Fatty liver: a quiet warning

Following on from last week’s blog about central and visceral fat, it feels right to look more closely at fatty liver and why it matters.

Most of us think of liver disease as something caused by alcohol.

That is understandable. Alcohol can damage the liver, and for many years it dominated the public conversation.

But there is another form of liver disease that is now extremely common. It is linked less to alcohol and more to the way modern life affects our metabolism, through weight gain, central fat, insulin resistance, type 2 diabetes, cholesterol, and blood pressure.

Some UK estimates suggest fatty liver disease affects around one in five adults, while NHS information suggests early fatty liver changes may affect up to a third of us already. This is not a rare specialist problem. It is a common warning sign that the body’s metabolism may be under strain.

Metabolism is the way the body handles energy. It includes how we process food, store fat, control blood sugar, manage cholesterol and use insulin. When that system is under strain, problems such as fatty liver, type 2 diabetes, high blood pressure and heart disease become more likely.

The medical terms for fatty liver do not exactly help. They can make a relatively simple idea sound unnecessarily complicated. So, let’s use the phrase most people understand: fatty liver.

Fatty liver used to be called non-alcoholic fatty liver disease, or NAFLD. You may still hear that term. It is now increasingly called MASLD, which stands for metabolic dysfunction associated steatotic liver disease.

To say the least this is not a very user-friendly phrase.  And this can stop people reading an article like this. Stick with me.

Put simply, it means fatty liver linked to the way the body handles energy, fat and sugar.

The liver is supposed to contain very little fat. When too much fat builds up inside liver cells, we call this fatty liver disease. In many people, early fatty liver causes no symptoms at all. It is often found by accident after abnormal liver blood tests or an ultrasound scan done for another reason.

That is part of the problem.

Fatty liver can be quiet for years.

Many people feel well. They may have no pain, no jaundice and no obvious warning sign. Yet under the surface, fatty liver may be part of a wider problem with weight, blood pressure, cholesterol, insulin resistance or rising blood sugar.

Importantly fatty liver is not just a liver issue.

Fatty liver is often a sign that the body is struggling with the way it handles energy, fat and sugar. It is commonly linked with type 2 diabetes, raised blood pressure, abnormal cholesterol and cardiovascular risk. In some people, it can also progress to liver inflammation, scarring and, less commonly, cirrhosis.

Most people with fatty liver will not develop cirrhosis. That is important to say. This should not be a panic diagnosis.

But nor should it be ignored.

The encouraging part is that fatty liver can often improve. In its earlier stages, it can sometimes be reversed. The liver is a remarkably forgiving organ when it is given the chance.

That chance usually comes through addressing the same factors that improve metabolic health elsewhere.

Weight loss where needed. Reduced central fat. Regular exercise. Better food quality. Calorie awareness. Less ultra processed food. Less sugar. Less alcohol. Better sleep. Improved blood pressure, cholesterol and blood sugar.

This is why fatty liver belongs in a men’s health conversation.  But this article does apply just as much to women.

More men carry their excess weight centrally. Many develop insulin resistance quietly. Many feel well until blood tests reveal that blood pressure, cholesterol, blood sugar or liver enzymes have started to drift.

The liver can become an early warning light.

Not a judgement. Not a failure.

So how is fatty liver identified?

The first step is usually simple.

A conversation about weight, alcohol intake, diet, exercise, medication, family history and risk factors. Then basic measurements such as weight, BMI, abdominal girth and blood pressure. Blood tests may include liver function tests, HbA1c for blood sugar, cholesterol, triglycerides and sometimes tests to exclude other causes of liver disease.

The difficulty is that routine liver blood tests do not tell the whole story. A person can have fatty liver with normal liver enzymes. Another person can have abnormal liver enzymes without serious liver scarring. So, blood tests are useful, but they are not enough on their own.

The next step may be an ultrasound scan. This can show fatty change in the liver, although it is not perfect and may miss milder disease.

Once fatty liver is suspected or confirmed, the most important question is not simply, “Is there fat in the liver?”

The more important question is, “Is there scarring?”

Scarring is called fibrosis. This is what determines long term liver risk. The more advanced the fibrosis, the more seriously the condition needs to be taken.

There are several ways to assess this.

Some scoring systems use routine blood results, age and platelet count to estimate fibrosis risk. Examples include FIB-4 and NAFLD fibrosis score. These are not perfect, but they can help decide who needs more detailed assessment.

