Fatty liver disease affects an estimated one in three adults in the United States, and most people don’t know they have it. The condition develops silently, often without symptoms, and is frequently discovered during routine blood tests or imaging performed for other reasons. In recent years, patients who have been told they have non-alcoholic fatty liver disease, or NAFLD, may also notice something else: the terminology has changed. In 2023, liver specialists introduced new names for the condition, replacing NAFLD with MASLD and NASH with MASH. The disease itself has not changed, but the new terminology reflects a clearer understanding of what drives it.

Fatty Liver Disease Is a Metabolic Condition

What the new name makes explicit is something that was already true about the disease: fatty liver is fundamentally a metabolic condition. The liver is central to how the body processes and stores fat, and when metabolic health is compromised, whether through obesity, insulin resistance, or related conditions, the liver can begin accumulating fat faster than it can clear it. That buildup, known as hepatic steatosis, is usually silent. Most patients have no symptoms in the early stages, which is why fatty liver so often surfaces incidentally during a blood test or imaging scan ordered for something else entirely.

For many patients, fatty liver remains stable and causes no serious harm, particularly if the underlying metabolic factors driving it are addressed early. But in some cases the condition progresses. When fat accumulation is accompanied by inflammation and liver cell damage, the disease has moved into the more serious stage now called MASH (metabolic dysfunction-associated steatohepatitis). Repeated cycles of that inflammation can lead to fibrosis, where scar tissue begins replacing healthy liver tissue, and in more advanced cases to cirrhosis or liver cancer. Most patients with MASLD will not reach those stages, but the risk of progression is what makes early detection and management worth taking seriously.1

Why NAFLD Became MASLD

The old terminology defined the disease by what it wasn’t, distinguishing metabolic fatty liver from alcohol-related liver disease in a way that was clinically useful but created problems in practice. Patients with NAFLD frequently found themselves explaining that their diagnosis had nothing to do with alcohol use. Having the word in the name at all invited confusion, and for some patients it carried an unwarranted stigma that made an already difficult diagnosis harder to talk about.

The shift to MASLD (metabolic dysfunction-associated steatotic liver disease) reframes the condition around its actual cause. Metabolic dysfunction is now the defining characteristic in the name itself, connecting fatty liver directly to the cluster of conditions that drive it: obesity, insulin resistance, elevated cholesterol, and high blood pressure. This matters because those are the same risk factors associated with type 2 diabetes and cardiovascular disease. Liver health and metabolic health are part of the same picture, and the updated terminology makes that relationship harder to overlook.2

Risk Factors for MASLD

Because MASLD typically develops without noticeable symptoms, many patients don’t know they have it until it shows up on a routine blood test or imaging scan. In some cases, doctors may also use specialized tools such as FibroScan, a noninvasive test that measures liver stiffness and fat levels, to evaluate whether fatty liver disease is present and how advanced it may be. By the time symptoms do appear, the disease has often already progressed to a more advanced stage. That makes awareness of risk factors particularly important, especially for patients who may have several of them without realizing the connection to their liver health.

The metabolic conditions that drive MASLD tend to cluster together, which means that a patient with one risk factor often has others. The following are the most significant:

  • Obesity or excess abdominal weight: Fat stored around the midsection is closely associated with fat accumulation in the liver. That said, MASLD can develop in people who are not overweight, particularly those with insulin resistance or a genetic predisposition.
  • Type 2 diabetes or insulin resistance: These are among the strongest risk factors for MASLD. Insulin resistance disrupts how the body handles fat and sugar, promoting fat storage in the liver even when caloric intake seems reasonable.
  • High cholesterol or triglycerides: Elevated blood lipids contribute to liver fat accumulation and often accompany other components of metabolic syndrome.
  • High blood pressure: Hypertension frequently occurs alongside the other conditions listed here and is considered part of the metabolic syndrome profile associated with MASLD.
  • Sedentary lifestyle and diet: Low physical activity and diets high in processed foods, refined carbohydrates, and added sugars are behavioral drivers of the metabolic dysfunction that underlies the disease.

Treatment and Management Options for MASLD

Treatment for MASLD is tailored to where a patient falls on the disease spectrum and what metabolic conditions are contributing to it. For most patients, the foundation of management is lifestyle modification, which has been shown to meaningfully reduce liver fat and in some cases reverse early-stage disease. Losing even five to ten percent of body weight, for instance, can produce measurable improvement in liver health. Beyond lifestyle changes, there are now more medical options available than there were even a few years ago.

  • Diet and weight management: A diet emphasizing vegetables, whole grains, lean protein, and healthy fats, similar to a Mediterranean-style eating pattern, is consistently associated with better liver outcomes. Reducing added sugars and processed foods is particularly important, as high fructose intake is directly linked to liver fat accumulation. Gradual, sustained weight loss is the goal; rapid weight loss through crash dieting can sometimes worsen liver inflammation.
  • Physical activity: Regular exercise improves insulin sensitivity and helps reduce liver fat independently of weight loss. Both aerobic exercise and resistance training have shown benefit. Consistency matters more than intensity, and even moderate activity like brisk walking several days a week produces measurable results.
  • Managing metabolic conditions: Controlling blood sugar, cholesterol, and blood pressure through both lifestyle and medication where appropriate reduces the metabolic burden on the liver. Many medications used to treat these conditions are safe in MASLD and may indirectly benefit the liver by addressing its underlying drivers.
  • Newly approved medication: In 2024, the FDA approved resmetirom, sold under the brand name Rezdiffra, as the first medication specifically indicated for MASH with liver fibrosis. This helps patients with more advanced disease who have not achieved sufficient improvement through lifestyle changes alone. GLP-1 receptor agonists like semaglutide, already widely used for diabetes and weight management, have also shown promising results in reducing liver inflammation and fibrosis in clinical trials.
  • Avoiding additional liver stress: Alcohol consumption can accelerate liver damage in patients with MASLD and is generally advised against. Certain supplements and over-the-counter medications can also affect the liver, so patients should discuss anything they are taking with their care team.

Request an Appointment with Cary Gastro

For patients who have been told they have NAFLD or NASH, or who recognize the risk factors associated with MASLD, a conversation with a gastroenterologist is a reasonable next step. Early evaluation can establish where the disease stands and what management approach makes the most sense given a patient's overall metabolic health. The team at Cary Gastroenterology has experience evaluating and managing fatty liver disease at every stage. Contact us today to request an appointment.




1https://liverfoundation.org/liver-diseases/veterans-information-center/metabolic-dysfunction-associated-steatotic-liver-disease-masld-and-liver-health-for-veterans/
2https://easl.eu/news/new_fatty_liver_disease_nomenclature-2/