Being diagnosed with liver disease can feel like a lot to handle — especially if you’re also thinking about changing your diet and lifestyle. Maybe you’ve recently learned that you have metabolic dysfunction-associated steatotic liver disease (MASLD). It happens when fat builds up in your liver, and you also have diabetes, obesity, high blood pressure, or high cholesterol. The Mediterranean diet has proven benefits for adults with MASLD and could be the right choice for you.
Food is energy, and energy builds up if we don't use it, according to Andres Gomez-Aldana, MD, an associate professor of clinical medicine specializing in gastroenterology and transplant hepatology at the University of Cincinnati College of Medicine. The body turns extra energy into fat, which it stores for later use. Just like other areas of the body, the liver can hold onto fat.
"The liver is the first organ that receives all the energy that you are eating after it's passed through the GI [gastrointestinal] tract," says Gomez-Aldana.
When fat builds up in the liver, it causes inflammation. The immune system then attacks liver fat, causing scarring that's also known as fibrosis. When fibrosis becomes severe, it's called cirrhosis.
Your diet can affect how well you're able to manage MASLD. What you eat becomes even more important as you reach your 40s and beyond. During this stage of life, you become more prone to developing diabetes, obesity, high blood pressure, or high cholesterol (also known as your cardiometabolic risk).
The Mediterranean diet is proven to help prevent MASLD from getting worse. Here's what to know about how the Mediterranean diet works, why it benefits liver health, and tips for following the diet.
What Is the Mediterranean Diet?
The Mediterranean diet is less "prescriptive” than many other diet options, says Annie Guinane, RD, LDN, MS, the liver transplant registered dietitian at the University of Chicago Medicine. For instance, you don't need to eat a certain number of calories or grams of protein per day.
"It's very generalized, which works for some people and hinders other people," Guinane says. If you want to try the Mediterranean diet but prefer having strict rules around what to eat, a dietitian can help set guidelines to keep you on track. (Or, get started with this sample meal plan!)
The Mediterranean diet focuses on whole plant-based foods, including fruits, vegetables, whole grains, nuts, and seeds. Healthy fats, especially olive oil, are another cornerstone of the diet. Lean proteins, such as salmon and Greek yogurt, are also "totally okay to have," Guinane says.
The main foods to avoid are red meat, sweets, and processed carbohydrates. A diet high in red and processed meat has been linked to a greater risk of developing insulin resistance and MASLD.
You may not need to abandon those foods entirely. The Mediterranean diet guidelines recommend eating red meat only once or twice per month, but Guinane helps patients find the right approach for their lifestyle. If they eat red meat daily, she'll suggest cutting back to once a week, for example.
Mediterranean diet benefits
There are many benefits to following the Mediterranean diet when you have MASLD. If you're 40 or older and have MASLD, the Mediterranean diet can also help counteract some of the effects of aging. As you get older, you're more vulnerable to weight gain and cardiometabolic diseases such as diabetes, obesity, high blood pressure, and high cholesterol, Guinane says.
Inflammation can raise your risk of developing cardiometabolic diseases. Inflammation happens when your immune cells attack an area of the body. Systemic inflammation — which affects the entire body — can put you at risk for diseases such as obesity, diabetes, and heart disease. Systemic inflammation has also been linked to insulin resistance, which develops when too much blood sugar enters your bloodstream. Many studies have shown that the Mediterranean diet can lower inflammation and insulin resistance, and support weight loss, making it a good choice for people with MASLD.
"Hippocrates said, 'let the food be the medicine and let the medicine be the food,'" Gomez-Aldana says. The Mediterranean diet is an excellent way to follow that advice, he adds, because it includes foods that are low in calories and that benefit your health — including liver health — in various ways:
Lowering inflammation. Fruits, vegetables, and whole grains are rich in nutrients called polyphenols, which travel to the liver and break down fat, lowering inflammation, says Gomez-Aldana.
Repairing cell damage. The Mediterranean diet is rich in antioxidants like Vitamin C, found in fruits and vegetables such as citrus fruits and bell peppers. Antioxidants help repair damage to your cells that can trigger inflammation.
