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Gastroenterology

NAFLD: When Your Liver Gets Fatty

Non-alcoholic fatty liver disease affects 1 in 4 people worldwide. Most don't know they have it until serious damage occurs. Learn how to protect your liver.

ICD Code: K76.0

What is NAFLD?

Non-alcoholic fatty liver disease (NAFLD) is exactly what it sounds like: excess fat accumulation in the liver of people who drink little to no alcohol. It's now the most common chronic liver disease worldwide, affecting roughly 1 in 4 people globally.

The Silent Epidemic

NAFLD progresses silently for most people. There are usually no symptoms until significant liver damage has occurred. The disease exists on a spectrum:

  1. Simple steatosis - Fat in liver (generally benign)
  2. NASH - Fat + inflammation + liver cell damage
  3. Fibrosis - Scarring from chronic inflammation
  4. Cirrhosis - Extensive scarring, liver failure risk
  5. Liver cancer - Increased risk in advanced disease

Up to 30% of people with NAFLD progress to NASH, and 20% of those develop cirrhosis.

Understanding Your Liver

Your liver is your body's largest internal organ and performs over 500 functions:

  • Filters blood from your digestive tract before sending it to the rest of your body
  • Detoxifies chemicals and metabolizes drugs
  • Produces bile for fat digestion
  • Makes proteins for blood clotting and other functions
  • Stores glucose as glycogen for energy reserves
  • Regulates blood sugar alongside the pancreas

When your liver is fatty, these functions become impaired—though you might not notice for years.

How Fatty Liver Develops

The Path to NAFLD

FactorEffectWhat to Do

Always tell your doctor about medications, supplements, and recent health events before testing.

Am I at Risk?

Risk FactorWhy It Increases RiskWhat You Can Do
Overweight/obesity80-90% of NAFLD patients are overweightWeight loss of 5-10% significantly reduces liver fat
Type 2 diabetes/prediabetesInsulin resistance drives liver fat productionTight blood sugar control, metformin may help
Metabolic syndromeStrong association with all 5 criteriaAddress all metabolic risk factors together
High sugar intake (especially fructose)Fructose metabolized directly by liver into fatEliminate sugary beverages, limit added sugars
PCOS (women)Insulin resistance promotes liver fatWeight management, insulin-sensitizing medications
Sleep apneaChronic hypoxia promotes liver inflammationTreat with CPAP, weight loss
Certain medicationsAmiodarone, methotrexate, tamoxifen, steroidsReview with doctor if liver enzymes elevated
Source

Diagnosis: How is NAFLD Detected?

When NAFLD Should Be Suspected

Screening is recommended for those with risk factors

Elevated liver enzymes (ALT, AST) on routine blood work
Fatty liver seen on ultrasound or CT scan (done for other reasons)
Enlarged liver on physical exam
Unexplained fatigue or right upper quadrant discomfort
Presence of metabolic syndrome or type 2 diabetes
Persistently elevated liver enzymes despite abstaining from alcohol
🩺
Diagnostic Tests

Initial evaluation:

  • Liver enzymes (ALT, AST, GGT) - Often elevated but can be normal
  • Ultrasound - Detects fat in liver (sensitive for moderate-severe fatty liver)
  • Fibroscan - Specialized ultrasound measuring liver stiffness (fibrosis)

Rule out other causes:

  • Viral hepatitis testing
  • Iron studies (hemochromatosis)
  • Autoimmune markers
  • Medication review

Assess severity:

  • Liver stiffness measurement (fibrosis assessment)
  • Non-alcoholic fatty liver disease fibrosis score (NFS) calculation
  • Consider liver biopsy if advanced disease suspected

Monitoring: Repeat liver enzymes and imaging every 6-12 months to track progression.

Treatment and Reversal

The exciting news about NAFLD: it's reversible, especially in early stages.

The Cornerstone: Lifestyle Change

🔬What Works for Fatty Liver

Weight loss:

  • 5-10% weight loss reduces liver fat by 25-40%
  • 10% weight loss can reverse NASH and reduce fibrosis
  • Rapid weight loss (＞1.5 lbs/week) can worsen fatty liver—aim for gradual loss

Dietary changes:

  • Eliminate sugary beverages - Single most effective dietary change
  • Limit added sugars - Especially fructose (sucrose is half fructose)
  • Mediterranean diet - Most evidence for benefit
  • Coffee - 2-3 cups daily associated with less liver fibrosis
  • Avoid alcohol - Even modest amounts can worsen fatty liver

Exercise:

  • Both aerobic AND resistance training beneficial
  • 150-300 minutes moderate activity weekly
  • Exercise reduces liver fat independent of weight loss

Sleep:

  • Treat sleep apnea if present (very common with NAFLD)
  • 7-9 hours nightly (short sleep worsens fatty liver)

Supplements with evidence:

  • Vitamin E - May improve NASH (discuss with doctor)
  • Omega-3 - Reduces liver fat and inflammation

Medication Options

🩺
When Medication is Considered

No medication is FDA-approved specifically for NAFLD, but several are used:

For NASH with fibrosis:

  • Vitamin E (tocopherol) - Antioxidant, improves NASH in non-diabetics
  • Pioglitazone - Improves insulin sensitivity, but causes weight gain
  • GLP-1 agonists - Show promise for NASH resolution

Treating associated conditions:

  • Metformin - Improves insulin resistance (though doesn't directly treat NAFLD)
  • Statins - Safe in fatty liver, treat cardiovascular risk
  • ACE inhibitors/ARBs - May reduce liver fibrosis

The most important 'medication': Lifestyle change. No drug matches the effectiveness of weight loss, dietary change, and exercise.

Prognosis: What to Expect

Frequently Asked Questions

References

References

  • [1]American Association for the Study of Liver Diseases (AASLD). NAFLD Practice Guidance. 2023. https://aasld.org/publication/nafld-practice-guidance-2023
  • [2]European Association for the Study of the Liver (EASL). Clinical Practice Guidelines for NAFLD. 2024. https://doi.org/10.1016/j.jhep.2024.01.012
  • [3]Chalasani N, et al. The Diagnosis and Management of NAFLD. Hepatology. 2023. https://doi.org/10.1002/hep.32763
  • [4]Younossi ZM, et al. Global prevalence and evaluation of fatty liver disease. Hepatology. 2024. https://doi.org/10.1002/hep.33042
  • [5]Eslami L, et al. A Clinical Practice Guideline for Diagnosis and Treatment of Nonalcoholic Fatty Liver Disease. Hepatology Communications. 2023. https://doi.org/10.1002/hep4.1964

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