Background and aim <p>Non-alcoholic fatty liver disease (NAFLD) represents a growing metabolic and hepatic health challenge worldwide, particularly in low- and middle-income regions such as Iraq. This study aimed to evaluate the safety and effectiveness of a combined nutrition education program and omega-3 fatty acid supplementation in improving anthropometric, biochemical, and hepatic outcomes among patients with NAFLD in Erbil City.</p> Method <p>This randomized controlled trial study was conducted from November 3rd, 2024 to March 3rd, 2025, at the outpatient clinic of Rizgary Teaching Hospital in Erbil City, Kurdistan Region, Iraq, using systematic sampling method. Data were collected using a structured questionnaire consisting of sociodemographic and clinical characteristics, anthropometric and biochemical measurements, the International Physical Activity Questionnaire (IPAQ), and dietary behavior scales. Statistical analyses were performed using IBM SPSS version 26 (IBM Corp., Armonk, NY).</p> Results <p>A total of 162 patients with non-alcoholic fatty liver disease (NAFLD) were included in the study. Both omega-3 supplementation and nutrition education interventions significantly improved anthropometric and biochemical parameters compared to baseline values. The nutrition education group achieved greater reductions in body weight (− 2.83&#xa0;kg, <i>p</i> &lt; 0.01), BMI (− 1.00&#xa0;kg/m², <i>p</i> &lt; 0.01), and liver enzymes (ALT and AST, <i>p</i> &lt; 0.01), along with improved lipid profiles and dietary behaviors. Total physical activity levels increased significantly in both intervention groups (<i>p</i> &lt; 0.001). Hierarchical multiple regression identified nutrition education (β = 0.428, <i>p</i> &lt; 0.001), omega-3 supplementation (β = 0.312, <i>p</i> &lt; 0.001), physical activity change (β = 0.284, <i>p</i> &lt; 0.001), and compliance (β = 0.258, <i>p</i> = 0.001) as key predictors of treatment success, collectively explaining 61% of the variance in outcomes.</p> Conclusions <p>The study demonstrated that a nutrition education and omega-3 supplementation program effectively improved hepatic function, lipid profile, and physical activity among patients with NAFLD in Erbil City. Integrating such low-cost, behaviorally oriented interventions into clinical practice may provide a sustainable approach for NAFLD management in resource-limited settings.</p> Trial registration <p>The clinical trial was prospectively registered at ClinicalTrials.gov (Identifier: NCT06627114; Registration date: October 2, 2024).</p>