A more specialist blood test called the ELF test can assess the risk of advanced fibrosis. Imaging can then add more information. FibroScan, also called transient elastography, measures liver stiffness and can help assess fibrosis. MRI based techniques can measure liver fat and, in some centres, liver stiffness in even more detail.

At the far end of the scale is liver biopsy. This is rarely the first step and is usually reserved for selected specialist cases where the diagnosis or severity remains uncertain.

So, the pathway usually runs from simple to more complex.

First, basic measurements such as weight, BMI, blood pressure and alcohol intake.

Then blood tests for liver function and metabolic health.

Then, if needed, an ultrasound scan.

If fatty liver is suspected or confirmed, the next question is whether there is any sign of scarring. That may involve fibrosis scores such as FIB-4, an ELF blood test, FibroScan, specialist imaging or, rarely, liver biopsy.

For many people, the most useful monitoring is much simpler than that.

Weight. BMI. Waist measurement. Blood pressure. HbA1c. Cholesterol. Triglycerides. Liver enzymes. Alcohol intake. Exercise. Medication review. Repeat fibrosis assessment where appropriate.

But this is where we reach a practical problem.

Fatty liver disease is now so common that the NHS cannot realistically offer detailed lifestyle medicine, repeated metabolic review, personalised weight support and advanced liver monitoring to every person at risk. That is not because the condition is unimportant. It is because the numbers are enormous. Some of the more detailed tests also carry significant cost (A FibroScan costs from £200-£450 on searching at the time of writing for example) and require access to specialist pathways. When early fatty liver changes may affect up to a third of adults, it is easy to see why the system focuses most attention on people who appear to be at higher risk.

This is one of the gaps between modern chronic disease and a health service designed mainly to respond to illness once it has declared itself.

In NHS general practice, abnormal liver tests are often repeated. Alcohol intake is discussed. Weight loss may be advised. Diabetes and cholesterol may be checked. Referral happens when results suggest higher risk.

All of that is sensible.

But for many people, especially those at an earlier stage, the opportunity is bigger than simply asking, “Do I need a liver specialist?”

The better question is, “What is this telling me about how my body is handling energy, fat and sugar, and what can I do now?”

Because early fatty liver is often a chance to intervene before diabetes, heart disease, cirrhosis or more serious illness develops.

Treatment follows a familiar pattern.

Lose weight if needed. Reduce central fat. Eat mostly real food. Reduce ultra processed food and added sugar. Build activity into the week. Include strength training. Reduce alcohol. Improve sleep. Treat blood pressure, cholesterol and diabetes properly. Use weight loss medication where appropriate and properly supervised.

For many people, losing even a modest amount of weight can improve liver fat and blood results. Greater weight loss may be needed to improve inflammation or fibrosis, but the first step is still the same. Start where you are. Move in the right direction.

Modern life makes fatty liver easy to develop. Food is abundant. Alcohol is normalised. Work is sedentary. Sleep is squeezed. Stress is constant. Ultra processed food is everywhere. Weight gain creeps on quietly.

But the same quiet process can be turned around.

The liver can improve.

Blood tests can improve.

Insulin resistance can improve.

Fatty change can reduce.

Risk can fall.

If you have been told you have fatty liver, raised liver enzymes, central weight, prediabetes, type 2 diabetes, raised triglycerides or metabolic syndrome, it is worth taking this seriously. These are all signs that the way your body handles energy, fat and sugar may need attention.

Not panic.

Attention.

So, please ask what your liver result means. Ask whether other causes have been excluded. Ask about your metabolic risk. Ask whether you need fibrosis assessment. Ask what should be monitored. Ask what change would make the biggest difference. 

And then, if you are ready, act.

Fatty liver disease may be quiet, but it is important.

It is often the liver’s way of telling us that the body’s metabolism is under strain.

The encouraging news is that strain can often be reduced.

That is not vanity.

That is preventive medicine.

Dr Mick Watts MBBS MRCGP is a GP in Windsor with a particular interest in men’s health, healthy ageing and lifestyle medicine.

This blog is written for general information and encouragement. It is not a substitute for personal medical advice. Every person’s health, circumstances and risks are different. If you have concerns about liver blood tests, fatty liver disease, alcohol intake, weight, diabetes, cholesterol or whether you need further assessment, please speak to your own GP or healthcare professional.

Dr Mick Watts