About one in four people in the United States has a condition in which some fat is found in their liver, according to the National Institutes of Health.

Many people assume problems with the liver are caused by too much drinking. In fact, this condition is not related to excessive alcohol consumption, which is why it has been called nonalcoholic fatty liver disease, which goes by the acronym NAFLD.

More recently, a global consensus of experts and patients proposed a more clear and non-stigmatizing term, metabolic dysfunction-associated steatotic liver disease, or MASLD. This name was selected because this condition is often associated with metabolic risk factors such as diabetes. As this name change adoption will take time, there will be a period where both names are used, including the acronym NAFLD/MASLD.

What’s most important for patients is that, while having excess fat in the liver may sound concerning, it is one of the most common causes of liver disease. In addition, not everyone with the condition needs treatment, and the condition is reversible with early diagnosis and treatment.

In this Q&A, Meena B. Bansal, MD, Professor of Medicine (Hepatology) at the Icahn School of Medicine at Mount Sinai, explains more about this disease—including possible treatments and when it could lead to complications. She is also Director of the Mount Sinai’s Center of Excellence for patients with this condition and Director of Translational Research, Division of Liver Diseases.

What is nonalcoholic fatty liver disease (NAFLD/MASLD)?

Many patients are told that they have fatty liver disease, either by their primary care doctor or by a radiologist who is doing an ultrasound. But not everyone with a little fat in their liver has NAFLD. People with NAFLD have fat in at least five percent of their hepatocytes, which are a type of liver cell. In some people, that fat stimulates inflammation and scarring of the liver.

Why is scarring important?

If the liver is injured, it responds by laying down scar, just as if you cut your hand you would develop a scar. If the injury is repetitive and continual, the liver continues to lay down scar. Scarring (also called fibrosis) accumulates over time and can cause cirrhosis. Fibrosis is the most important determinant of clinical outcomes in fatty liver disease. Some people develop a more advanced form of NAFLD, which is called nonalcoholic steatohepatitis (NASH), or in the new nomenclature (metabolic-dysfunction associated steatohepatitis (MASH).

How common is this condition? Who is most at risk?

The prevalence of NAFLD in the general population is about 25 percent. Fatty liver disease is very complex; there are a number of determinants, including genes, environment, diabetes, and obesity. If you have diabetes, are obese, have metabolic syndrome, or have HIV, you are at increased risk of developing NAFLD. You are also at increased risk if you have metabolic syndrome, which includes a number of conditions such as prediabetes, central adiposity (having a little excess weight around the waist), high triglycerides, low HDL (good cholesterol), or high blood pressure.

How can I get screened for this condition?

Your primary care doctor or any doctor can calculate a fib-4 score, which is based on four variables: age, platelet count, aspartate aminotransferase (AST), and alanine aminotransferase (ALT). AST and ALT are liver enzymes. Your doctor probably already has these four pieces of information, so you shouldn’t need any additional blood test to get your fib-4 score. The FIB-4 score is very good—but not perfect—at ruling out significant liver disease. If your score is low, you can feel relatively confident that you don’t have cirrhosis or advanced liver disease. If the score is very high, you should see a liver expert (hepatologist) for further evaluation. And if you’re somewhere in between, you need some additional assessment.

What additional assessment would be needed?

If you have an intermediate Fib-4 score, you can get a Vibration Controlled Transient Elastography (VCTE) or Fibroscan. This test measures the stiffness of your liver. Many hepatologists have this scanner in their offices; Mount Sinai has a number of the scanners at various satellite locations. The machine sends a pressure wave through your liver and measures how fast the wave propagates. If your liver is soft, the wave goes slowly. If your liver is stiff because of scarring and inflammation, it moves faster.

What is cirrhosis?

Cirrhosis is when you have so much scarring it forms round nodules in your liver. It’s a natural wound healing response that has just been pushed to the limit.

Is NAFLD/MASLD treatable?  

The good news is fatty liver is completely reversible. We can reverse it with weight loss, exercise, and lifestyle modifications. In addition, the scarring that NAFLD/MASLD causes is also reversible. The most important thing to know is how much fibrosis you have. Then you and your doctor can work on interventions and track your liver’s response to them. Even early cirrhosis is reversible. However, once you have had cirrhosis for a prolonged period, you may reach the point where it is not reversible. Our goal is to help you before you get to that point.

How can Mount Sinai help?

When someone is referred to us for fatty liver disease (NAFLD/MASLD), we first confirm the diagnosis. It’s very important to make sure there are no other ongoing liver diseases that would require a different treatment course. Next, we assess how much scarring your liver has. Once we’ve established that, we develop a treatment plan.

What does a treatment plan look like?

The best treatment for fatty liver disease is exercise and weight loss. Studies show that losing 10 percent of your body weight causes fibrosis regression or a decrease in scarring. We recommend a Mediterranean diet. This approach emphasizes eating plant-based foods and healthy fats. In addition, we recommend black coffee, which is protective for the liver—you can have a couple of cups a day. If you have significant scarring in the liver, we may want to see if you might be eligible for one of our many clinical trials. We usually have at least ten active clinical trials for patients with various levels of fatty liver disease or fibrosis. We will also monitor how your liver is doing over time. Is the scar accumulating at a rapid rate or is it mostly stabilized? Each patient is different and it is important to know your trajectory.

