Steatotic liver disease can be treated with weight loss, exercise

Dear Dr. Roach: I had right upper abdominal pain, and my doctor suspected gallbladder problems. The abdominal ultrasound showed that my gallbladder was normal, and the HIDA scan showed normal gallbladder function. But the ultrasound reported “hepatic steatosis,” aka fatty liver disease. My labs were all normal, including an ALT test of 19.

My doctor did not seem concerned about this diagnosis and had little to offer. I’ve gleaned what information I can from the internet. Everyone seems to be selling supplements!

Could you please discuss nonalcoholic fatty liver disease? It seems to be exceedingly common but rarely mentioned. I’d be particularly interested in any dietary or supplemental recommendations.

Anon.

Answer: The word “fatty” carries a stigma, so the names have changed. Nonalcoholic fatty liver disease, now called steatotic liver disease, is a spectrum of illness – from the more-benign metabolic dysfunction-associated steatotic liver disease (MASLD) to metabolic dysfunction-associated steatohepatitis (MASH). The difference between the two is liver inflammation that may lead to liver fibrosis and even cirrhosis, which is the end stage of liver disease.

Steatotic liver disease is increasingly prevalent in recent years, with studies showing diagnoses in 30% to 46% of people in the United States and 25% in Canada. Risk factors include obesity, especially central obesity; diabetes; high cholesterol; and high blood pressure. Although liver tests like the ALT are often elevated, they do not always have to be to receive a diagnosis. Most people are in their 40s and 50s at the time of diagnosis. The diagnosis is usually made by ultrasound, but a biopsy is advised in some cases.

Treatment of MASLD, even in people without MASH, includes avoiding alcohol. It is clear that heavy alcohol use makes the disease progress, but even occasional use may also be harmful. So, it is best to avoid it. Most people with MASLD are overweight, and even in people whose weight is in the average range (specifically people with a BMI above 25) benefit from weight loss of 5% to 7%. For most people, weight loss is the primary therapy.

The specific diet is less important than the actual weight loss, but I want to be clear here that crash or fad diets, many of which cause short-term weight loss that includes a lot of “water weight” or muscle loss, are not healthy and rarely lead to sustained weight loss. Working with a registered dietician can help ensure a good diet, and I strongly recommend a regular moderate exercise program as well.

Supplements are not part of therapy for most people with MASLD. Vitamin E is used for some people who have MASH but don’t have diabetes; this decision requires careful consideration and consultation with an expert. Vitamin E has not been proven effective in people with diabetes, and it has been shown in one large trial to increase the risk for prostate cancer. So, it should not be used in a person at a very high risk for, or with a history of, prostate cancer.

Drug therapy to help a person lose weight, such as semaglutide, can be considered in people who would benefit from weight loss but who have not been able to accomplish this with lifestyle changes alone.