A claim you hear on longevity podcasts

Does cutting sugary drinks reduce liver fat?

The claim checked: Cutting sugary drinks is one of the best diet moves for a fatty liver Hear it at 24:33

What do the studies say?

Leaning for

Five studies found that less sugar meant less liver fat, or more sugar meant more. In adolescent boys, 8 weeks on a low-sugar diet improved liver fat. A sugar-cutting program in Latino youth found no change. Four reviews and trials found small or uncertain effects.

Computed from 10 studies that test this point, each judged by two readers, in full. 3 more studies are waiting for a full read and do not count yet.

What was said on the podcast?

“So the practical advice holds cutting sugar sweetened beverages is absolutely one of the higher yield dietary moves for someone with insulin resistance or liver disease.”

Peter Attia, The Drive · Metabolic liver health: how to assess risk, catch dysfunction early, and more (AMA 88 sneak peek) · 24:33 on YouTube

Point 1 of 2 Leaning for

Cutting sugar-sweetened beverages reduces liver fat

Agree 5

controlled trial · 2012 · landmark

“Accumulation of liver fat was higher after regular cola (overall P = 0.01, ANOVA) than after milk (143%; 95% CI: 50, 236; P < 0.05), diet cola (139%; 95% CI: 50, 227; P < 0.05), and water (132%; 95% CI: 43, 222; P < 0.05; Figure 1B).”

Sucrose-sweetened beverages increase fat storage in the liver, muscle, and visceral fat depot: a 6-mo randomized intervention study. Am J Clin Nutr
Who: Healthy nondiabetic overweight adults, BMI 26-40, aged 20-50 y, in Denmark; 60 randomized, 47 completed (30 women, 17 men)
PMID 22205311

controlled trial · 2019 · landmark

“In this study of adolescent boys with NAFLD, 8 weeks of provision of a diet low in free sugar content compared with usual diet resulted in significant improvement in hepatic steatosis.”

Effect of a Low Free Sugar Diet vs Usual Diet on Nonalcoholic Fatty Liver Disease in Adolescent Boys: A Randomized Clinical Trial. JAMA
Who: Adolescent boys aged 11-16 (95% Hispanic) with biopsy-diagnosed NAFLD, MRI-PDFF >=10% and ALT >=45 U/L, consuming >=3 servings/week of juice or sugar-sweetened beverages
PMID 30667502

trial or observed group · 2021

“CONCLUSION. Our results suggest that dietary sugar restriction reduces hepatic DNL and fasting insulin, in addition to reductions in hepatic fat and ALT, among adolescents with NAFLD.”

Dietary sugar restriction reduces hepatic de novo lipogenesis in adolescent boys with fatty liver disease. J Clin Invest
Who: Adolescent boys with biopsy-diagnosed NAFLD (MRI-PDFF >=10%, ALT >=45 U/L) who drank at least 3 servings/week of sugar-sweetened beverages or juice; DNL substudy of an 8-week open-label RCT
PMID 34907907

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other primary study · 2017 · landmark

“Short-term (9 day) isocaloric fructose restriction decreased liver fat, VAT, and DNL, and improved insulin kinetics in children with obesity.”

Effects of Dietary Fructose Restriction on Liver Fat, De Novo Lipogenesis, and Insulin Kinetics in Children With Obesity. Gastroenterology
Who: Latino and African-American children aged 9-18 with obesity and metabolic syndrome who were high habitual sugar consumers
PMID 28579536

trial or observed group · 2015

“The observation that substitution of CCHO for fructose, even for this short period, was associated with reductions in all of these outcomes suggests a potential role for fructose in metabolic abnormalities and the development of fatty liver.”

Effect of a High-Fructose Weight-Maintaining Diet on Lipogenesis and Liver Fat. J Clin Endocrinol Metab
Who: Healthy men aged 18-65 (mean 42, BMI <30, liver fat <5%) studied as inpatients
PMID 25825943

Partly agree 4

pooled analysis · 2022

“Although we were unable to assess interaction by food source at these levels of energy control, the large increase in IHCL in the addition trials and no effect in IHCL in the subtraction trials was specific to a single food source: SSBs.”

