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Fatty Liver Biomarkers: In your view, what should be the complete list of biomarkers to monitor for those who already have fatty liver and how often should they get tested on these biomarkers?

Blood chemistry biomarkers to be monitored during NAFLD include traditional liver function tests as well as markers of insulin resistance, include liver enzymes, hs-CRP, vitamin D, cholesterol, triglycerides, fasting glucose, insulin, every 6 months

Non-alcoholic fatty liver disease (NAFLD) is becoming increasingly prevalent and extends beyond liver function. It is closely related to metabolic syndrome, oxidative stress, endothelial dysfunction, and cardiovascular disease. Therefore, a comprehensive blood chemistry analysis should provide a baseline for monitoring these disorders as well (Sg 2017).

Monitor traditional liver function tests along with markers for insulin resistance in those with diagnosed NAFLD (Fracanzani 2008):

  • Albumin, globulin
  • Bilirubin
  • Cholesterol
  • Enzymes: ALT, AST, GGT, alkaline phosphatase
  • Ferritin
  • Uric acid
  • Vitamin D 25(OH)D
  • Fasting glucose and insulin
  • Fasting triglycerides
  • Hs-CRP

Assessing the ratio of ALT to AST can be useful as well. A progressively increasing ALT:AST ratio suggests worsening NAFLD. For example, ALT:AST ratio of 1.07 may reflect low grade disease in established NAFLD, while a ratio of 1.46 would be associated with more severe disease (Lu 2019).

Biomarkers can be monitored every six months for signs of improvement, especially markers of liver function, insulin resistance, inflammation, and oxidative stress. Monitoring other parameters such as visceral adiposity, lean body mass, BMI, and waist circumference will help evaluate progress as well (Vernon 2011).

It is also vital that clients optimize their diet and nutrition status as well. A well-balanced plant-based diet such as the Mediterranean diet will provide valuable micronutrients, fiber, antioxidants, anti-inflammatory compounds, monounsaturated fats, and omega-3 fatty acids, while restricting animal protein, saturated fats, trans fat, excess sugars, and processed foods (Anania 2018). Adherence to the Mediterranean diet was found to significantly improve fasting glucose, hemoglobin A1C, C-reactive protein, oxidized LDL, blood pressure, and liver fibrosis score in 44 patients with NAFLD (Kaliora 2019)

Environmental industrial toxins such as lead, mercury, and organochlorine insecticides should be avoided as well. They are associated with a dose-dependent increase in ALT, a surrogate marker for NAFLD (Wahlang 2020).


Anania, Caterina et al. “Mediterranean diet and nonalcoholic fatty liver disease.” World journal of gastroenterology vol. 24,19 (2018): 2083-2094. doi:10.3748/wjg.v24.i19.2083

Fracanzani, Anna Ludovica et al. “Risk of severe liver disease in nonalcoholic fatty liver disease with normal aminotransferase levels: a role for insulin resistance and diabetes.” Hepatology (Baltimore, Md.) vol. 48,3 (2008): 792-8. doi:10.1002/hep.22429

Gatselis, Nikolaos K et al. “Adiponectin: a key playmaker adipocytokine in non-alcoholic fatty liver disease.” Clinical and experimental medicine vol. 14,2 (2014): 121-31. doi:10.1007/s10238-012-0227-0

Kaliora, Andriana C et al. “The Effectiveness of Mediterranean Diet in Nonalcoholic Fatty Liver Disease Clinical Course: An Intervention Study.” Journal of medicinal food vol. 22,7 (2019): 729-740. doi:10.1089/jmf.2018.0020

Lu CW, Lin MS, Lin YS, et al. Aminotransferase Ratio Is a Useful Index for Hepatosteatosis in Children and Adolescents: A Cross-Sectional Observational Study. Gastroenterol Nurs. 2019 Nov/Dec;42(6):486-495.

Vernon, G et al. “Systematic review: the epidemiology and natural history of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis in adults.” Alimentary pharmacology & therapeutics vol. 34,3 (2011): 274-85. doi:10.1111/j.1365-2036.2011.04724.x

Wahlang, Banrida et al. “Insecticide and metal exposures are associated with a surrogate biomarker for non-alcoholic fatty liver disease in the National Health and Nutrition Examination Survey 2003-2004.” Environmental science and pollution research international vol. 27,6 (2020): 6476-6487. doi:10.1007/s11356-019-07066-x