Fatty Liver Disease (NAFLD/MASLD) Treatment in Dallas, TX

What Is Fatty Liver Disease?

Fatty liver disease, medically known as hepatic steatosis, occurs when excess fat accumulates in the cells of the liver. A healthy liver contains a small amount of fat, but when fat makes up more than 5 percent of the liver's weight, the condition is classified as fatty liver disease. It is the most common chronic liver disease in the United States and worldwide, affecting an estimated 25 to 30 percent of American adults — approximately 80 to 100 million people.

When fatty liver disease occurs in the absence of significant alcohol consumption (generally defined as fewer than two drinks per day for women and three for men), it has traditionally been called nonalcoholic fatty liver disease (NAFLD). In 2023, a multisociety consensus led by the American Association for the Study of Liver Diseases (AASLD) introduced updated terminology: metabolic dysfunction-associated steatotic liver disease (MASLD). This new name better reflects the metabolic origins of the condition and reduces the stigma associated with the term "nonalcoholic." Both terms are currently used in clinical practice and medical literature.

At Texas Gut Health in Sachse, TX, Dr. Jaison John provides comprehensive evaluation and management of fatty liver disease using advanced diagnostic tools including FibroScan (transient elastography). Dr. John completed his gastroenterology fellowship at UT Medical Branch, where he served as Chief Fellow, and his internal medicine residency at UT Austin Dell Medical School, where he served as Chief Resident. He holds dual board certifications from the American Board of Internal Medicine in both internal medicine and gastroenterology.

Types of Fatty Liver Disease: NAFLD/MASLD vs. NASH/MASH

Fatty liver disease exists on a spectrum that ranges from simple fat accumulation to progressive liver damage. Understanding the distinction between the subtypes is essential for determining prognosis and guiding treatment decisions.

Simple Steatosis (NAFL / Metabolic Dysfunction-Associated Steatotic Liver, or MASL)

In the majority of patients, fatty liver disease presents as simple steatosis — the presence of excess fat in the liver without significant inflammation or liver cell damage. Simple steatosis is generally considered a benign condition. Most patients with simple steatosis do not develop progressive liver disease, although they remain at increased cardiovascular risk due to their underlying metabolic profile. Approximately 75 to 80 percent of patients with NAFLD/MASLD have simple steatosis.

Steatohepatitis (NASH / MASH)

Approximately 20 to 25 percent of patients with fatty liver disease have nonalcoholic steatohepatitis (NASH), now called metabolic dysfunction-associated steatohepatitis (MASH). In NASH/MASH, fat accumulation is accompanied by inflammation (hepatitis), liver cell injury (ballooning degeneration), and varying degrees of fibrosis (scarring). NASH/MASH is the form of fatty liver disease that can progress to advanced fibrosis, cirrhosis, liver failure, and hepatocellular carcinoma (liver cancer).

The distinction between simple steatosis and NASH/MASH has historically required a liver biopsy, although noninvasive tools such as FibroScan and specialized blood panels are increasingly used to estimate fibrosis severity and guide management without the need for biopsy in many cases.

Risk Factors

Fatty liver disease is strongly associated with metabolic syndrome and its component conditions. The major risk factors include:

• Obesity — The most significant risk factor. Approximately 75 to 90 percent of patients with severe obesity (BMI greater than 40) have some degree of fatty liver disease. However, NAFLD/MASLD can also occur in lean individuals, particularly those of Asian descent.
• Type 2 diabetes and insulin resistance — Insulin resistance is considered the central driver of fat accumulation in the liver. Up to 70 percent of patients with type 2 diabetes have fatty liver disease, and having diabetes significantly increases the risk of progressing to NASH/MASH and advanced fibrosis.
• Dyslipidemia — Elevated triglycerides and low HDL ("good") cholesterol are common in patients with fatty liver disease.
• Metabolic syndrome — The combination of central obesity, elevated blood pressure, high blood sugar, elevated triglycerides, and low HDL cholesterol. Having three or more of these features significantly increases the risk of fatty liver disease.
• Obstructive sleep apnea — Intermittent oxygen deprivation during sleep has been linked to the development and progression of fatty liver disease, independent of obesity.
• Polycystic ovary syndrome (PCOS) — Women with PCOS have a higher prevalence of NAFLD/MASLD, likely related to insulin resistance and hormonal factors.
• Hypothyroidism — Underactive thyroid function has been associated with increased liver fat accumulation.
• Age and ethnicity — The prevalence of fatty liver disease increases with age and is highest among Hispanic Americans, followed by White Americans and African Americans.