Important Food Sources of Fructose-Containing Sugars and Non-Alcoholic Fatty Liver Disease: A Systematic Review and Meta-Analysis of Controlled Trials. Nutrients
Who: Controlled trials in predominantly healthy mixed-weight or overweight/obese younger adults, some with NAFLD or diabetes
PMID 35889803

controlled trial · 2021

“In conclusion, in this double-blind randomized controlled trial, we showed that a 6-wk fructose restriction per se results in a small but statistically significant decrease in IHL content in overweight adult individuals with a high FLI in comparison with an isocaloric control group.”

Effects of fructose restriction on liver steatosis (FRUITLESS); a double-blind randomized controlled trial. Am J Clin Nutr
Who: Overweight adults (BMI >=28 or high fatty liver index >=60) in the Netherlands
PMID 33381794

pooled analysis · 2016

“No changes in liver fat or VAT depots were observed after the nutrition education intervention.”

Potential link between excess added sugar intake and ectopic fat: a systematic review of randomized controlled trials. Nutr Rev
Who: RCTs in adults and children older than 4 years testing added sugars (fructose, sucrose, HFCS, SSBs) with imaging- or biopsy-measured ectopic fat
PMID 26518034

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pooled analysis · 2014

“Together, there was insufficient evidence to draw a conclusion for effects of a hypocaloric fructose diet on the progression of NAFLD in patients with NAFLD because of high risks for biases, although both studies did not find that a hypocaloric fructose diet had a significant effect on ALT and AST concentrations.”

Fructose, high-fructose corn syrup, sucrose, and nonalcoholic fatty liver disease or indexes of liver health: a systematic review and meta-analysis. Am J Clin Nutr
Who: Observational and intervention studies of fructose, HFCS or sucrose intake and liver health, mostly healthy young men; fructose-reduction trials in 10 obese children and 10 overweight adults with NAFLD
PMID 25099546

Disagree 1

controlled trial · 2022

“In Latino youth with obesity, a dietitian-led sugar reduction intervention did not improve liver outcomes compared with control, regardless of PNPLA3 genotype.”

Clinical Intervention to Reduce Dietary Sugar Does Not Affect Liver Fat in Latino Youth, Regardless of PNPLA3 Genotype: A Randomized Controlled Trial. J Nutr
Who: Latino adolescents aged 11-18 y with obesity (BMI >= 95th percentile), mean age 14.8 y, mean baseline liver fat 12.7%, 73% meeting NAFLD criteria
PMID 35218194

Point 2 of 2 Strong consensus for

Drinking sugar-sweetened beverages is linked to a higher risk of fatty liver disease

Eight studies linked sugary drinks to fatty liver. A pooled analysis of 12 studies put the risk 1.39 times higher in people who drink them. Two found the link only for some groups or some drinks.

Computed from 10 studies that test this point, each judged by two readers, in full. 9 more studies are waiting for a full read and do not count yet.

Agree 8

other primary study · 2008 · landmark

“Our primary finding was that subjects with NAFLD have a significantly greater intake of sweetened beverages by history, representing two-fold greater than the mean intake in both controls and in population-based studies.”

Fructose consumption as a risk factor for non-alcoholic fatty liver disease. J Hepatol
Who: Adults with biopsy-proven NAFLD without cirrhosis and controls matched for gender, age and BMI (University of Florida); liver mRNA in 6 vs 6; plus mouse AML-12 hepatocytes
PMID 18395287

controlled trial · 2012 · landmark

other primary study · 2008

“The follow-up data, the correlation between severity of fatty liver and amount of soft drink consumption, and the fact that soft drink consumption was the only independent predictor of fatty liver support the association between soft drink consumption and fatty liver.”

Soft drink consumption linked with fatty liver in the absence of traditional risk factors. Can J Gastroenterol
Who: Israeli outpatients with ultrasound-diagnosed NAFLD and no classic risk factors (no diabetes, obesity, hyperlipidemia or hypertension; mean age 30) vs age- and sex-matched healthy controls
PMID 18925303

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trial or observed group · 2015

“In this large, cross-sectional study of middle-aged adults, we observed a significant dose-response relationship between SSB and fatty liver disease, with a 56% increased risk of fatty liver disease in daily consumers of SSB compared to non-SSB consumers.”

