you have any risk factors for NAFLD, advocate for yourself and proactively ask your clinicians if you should be evaluated for the condition.
Are people with type 1 diabetes at risk of developing NAFLD?
According to the ADA Standards, screening in people with type 1 diabetes should only be considered if they have other risk factors for NAFLD and related conditions. An increasing number of people with type 1 diabetes have excess weight or obesity, which is a risk factor for NAFLD.
“This type of liver damage is not well-studied in people with type 1 diabetes,” Cusi said. “If a person with type 1 diabetes remains lean through the years, it’s likely they will not deal with this complication.”
Are people with type 2 diabetes at risk of developing NAFLD?
Knowledge about the connection between type 2 diabetes and liver disease is relatively new. Our understanding of how it occurs, and how to detect and manage it, is limited. That being said, more than 70 percent of people with type 2 diabetes are estimated to have NAFLD, and roughly half of these people could have NASH.
Such damage to the liver as a result of type 2 diabetes that is not managed can occur without warning. As with most diabetes complications, it often progresses over many years and is typically the result of having excess weight, high glucose levels, abnormal blood lipid levels, and high blood pressure.
Conversely, people who develop NAFLD first are also more likely to later develop type 2 diabetes. They are at a higher risk of heart and blood vessel disease as well.
The link between hepatitis C and type 2 diabetes
Infection with hepatitis C virus (HCV), a virus that targets the liver, is associated with a higher risk for type 2 diabetes; in fact, type 2 diabetes is seen in up to a third of people with chronic HCV. This occurs because the virus may impair how glucose is handled by the body.
The use of a newer antiviral medication to treat HCV leads to a cure of the virus in nearly all cases and improves elevated glucose levels as well.
Treatment options if you have diabetes and liver disease
The treatment for NAFLD and NASH includes behavioral changes recommended to prevent and delay other diabetes-related complications.
In addition to outlining these lifestyle changes and self-care behaviors, Dawson suggested strategizing with your healthcare provider to determine which changes best align with your diabetes management.
Losing at least five percent of your initial body weight may improve and reduce fat deposits in the liver. Losing 10 percent of your body weight is preferable and is usually necessary to improve tissue scarring associated with NASH. In collaboration with their healthcare providers, people may consider taking a medication that can assist with weight loss or having bariatric or metabolic surgery.
It’s possible to reduce the amount of fat deposited in their liver by reducing ultra-processed foods and sources of refined carbohydrates such as sugary foods, desserts, and drinks. AACE guidelines also encouraged a reduction of saturated fat consistent with healthy eating guidance for diabetes.
Instead, Dawkins suggests eating fiber-packed sources of healthy carbohydrates including vegetables, fruits and whole grains, along with lean protein and healthy fats, in a diet that mimics the Mediterranean eating plan.
Daily movement is very important to improve the way the body uses glucose and insulin and to reduce the amount of fat deposited in the liver and damage to liver cells.
Consistent aerobic and resistance training exercises are recommended, with the amount and intensity varying based on what is best for you. The goal is to increase to 150 minutes of exercise per week, but any regular movement is beneficial.
There is no clear consensus on whether drinking alcohol is okay. The default recommendation is to avoid alcohol. However, some studies show that light to moderate alcohol intake may be okay for those with a low or intermediate risk for NAFLD.
If you suspect you may have NAFLD or NASH or are told you have one of them, be sure to take the next steps quickly. These problems will likely progress without timely self-care, lifestyle changes, and medication.
Recommendations in this article are aimed at adults with type 1 and type 2 diabetes and exclude children and adolescents as well as pregnant people with diabetes. Discuss your targets with your healthcare providers; they may vary based on personal factors.
About this series
Each year the American Diabetes Association updates its Standards of Medical Care in Diabetes based on current science. We’ve translated key points of the up-to-date Standards into plain English so you know how to stay healthy and minimize diabetes complications.
Other articles in this series: