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5 Surprising Things to Know About Fatty Liver Disease

One type, in particular, often goes missed — and it’s on the rise in the U.S.

Fatty liver disease is on the rise.
Martin Barraud / Getty Images

A common — though commonly misunderstood — liver disease is on the rise, even among people who rarely reach for the bottle.

About 1 in 4 people have what’s called nonalcoholic fatty liver disease (NAFLD), a condition that occurs when abnormal amounts of fat build up in the liver. And because it’s often missed in routine medical screenings, most people with NAFLD don’t even know they have it, according to a new report in the journal Arteriosclerosis, Thrombosis, and Vascular Biology.

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“Nonalcoholic fatty liver disease is typically diagnosed as an incidental finding when patients are noted to have asymptomatic elevation of liver enzymes on routine laboratory tests or features of a fatty liver on abdominal imaging,” says Manal Abdelmalek, M.D., professor of medicine and director of the Hepatobiliary Disease Interest Group in the Division of Gastroenterology & Hepatology at the Mayo Clinic.

Why the uptick in NAFLD? Part of it has to do with the parallel increase in obesity, type 2 diabetes and high cholesterol — all risk factors for NAFLD, says Po-Hung (Victor) Chen, M.D., assistant professor of medicine at the Johns Hopkins University School of Medicine. Research suggests that up to 75 percent of people who are overweight and more than 90 percent of people with obesity have NAFLD. What’s more, up to 65 percent of people with type 2 diabetes have NAFLD.

And though the name might suggest otherwise, alcohol can also play a role in the progression of NAFLD. “Even modest alcohol use in the presence of these metabolic risk factors [like obesity] can eventually injure the liver,” Chen says. “And alcohol use has increased in the United States, particularly during the pandemic.” A national survey of U.S. adults found that excessive drinking increased by 21 percent during the COVID-19 pandemic.

Here are five surprising things you need to know about NAFLD.

1. You can be a teetotaler and have NAFLD

There are two types of liver disease that are caused by an abnormal buildup of fat in the liver. NAFLD is the one not caused directly by alcohol consumption, even though alcohol use can aggravate it.

And while it’s true that you can live with a fatty liver, it’s also true that doing so raises your risk for type 2 diabetes and cardiovascular disease, both of which are linked to an increased risk for liver disease, Abdelmalek says. “Simple fatty liver does not disturb liver function; however, progressive liver injury and advanced [liver scarring] can impact liver function.”

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Are You At Risk?

A number of diseases and conditions raise your risk for NAFLD. Here are a few.

  • High cholesterol
  • High levels of triglycerides (a type of fat) in the blood
  • Metabolic syndrome
  • Obesity, and especially if fat is concentrated in the abdomen
  • Polycystic ovary syndrome
  • Sleep apnea
  • Type 2 diabetes
  • Hypothyroidism
  • Hypopituitarism 

Source: Mayo Clinic

2. Most people with NAFLD don’t have significant liver damage

In about 15 to 20 percent of cases, however, the excess fat in the liver is accompanied by inflammation and damage to the liver’s cells, leading to an aggressive form of the disease called nonalcoholic steatohepatitis (NASH, for short). With NASH, the liver damage is similar to the kind that’s caused by heavy alcohol use. There’s scarring of the liver (cirrhosis), liver cancer or liver failure.

Not surprisingly, people with NASH are five times more likely to die of liver disease than those with NAFLD that hasn’t progressed, according to research published in Clinical Liver Disease. Among people with NAFLD that hasn’t progressed to the far more serious NASH, cardiovascular disease is the leading cause of death “due to the many shared metabolic risk factors,” Chen says. “Liver disease is the second leading cause of death.”

3. You can have NAFLD without knowing it

People in the early stages of NAFLD usually have no symptoms, and routine blood tests may not show anything amiss with the liver, Abdelmalek says. Complicating matters, elevated liver enzymes in the blood, a possible sign of NAFLD, are often dismissed as a side effect of other medications or the result of recent alcohol consumption.

“The disease has no specific symptoms until the very late stages, which occur after decades, so the disease is often undetected unless the patient has abnormal liver tests or an abdominal ultrasound that demonstrates fat,” says Scott Friedman, M.D., chief of liver diseases and dean for therapeutic discovery at the Icahn School of Medicine at Mount Sinai in New York City.

“Physicians caring for patients with type 2 diabetes, hypertension or high blood lipids — especially if these patients are obese — should consider the possibility of underlying NAFLD. Patients should also encourage their physicians to screen for this condition under these circumstances,” he adds.

NAFLD can be diagnosed through standard blood tests for the liver, “combined with imaging that includes either ultrasound or a bedside test that can measure liver stiffness,” Friedman says. This test, known as Fibroscan or transient elastography, is now widely available in most liver specialists’ offices.

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4. Women are at greater risk of NAFLD as they age

Although researchers aren’t entirely sure why that is, they think the reason has to do with sex hormones. “Estrogens are protective against severe liver disease in premenopausal women,” Friedman says, echoing the results of a review of more than 60 studies published in the journal Endocrinology. “After menopause, however, the progression of liver disease accelerates and equals that of men the same age.”

That’s not to say that premenopausal women aren’t at risk of NAFLD, cautions Friedman, “especially if multiple risk factors are present.”

5. Weight loss is the best prescription for NAFLD

Yet another reason to get rid of extra weight: Research shows that losing at least 10 percent of body weight through a combination of diet and exercise can reverse NASH. (A Mediterranean-style diet is the only specific plan recommended by a consortium of professional groups for the treatment of NAFLD and NASH.)

“As clichéd as it may sound, nothing beats addressing the metabolic risk factors through diet, exercise and weight loss,” Chen says. “It’s also essential to control diabetes and high cholesterol, with medications if necessary.”

Also key: avoiding alcohol. Although some research suggests that moderate drinking (defined as one drink per day for women and up to two per day for men) may reduce the risk of NASH and cardiovascular disease, studies show that any amount of alcohol can aggravate NAFLD and interfere with the liver’s ability to heal.

Beyond lifestyle changes, there are no treatments for NAFLD, but “given the precipitous rise in prevalence of NAFLD, there has been an intense effort for the past five to 10 years to understand the disease better and uncover targets for treatment,” Friedman explains.

There are currently more than 100 drugs in clinical trials for this condition. And although none have been approved by the Food and Drug Administration, Friedman says, “We’re getting much closer every day.”

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