Symptoms of Fatty Liver Disease

One of the most challenging aspects of fatty liver disease is that it is typically a "silent" condition. The vast majority of patients have no symptoms in the early stages, and the disease is often discovered incidentally through abnormal liver enzymes on routine blood work or findings on an imaging study performed for another reason.

When symptoms do occur, they tend to be nonspecific and may include:

• Fatigue — The most commonly reported symptom, often described as a persistent sense of tiredness or low energy that is not relieved by rest.
• Right upper abdominal discomfort — A vague, dull ache or sense of fullness in the right upper quadrant, where the liver is located. This discomfort results from stretching of the liver capsule due to enlargement (hepatomegaly).
• Malaise — A general feeling of being unwell.

As the disease progresses to advanced fibrosis or cirrhosis, more significant symptoms may develop, including:

• Jaundice (yellowing of the skin and eyes)
• Ascites (fluid accumulation in the abdomen)
• Easy bruising and prolonged bleeding
• Spider angiomata (small, spider-like blood vessels on the skin)
• Hepatic encephalopathy (confusion, difficulty concentrating, personality changes)
• Unexplained weight loss

Because fatty liver disease is so commonly asymptomatic, screening is recommended for patients with metabolic risk factors, particularly those with type 2 diabetes, obesity, or metabolic syndrome.

Diagnosis and Staging

Accurate diagnosis and staging of fatty liver disease are critical for determining prognosis and guiding treatment. The diagnostic workup typically involves several components:

Blood Tests

Initial laboratory evaluation includes liver enzymes (ALT and AST), which may be mildly elevated, though normal levels do not exclude significant liver disease. A comprehensive metabolic panel, complete blood count, lipid panel, and hemoglobin A1c are typically ordered to assess metabolic risk factors. The FIB-4 index, a simple calculation using age, platelet count, AST, and ALT, is recommended by the AASLD as a first-line noninvasive screening tool to estimate fibrosis risk.

FibroScan (Transient Elastography)

FibroScan is a specialized, noninvasive test that has become an essential tool in the evaluation of fatty liver disease. Performed in the office in approximately 10 minutes, FibroScan uses ultrasound-based transient elastography to measure two key parameters:

• Liver stiffness measurement (LSM) — Correlates with the degree of fibrosis (scarring) in the liver. Higher stiffness values indicate more advanced fibrosis.
• Controlled attenuation parameter (CAP) — Estimates the amount of fat in the liver, providing an objective measure of steatosis severity.

FibroScan allows Dr. John to assess disease severity and track changes over time without the risks and discomfort of repeated liver biopsies. The AASLD practice guidance endorses transient elastography as an appropriate noninvasive tool for assessing fibrosis in patients with NAFLD/MASLD.

Imaging Studies

Abdominal ultrasound is often the first imaging study to suggest fatty liver, showing increased liver echogenicity (brightness). However, ultrasound has limited sensitivity for detecting mild steatosis and cannot reliably assess fibrosis. MRI-based techniques, including MRI proton density fat fraction (MRI-PDFF) and magnetic resonance elastography (MRE), provide the most accurate noninvasive measurements of liver fat and fibrosis but are more costly and less widely available than FibroScan.

Liver Biopsy

Liver biopsy remains the gold standard for distinguishing simple steatosis from NASH/MASH and for grading the severity of inflammation and fibrosis. However, because biopsy is invasive and carries a small risk of complications, it is generally reserved for cases where the diagnosis is uncertain, when competing causes of liver disease need to be excluded, or when the results would change clinical management. The growing availability of reliable noninvasive tests has reduced the need for biopsy in many patients.

Treatment and Management

The management of fatty liver disease is multifaceted and depends on the severity of the disease. For most patients, lifestyle modification remains the cornerstone of treatment.

