1. Confirm the diagnosis and stage the risk

• Exclude other causes of steatosis:
  • Alcohol: more than 20 g/day for women or 30 g/day for men points to alcohol-related disease.
  • Viral hepatitis: check HBsAg and anti-HCV.
  • Drugs: amiodarone, methotrexate, tamoxifen, steroids and valproate can cause it.
  • Other causes: hemochromatosis, Wilson disease and autoimmune hepatitis.
• Look for metabolic risk factors: obesity, type 2 diabetes or prediabetes, dyslipidemia, hypertension and obstructive sleep apnea.
• Baseline labs: LFTs (ALT, AST, GGT), platelets, fasting glucose or HbA1c, lipid profile, and creatinine.
• Fibrosis risk is what determines prognosis, not the ultrasound grade. Use FIB-4 (age, AST, ALT, platelets) first.
  • FIB-4 below 1.3 (below 2.0 if age 65 or older): low risk. Manage in primary care and repeat the assessment every 1 to 3 years.
  • FIB-4 of 1.3 to 2.67: indeterminate. Do a second test, either transient elastography (FibroScan) or the ELF test.
  • FIB-4 above 2.67, or elastography of about 8 kPa or higher: intermediate or high risk. Refer to hepatology.

2. Lifestyle (the mainstay of treatment)

• Weight loss, step by step:
  • 3 to 5% of body weight improves steatosis.
  • 7 to 10% improves inflammation (steatohepatitis).
  • 10% or more can regress fibrosis.
  • Aim for 0.5 to 1 kg per week. Avoid crash dieting, which can worsen the liver.
• Diet:
  • Use a Mediterranean-style diet with a deficit of 500 to 1000 kcal/day.
  • Cut out sugar-sweetened drinks and fructose, ultra-processed food and refined carbohydrates.
  • Eat more vegetables, whole grains, legumes, nuts, olive oil and fish.
• Exercise:
  • Do at least 150 to 300 minutes per week of moderate aerobic activity, plus resistance training 2 to 3 times a week.
  • Exercise reduces liver fat even without weight loss.
• Alcohol: minimise it or avoid it, especially if there is any fibrosis.
• Coffee: 2 to 3 cups a day is associated with lower fibrosis risk. It is optional.
• Smoking: advise stopping.

3. Treat the associated conditions

• Diabetes:
  • Pioglitazone, GLP-1 receptor agonists (semaglutide, liraglutide) and SGLT2 inhibitors help both glycemia and liver fat.
  • Semaglutide is approved for MASH with F2 to F3 fibrosis.
  • Metformin is fine for diabetes but does not treat the liver itself.
• Dyslipidemia: statins are safe in fatty liver and recommended for cardiovascular protection. Do not withhold them because of mildly raised ALT.
• Hypertension: control it. ACE inhibitors or ARBs are reasonable choices.
• Obesity: consider an anti-obesity drug or bariatric surgery if BMI is 35 or higher, or 30 or higher with comorbidities.
• Cardiovascular risk is the leading cause of death in MASLD, so assess and manage it actively.

4. Drugs aimed at the liver

• Most grade 1 patients do not need liver-specific drugs.
• Vitamin E 800 IU/day: consider only in biopsy-proven MASH without diabetes or cirrhosis.
• Resmetirom: approved for non-cirrhotic MASH with F2 to F3 fibrosis.
• Not recommended: ursodeoxycholic acid, omega-3 fatty acids for the liver, and unproven "liver supplements".

5. Follow-up

• Low fibrosis risk: review lifestyle and metabolic control yearly. Repeat LFTs and FIB-4 every 1 to 3 years.
• Intermediate or high risk: hepatology follow-up and periodic elastography.
• Cirrhosis: screen for hepatocellular carcinoma (ultrasound every 6 months) and for varices.
• Refer earlier if you see: persistently raised ALT or AST, low platelets, FIB-4 or elastography in the intermediate or high range, or a suspicion of another liver disease.

Management of grade 1 fatty liver (mild hepatic steatosis)

• Yamada's Textbook of Gastroenterology, 7e, p. 2229-2230: "Fibrosis is the most significant factor in defining clinical outcomes and risk stratification."
• Isolated steatosis often stays stable. A small proportion of patients progress to steatohepatitis (MASH) and fibrosis.
• In MASLD overall, cardiovascular disease is the most common cause of death. Managing cardiometabolic risk matters as much as the liver itself.