Lowering the risk of diabetes. One study compared people who ate a low-fat diet with those who ate the Mediterranean diet for two years. Those who followed the Mediterranean diet lost more weight and had greater improvements in inflammation and insulin resistance.
Improving insulin and blood sugar control. Another study found that people who followed either the Mediterranean diet or a low-carbohydrate diet lost more weight after two years compared to those who followed a diet low in fat and calories. The Mediterranean diet also improved insulin levels among people with diabetes more than the other two diets.
Helping with weight loss. The Mediterranean diet can help you lose weight too, says Gomez-Aldana. High-fiber vegetables, such as lettuce and broccoli, make you feel full so you eat less. Doing so can help regulate the hormones adiponectin and leptin, which affect hunger, insulin sensitivity, and inflammation. One review of research confirmed that the Mediterranean diet can help manage and prevent obesity more effectively than other diets.
Lowering the risk of heart attack or stroke. Among those with a high risk of developing heart disease, eating the Mediterranean diet — supplemented with olive oil or mixed nuts — lowered the risk of a major cardiovascular event more than following a low-fat diet, according to a study of nearly 7,500 people aged 55-80.
What Fats Help Your Liver (and Which Don't)?
It might sound strange, but eating certain fats can actually reduce the amount of fat in your liver. These healthy fats also help prevent heart disease by lowering your LDL (bad) cholesterol level. Examples of good fats include monounsaturated fats, which are found in Mediterranean diet staples such as olive oil, nuts, and avocados, Guinane says.
Olive oil also causes your body to release your own GLP-1, a hormone that moderates blood sugar levels, hunger, and digestion. That means consuming olive oil can help you feel full, according to Gomez-Aldana.
Another healthy fat is polyunsaturated fats, such as omega-3 fatty acids. Omega-3s are important for the health of your cells and are found in salmon, flax and chia seeds, and walnuts.
Other fats should be avoided because they can increase fat in the liver. These so-called "bad fats" include saturated fats and trans fats, says Guinane. Fatty red meats, high-fat dairy products such as whole milk or butter, and ultra-processed foods tend to be higher in bad fats.
What Ingredients Do You Use in the Mediterranean Diet?
The Mediterranean diet is based on the diet followed by people living along the Mediterranean Sea, including Greece, Italy, and Turkey. But the diet is also flexible, says Guinane.
"The Mediterranean diet isn't just salmon and feta cheese. You can have a turkey sandwich and that counts," she says.
Guinane often helps patients adapt their cultural cuisine to include elements of the Mediterranean diet. For example, she teaches people from Mexican backgrounds to include whole grains and fresh vegetables in dishes such as tacos.
Foods to use
When you're cooking Mediterranean meals at home, there are key components to keep in mind. For good nutrition, Guinane suggests creating meals that use the core ingredients and examples listed below:
- Whole grains: Brown rice, oats, quinoa, barley, farro, 100% whole wheat pasta, bread, or tortillas
- Legumes: Lentils, chickpeas, beans
- Fresh vegetables: Non-starchy vegetables, such as leafy greens, tomatoes, peppers, onions, broccoli, asparagus, carrots, celery, eggplant, radishes, mushrooms, bok choy, beets, artichokes
- Fresh fruits: Apples, avocados, berries, cherries, figs, grapes, kiwis, oranges, pomegranates, peaches, nectarines, plums
- Proteins: Fish, chicken, turkey, eggs, Greek yogurt
- Healthy fats: Olive oil, avocado oil, nuts, seeds
How to cook
Guinane suggests cooking with avocado oil and finishing dishes with olive oil. Avocado oil has a higher smoke point, whereas high heat causes olive oil to break down, creating free radicals that can lead to aging, inflammation, and chronic diseases. Overheating olive oil can also cause a loss of nutrients, including the antioxidants found in extra virgin olive oil, she says. Use herbs and spices, garlic, and vinegar to add flavor to recipes.
Foods to avoid
Try to limit or avoid the following ingredients:
- Ultra-processed foods: refined carbohydrates, such as white bread, breakfast cereals, pastries, cakes, cookies, and candy; flavored yogurts; sugar-sweetened beverages, such as sodas and fruit juices; processed meats, such as chicken nuggets, deli meats, and hot dogs
- Red meat: beef, lamb, pork, elk, veal, venison
