Fatty Liver DIsease (NAFLD)

WHAT YOU NEED TO KNOW

Fatty liver disease (NAFLD) affects upwards 30% of people worldwide and should be managed without weight loss, despite what healthcare providers might suggest. This guide explains how to address fatty liver using evidence-based approaches that don’t involve dieting or weight loss.

What Is Idiopathic Fatty Liver Disease?

Fatty liver disease (NAFLD) occurs when fat builds up in liver cells. Think of your liver as your body’s processing plant – normally it handles fats efficiently, but with fatty liver, excess fat accumulates. This is a real physiological process, not a personal failing or lifestyle choice to be judged.

Main Types of Fatty Liver Disease:

  • Simple Fatty Liver (Hepatic Steatosis): Fat in at least 5% of liver cells without inflammation or damage. Most common type with a very benign course.
  • NASH (Non-Alcoholic Steatohepatitis): Fat buildup is associated with inflammation that has the potential to lead to scarring
  • Fibrosis: Reversible scarring in early stages
  • Cirrhosis: Severe, irreversible scarring (extremely rare in NAFLD)

 

The medical term NAFLD (Non-Alcoholic Fatty Liver Disease) is increasingly being replaced by MAFLD (Metabolic Dysfunction-Associated Fatty Liver Disease) as we better understand its relationship to metabolic health rather than alcohol.

Important Facts About Fatty Liver

What Actually Causes Fatty Liver?

Fatty liver has many contributing factors:

  • Genetics 
  • Insulin resistance
  • Hormonal imbalances
  • Gut microbiome disruptions
  • Inflammation
  • Medications (including some common prescriptions)
  • Environmental factors

 

The Truth About Weight and Fatty Liver

Despite common beliefs, the evidence for weight loss as a treatment is surprisingly weak:

  • The UK’s National Institute of Clinical Excellence (NICE) found zero studies supporting weight loss for NAFLD
  • 40% of people with fatty liver are not Fat and 20% have what’s called “lean NAFLD”
  • Most deaths in people with NAFLD are from heart disease and other conditions, not liver disease 
  • Weight cycling and weight stigma can actually worsen insulin resistance and inflammation, whichare both thought to cause fatty liver. 

How Weight Stigma Affects Your Care

Weight stigma in healthcare can seriously impact fatty liver treatment:

  • Diagnosis of more advanced stages may be delayed while focusing unnecessarily on weight
  • You might be pressured into harmful restrictive diets
  • The stress of forced weight loss attempts could worsen metabolic health
  • Important symptoms might be dismissed or blamed on weight
  • Medical conditions might progress while waiting for weight loss to “work”

Evidence-Based Management Options

In most cases, no action needs to be taken. On the odd occasion that treatment is necessary, there are several approaches that don’t involve weight loss:

  • Treatment of underlying insulin resistance
  • Management of metabolic health markers
  • Addressing hormonal imbalances
  • Appropriate medication adjustments if needed

 

Monitoring

Evidence-based monitoring includes:

  • Annual liver function tests
  • Assessing fibrosis score using a recognised risk calculator
  • Appropriate imaging as recommended
  • Focus on metabolic health markers (such as blood pressure, cholesterol etc) rather than weight

 

Understanding Fatty Liver Tests

There are several types of tests:

  • Liver function blood tests (ALT, AST)
  • Imaging (ultrasound, FibroScan, MRI)
  • Rarely, liver biopsy for advanced cases

Your healthcare provider should explain their reason for requesting them and what they mean. In general :

  • Elevated enzymes indicate inflammation
  • Imaging shows fat content and potential scarring
  • Results should guide treatment of actual liver health, not weight

Weight Inclusive Treatment

Your Rights as a Patient

You deserve healthcare that:

  • Investigates your condition without blame
  • Doesn’t involve unnecessary testing (such as a liver scan with a low Fib4 risk score)
  • Doesn’t delay proper treatment by focusing on weight loss
  • Considers all available evidence-based options
  • Respects you and takes your concerns seriously
  • Recognizes that weight loss lacks evidence as a treatment

 

Getting Good Care

If your healthcare provider focuses primarily on weight loss:

  1. You can share this information: “According to guidelines, there is no evidence supporting weight loss as a treatment for fatty liver disease.”
  2. Ask these questions:
    • “How would your recommendations change if weight wasn’t a factor?”
    • “What evidence-based treatments can we focus on instead?”
    • “What specific markers will we monitor to track my liver health?”
  3. Request to focus on:
    • Managing metabolic health
    • Addressing any underlying conditions
    • Regular monitoring without weight stigma
    • Building sustainable health habits

 

Remember: Fatty liver is a typically a slowly progressing condition. With proper evidence-based management, most people never develop serious liver complications. It is NOT your fault, at least 40% of people with fatty liver are NOT fat, and there is zero evidence supporting weight loss as treatment. You have the right to evidence-based treatment that addresses your actual symptoms, not just advice about weight loss.

 

Effective Sample Script

You can use this script with healthcare providers:

“I am aware of the association between NAFLD and higher weight. I have done my research regarding the benefits and risks of intentional weight loss for my condition. I have decided that I do not wish to pursue this avenue. I therefore do not consent to discussing my weight or weight loss during this or any future consultation. Any attempts to do so will only serve to stigmatize me further.”

This information is provided by Dr. Asher Larmie, The Fat Doctor. For more detailed information and resources, check out his masterclass. This information is provided for educational purposes and should not replace professional medical advice. Always consult with healthcare providers for personal medical decisions.