Weight Loss

Weight loss is the most effective treatment for fatty liver disease and is supported by the strongest evidence. The AASLD practice guidance recommends the following targets:

• 5 percent body weight loss — Can reduce liver fat content significantly.
• 7 to 10 percent body weight loss — Can improve inflammation (steatohepatitis) and may begin to improve fibrosis.
• 10 percent or greater body weight loss — Has been shown to resolve NASH/MASH in a significant proportion of patients and can lead to measurable fibrosis regression.

Weight loss should be achieved through a combination of dietary changes and increased physical activity. Rapid weight loss (more than 3 to 5 pounds per week) should be avoided, as it can paradoxically worsen liver inflammation.

Diet

No single diet has been proven definitively superior for fatty liver disease, but a Mediterranean-style diet is the most frequently recommended by hepatology experts. This dietary pattern emphasizes fruits, vegetables, whole grains, lean proteins (especially fish), olive oil, and nuts while limiting red meat, processed foods, refined carbohydrates, and added sugars. Fructose, particularly from sugar-sweetened beverages and processed foods, has been specifically implicated in promoting liver fat accumulation and should be minimized.

Exercise

Regular physical activity reduces liver fat independently of weight loss. The ACG and AASLD recommend at least 150 minutes of moderate-intensity aerobic exercise per week (such as brisk walking, cycling, or swimming). Both aerobic exercise and resistance training have been shown to reduce liver fat, and the best exercise program is one that the patient can maintain consistently over time.

Medications

For patients with NASH/MASH and significant fibrosis who do not achieve adequate improvement with lifestyle changes alone, pharmacologic therapy may be considered:

• Resmetirom (Rezdiffra) — Approved by the FDA in March 2024, resmetirom is the first medication specifically approved for the treatment of adults with NASH/MASH with moderate to advanced liver fibrosis (stages F2-F3). It is a thyroid hormone receptor-beta agonist that reduces liver fat, inflammation, and fibrosis. It is used in combination with diet and exercise.
• Vitamin E — High-dose vitamin E (800 IU daily) has been shown to improve steatohepatitis in non-diabetic adults with biopsy-proven NASH. It is not recommended for patients with diabetes, those without biopsy-confirmed NASH, or those with cirrhosis.
• Pioglitazone — This insulin-sensitizing medication has been shown to improve steatohepatitis in patients with and without diabetes, though it carries risks of weight gain, fluid retention, and bone loss.
• GLP-1 receptor agonists — Medications such as semaglutide, originally developed for diabetes and weight management, have shown promising results in clinical trials for NASH/MASH, with improvements in steatohepatitis and potential for fibrosis improvement.

Alcohol Avoidance

Patients with fatty liver disease should avoid or significantly limit alcohol consumption, as alcohol can compound liver injury and accelerate disease progression. The AASLD recommends that patients with NAFLD/MASLD and any degree of fibrosis abstain from alcohol entirely.

Managing Metabolic Comorbidities

Because cardiovascular disease is the leading cause of death in patients with fatty liver disease, aggressive management of metabolic risk factors is essential. This includes optimal control of blood sugar, blood pressure, and cholesterol. Statins are safe and appropriate for patients with fatty liver disease who meet criteria for cholesterol treatment, despite common misconceptions about their effects on the liver.

Ongoing Monitoring

Fatty liver disease requires ongoing monitoring to track disease progression, assess treatment response, and screen for complications. Dr. John recommends the following approach for patients in the Dallas-Fort Worth area:

• Regular blood work — Liver enzymes, metabolic panels, and fibrosis markers (FIB-4 index) should be checked at regular intervals, typically every 6 to 12 months.
• Serial FibroScan assessments — Repeat FibroScan testing at intervals of 1 to 2 years allows Dr. John to monitor changes in liver stiffness and fat content over time, providing objective evidence of improvement or progression.
• Hepatocellular carcinoma (HCC) surveillance — Patients with cirrhosis from NASH/MASH should undergo surveillance for liver cancer with abdominal ultrasound and alpha-fetoprotein (AFP) blood test every 6 months, in accordance with AASLD guidelines. There is growing recognition that HCC can occur in NASH/MASH patients even before cirrhosis develops, though screening guidelines for non-cirrhotic patients are still evolving.
• Cardiovascular risk assessment — Because heart disease is the leading cause of mortality in NAFLD/MASLD patients, regular assessment and management of cardiovascular risk factors is a critical component of care.

Frequently Asked Questions