In 2011, Susan Zuckerman-Seely was taking back control of her life. Fresh out of a bad relationship, she was finally going to see her primary doctor for that long-overdue checkup. And she was ready to do something about the 100 extra pounds she was carrying.
When her blood tests showed high levels of liver enzymes, her doctor took an ultrasound of her liver and sent her for a liver biopsy.
“They could see that I had fatty liver on the ultrasound. They just said, ‘You have fatty liver. Diet and exercise.’” But she still had the liver biopsy coming up. She expected to get a call and more information after that.
But Zuckerman-Seely never got a call after the biopsy or any further guidance on what to do about her fatty liver disease. So she went on with her life and continued her plan to get healthier. She improved her diet and hired a personal trainer.
But it was a slow process. Eight years later, in 2019, she was still 60 pounds overweight but continuing on the right track. Another checkup that year showed that her liver enzymes were still very high.
That’s when she remembered the liver biopsy from eight years ago that no one had ever called her about. She called the doctor to get the results.
For the last eight years, Zuckerman-Seely had been unknowingly living with stage III metabolic dysfunction-associated steatohepatitis (MASH), an advanced stage of fatty liver disease, the last stage before full cirrhosis of the liver.
“No one called me. Why didn’t they tell me? I needed to see a hepatologist immediately,” she says.
MASH, also known as nonalcoholic fatty liver disease, happens when fat cells build up in the liver. If left unchecked, the excess fat cells cause inflammation, liver damage, scarring of the liver called fibrosis, then severe scarring called cirrhosis, and eventually liver failure.
Why Does Fatty Liver Often Go Undetected?
It’s not unusual for fatty liver disease to go undetected, says Sammy Saab, MD, Medical Director of the Pfleger Liver Institute at UCLA Health in Los Angeles.
In its early stages, MASH may not cause symptoms that would lead you to see a doctor. The disease may not even lead to an abnormal blood test until it has already caused major damage to your liver.
“People often assume that you don’t have liver damage unless your liver tests are elevated,” Saab says. “The problem is that many people, if not most, with fatty liver disease have normal liver tests.”
But even though you may not have symptoms of fatty liver disease, medical guidelines recommend that doctors screen anyone who has risk factors for the disease, which include:
- Obesity or overweight
- Type 2 diabetes
- High cholesterol
- High blood pressure
But proper screening requires a special ultrasound test called transient elastography . It measures liver stiffness and scarring, and not just any doctor’s office can do it.
“Large academic hospitals may have a FibroScan, but a community doctor may not have access to that. So, that’s a big problem,” Saab says. Alternatives to this test, such as the enhanced liver fibrosis (ELF) blood test, he adds, often are not covered by health insurance.
Finally, doctors may not prioritize early detection of liver disease because, until 2024, there weren’t any medications to treat it. “So, they thought, ‘You have it, but we can’t do much about it other than lifestyle changes,’” Saab says.
When Zuckerman-Seely asked her doctor why she hadn’t discussed her liver disease with her, the doctor said, “All you can do is diet and exercise, and you were already doing that,” she recalls.
Why Are There Gaps in Preventive Care?
Prevention and early detection of fatty liver disease are challenging. Early fatty liver disease doesn’t always lead to a spike in liver enzymes, so there’s no clear test to spot the condition before it becomes advanced.
As for prevention, that happens through a healthy diet and plenty of exercise. Doctors often recommend the same to patients, but sometimes, it may drive patients away.
“Any time I went to a doctor, I knew they were going to tell me to lose weight, so it just made me not even want to go to the doctor,” says Stephen Silva-Brave, a 41-year-old PhD student in Dallas, Texas, whose liver disease had advanced to cirrhosis before he understood how serious it was.
Silva-Brave, who was extremely overweight and a heavy drinker, went to the doctor for severe back pain. The doctor ordered some blood tests and diagnosed him with fatty liver disease along with a long list of other issues. “They’re telling me, ‘This number is bad. That number is bad. You have high blood pressure, fatty liver, high cholesterol, and you need to change your diet and exercise,” he recalls. “I’m thinking, ‘I already know I need to lose weight. What about my back?’”
The doctor didn’t separate fatty liver from high blood pressure and high cholesterol, issues that Silva-Brave already knew he had. The doctor didn’t explain what fatty liver was and the dangers of allowing it to advance.
