What is the diagnosis and treatment for fatty liver (steatosis)?

From the Guidelines

Lifestyle modification, including weight loss of 7-10% of body weight, a Mediterranean diet, and regular physical activity, is the most effective treatment for fatty liver disease, and should be prioritized to improve liver health and reduce the risk of cardiovascular disease and diabetes complications. Fatty liver, or hepatic steatosis, is a condition where excess fat accumulates in the liver cells, and it is estimated to affect approximately 30% of the adult population in many developed countries 1. The condition can progress to inflammation (steatohepatitis), fibrosis, and cirrhosis if left untreated, making early intervention crucial.

The most recent and highest quality study on the management of metabolic dysfunction-associated steatotic liver disease (MASLD) recommends a stepwise approach using blood-based scores and imaging techniques to rule-out/in advanced fibrosis, which is predictive of liver-related outcomes 1. This study also advises lifestyle modification, including weight loss, dietary changes, physical exercise, and discouraging alcohol consumption, as well as optimal management of comorbidities, including use of incretin-based therapies for type 2 diabetes or obesity, if indicated.

Key components of the recommended lifestyle modification include:

• A Mediterranean diet rich in fruits, vegetables, whole grains, lean proteins, and healthy fats like olive oil
• Limiting processed foods, added sugars, and saturated fats
• Regular physical activity of at least 150 minutes per week of moderate-intensity exercise
• Weight loss of 7-10% of body weight through a combination of calorie restriction and regular exercise
• Avoiding alcohol completely, as it worsens liver damage

For those with diabetes, good glycemic control is essential, and medications like pioglitazone, GLP-1 receptor agonists, or vitamin E (800 IU daily) may be considered in specific cases under medical supervision 1. Regular monitoring with liver function tests and imaging is important to track progress, and bariatric surgery may be an option in individuals with MASLD and obesity 1.

Overall, the goal of treatment is to improve liver health, reduce the risk of cardiovascular disease and diabetes complications, and prevent the progression of fatty liver disease to more advanced stages. By prioritizing lifestyle modification and optimal management of comorbidities, individuals with fatty liver disease can reduce their risk of liver-related outcomes and improve their overall health and well-being.

From the Research

Definition and Prevalence of Fatty Liver

• Non-alcoholic fatty liver disease (NAFLD) is the most common cause of abnormal liver enzymes and chronic liver disease in the US, with an expected rise in incidence paralleling the epidemic of obesity 2.
• NAFLD comprises a wide spectrum of pathologies ranging from non-alcoholic fatty liver (NAFL), characterized by simple steatosis without inflammation, to non-alcoholic steatohepatitis (NASH), characterized by steatosis of the liver accompanied by inflammation and hepatocyte ballooning 3.

Treatment Options for Fatty Liver

• Lifestyle modifications such as weight loss, a Mediterranean diet, and physical activity are considered the backbone of management of NASH, but it has proved challenging for patients to achieve and maintain weight loss goals 2, 3.
• Insulin sensitizers including the biguanides (metformin), thiazolidinediones (pioglitazone and rosiglitazone), and glucagon-like peptide-1 receptor agonists (exenatide) are large groups of medications that have been studied for the treatment of NASH 2.
• Other agents with anti-inflammatory, anti-apoptotic, or anti-fibrotic properties which have been studied in NASH include vitamin E, pentoxifylline, betaine, and ursodeoxycholic acid 2, 4.
• Pioglitazone is the only agent that has shown consistent benefit and efficacy in clinical trials for the treatment of NAFLD/NASH 4.

Pathophysiology of Fatty Liver

• The mechanism by which simple steatosis progresses to steatohepatitis is not entirely clear, but multiple pathways have been proposed, including disruption of the homeostasis of bile acids 5.
• Bile acids act as ligands, binding to farnesoid X receptor, which is critically involved in many of the pathways responsible for maintaining bile acid, glucose, and lipid homeostasis 5.
• Alterations to these pathways can lead to dysregulation of energy balance and increased inflammation and fibrosis, which may result in steatohepatitis 5.