Fatty Liver Disease: A Comprehensive Guide

Fatty liver disease means that extra fat builds up inside liver cells, impairing the organ’s ability to function. It’s a spectrum: some people have simple fat accumulation with no injury (formerly called non‑alcoholic fatty liver, now metabolic dysfunction‑associated steatotic liver, or MASL). 

Others develop inflammation and damage (previously non‑alcoholic steatohepatitis, now metabolic dysfunction‑associated steatohepatitis, or MASH) that can lead to scarring and cirrhosis. 

This guide explains what fatty liver disease is, why it happens, how it’s diagnosed and treated, and what you can do to protect your liver. The information is drawn from major health organisations and scientific studies to help readers and families make informed decisions.

What is Fatty Liver Disease?

Fatty liver disease means > 5 % of liver cells contain fat. When heavy drinking causes this, it’s called alcohol‑associated liver disease (ALD). When it occurs without heavy alcohol use and is linked to metabolic problems (obesity, diabetes, high triglycerides), it’s now termed MASLD. 

MASLD includes two subtypes:

Under the new steatotic liver disease (SLD) umbrella, patients are classified into MASLD (metabolic), ALD (alcohol‑related) and MetALD (both metabolic and increased alcohol intake). To be diagnosed with MASLD, doctors must see hepatic fat plus at least one metabolic risk factor. Because most people with the old NAFLD diagnosis already had metabolic risks, more than 95 % of them meet MASLD criteria.

Why Does Fat Build up in the Liver?

The liver plays a central role in processing fats and sugars. When we eat more calories than we burn, especially sugar and saturated fats, the liver converts the excess into triglycerides for storage. Over time, fat builds up faster than the liver can export it, leading to steatosis. The main drivers are:

• Insulin resistance and metabolic syndrome: High insulin levels and resistance increase fat uptake in the liver. MASLD is strongly associated with obesity, high waist circumference, high blood pressure, high triglycerides, high blood sugar and low HDL cholesterol. 

Conditions like polycystic ovary syndrome, obstructive sleep apnea and hypothyroidism also raise risk.

• Sedentary lifestyle and diets high in processed carbohydrates or fructose: Diets rich in sugar-sweetened beverages and refined carbohydrates raise liver fat, while physical inactivity reduces the liver’s ability to burn fat.

Researchers are studying whether high-fructose diets and imbalances in gut bacteria further increase risk.

• Genetics: Variants in genes like PNPLA3 make some people more susceptible[. This partly explains why MASLD is more common in Hispanic and South Asian populations.

• Medications and toxins: Corticosteroids, certain HIV treatments, oestrogens, and some cancer drugs can cause fatty liver. Second‑generation antipsychotics and long-term steroids are also implicated.

• Rapid weight loss or malnutrition: Rapid fat loss floods the liver with free fatty acids.

Symptoms and Complications

Many people with MASLD have no symptoms. Often, the disease is discovered incidentally during an ultrasound or blood tests. Possible symptoms include:

• Fatigue or a general feeling of malaise.
• Discomfort or pain in the upper right abdomen.
• Hepatomegaly (enlarged liver): doctors may notice an enlarged liver on examination.
• Bloating, increased thirst and sleep disturbances.

Because symptoms are vague, regular screening is important for people at risk (see Section 8). If inflammation (MASH) or scarring develops, complications can include:

• Fibrosis and cirrhosis: Scarring impairs liver function and can lead to liver failure.
• Hepatocellular carcinoma (liver cancer): MASH is one of the leading causes of liver cancer.
• Cardiovascular disease: MASLD increases the risk of heart disease and stroke and is the leading cause of death in people with MASLD.
• Type 2 diabetes: MASLD can worsen insulin resistance and increase the risk of developing diabetes.

Risk factors

Metabolic risk factors

The major risk factors for MASLD are components of metabolic syndrome. You are more likely to develop MASLD if you have:

• Overweight or obesity, especially abdominal fat.
• Insulin resistance or type 2 diabetes.
• Abnormal fats in your blood: high triglycerides, high LDL cholesterol or low HDL cholesterol.
• High blood pressure and high fasting blood sugar.

Having more than one of these conditions increases the risk of progression to MASH. Up to 70 % of people with type 2 diabetes have MASLD. Among those with both MASLD and diabetes, about half have MASH and one-third have significant fibrosis.

