Steatotic (Fatty) Liver Disease

What is steatotic (fatty) liver disease?

Steatotic liver disease (SLD) includes several conditions associated with steatosis in your liver. “Steatosis” is a term healthcare providers use to describe fat buildup in an organ (usually your liver). A healthy, high-functioning liver contains a small amount of fat. Fat buildup becomes a problem when it reaches over 5% of your liver’s weight.

Why was fatty liver disease renamed steatotic liver disease?

Previously, steatotic liver disease was known as “fatty liver disease.” In 2023, experts renamed the condition and its subcategories to reflect its causes more accurately. For example, while some conditions associated with fat composition in your body (like obesity) can increase your risk of steatosis, there are several risk factors unrelated to weight or body mass index (BMI).

The renaming also avoids language that’s potentially stigmatizing toward people with SLD.

What are the types of steatotic (fatty) liver disease?

Healthcare providers classify SLD based on its causes and the conditions associated with it.

Alcohol-related liver disease (ALD)

With ALD, steatosis occurs because of excessive alcohol consumption. Each time your liver filters alcohol, some of its cells die. Usually, your liver can make new cells to replace the old ones, so there isn’t a problem. But if you drink too much alcohol, your liver may not be able to keep up. Instead, steatosis may set in.

Metabolic dysfunction-associated steatotic liver disease (MASLD)

Previously, healthcare providers referred to MASLD as non-alcohol related fatty liver disease (NASLD) because the steatosis isn’t associated with heavy alcohol consumption. Experts renamed the condition to reflect what the fat buildup in your liver is associated with. With MASLD, the culprit is cardiometabolic risk factors. These factors include conditions and characteristics that pose risks to your heart health.

Risk factors associated with MASLD include:

• Obesity.
• Type 2 diabetes.
• High blood pressure.
• Lipid abnormalities (lipids are fatty compounds found in cells).

MASLD also applies if you consume small amounts of alcohol weekly. “Small amounts” means less than 140 grams per week for females and less than 210 grams per week for males. For reference, in the U.S., one standard, 12-oz. beer contains about 14 grams of alcohol.

Metabolic-associated steatohepatitis (MASH)

Metabolic-associated steatohepatitis (MASH) is a serious form of MASLD. With MASH, fat buildup progresses to inflammation, then tissue damage and scarring (fibrosis). Previously, healthcare providers referred to MASH as non-alcohol related steatohepatitis (NASH).

MASLD and increased alcohol intake (MetALD)

If you have MetALD, both metabolic risk factors and alcohol consumption play a role in fat buildup in your liver. With MetALD, you have a cardiometabolic risk factor and consume more than 140 grams per week (female) or more than 210 grams per week (male).

What contributes most to the fat buildup in your liver (alcohol consumption or metabolic risk factors) varies from person to person.

Other forms of SLD

SLD can result from causes other than alcohol use or cardiometabolic risk factors. For example, various medications and diseases can cause steatosis. Sometimes, healthcare providers can’t identify a specific cause. SLD without a clear cause is called cryptogenic SLD.

Is steatotic (fatty) liver disease a serious problem?

In most cases, the fat buildup doesn’t cause serious problems or prevent your liver from functioning normally.

In some cases, the condition progresses to liver disease. It usually progresses in stages:

1. Hepatitis: Your liver goes from fatty to inflamed (swollen). The inflammation damages tissue. This stage is called steatohepatitis. For example, this is what happens when MASLD becomes MASH.
2. Fibrosis: Bands of scar tissue form where the inflammation damages your liver, causing it to stiffen. This process is called fibrosis.
3. Cirrhosis: Extensive scar tissue replaces healthy tissue. At this point, you have cirrhosis of the liver. Without treatment, cirrhosis can lead to potentially fatal conditions like liver failure and liver cancer. About 90% of people who develop hepatocellular carcinoma (HCC) — a type of liver cancer — have cirrhosis.

This is why it’s so important to learn what’s causing fat buildup in your liver and get treated. Even if you have early-stage cirrhosis, there are steps you can take to protect your liver from further damage. In some instances, you can even reverse some damage by following your provider’s treatment plan for you.

What are the signs and symptoms of steatotic (fatty) liver disease?

SLD doesn’t always cause symptoms. When they’re present, symptoms include:

• Abdominal pain or a feeling of fullness in the upper right side of your abdomen (belly).
• Extreme exhaustion or weakness (fatigue).

More commonly, people notice symptoms once SLD has progressed to cirrhosis of the liver. When cirrhosis develops, you may experience:

• Nausea.
• Loss of appetite.
• Unexplained weight loss.
• Yellowish skin and whites of the eyes (jaundice).
• Swelling in your abdomen (ascites)
• Swelling in your legs, feet or hands (edema).
• Bleeding (that your provider finds in your esophagus, stomach or rectum).

What causes steatotic (fatty) liver disease?