Halloween is an exciting time for kids to dress up in a costume, trick-or-treat, and of course, enjoy some treats.

Janna Banks, MS

Sweets are a part of life, especially Halloween, and may be incorporated into a healthy lifestyle. Instead of trying to restrict, it can be beneficial to approach the holiday as an opportunity to guide your child to make healthy choices that they can incorporate as they grow into adults.

Janna Banks, MS, Pediatric Dietitian and Diabetes Educator in the Mount Sinai Pediatric Healthy Lifestyle Clinic, shares eight suggestions on how you can healthily navigate all that candy at Halloween.

• Make sure to enjoy a balanced and satisfying dinner before trick-or-treating so your child has plenty of energy for the fun ahead, and candy can be just one part of their night.
• Buy candy just before Halloween so it is not sitting around the house and you and your kids are not tempted to eat it before you hand it out. If you do buy candy in advance, then keep it out of sight.
• In addition to handing out candy, you can hand out fun items like stickers, toys, or bracelets and kids’ temporary tattoos. This can help to take the focus off of the candy—it’s also a great alternative for trick-or-treaters with have food allergies.
• Take a smaller bag trick-or-treating, and go home when it’s full.
• After trick-or-treating, prioritize and pick out your child’s favorite candy and donate or give the rest away.
• Be mindful how you talk about foods, avoid labels, and use the actual words. For example, use the word “candy” or “cookie” rather than “sweet treat” or “unhealthy food” so your child can enjoy the holiday and not attach negative connotations.
• Don’t deny your kids candy. The more you say no, the more they will want it or hide their candy.
• Empower your children and help them make healthy choices. Offer them a piece of candy at snack time or after a meal, and offer another choice too. The more they are involved, the more they will start to make decisions for themselves and make wise choices.

For parents with children who have a food allergy, sending kids off to school can be worrisome.

In fact, about two children in every classroom have a food allergy. The most common food allergies are peanut, tree nuts (like walnut, cashew), shellfish (like shrimp), egg, milk, wheat, soy, fish (like salmon and cod) and sesame seeds.

Treatments are emerging and researchers at the Jaffe Food Allergy Institute at Mount Sinai are working hard to find better therapies and cures.

For now, the primary approach to managing food allergy is to avoid eating certain foods and to recognize allergic reactions and treat them promptly. Serious allergic reactions are treated with epinephrine, a safe medication delivered through an autoinjector. The epinephrine helps to relieve symptoms that can be life-threatening, such as trouble breathing and problems with blood circulation.

Scott Sicherer, MD

If you are sending your child to school with food allergies, here is a checklist of tips from Scott Sicherer, MD, Director of the Jaffe Food Allergy Institute and author of The Complete Guide to Food Allergies in Children and Adults (Johns Hopkins University Press).

 Make sure you work with your allergist to confirm the diagnosis of food allergy. Often, children are avoiding foods to which they are not truly allergic. Sometimes they may be allergic to a food not yet identified. Your allergist will consider the past reactions, and allergy test results to make sure your child’s food allergies are properly identified.

 If there is a potential severe food allergy (anaphylaxis), learn how to recognize and treat it. Talk to your allergist or pediatrician about symptoms of an allergic reaction. These can include:

• hives (itchy rashes that look like mosquito bites) on the skin
• swelling of the lips/face
• gut symptoms such as vomiting, nausea, or pain
• asthma type symptoms like cough, wheeze, trouble breathing, voice changes, and throat or chest tightness
• signs of poor circulation such as paleness, dizziness, or passing out

It is important to treat a progressive allergic reaction early with epinephrine and to seek medical attention for severe reactions, such as calling 911. Several epinephrine products are on the market and are activated in different ways—check out online videos and practice with trainer devices.

Share a written food allergy and anaphylaxis emergency plan with the school. A written plan is important to confirm with your school that there are allergies, and what to do in the event of a reaction.  An example plan from the American Academy of Pediatrics is here.

In an age-appropriate fashion, make sure your child knows how to avoid allergens and when to inform an adult for any reactions. Depending upon their age and abilities, children may either have simple responsibilities (such as knowing who is trusted to provide them food and snacks and to let an adult know if they are not feeling well), or they may be able to read ingredient labels, identify allergic reactions, carry medications and even self-treat. However, in school, adults should be ultimately responsible to assure avoidance strategies are in place and to have a plan to identify and treat any allergic reactions.

Check that your child’s medications are up-to-date. Epinephrine autoinjectors may need to be renewed. Keep track of expiration dates.

Discuss how the school will keep your child safe. Most schools have had experience with children having food allergies. Discuss their approaches. Craft projects using food can avoid the allergen with substitutions. Celebrations could favor non-food approaches, such as playing a game or watching a video. Younger children may have supervision during meals. Discuss how food service will provide safe meals, including careful ingredient control with attention to avoiding allergen cross contact and identifying hidden allergenic ingredients. Supervising adults should be familiar with recognizing and treating allergic reactions.

Think about bullying. Children with food allergies report a high rate of bullying associated with their allergies. Ask your child about this. Let the school know if there are any issues.

On the bus. For those taking the bus, some good approaches include:

• ensuring the driver knows about the allergy and has a cell phone in case of any emergency
• not eating on the bus
• never putting a child on the bus if they are experiencing a possible allergic reaction
• having younger children with food allergy sit closer to the driver