Fatty Liver (MASLD): What It Is, How It Is Staged, and What Reverses It

Reclaim PowerTELEHEALTH

Metabolism & Weight · Liver

It is common, it is usually silent, and it is one of the most reversible conditions in medicine. Most people who have it have never been told.

Written for my patients. If you are not one, read "call me" as "call your own clinician", and take the questions here to them.

Roughly a third of adults have extra fat stored inside their liver cells. Most of them feel fine. It shows up, if it shows up at all, as a slightly high ALT on a routine panel that nobody mentions, or as an incidental note on an ultrasound ordered for something else.

I look for it in every metabolic workup, because it is one of the earliest visible signs that insulin resistance has moved from a lab pattern into an organ, and because catching it early is where nearly all of the good news lives.

What it is, and why the name changed

In 2023 the condition was renamed MASLD, metabolic dysfunction-associated steatotic liver disease, replacing the older NAFLD. The new name says the important thing out loud: this is driven by the same forces as insulin resistance. Weight carried around the middle, high blood sugar, high triglycerides, high blood pressure. It is a metabolic condition that happens to live in the liver.

How I find it and stage it

Almost never from symptoms. Usually from a high ALT, or from fat seen on imaging. The question that matters after that is not "is there fat" but "is there scarring," because scarring is what determines risk.

To answer that without a biopsy, I start with a FIB-4 score, calculated from your age and routine labs you already have. If it is low, we watch and work on the metabolic picture. If it is borderline or high, the next step is a FibroScan, a quick ultrasound-based measurement of liver stiffness that takes about ten minutes and does not hurt.

What reverses it

Strong evidence

Supportive

The newer medications

For years there was no approved drug for this. That changed recently. In 2024 the FDA approved resmetirom (Rezdiffra), a daily pill, for MASH with moderate to advanced scarring. In August 2025 it approved semaglutide (Wegovy) for the same group, based on a 72-week trial worth showing you.

Both medications are used alongside, not instead of, the weight, exercise and alcohol work above. And notice the placebo numbers: a third of people improved with lifestyle change alone. That is the reversibility I keep talking about.

What to watch for

Fatty liver raises your risk of heart disease more than it raises your risk of liver disease. So when I find it, we also work on blood pressure, cholesterol and blood sugar, because that is where the actual danger is for most people.

Supplements marketed for "liver detox" have not been shown to help, and some have caused real liver injury, including high-dose green tea extract and turmeric. Please run any liver supplement by me first. Your liver does not need cleaning. It needs less to process.

A note on how to use this. General information for my patients, not individualized advice.

1. Rinella ME et al. AASLD practice guidance on the clinical assessment and management of nonalcoholic fatty liver disease. Hepatology 2023;77(5):1797–835.
2. Vilar-Gomez E et al. Weight loss through lifestyle modification significantly reduces features of nonalcoholic steatohepatitis. Gastroenterology 2015;149(2):367–78.
3. Harrison SA et al. A phase 3 trial of resmetirom in NASH with liver fibrosis (MAESTRO-NASH). N Engl J Med 2024;390(6):497–509.
4. Novo Nordisk. Wegovy approved in the US for treatment of MASH. August 2025; ESSENCE trial part 1.

Trang Ca Laube, FNP-BC, FMACP · Reclaim Power Telehealth · Updated September 2026