Fatty liver is a common condition that affects 1 in 4 European adult populations. It is the most common cause of chronic liver disease in developed countries. It is considered to be the hepatic manifestation of the metabolic syndrome.

Fatty Liver or Metabolic-Associated Fatty Liver Disease (MAFLD) is a term used to describe a condition caused by the build-up of fat in liver cells. A liver normally contains a certain amount of fat, but if fat represents more than 5% of the weight of the liver, that person is said to have “fatty liver” or steatosis.

MAFLD presents as two distinct forms: fat (simple steatosis), and MASH (steatohepatitis)  where fat in the liver results in cellular changes and reactions that results in  inflammation. MASH is a more aggressive form of the condition, and some patients with MASH develop fibrosis, where the persistent inflammation in the liver results in the generation of fibrous scar tissue around the liver cells.

Fatty liver is usually associated with the following:

• Obesity
• High cholesterol
• Type 2 diabetes
• High blood pressure

However, recent research is suggesting a genetic involvement in the development of fatty liver. Some patients may be more genetically susceptible to developing fatty liver.

Fatty liver usually is found or suspected when:

• Abnormal liver tests are found on routine blood testing
• Fat is seen on ultrasound examination of the abdomen, performed for other reasons such as the diagnosis of gallstones
• The liver is enlarged on physical examination of a patient

If there is any doubt regarding the diagnosis or if there is a need to determine the severity of liver damage, a liver biopsy may be performed. A non-invasive, painless alternative to a liver biopsy is the FibroScan® test.

The difference between isolated simple fatty liver and steatohepatitis (MASH) is the presence of inflammation and damage to the liver cells in MASH. Although 1 in 4 of the general population has fatty liver, approximately 10% have MASH. It is believed that the inflammation and damage of liver cells are caused by the toxic effects of the fatty acids released by fat cells.

The consequences of fat in the liver depend greatly on the presence or absence of inflammation and subsequent damage in the liver. Isolated fatty liver does not progress to significant liver disease. However, MASH can progress through the formation of scarring (fibrous tissue) to cirrhosis. The complications of cirrhosis include gastrointestinal bleeding, confusion (encephalopathy), liver failure, and liver cancer.

The main focus of treatment is lifestyle intervention including diet and exercise. Scientific studies have reported  that a 10% decrease in body weight results in a significant reduction in liver fat-related inflammation and fibrosis in MASH patients. Scientific evidence suggests that the anti-oxidant Vitamin E may also help, reduce liver fat and inflammation and possibly fibrosis, but its long-term effectiveness and safety have not been well studied.

In severe cases where liver failure has developed, liver transplantation may be considered.

The main focus of treatment is lifestyle intervention including diet and exercise with the aim of reducing body weight. There are currently GLP1 receptor agonist drugs available,  such as semaglutide, which are used in the management of type 2 diabetes and overweight and or obesity which has shown to be effective in improving many metabolic pathways associated with glucose metabolism.

This class of drugs (which includes those containing semaglutide (Ozempic, Wegovy) and tirzepatide (Mounjaro, Zepbound) were found to also help with weight loss by reducing appetite. By mimicking a natural hormone that controls hunger, these drugs can make you feel full sooner and for longer. This helps you eat less and gradually lose weight over time.

However, these drugs work best when combined with a healthy diet and regular exercise.

Cardiovascular disease, especially heart attacks and strokes, is commonly seen in patients with fatty liver, and cardiovascular causes of death occur more frequently than liver-related deaths. Since the treatments for fatty liver disease are limited, it is important that the manifestations of the metabolic syndrome -obesity, high blood pressure, diabetes, dyslipidemia (abnormalities of lipids in the blood) – are aggressively treated.