SLD has multiple causes. Still, you’re more likely to develop SLD if you have a cardiometabolic risk factor, if you consume unhealthy amounts of alcohol or both.

You have a greater chance of developing SLD if you:

• Have alcohol use disorder (frequent or heavy alcohol use).
• Have metabolic syndrome (insulin resistance, high blood pressure, high cholesterol and high triglyceride levels).
• Have Type 2 diabetes.
• Have overweight (BMI 25 to 29.9 kilograms kg/m2).
• Have obesity (BMI 30 kg/m2 and above).
• Have polycystic ovary syndrome (PCOS).
• Have obstructive sleep apnea.
• Have hypothyroidism (low thyroid hormones).
• Have hypopituitarism (low pituitary gland hormones).
• Have hypogonadism (low sex hormones).
• Take certain prescription medications, such as amiodarone (Cordarone®), diltiazem (Cardizem®), tamoxifen (Nolvadex®) or steroids. (Fat buildup in your liver can be a medication side effect.)

What are the complications of SLD?

Without treatment, a steatotic liver can progress to cirrhosis of the liver, which can lead to liver failure, liver cancer and cancers outside your liver. People with MASLD are also at increased risk of heart disease. Heart disease — not liver disease — is the leading cause of death in people with MASLD.

How is steatotic (fatty) liver disease diagnosed?

Because SLD doesn’t usually cause symptoms, your healthcare provider may be the first to notice an issue. High levels of liver enzymes that turn up on a blood test for other conditions may raise a red flag. Elevated liver enzymes are a sign your liver is injured.

To make a diagnosis, your provider may perform:

• A medical history that includes questions about your conditions, how much alcohol you drink and which medicines you’re taking.
• A physical exam to check for signs of inflammation, like an enlarged liver, or signs of cirrhosis, like jaundice.
• Imaging procedures, including an ultrasound, CT scan (computed tomography scan) or MRI (magnetic resonance imaging), to check your liver for signs of inflammation and scarring. They may order a specialized ultrasound called FibroScan® to learn the amount of fat and scar tissue in your liver.
• A liver biopsy (tissue sample) to determine how far the liver disease has progressed. A liver biopsy is the only way to distinguish MASLD from MASH.

How is steatotic (fatty) liver disease treated?

There’s no specific treatment or medications. Instead, providers focus on helping you manage risk factors that contribute to the condition. This includes making lifestyle changes that can improve your health.

Your provider may recommend that you:

• Avoid alcohol: Steer clear of alcohol even if your SLD isn’t related to alcohol use.
• Lose weight: Exercising, changing what you eat and drink (under the supervision of a nutritionist) and taking medications, such as GLP1RA, can help with weight loss. You may qualify for bariatric surgery, which can also help you lose weight.
• Take medications to manage metabolic conditions: Take prescribed medicines to manage diabetes, cholesterol and triglycerides (fat in the blood). You may also need to take vitamin E and thiazolidinediones (drugs used to treat diabetes, such as Actos® and Avandia®) in specific instances.
• Get vaccinated for hepatitis A and hepatitis B: These viral infections are especially dangerous if you already have liver disease.

Your provider may change your prescriptions if your medicine is causing fat to accumulate in your liver.

How can steatotic (fatty) liver disease be prevented?

The best way to avoid SLD is to maintain your overall health:

• Exercise regularly.
• Limit your alcohol consumption.
• Maintain a weight that’s healthy for you.
• Take medications as prescribed if you have Type 2 diabetes or metabolic syndrome.

Does steatotic (fatty) liver disease go away?

Depending on the severity of your condition, it’s possible to get rid of SLD and even some scarring. Your liver has an amazing ability to repair itself. If you follow your provider’s treatment plan, it’s possible to reduce liver fat and inflammation. You can prevent the damage from worsening and, in some cases, reverse early liver damage.

Will SLD kill you?

SLD doesn’t cause major problems for most people unless they develop advanced cirrhosis. Many people with SLD have a normal life expectancy.

Untreated cirrhosis of the liver eventually leads to liver failure or liver cancer. Your liver is an organ you can’t live without. This is why it’s so important to protect your liver if you learn you have SLD.

What is a good diet to follow with SLD?

If your SLD is weight-related, follow a balanced diet to lose weight slowly but steadily. Healthcare providers often recommend steering clear of sugar and trying the Mediterranean diet, which is high in vegetables, fruits and good fats. Other foods and diets rich with nuts, seeds, whole grains, and fish and chicken are helpful food choices for SLD. It’s also important to avoid eating too much red meat or drinking sugary beverages.

Ask your doctor or nutritionist for advice on healthy weight loss techniques.

What questions should I ask my healthcare provider?

Questions include:

• How much damage does my liver have?
• How long will it take to reverse the liver damage?
• Am I taking any medications that could contribute to SLD?
• What’s a healthy weight for me?
• Can I talk to a nutritionist or attend classes to learn about healthy eating?
• How can I get treatment for alcohol use disorder?