Fatty Liver Disease: Symptoms, Causes, Diet and How to Reverse It

Fatty liver disease means too much fat has built up in liver cells. The most common form, now called metabolic dysfunction-associated steatotic liver disease (MASLD), previously known as non-alcoholic fatty liver disease (NAFLD), is linked to insulin resistance, obesity, diabetes, high blood pressure and abnormal cholesterol. It affects roughly 1 in 3 adults worldwide, and rates are high in South Asia, including Sri Lanka. In most people it is harmless in the short term, but in some it progresses to serious liver damage. The good news is that it is often reversible.

Types

• MASLD (metabolic fatty liver): fat in the liver with at least one heart-metabolic risk factor, and little or no alcohol.
• Alcohol-related liver disease: caused by regular heavy drinking.
• MetALD: a mix of metabolic risk factors and moderately high alcohol intake.
• MASH (previously NASH): fat plus inflammation and liver cell damage, which can lead to scarring.

Symptoms

Most people have no symptoms for years. Possible signs include:

• Tiredness, vague discomfort in the upper right abdomen
• Dark skin patches on the neck and armpits (insulin resistance)
• Enlarged liver found on examination

Advanced disease (cirrhosis): yellow skin and eyes (jaundice), swollen legs or abdomen, easy bruising, itching, confusion, vomiting blood or black stools.

Why Asians are affected

• Higher body fat and visceral fat at lower BMI, so fatty liver can occur in people with a "normal" weight
• High intake of refined carbohydrate, sugary drinks and fried foods
• Genetic factors, including variants such as PNPLA3, which are common in Asians
• High rates of diabetes and metabolic syndrome

Causes and risk factors

• Obesity, especially abdominal obesity
• Type 2 diabetes and prediabetes. See normal blood sugar for Asian adults
• High blood pressure, high triglycerides and low HDL
• PCOS, sleep apnoea and an underactive thyroid
• Rapid weight loss, malnutrition or certain medicines (steroids, tamoxifen, amiodarone, methotrexate)
• Heavy alcohol use, which also causes liver damage

Diagnosis

• Blood tests: liver enzymes (ALT, AST, GGT) may be normal or mildly raised. They do not show how much scarring exists.
• Ultrasound is the usual first test and shows a "bright" liver.
• Fibrosis assessment is the key step: calculating a FIB-4 score from age, ALT, AST and platelets, followed by FibroScan (transient elastography) or other blood tests if the score is intermediate or high.
• Other tests: blood sugar, HbA1c and cholesterol, and tests to exclude viral hepatitis B and C, autoimmune and other liver diseases.
• Liver biopsy is rarely needed.

How to reverse fatty liver

There is no single cure, but lifestyle change is the main treatment.

1. Lose weight gradually. Losing 5% reduces liver fat, 7-10% improves inflammation, and 10% or more can reverse scarring. Avoid rapid crash diets, which can worsen liver inflammation. See how to lose weight safely.
2. Eat a Mediterranean-style, low-sugar diet.

• Cut sugary drinks, sweets, fruit juice, and added sugar (fructose is particularly harmful for the liver).
• Reduce refined starch: white rice, bread, noodles and bakery products.
• Eat more vegetables, pulses, fish, nuts, whole grains and olive or other unsaturated oils.
• Limit fried foods, red and processed meats and coconut fat.
• Coffee (2-3 cups a day without much sugar) is linked with lower liver fibrosis, if your doctor agrees.

1. Exercise: 150-300 minutes of moderate activity a week, plus strength training. Exercise reduces liver fat even without weight loss.
2. Avoid alcohol, or keep to very little. If you have advanced fibrosis or cirrhosis, avoid it entirely.
3. Control diabetes, blood pressure and cholesterol. Some diabetes medicines (such as pioglitazone, GLP-1 agonists and SGLT2 inhibitors) also improve fatty liver. See our diabetes diet for South Asians.
4. Review medicines with your doctor, and avoid unregulated herbal remedies and supplements, which can injure the liver.
5. Get vaccinated against hepatitis A and B.
6. Quit smoking.

Medicines for fatty liver

• Resmetirom is approved in some countries for MASH with moderate to advanced fibrosis. Other medicines are being studied.
• Vitamin E may be used in selected non-diabetic patients under specialist care.
• Bariatric surgery can improve or resolve MASH in people with severe obesity.
• Statins are safe in fatty liver and protect the heart. Do not stop them because of mildly raised liver enzymes without medical advice.

Why it matters beyond the liver

People with fatty liver have a higher risk of heart disease, type 2 diabetes and chronic kidney disease, and heart disease is the most common cause of death among them. Treating fatty liver means treating overall metabolic health. See how to lower cholesterol and heart-healthy diet in Sri Lanka.

Follow-up

• Low fibrosis risk: repeat assessment every 2-3 years
• Intermediate or high fibrosis: specialist review and regular monitoring every 6-12 months
• Cirrhosis: screening for liver cancer with ultrasound every 6 months and for oesophageal varices

When to see a doctor

See a doctor if your ultrasound shows fatty liver, your liver tests are abnormal, you have diabetes or obesity and have never had your liver checked, or you drink alcohol regularly. Go to hospital urgently for yellow eyes with confusion, vomiting blood, black stools or a swollen abdomen with fever.

References

• European Association for the Study of the Liver (EASL), EASD, EASO: clinical practice guidelines on MASLD
• American Association for the Study of Liver Diseases: practice guidance on MASLD
• Asia-Pacific Working Party on NAFLD: guidelines
• World Health Organization: obesity and overweight fact sheet