1. Confirm the diagnosis and exclude other causes

• Alcohol: Quantify intake. Moderate intake can overlap with MASLD, and the 2024 EASL-EASD-EASO guideline advises discouraging alcohol.
• Other causes: Consider viral hepatitis (HBsAg, anti-HCV), steatogenic drugs (steroids, amiodarone, methotrexate, tamoxifen), hemochromatosis, celiac disease and thyroid disease where the history suggests them.
• Baseline labs: LFTs (ALT, AST, GGT), platelets, fasting glucose or HbA1c, and a lipid profile.
• Cardiometabolic screen: BMI, waist circumference and blood pressure. Look for diabetes, dyslipidemia, hypertension and sleep apnea.

2. Stage fibrosis (the key step)

1. Calculate FIB-4 (age, AST, ALT, platelets).
2. FIB-4 below 1.3 (the cutoff is higher in people over 65): low risk. Manage in primary care and repeat FIB-4 every 1 to 3 years.
3. FIB-4 of 1.3 or above: do a second test, either vibration-controlled transient elastography (FibroScan) or the ELF test. Vibration-controlled elastography can now be done at the point of care (Goldman-Cecil Medicine).
4. Elastography above about 8 to 10 kPa, or other signs of significant fibrosis: refer to hepatology.

3. Lifestyle is the main treatment

• Weight loss is the cornerstone of therapy. A loss of 5% or more improves steatosis, ballooning, inflammation and fibrosis on paired biopsies. The greatest fibrosis regression occurs with more than 10% loss (Yamada's, p. 2230).
• Goldman-Cecil Medicine, Treatment section: "Lifestyle modification with dietary restriction and regular exercise is the first choice." It recommends gradual loss of about 10% of body weight and a low refined-sugar diet. A multidisciplinary approach (behavioral therapy, dietitian, exercise expert) works better than a prescriptive one.
• Practical targets:
  • Lose 5% or more for steatosis, and 7 to 10% for steatohepatitis and fibrosis.
  • Use a calorie deficit of 500 to 1000 kcal/day. Fuster and Hurst's The Heart, 15e (Lifestyle Medicine) describes this as 1 to 2 lb per week.
  • Eat a Mediterranean-style diet: vegetables, fruit, legumes, nuts, olive oil, fish and whole grains. Limit sugar-sweetened drinks, fructose, refined carbohydrates and ultra-processed or red meat.
  • Do at least 150 minutes per week of moderate aerobic exercise, plus resistance training. Exercise reduces liver fat even without weight loss.
  • Limit alcohol, ideally to none.
  • Coffee (2 to 3 cups a day) is associated with lower fibrosis risk. Stop smoking.
• If the BMI is 23 or above (Asian cutoffs) and the patient is lean, the same advice applies. Lean MASLD still responds to modest weight loss and to avoiding visceral fat gain.

4. Treat the comorbidities

• Type 2 diabetes: Prefer agents with liver benefit. GLP-1 receptor agonists (semaglutide, liraglutide) and tirzepatide help. Pioglitazone and SGLT2 inhibitors are also reasonable.
• Dyslipidemia: Use statins as indicated. They are safe in MASLD and reduce cardiovascular risk.
• Hypertension, obesity, sleep apnea: Treat each as usual. Check cardiovascular risk and consider antiplatelet or lipid therapy by standard criteria.

5. Drug therapy for grade 1 steatosis

• Simple steatosis with low-risk fibrosis needs no liver-specific drug. Lifestyle and comorbidity control are enough.
• Liver-directed drugs are for steatohepatitis with fibrosis of stage F2 or higher:
  • Resmetirom has FDA approval (March 2024) for noncirrhotic MASH with F2 to F3 fibrosis.
  • Semaglutide has been added to AASLD guidance for the same group.
  • Vitamin E (800 IU/day) and pioglitazone are options in selected biopsy-proven non-diabetic MASH (Goldman-Cecil Medicine). Vitamin E carries concerns about prostate cancer and hemorrhagic stroke risk.
  • Bariatric surgery is considered for obesity with MASH. Goldman-Cecil Medicine reports histologic resolution in about 80% of patients.
• Do not rely on silymarin, "liver tonics" or other supplements. Evidence is weak.

6. Follow-up

Red flags that warrant earlier referral

• Persistently raised ALT or AST, or ALT above 2 to 3 times normal despite lifestyle change
• Low platelets
• Raised bilirubin or low albumin
• Splenomegaly
• Elevated stiffness

Recent evidence check

• Wang 2024, Obes Rev (PMID 38509775)
• Wang 2024, Drugs (PMID 38478331)
• Zhang 2025 (PMID 40738719)