Other risk factors

• Sedentary lifestyle and diets high in refined carbohydrates or fructose.
• Polycystic ovary syndrome (PCOS), obstructive sleep apnea or hypothyroidism.
• Certain medications such as corticosteroids, some HIV treatments, antipsychotics and oestrogens.
• Genetic variants (e.g., PNPLA3), which may explain ethnic differences.
• Moderate to heavy alcohol consumption combined with metabolic risks. New guidelines define a mixed category (MetALD) for people with MASLD who drink 20–50 g/day for women or 30–60 g/day for men. 

When alcohol consumption exceeds 210 g/week for men or 140 g/week for women, the disease is classified as mixed MASLD and ALD (a combination of metabolic and alcohol-related liver disease).

• Rapid weight loss or malnutrition.

How can Fatty Liver be Treated?

Lifestyle is the Cornerstone

There is no approved drug to cure MASLD/MASH. The most effective treatment is lifestyle change aimed at weight loss. Evidence shows that:

• Losing 5 % of body weight reduces liver fat by about 25 %.
• Losing 7–10 % of body weight can reduce inflammation and even reverse scarring in MASH. A landmark study found that losing 10 % of body weight resolved inflammation and improved fibrosis.
• Weight loss should be gradual (0.5–1 kg per week) and sustainable. Crash diets can worsen liver inflammation.

Recommended diet patterns

A balanced eating pattern improves liver health and helps with weight loss:

• Mediterranean or DASH-style diet: Emphasises vegetables, fruits, whole grains, legumes, nuts, seeds, olive oil and fatty fish. These diets are rich in fibre and unsaturated fats and are associated with reduced liver fat and inflammation.

• High-fibre, low‑glycaemic foods: Such as oats, whole barley, millets, brown rice, legumes, and vegetables help control blood sugar and reduce fat accumulation. 

A clinical trial on traditional Indian foods reported that dishes like white chickpea ‘sundal’ (GI 24–29), broken wheat upma (GI ~52) and other whole-grain pulses have low glycaemic indices, making them good choices for people in South Asia.

• Limit saturated fat and refined carbohydrates: Avoid red meat, fried foods, bakery products made from white flour, and sugary drinks. They raise liver fat and triglyceride levels. Instead, choose lean proteins (beans, tofu), low-fat dairy and fish.

• Coffee, nuts, green tea and turmeric: Observational studies suggest that coffee, green tea, walnuts and turmeric may have protective effects on the liver due to their antioxidant and anti-inflammatory properties.

Foods to Avoid or Limit

• Alcohol: A major cause of liver disease; avoid or limit it. Even moderate drinking can worsen MASLD when combined with metabolic risk factors.

• Added sugars: Candy, cookies, sweetened beverages and fruit juices raise blood sugar and promote fat deposition in the liver.

• Fried foods and processed meats: High in calories, saturated fat and sodium.

• Refined grains: White bread, rice and pasta cause rapid spikes in blood sugar and lack fibre.

• Excess salt: Aim for less than 2,300 mg sodium per day; people with high blood pressure should limit to 1,500 mg.

Exercise Guidelines

Regular physical activity enhances insulin sensitivity and helps burn liver fat. Aim for:

• At least 150 minutes of moderate‑intensity aerobic exercise per week, such as brisk walking, cycling or swimming.

• Include resistance training (strength exercises) two to three times per week to build muscle and improve metabolism.

• Any movement helps: housework, yoga, gardening and active commuting all count.

Weight-loss Surgery and Medications

• Bariatric surgery may be considered for people with severe obesity who cannot lose weight through lifestyle changes alone. Surgery can improve or even resolve steatosis and inflammation. Sleeve gastrectomy and gastric bypass are common options.

• Pharmacologic treatments: There are no FDA‑approved drugs specifically for MASH. However, medicines used for diabetes and weight loss may help.

• Vitamin E (800 IU/day) can improve liver inflammation in non‑diabetic patients with biopsy‑proven MASH. It should be avoided in men with prostate cancer.

• Pioglitazone (a thiazolidinedione) improves liver histology in patients with or without diabetes. It may cause weight gain and should be discussed with a doctor.

• GLP‑1 receptor agonists (e.g., liraglutide, semaglutide) and SGLT‑2 inhibitors used for diabetes have shown promise in reducing liver fat and weight.

• New agents: Resmetirom (a thyroid hormone receptor‑β agonist) and other drugs are in late‑stage trials and may soon offer options for reversing fibrosis.

Always discuss medication options with a healthcare provider; treatment decisions depend on individual risk factors.