Sugar-sweetened beverage, diet soda, and fatty liver disease in the Framingham Heart Study cohorts. J Hepatol
Who: Middle-aged, mostly Caucasian adults from the Framingham Offspring and Third Generation cohorts (men >=35, non-pregnant women >40 for CT; high alcohol consumers excluded)
PMID 26055949

pooled analysis · 2019

“The pooled RR of NAFLD in individuals consuming sugar-sweetened beverages was 1.39 (95% CI, 1.29–1.50).”

Consumption of Sugar-Sweetened Beverages Has a Dose-Dependent Effect on the Risk of Non-Alcoholic Fatty Liver Disease: An Updated Systematic Review and Dose-Response Meta-Analysis. Int J Environ Res Public Health
Who: 12 observational studies (9 cross-sectional, 2 case-control, 1 cohort) from China, USA, Germany, Australia and Israel; mostly adults, some adolescent and child samples
PMID 31234281

trial or observed group · 2022

“Higher average SSB intake is associated with increase in liver fat over 6 years of follow-up and increased odds of incident NAFLD especially among the older cohort, whereas no consistent association was observed for the younger Third Generation cohort.”

Sugar-Sweetened Beverage, Diet Soda, and Nonalcoholic Fatty Liver Disease Over 6 Years: The Framingham Heart Study. Clin Gastroenterol Hepatol
Who: Framingham Heart Study Offspring (mean age 62.8) and Third Generation (mean age 48.4) participants with repeat CT scans, high alcohol consumers excluded; primarily white, non-Hispanic
PMID 34752964

other primary study · 2021

“These findings demonstrate that compared with aspartame-SB, the consumption of HFCS- or sucrose-SB at 25% Ereq for 2 weeks increased hepatic lipid content and decreased insulin sensitivity in healthy young adults, but there were no differences between effects of the 2 different sugars.”

Consuming Sucrose- or HFCS-sweetened Beverages Increases Hepatic Lipid and Decreases Insulin Sensitivity in Adults. J Clin Endocrinol Metab
Who: Healthy young adults aged 18-40 with BMI 18-35 kg/m2, no diabetes or liver disease, non-randomized groups matched for sex, BMI and lipids
PMID 34265055

other primary study · 2023

“Compared with non-SSB consumers, individuals who had ≥72 (male) and 50 (female) grams of sugar intake from total SSBs had a significantly higher risk of having NAFLD (aOR = 1.60, 95% CI = 1.05–2.45), after adjusting for demographic factors, risk behaviors, and BMI (Model 3).”

Sugar-Sweetened Beverages and Artificially Sweetened Beverages Consumption and the Risk of Nonalcoholic Fatty Liver (NAFLD) and Nonalcoholic Steatohepatitis (NASH). Nutrients
Who: Nationally representative US adults over 20 from NHANES 2017-March 2020 with transient elastography and two 24 h dietary recalls; heavy drinkers and known liver disease excluded
PMID 37764782

Partly agree 2

pooled analysis · 2022

“The evidence provides a good indication that SSBs providing excess energy at high doses lead to large increases liver fat and small important increases in ALT, whereas there is a less of an indication that the removal of energy from mixed sources (with SSBs) results in moderate reductions in AST.”

Important Food Sources of Fructose-Containing Sugars and Non-Alcoholic Fatty Liver Disease: A Systematic Review and Meta-Analysis of Controlled Trials. Nutrients
Who: Predominantly healthy mixed weight or overweight/obese younger adults (some with NAFLD or diabetes, a few child trials) in controlled feeding trials
PMID 35889803

other primary study · 2019

“We found that those participants classified as positive by FLI (true positive and false positive) consumed more SSB than those classified as negative, and that those classified as NAFLD consumed more natural juices than those without the diagnosed.”

Dietary Sources of Fructose and Its Association with Fatty Liver in Mexican Young Adults. Nutrients
Who: Healthy young adults (mean age 21.4, 54% male) in Mexico City from the ELEMENT birth cohort
PMID 30823422

Disagree 0

None.

What else was said but not tested?

Calorie for calorie, swapping fructose for other carbohydrates barely changes liver fat

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