What is fatty liver and how is it managed?

What is Fatty Liver?

Fatty liver is a condition where excess fat accumulates in your liver cells—specifically when more than 5% of your liver is made up of fat—and it develops primarily because of insulin resistance, obesity, diabetes, or high cholesterol, not from drinking too much alcohol. 1

Understanding the Basics

Your liver normally contains some fat, but when fat builds up excessively, it creates problems. Think of it like your liver becoming "clogged" with fat droplets inside the liver cells themselves. 1

There are two main types you need to know about:

• Simple fatty liver (NAFL): Just fat accumulation without damage—this is relatively benign and reversible 1
• Fatty liver with inflammation (NASH): Fat plus liver cell injury and inflammation, which can progress to scarring (fibrosis), cirrhosis, liver failure, and even liver cancer 1

Who Gets Fatty Liver?

Fatty liver affects approximately 25-30% of adults in developed countries, making it the most common liver disease worldwide. 1

You're at highest risk if you have:

• Obesity (present in ~90% of fatty liver patients) 1, 2
• Type 2 diabetes (present in 43-60% of diabetics) 3
• High cholesterol or triglycerides (present in ~90% of patients with hyperlipidemia) 3
• Metabolic syndrome (combination of belly fat, high blood pressure, high blood sugar, abnormal cholesterol) 1

Even lean individuals can develop fatty liver if they have insulin resistance or metabolic problems—this affects 7-20% of fatty liver patients. 1, 4

How is Fatty Liver Managed?

Step 1: Determine Your Risk Level

Your doctor will first assess whether you have dangerous liver scarring (fibrosis) using blood tests or imaging: 1, 5

• Low risk (FIB-4 score <1.3 or liver stiffness <8.0 kPa): Focus only on lifestyle changes 1, 5
• Intermediate/high risk (FIB-4 ≥1.3 or liver stiffness ≥8.0 kPa): Referral to liver specialist needed 1, 5

Step 2: Lifestyle Changes (The Foundation for Everyone)

Weight loss is the single most effective treatment—no medications can replace this: 1, 5

• Lose 5-7% of your body weight to reduce liver fat and inflammation 5
• Lose 7-10% of your body weight to potentially reverse liver inflammation and scarring 1, 5
• Aim for gradual weight loss of less than 1 kg per week to avoid worsening liver disease 5

Follow a Mediterranean diet specifically: 1, 5

• Daily vegetables, fresh fruits, fiber-rich whole grains, nuts, fish or white meat, olive oil 1
• Minimize simple sugars, processed foods, red meat, and foods with added fructose 1
• Avoid excess alcohol completely—even moderate drinking (9-20g daily) doubles the risk of liver complications in fatty liver patients 1

Exercise regularly, even without weight loss: 5

• 150-300 minutes of moderate-intensity exercise per week (brisk walking, cycling) 5
• OR 75-150 minutes of vigorous-intensity exercise per week (running, swimming) 5
• Exercise reduces liver fat even if you don't lose significant weight 5

Step 3: Manage Related Health Conditions

Control diabetes aggressively: 5

• GLP-1 medications (semaglutide, liraglutide) are preferred because they improve both blood sugar and liver health 5

Treat high cholesterol: 5

• Statins are safe and recommended for all fatty liver patients with high cholesterol—they reduce liver cancer risk by 37% 5

Step 4: Consider Advanced Treatments (Only for Severe Cases)

Bariatric surgery (weight loss surgery) should be considered if: 1

• You have severe obesity and meet national criteria for surgery 1
• 85% of patients show resolution of liver inflammation one year after surgery 1

Medications are reserved only for biopsy-proven inflammation with significant scarring (≥F2 fibrosis): 5

• Vitamin E may be considered in select non-diabetic patients with proven inflammation 5
• Pioglitazone can improve liver scarring but has side effects 6

Step 5: Ongoing Monitoring

If you have low-risk fatty liver: 1, 5

• Annual follow-up with repeat blood tests and non-invasive fibrosis testing 1, 5

If you have cirrhosis (advanced scarring): 5

• Regular screening for liver cancer every 6 months 5
• Screening for esophageal varices (enlarged veins) if liver stiffness ≥20 kPa 5

Critical Points to Remember

The vast majority of people with simple fatty liver will never develop serious liver disease if they lose weight and maintain healthy habits. 2 However, fatty liver increases your risk of dying from heart disease and cancer more than from liver failure itself, so managing your overall metabolic health is crucial. 1

Common pitfall: Normal liver blood tests (ALT) do NOT mean your liver is fine—14-24% of patients with normal ALT still have significant liver scarring and disease progression. 7