How Should Patients with Fatty Liver Disease Exercise?

Fatty liver disease refers to a condition where excessive fat accumulates inside liver cells due to various causes. In a healthy individual, the total fat content in the liver accounts for about 5% of the liver's weight, including phospholipids, triglycerides, fatty acids, cholesterol, and cholesteryl esters. When the fat content exceeds 5%, it is classified as mild fatty liver; beyond 10% is considered moderate; and over 25% is categorized as severe. When the fat content reaches more than 30%, it can be detected by ultrasound and diagnosed as fatty liver disease. In some patients, the fat level may even reach 40%-50%, and in extreme cases, over 60%, primarily composed of triglycerides and fatty acids, with only a small increase in phospholipids and cholesterol. Generally, fatty liver disease is reversible, and early diagnosis combined with timely treatment can often restore the liver to normal.

Aerobic exercise is particularly effective for managing fatty liver disease. This type of activity involves sustained movement for more than five minutes without excessive fatigue. It helps overcome the body's physiological inertia, improves respiratory and circulatory function, and enhances overall physical fitness. During aerobic exercise, the body maintains a dynamic balance between oxygen demand and supply, preventing lactic acid buildup. Heart rate, cardiac output, and ventilation remain stable, allowing for prolonged exercise duration with high safety and significant fat burning. Regular aerobic training also increases oxygen uptake and anaerobic threshold, improving overall aerobic capacity. With consistent training, the same level of physical activity will result in lower heart rate and blood pressure responses, reduced oxygen consumption, and more efficient energy metabolism, which lowers cardiovascular stress and improves physical performance.

For patients with non-alcoholic fatty liver disease, low-intensity, long-duration aerobic exercise should be the focus of their fitness routine. Activities that rely on aerobic metabolism are especially effective for reducing body fat and promoting the regression of liver fat. Here are some suitable exercise options:

1. Walking for Weight Loss
- Leisure Walking: Walk at a slow or moderate pace for 30-60 minutes, 2-3 times daily. Ideal in scenic areas for relaxation.
- Brisk Walking: Walk at a speed of 5-7 km/h for 30-60 minutes per session, keeping the heart rate below 120 beats per minute.
- Incline Walking: Start with 100 meters on a 3-degree incline, gradually increasing to 15 minutes on a 5-degree incline followed by 15 minutes on flat ground.
- Arm-Swing Walking: Swing your arms rhythmically while walking to enhance shoulder and chest movement, beneficial for those with respiratory issues.
- Abdominal Massage Walking: Combine walking with gentle abdominal massage, which supports digestion and benefits those with gastrointestinal concerns.

2. Tai Chi for Weight Loss
Tai Chi is a gentle and safe option, especially for older adults. Due to its low intensity, longer sessions are recommended to achieve meaningful benefits.

3. Swimming
- High Calorie Burn: Water resistance is much higher than air resistance, making even basic movement in water physically demanding. Combined with water's superior thermal conductivity, swimming results in significant heat loss and calorie expenditure—more than land-based activities like running.
- Reduced Joint Strain: Swimming supports body weight through buoyancy, significantly reducing stress on the knees and lower back. This makes it ideal for individuals with obesity or joint issues who may struggle with land-based workouts.

Who Should Consider Exercise Therapy?
Exercise therapy is most suitable for patients with fatty liver disease associated with insulin resistance and overweight conditions. Individuals with obesity, type 2 diabetes, or hyperlipidemia-related fatty liver, as well as those with post-hepatitis fatty liver, can benefit from supervised physical activity. In fact, exercise ranks second only to dietary control in managing these types of fatty liver conditions. When diet alone is used for weight loss, the basal metabolic rate often decreases. Adding exercise increases energy expenditure, enhancing fat loss while preserving lean body mass. This combination supports healthier body composition, improved glucose control, lower blood pressure and lipids, and faster regression of liver fat. Research indicates that combining exercise and calorie restriction leads to more favorable lipid profile changes than diet alone, as physical activity specifically targets fat metabolism.

Who Should Avoid Exercise?
Not all patients with fatty liver disease are suitable candidates for exercise. Contraindications include:

- Severe complications such as acute myocardial infarction, unstable angina, congestive heart failure, severe arrhythmia, advanced hypertension, type 1 diabetes, kidney failure, severe liver damage, or decompensated cirrhosis.
- Fatty liver caused by malnutrition, hyperthyroidism, or tuberculosis—excessive exercise may worsen these conditions.
- Drug-, alcohol-, or toxin-induced fatty liver disease, where exercise could further disrupt metabolic balance.
- Acute fatty liver of pregnancy, which requires increased rest and limited physical activity.

Additionally, exercise therapy is best suited for primary obesity cases, not secondary obesity. Before starting any exercise program, patients should undergo medical evaluation and set realistic weight goals. Those with obesity exceeding 70% above ideal body weight may benefit from medication-based weight loss first, transitioning to exercise therapy once the excess drops below 50%.