Outside of liver specialists, other doctors may not be aware of the seriousness of this condition. “It’s just not on doctors’ radars,” Saab says. “It’s so common that they think it’s a benign condition, and they don’t always understand the clinical ramifications of fatty liver.”
Doctors may tell patients to eat a healthy diet and exercise to prevent or slow fatty liver disease, but they may not understand or address what makes it hard for patients to follow that advice.
“We talk about eating a Mediterranean diet and exercising every day,” Saab says, “but many pockets of the population have no idea what a Mediterranean diet is.”
As for exercise, he adds, with full-time work, long commutes, and family obligations, “I’m not sure how realistic it is to exercise on a daily basis to treat fatty liver disease.”
How Common Is Late Diagnosis of Fatty Liver?
Stories like those of Zuckerman-Seely and Silva-Brave — patients who learned about their liver disease only after it was very advanced — are all too common.
“I would love to say it’s uncommon,” Saab says, “but unfortunately it’s the norm.” Saab says a recent patient already had a tumor on her liver (which is a risk of advanced fatty liver disease) by the time her fatty liver disease was detected on ultrasound.
What Do I Do Now For My Fatty Liver?
Even when you have advanced MASH, there’s still plenty that you and your doctor can do to turn your condition around.
Both Zuckerman-Seely and Silva-Brave learned they had advanced MASH years before there was medication for the disease. They put their livers back in shape with major lifestyle changes.
A healthier diet
“I followed the MASH diet like an obsessed person,” Zuckerman-Seely says. “Nothing white. No white bread, no white rice, no white potatoes. Everything fresh: fruits, vegetables, chicken, fish.”
She’s describing the Mediterranean diet, which is the most researched diet for slowing, stopping or reversing, fatty liver disease. This eating pattern emphasizes:
- Fish high in omega-3 fatty acids, such as salmon
- Other sources of “good” fat, such as olive oil, flax meal, chia seeds, and avocados
- Whole grains and starches, such as whole wheat bread and brown rice instead of their white counterparts
- Fruits and vegetables
- Plant-based proteins such as legumes and nuts
- Meat-free proteins, such as egg whites and Greek yogurt
Stop drinking
If you have MASH, your liver can no longer process alcohol. Even a drink or two a day can make the inflammation and liver damage worse.
Silva-Brave’s liver disease had advanced to the point that whenever he drank alcohol, he immediately vomited. With the support of his wife and mother, and motivated by his two young children, Silva-Brave joined a 12-step program and gave up alcohol completely.
“The amount of time that I used to spend drinking and hanging out, I now spent going to recovery meetings and walking,” he says.
Daily exercise
When he was at his worst, Silva-Brave didn’t exercise at all, but he gradually increased his physical activity levels. “I was once someone who couldn’t walk down the block to the grocery store,” he says. But his walks soon became runs, and Silva-Brave eventually ran a marathon.
If you’re starting from zero, that’s OK. Ultimately, your goal should be to get 150-300 minutes of moderate-intensity aerobic activity, such as brisk walking or cycling, every week. That’s at least 30 minutes for five days a week. While that should be your goal, you may start with just a couple of 5- to 10-minute walks per day.
Lose weight
A Mediterranean diet, quitting alcohol, and exercising daily may naturally lead to weight loss.
“If you lose 10% of your body weight, you could reverse liver damage,” Saab says. “Stage III becomes stage II, stage II becomes stage 1.” For someone who weighs 200 pounds, that’s just a 20-pound loss to start reversing the damage.
With diet and exercise, Zuckerman-Seely lost 100 pounds and reversed her fatty liver disease. “I was released by my hepatologist in 2023,” she says.
Silva-Brave also reversed his diseases with diet, exercise, sobriety, and weight loss. His last ultrasound revealed that he only has light scarring on his liver. “My doctor says it looks more like someone on the front end of the disease, not someone who already had cirrhosis.”
Talk to your doctor about medication
Zuckerman-Seely and Silva-Brave didn’t have the help of medications. Now the FDA has approved two medications for people with stage II or III MASH, which involves stiffening and scarring of the liver. These medications are resmetirom (Rezdiffra) and semaglutide (Wegovy).
Ask your doctor if you’re eligible for treatment with prescription medication.
It’s not too late
You can still benefit from lifestyle changes and potentially medication — even after you’re diagnosed with fatty liver disease.
“Fatty liver is not a death sentence,” Silva-Brave says. “It takes work, but you can heal. It can be done.”
