An Unusual Dietary Approach to NAFLD

An Unusual Dietary Approach to NAFLD

A buildup of extra fat in the liver, not caused by alcohol abuse, is known as Nonalcoholic Fatty Liver Disease (NAFLD). NAFLD has become the most common form of chronic liver disease in Western countries. With rates as high as 30%, it is more common than viral hepatitis or alcoholic liver disease.  Unfortunately, NAFLD is often a disease that shows no obvious symptoms, but when left undiagnosed can lead to further complications, including inflamed liver, and cirrhosis.

The primary causes of NAFLD are two-fold: vitamin D deficiency (which I covered in this newsletter Low vitamin D may increase risk of nonalcoholic fatty liver disease); and metabolic syndrome (insulin resistance), which is in turn linked to obesity and sedentary lifestyle. Metabolic syndrome is caused by a diet with excessive amounts of sugar and bad fats (fried and processed foods, and vegetable oils high in omega 6 fatty acids), thus these foods will contribute to causing NAFLD.  From the medical perspective, there is no approved treatment for NAFLD except for a recommendation to follow a healthy diet and exercise regularly.

Dangers of NAFLD

This accumulation of fat in the liver can ultimately lead to terminal liver disease. And, this progression towards dangerous liver disease occurs, as with many ailments, in stages. In the first stage, one develops “simple fatty liver” (steatosis), which, if it worsens, becomes non-alcoholic steatohepatitis (NASH), leading to serious liver damage.

The medical hypothesis on the progression from simple steatosis to NASH is such: steatosis weakens the liver, leaving it vulnerable to excess damage being caused by other malfunctions in the body, including chronic inflammation, free radical attacks, and mitochondrial dysfunction. Unable to cope normally with these internal issues, the liver suffers from fibrosis, inflammation, and cellular death (all symptoms of NASH).  In 2016, a group of researchers set out to find “food components” that might help prevent the progression of simple fatty liver into the dangerous NASH.


The researchers turned to cocoa, based on its long history of health benefits, as many studies have “confirmed various health-beneficial effects associated with cocoa products including their multifactorial ability to modulate immune response, and anti-inflammatory, anti-radical and anti-carcinogenic properties”.

I have covered many of these benefits in an earlier newsletter titled, Eat More Chocolate. There I discuss how cocoa has been proven to be of therapeutic value in  preventing and/or treating cardiovascular disease, diabetes, inflammation, and prostate issues. As well, cocoa helps to reduce stress, aid in weight loss, support immune function, and prevent facial wrinkling and DNA damage.  Given that the health properties of cocoa might address some of the disease-inducing factors leading to NASH, the scientists set up a study to examine the protective effect of cocoa on mice fed a high fat diet designed to induce steatosis.

“In this research, we hypothesized that cocoa supplementation can ameliorate obesity related NAFLD through modulating lipid metabolism pathway, boosting endogenous antioxidant defense capacity, enhancing mitochondrial biogenesis, and reducing chronic inflammation in mice.” 

Here it is interesting to observe just how you induce simple steatosis in a mouse (the process being the same in humans): “Mice were fed with a high fat diet (60% calorie from fat) for 8 weeks to induce steatosis.”   After the eight week induction period, the mice were randomly divided into two groups: both remained on the high fat diet for another 10 weeks, but one group had their diet include 8% cocoa.

Study Conclusions 

So, what did this study ultimately reveal?
In the words of the researchers:

  • “…cocoa-treated obese mice decrease triglycerides (TAG), an important diagnostic marker of NAFLD, by enhancing fatty acid disposal and reducing lipogenesis (fatty acid synthesis) in the liver.” 
  • “…the beneficial effects of cocoa supplementation on NAFLD is through increasing mitochondrial biogenesis and related antioxidant response signaling.”
  • “…dietary cocoa is able to alternatively activate M2 KCs in High Fat-fed mice, and this phenotypic switch protects mice from ongoing liver damage.”  (During the repair phase of the liver, the M2 KCs release anti- inflammatory cytokines.)

