Fatty Liver (MASLD): Causes, Symptoms and How It Can Reverse

What is a fatty liver?

With a fatty liver, too much fat builds up in the liver cells (medically called steatosis). Above a certain amount, it is called a fatty liver. It is the most common chronic liver disease and affects a large share of adults worldwide, often without those affected knowing.

A simple fatty liver is usually harmless at first. But it can develop into inflammation and, over time, into scarring of the liver. The good news is further down: in early stages, a fatty liver can reverse well.

MASLD: why fatty liver has a new name

You may not have read the word fatty liver in a report, but an abbreviation such as MASLD. Since 2023, a new, internationally agreed term has applied, which has also been used in Germany since 2024. Here is what you should know:

• SLD (steatotic liver disease) is the new umbrella term for all forms of fatty liver.
• MASLD (metabolic dysfunction-associated steatotic liver disease) replaces the old term NAFLD, the non-alcoholic fatty liver. It is present when fat is stored in the liver and, in addition, at least one metabolic risk factor exists, for example excess weight, diabetes, high blood pressure or unfavourable blood lipids.
• MASH replaces the term NASH and stands for the inflammatory, progressive form.
• MetALD describes a mixed form of metabolic fatty liver plus increased alcohol consumption.

Why the renaming? The old term non-alcoholic described the disease only by what it is not. The new name names the actual cause, the metabolic disorder, and is considered less stigmatising. For you it mainly means: MASLD and the former NAFLD mean practically the same thing.

Symptoms

A fatty liver often causes no symptoms at all for a long time. That is exactly what makes it tricky. It is therefore frequently found by chance, for example through raised liver values in the blood or a fatty liver on ultrasound. Possible signs are:

• persistent tiredness and a lack of energy.
• a feeling of pressure or fullness in the upper right abdomen.

Clear symptoms usually appear only when the liver disease is well advanced. Signs such as yellowish skin or eyes can point to a liver that is already damaged. More on this: Jaundice.

How a fatty liver progresses

A fatty liver is usually the first step of a possible development over several stages. Important: it does not progress in everyone, and in early stages it is reversible.

• Simple fatty liver: only fat in the liver, without notable inflammation. Usually harmless.
• Inflammation (steatohepatitis, MASH): the fat leads to inflammation and damage to the liver cells. This form can progress.
• Scarring (fibrosis) up to cirrhosis: if the inflammation persists, the tissue scars more and more. In the end stage (cirrhosis), the liver is permanently remodelled and the risk of complications and liver cancer rises.

Causes and risk factors

The metabolic fatty liver develops mainly through a lifestyle that overloads the metabolism. The most important risk factors are:

• excess weight, especially abdominal fat.
• insulin resistance and type 2 diabetes. More on this: Type 2 diabetes.
• unfavourable blood lipids (high triglycerides, low HDL cholesterol).
• high blood pressure. More on this: High blood pressure.
• a lot of sugar, especially from sweet drinks, and heavily processed food.
• lack of exercise and a family tendency.

Alcohol is a separate, additional cause of a fatty liver. When increased alcohol consumption is added to a metabolic fatty liver, this is called MetALD.

Diagnosis: how is it determined?

It usually starts with abnormal liver values in the blood or an ultrasound. The work-up includes:

• liver values: mainly ALT, AST and GGT. They can be raised, but do not have to be.
• ultrasound: a fatty liver appears typically bright in the image.
• ruling out other causes: such as viral hepatitis or increased alcohol consumption.
• test for scarring: a simple blood test (FIB-4) and a special ultrasound measurement (elastography) show whether fibrosis is already present.

The good news: a fatty liver can reverse

The most important message first: a fatty liver is reversible in early stages. The liver can recover when the cause is addressed. And that succeeds mainly through weight. The figures are surprisingly concrete:

• Just about 5 percent less body weight noticeably reduces liver fat.
• About 7 to 10 percent weight loss can reverse existing inflammation and even improve early scarring.

What matters is slow, lasting weight loss rather than a crash diet.

Your plan in practice

Here is what a concrete plan looks like to relieve your liver step by step:

• Weight: aim for slow weight loss of 7 to 10 percent of your body weight, around 0.5 to 1 kilo per week.
• Cut sugar: above all drop sugary drinks and juices, they drive liver fat in particular.
• Eat Mediterranean: plenty of vegetables, pulses, olive oil, nuts and fish, little heavily processed food.
• Exercise: at least 150 minutes of moderate activity per week, plus strength training. Exercise lowers liver fat even without major weight loss.
• Control your metabolism: have your blood sugar, blood lipids and blood pressure well treated.
• Alcohol: cut it down sharply or leave it out entirely.

Medication: what supports it

The basis always remains weight and lifestyle. But there are medicines that support this, especially when type 2 diabetes is also present:

• SGLT2 inhibitors such as empagliflozin and GLP-1 agents (for example semaglutide) improve metabolism and help with weight loss. More on this: Empagliflozin.
• Statins lower raised blood lipids and can be used safely with a fatty liver.
• For the advanced form (inflammation with scarring), since 2024 there is for the first time a specific drug (resmetirom), which is recommended in the European guideline. Availability can differ from country to country.

There is no miracle cure. Medication does not replace the change in lifestyle, it complements it.

When to see a doctor

A doctor's visit makes sense in these cases:

• when you have risk factors such as excess weight, type 2 diabetes or unfavourable blood lipids and want your liver checked.
• when your liver values are raised or a fatty liver shows up on ultrasound.
• to have it checked whether scarring is already present, for example with the blood test FIB-4 or an elastography.

Metabolism under control: keep the overview with brite

Whether diabetes medication, lipid-lowering drugs or blood pressure medicines: brite helps you remember to take them and track your values.

• Intake reminders: reliably remember every medication, every day.
• Readings diary: record weight, blood sugar and blood pressure and see your progress.
• Interaction check: see at a glance whether your medications work well together.
• Medication plan: always up to date and ready for your next appointment.

Sign up for free

Related topics