Fatty Liver Disease (MASLD)
Excess fat in the liver linked to metabolic risk — the most common chronic liver disease worldwide.
Overview
Metabolic-dysfunction-associated steatotic liver disease (MASLD, previously NAFLD) affects up to 30% of adults. A subset progresses to steatohepatitis (MASH), fibrosis and cirrhosis. Early detection and metabolic optimisation can reverse progression.
Symptoms
- • Usually asymptomatic
- • Right upper quadrant discomfort or fatigue
- • Hepatomegaly on examination
- • Signs of advanced liver disease only when cirrhosis develops
Risk factors
- • Obesity, type 2 diabetes, dyslipidaemia, hypertension
- • PCOS, hypothyroidism
- • Age >50
- • South Asian ancestry
Causes
- • Insulin resistance and metabolic syndrome
- • Genetic factors (PNPLA3, TM6SF2)
- • Concurrent alcohol may accelerate (MetALD)
- • Drugs (amiodarone, methotrexate, tamoxifen)
🚨 Red flags — seek urgent care
- • Jaundice, ascites, encephalopathy — advanced disease
- • Variceal bleeding (haematemesis, melaena)
- • Rapidly rising transaminases — alternative cause likely
When to seek care
- • Incidental fatty liver on ultrasound
- • Persistently raised ALT with metabolic risk
- • Type 2 diabetes — screen for advanced fibrosis
Diagnosis
- • Liver ultrasound or controlled-attenuation parameter (CAP)
- • Exclude alcohol, viral hepatitis, autoimmune, haemochromatosis, Wilson's
- • Risk stratify with FIB-4; ELF, FibroScan if intermediate/high
- • Liver biopsy only if diagnosis uncertain or advanced fibrosis suspected
Treatment
- • Weight loss ≥7% reverses steatosis; ≥10% reverses fibrosis
- • Mediterranean diet; reduce sugar-sweetened beverages and ultra-processed food
- • ≥150 minutes/week moderate aerobic activity plus resistance training
- • Optimise diabetes (GLP-1 agonists, pioglitazone where appropriate), lipids, BP
- • Resmetirom (where licensed) for biopsy-proven MASH with fibrosis F2–F3
- • Avoid alcohol; vaccinate against hepatitis A and B
Prevention
- • Maintain healthy weight, active lifestyle, balanced diet
- • Control diabetes and metabolic syndrome
- • Limit alcohol
Complications
- • Steatohepatitis (MASH), fibrosis, cirrhosis
- • Hepatocellular carcinoma
- • Cardiovascular disease — leading cause of death in MASLD
- • Type 2 diabetes progression
Prognosis
Simple steatosis has good prognosis with lifestyle change. MASH with fibrosis carries higher liver and cardiovascular mortality but is often reversible if addressed early.
Education & self-care
MASLD is metabolic disease that happens to live in the liver. Treating the metabolic root — weight, diet, activity, diabetes control — protects the liver and the heart at the same time.
Frequently asked questions
Can fatty liver be reversed?
Yes — sustained weight loss of 7–10% can reverse fat and even early fibrosis.
Do I still need to avoid alcohol?
Alcohol accelerates MASLD progression. Minimising or avoiding it is strongly recommended.
Can fatty liver be reversed?
Yes. A sustained 7–10% weight loss can reverse steatohepatitis and even early fibrosis. Mediterranean-style eating, regular activity and reducing fructose-sweetened drinks all help.
Do I need a liver biopsy?
Most people do not. Non-invasive tools — FIB-4 score, ELF blood test and FibroScan elastography — accurately identify those at low risk and flag the minority needing biopsy or specialist referral.
Is alcohol safe in fatty liver disease?
Even moderate alcohol accelerates fibrosis in metabolic-associated fatty liver. The safest level is none, and certainly under 14 units a week spread across the week.