“In conclusion, we demonstrated that cocoa supplementation did mitigate obesity-related fatty liver disease, and could be useful in preventing the progression of hepatic steatosis to NASH. These effects are caused by three mechanisms: modulating lipid metabolism pathway, boosting endogenous antioxidant defense capacity, increasing mitochondria biogenesis and reducing chronic inflammation.” 

In fact, to be a bit more specific, those mice whose high fat diet was supplemented with cocoa powder had a 22% lower rate of body weight gain, 28% lower liver triglycerides, 57% less oxidative degradation of lipids, and 75% reduction in mitochondrial DNA damage, than those mice who did not receive the cocoa.

Furthermore, “these changes were associated with higher hepatic superoxide dismutase and glutathione peroxidase enzyme activity and increased expression of markers of hepatic mitochondrial biogenesis”. Which means that the most powerful antioxidants in the body were mightily increased in the liver, and cellular regeneration had begun, indicating that this protocol can heal liver damage as well as prevent it.  (Study)

How Much Cocoa?

Let’s start with a little historical digression.  According to accounts from the period, 16th-century Aztec ruler Moctezuma II drank 50 cups of chocolate a day, in order to increase his libido. Conquistador Hernán Cortés, and his Spanish officers, dined with Moctezuma, observing, among other things, that his chocolate was served in cups made of pure gold.

From the journal of  Cortés: “These seeds which are called almonds or cacao are ground and made into powder, and other small seeds are ground, and this powder is put into certain basins with a point… and then they put water on it and mix it with a spoon. And after having mixed it very well, they change it from one basin to another, so that a foam is raised which they put in a vessel made for the purpose. And when they wish to drink it, they mix it with certain small spoons of gold or silver or wood, and drink it, and drinking it one must open one’s mouth, because being foam one must give it room to subside, and go down bit by bit. This drink is the healthiest thing, and the greatest sustenance of anything you could drink in the world, because he who drinks a cup of this liquid, no matter how far he walks, can go a whole day without eating anything else.”   (Source)

Now, for our purposes we don’t need quite as much cocoa as Moctezuma used. In the study we have been looking at, the amount of cocoa ingested by the mice would be the equivalent of about 10 tablespoons of cocoa powder a day, for adult humans. Or, according to the directions on a box of Hershey’s cocoa, about five cups of hot chocolate drink.

The problem for most of us is we do not like bitter tastes, thus our chocolate, and cocoa is often sweetened, usually over-sweetened. And, “too much refined sugar and high-fructose corn syrup causes a fatty buildup that can lead to liver disease. Some studies show that sugar can be as damaging to the liver as alcohol, even if you’re not overweight”.    (Source)

Therefore, if one were to attempt to use cocoa as a therapeutic agent they would be advised to sweeten it without sugar, using stevia and/or xylitol. Occasionally, some honey would be acceptable as well.

Cocoa vs Cacao

These days, to many health aficionados anything raw is considered superior, but that is not always so. We do know that cacao, or unprocessed cocoa, has a higher antioxidant profile than processed chocolate, but it also has a more bitter and astringent taste than processed cocoa, due to its high phenolic content (source of antioxidants).  Processing of chocolate beans is done by allowing fermentation of the cacao pulp surrounding the beans. “Fermentation allows the enzymatic breakdown of proteins and carbohydrates inside the bean, creating flavor development.”  (Source)

However, the “post-harvest processing of cocoa beans, such as fermentation, not only determines the formation of aroma and flavor compounds, but also contributes to the formation of bioactive compounds with health benefits”.  According to this research, most chocolate studies associate the beneficial effects to the polyphenols (antioxidants) present, “and little is known about the potential health effects of other cocoa components such as bioactive peptides”. Thus, in the review of cocoa to be found in this link, the researchers focused “on the role of cocoa bean protein hydrolysis for the release of bioactive peptides. Also, the potential health benefits of cocoa bean hydrolysates and peptides, specifically, antioxidant, antihypertensive, antidiabetic, anti-Alzheimer, anti obesogenic and antitumor activities”.

The point being, it may well be that the processing of cacao into cocoa provides more health benefits than raw cacao does. And, of course, the study we have been examining was done with cocoa, and not cacao. In either case, feel free to go coco-loco, with no worries, though, as usual, I do strongly recommend you choose an organic product (ideally fair-trade as well).

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