Protect Your Liver

• Avoid heavy drinking and be honest with your doctor about alcohol use.
• Get vaccinated against hepatitis A and B.
• Check other medications and supplements with your doctor; some herbs and over‑the‑counter remedies may harm the liver.
• Manage other health conditions such as high blood pressure, diabetes and cholesterol.
• Don’t smoke; smoking worsens heart and liver disease.
• Prioritise sleep and stress management; poor sleep can worsen insulin resistance.

Screening and Monitoring

Because MASLD is common and often silent, routine screening is important for people with metabolic risk factors. Guidelines suggest:

• Annual to three‑year screening with liver enzyme tests and/or ultrasound for patients with obesity, type 2 diabetes or metabolic syndrome.
• Use non‑invasive fibrosis scores such as FIB‑4 or NAFLD Fibrosis Score; low scores may allow monitoring by primary care doctors, while high scores prompt referral to hepatology.
• Elastography to assess liver stiffness in patients with elevated fibrosis scores.
• Liver biopsy if imaging and blood tests suggest inflammation or advanced fibrosis, or when considering experimental treatments.

Conclusion 

Fatty liver disease is now one of the most common liver conditions worldwide, but it is often silent until severe damage develops. The good news is that early action can make a significant difference. Simple lifestyle steps like gradual weight loss, a balanced diet rich in whole foods, and regular physical activity can reduce liver fat and even reverse early inflammation. 

Screening is essential for people with diabetes, obesity, or other metabolic risks. While no specific drug is approved yet, ongoing research offers hope. Protecting your liver today helps prevent complications tomorrow and supports overall health.

Frequently Asked Questions (FAQs)

1. Is MASLD the same as NAFLD? 

Essentially yes. The term MASLD replaced NAFLD in 2023 to emphasise the role of metabolic factors and remove stigma around the word “alcoholic.” MASLD requires hepatic steatosis plus at least one metabolic risk factor and applies even if there is moderate alcohol use.

2. Can lean people get MASLD? 

Yes, up to 20 % of lean individuals may develop MASLD due to insulin resistance, high body fat or genetic factors. Screening decisions should be based on metabolic risk, not just weight.

3. What happens if MASLD is left untreated? 

Without intervention, MASLD can progress to MASH, fibrosis, cirrhosis and liver cancer. Early lifestyle changes can prevent or reverse this progression.

4. How quickly can I reverse fatty liver? 

Liver fat often decreases within a few months of sustained weight loss, but reversing inflammation and scarring can take longer. Gradual weight loss (5–10 % of body weight) and regular exercise are key.

5. Are herbal supplements safe for fatty liver? 

Be cautious. Some herbs, including high-dose green tea extracts, can damage the liver. Always talk with a doctor before taking supplements.

6. Do I need to stop drinking coffee? 

No. Several studies suggest that regular coffee consumption may protect against liver fibrosis and cancer, so it is generally safe unless advised otherwise.

Key Takeaways

• Fatty liver disease (MASLD/MASH) is extremely common—affecting roughly one in four adults worldwide and more than one in three Indian adults.
• Major risk factors include obesity, type 2 diabetes, high triglycerides, high blood pressure, insulin resistance and certain medications; however, lean people with insulin resistance or genetic predisposition are also affected.
• Many people have no symptoms, making screening vital for those with metabolic risks.
• Diagnosis is based on blood tests, ultrasound and non‑invasive fibrosis scores; biopsy is reserved for uncertain or advanced cases.
• Lifestyle changes are the best treatment: a Mediterranean‑style diet, avoiding processed foods and sugar, regular exercise and gradual weight loss (7–10 %) can reduce fat, inflammation and scarring.
• No drug is yet approved specifically for MASLD/MASH, but medications used for diabetes and weight loss may help; consult a healthcare professional.
• Avoid heavy drinking; moderate alcohol combined with metabolic factors can worsen the disease.
• Early detection and sustained lifestyle modifications can reverse fatty liver and prevent serious complications.

This guide is intended for general informational purposes and does not replace professional medical advice. Consult your healthcare provider for personalised recommendations.

References:

1. Carbohydrate profiling & glycaemic indices of selected traditional Indian foods - PMC 

https://pmc.ncbi.nlm.nih.gov/articles/PMC9552392/

2. Fatty Liver Diet: What Foods to Eat and What Foods to Avoid

https://www.healthline.com/health/fatty-liver-diet