Fatty Liver: Small Steps That Start at the Table

A quietly common problem

The name of fatty liver changed in 2023: formerly NAFLD (nonalcoholic fatty liver disease), it is now called MASLD. The definition is simple: there is fat in the liver (steatosis) together with at least one cardiometabolic criterion, such as excess weight or a large waist, high blood sugar, high blood pressure or abnormal blood fats. When inflammation and cell damage are added to the fat, the condition is called metabolic dysfunction-associated steatohepatitis (MASH). In short, MASLD is a condition that concerns not only the liver but metabolic health as well.

According to the data in the presentation, MASLD affects 30–38% of adults worldwide and is the most common chronic liver disease. In a study of adults with cardiometabolic risk factors in Türkiye, the rate was found to be much higher. Moreover, the leading cause of death in people with MASLD is cardiovascular disease.

What matters is the scarring

The process can run from fatty change to MASH, then to fibrosis (build-up of scar tissue in the liver), cirrhosis and liver cancer. What decides the outcome most is the stage of fibrosis. The good news is that reversal can be possible in the early stages: fat can recede, MASH can resolve and fibrosis can lessen. Sustained weight loss is described as the strongest tool for this. Because the same lifestyle change also lowers the risk of diabetes, hypertension and cardiovascular disease, the liver is not the only target.

So how is the risk of advanced fibrosis assessed? First comes a simple calculation: the Fibrosis-4 index (FIB-4). Worked out from age, AST, ALT (liver enzymes) and platelet count, this score sorts the risk into low, intermediate and high. With intermediate and high values, elastography, which measures liver stiffness, comes into play; high risk calls for follow-up with a liver specialist. With low risk, lifestyle treatment continues and the score is repeated every 1–3 years.

What does the science suggest?

In people with excess weight, the effect is dose-dependent: the greater the loss, the deeper the response in the liver. In studies, losing at least 5% of body weight was linked to a marked drop in liver fat, 7% to a greater chance of MASH resolving, and 10% or more to the highest chance of fibrosis improving. The response differs from person to person. The goal is not fast but sustainable loss.

For eating, the model is the Mediterranean style: vegetables and whole fruit, legumes (lentils, chickpeas, beans), whole grains (bulgur, oats), olive oil, walnuts, almonds and fish; coffee is not restricted. What to cut back on: sugary drinks and fruit juice, added sugar including the sugar in tea, simit, pastries and white bread, ultra-processed packaged foods, and processed meats such as sausage and salami. 'Liver detox' products and herbal supplements have no proven benefit.

For alcohol, no safe level has been defined in MASLD; avoiding it is advised even without fibrosis. In advanced fibrosis or cirrhosis, alcohol is stopped completely and permanently. Exercise has a value of its own: it lowers liver fat even without weight loss. At moderate intensity (you can talk but not sing), 150–300 minutes of aerobic activity a week and resistance exercise 2–3 days a week are recommended. Not sitting for long stretches also matters: getting up every 30–60 minutes for a short 2–5-minute walk is recommended.

Swaps, not bans: small steps

The most practical message of the presentation is to show what can replace what. Eggs, cheese, tomato and cucumber, a slice of whole-grain bread and unsweetened tea instead of simit and sweet tea; water, mineral water or whole fruit instead of fruit juice and cola; bulgur pilaf with chickpeas instead of white rice pilaf; a handful of raw almonds or walnuts instead of late-night sunflower seeds and chips. An earlier, lighter evening meal instead of a heavy dinner at 22:00 is also among the suggestions.

For someone who is inactive, the start can be modest: 3 × 10 minutes of walking a day, then a gradual weekly increase. Enough sleep (7–9 hours for adults), staying away from cigarettes and waterpipe, stress management and family support are also part of the plan; planning meals together improves adherence. For quitting smoking, the Ministry of Health’s ALO 171 line and smoking cessation clinics offer support.

Medicines and surgical options also exist; the physician, together with a liver specialist when needed, decides which is suitable for whom. In Türkiye, licensing and reimbursement conditions are part of that assessment too. However, medicines are added on top of lifestyle treatment, not instead of it; the foundation of the plan remains food, movement and daily habits.