When you carry excess body weight, your body can become resistant to insulin. Insulin is the hormone that helps your cells use sugar for energy. When cells stop responding to insulin properly, sugar and fat build up in your bloodstream instead of being used. The liver tries to store that overflow — and fat accumulates there.

Up to 70% of people with type 2 diabetes also have NAFLD. That’s not a coincidence — both conditions are driven by the same root problem: the body struggling to manage blood sugar and fat.

• Other risk factors include:
• Obesity or being significantly overweight
• High cholesterol or high triglycerides (fats in the blood)
• High blood pressure
• Metabolic syndrome (a combination of the above)
• A diet high in sugar, refined carbs, and processed foods
• Being physically inactive
• Family history

Given the rising rates of obesity and type 2 diabetes, experts estimate more than
30% of people worldwide have this condition.

This is what makes NAFLD so dangerous — you can have it for years and feel
completely fine.

NAFLD is sometimes called a “silent” liver disease. That’s because it often doesn’t
show symptoms, especially early on.

Your liver doesn’t have many pain receptors. Even when fat is building up inside it, it usually doesn’t hurt. There’s no warning signal telling you something is wrong. Most people find out they have it by accident — a routine blood test comes back with elevated liver enzymes, or a doctor spots something on an ultrasound done for a different reason.

If symptoms do appear, they usually include fatigue, weakness, or mild discomfort or pain in the upper right side of the belly. The takeaway: you cannot rely on how you feel to know if your liver is healthy. If you have risk factors — obesity, type 2 diabetes, high cholesterol, or high blood pressure — talk to your doctor about getting checked, even if you feel fine.

Not everyone with NAFLD will get worse. Many people have simple fatty liver their whole life with no serious problems. But for some, the condition can slowly advance through several stages:

Stage 1 — NAFLD (Fatty Liver): Fat builds up in the liver, but there’s no inflammation yet. The liver is still functioning. This stage is often reversible with lifestyle changes.

Stage 2 — NASH (Nonalcoholic Steatohepatitis): The fat begins to cause irritation and inflammation inside the liver. The liver cells start to get damaged. This is where the disease becomes more serious. About 20% of patients with NASH will develop significant liver disease.

Stage 3 — Fibrosis: The ongoing inflammation causes scar tissue to form inside the liver. The liver is trying to heal itself, but the scars make it harder for it to work properly. At this stage, the damage may not be fully reversible, but it can often be slowed or stopped.

Stage 4 — Cirrhosis: Severe, widespread scarring. Large portions of the liver are replaced by scar tissue. The liver can no longer do its job well. Cirrhosis can lead to liver failure, liver cancer, or the need for a liver transplant.

Over time, NASH can lead to complications such as heart disease, kidney
conditions, liver scarring (fibrosis), or even liver failure and the need for a liver transplant.

The good news: most people with NAFLD never reach the later stages — especially if it’s caught and managed early.

Because NAFLD has no obvious symptoms, it’s most often found through testing rather than complaints. Here’s how doctors check for it:

Blood tests: Your doctor may notice that your liver enzymes (ALT and AST) are higher than normal on routine bloodwork. This is often the first clue. A score called the FIB-4 index — calculated using your age, platelet count, and liver enzyme levels — can help estimate whether there’s significant scarring. It’s the most highly validated initial test for assessing fibrosis.

Ultrasound: The primary imaging test for suspected NAFLD is an ultrasound. It’s inexpensive, widely available, has no side effects, and can be repeated as often as needed. It can show whether fat is present in the liver and give doctors a general picture of liver health.

FibroScan (elastography): A specialized, painless imaging test that measures how stiff the liver is. Stiffness indicates scarring. Imaging tests like ultrasound- based elastography are superior to blood tests alone for identifying patients with significant to advanced fibrosis or cirrhosis.

Liver biopsy: A small needle is used to take a tiny sample of liver tissue, which is examined under a microscope. This is the most accurate way to confirm NASH and measure the degree of scarring — but it carries some risk, so it’s only used when other tests aren’t giving a clear enough picture.

Here’s the encouraging part — lifestyle changes can make a real difference, especially if NAFLD is caught before it advances.

Lose weight gradually. Losing weight and becoming more active may slow down or even reverse liver damage from NAFLD. Research shows that losing just 5–10% of your body weight can meaningfully reduce fat in the liver. Losing more — around 10% or more — can reduce inflammation and even improve scarring in some people. Crash dieting is not the answer; slow, steady weight loss is safer and more effective.

• Change your diet. Focus on:
• More vegetables, fruits, whole grains, beans, and lean proteins
• Less sugar — especially sugary drinks like sodas and juices (fructose is particularly hard on the liver)
• Less white bread, white rice, and processed snacks
• Healthy fats like olive oil, avocado, and nuts
• The Mediterranean diet is widely recommended by liver specialists for NAFLD

Get moving. Exercise alone may reduce fat in the liver, even without significant weight loss. Aim for at least 150 minutes of moderate activity per week — things like brisk walking, swimming, or cycling.

Manage your metabolic conditions. Keeping blood sugar, blood pressure, and cholesterol under control directly helps the liver. Work with your doctor on managing type 2 diabetes if you  have it.

Avoid alcohol. Even moderate drinking can make liver inflammation worse when NAFLD is already present.

Avoid unnecessary medications and supplements. Some medications are processed by the liver and can add to its workload. Never take herbal supplements or weight loss pills without your doctor’s knowledge.

Your primary care doctor can diagnose and monitor early NAFLD. But there are times when seeing a gastroenterologist (a doctor who specializes in digestive and liver conditions) is the right move:

• Your bloodwork or imaging suggests moderate to advanced scarring (fibrosis)
• Simple lifestyle changes haven’t improved your liver enzyme levels after several months
• You have type 2 diabetes AND signs of liver disease — this combination raises your risk significantly
• You’ve been told you may have NASH (the more serious, inflamed stage)
• You’re considering weight loss surgery — nearly 1 in 12 patients undergoing bariatric surgery will have significant fibrosis, and up to 1 in 25 will have cirrhosis, so a liver evaluation beforehand is important
• You develop new symptoms like swelling in your belly or legs, yellowing of the skin or eyes, or unusual tiredness that won’t go away

A gastroenterologist can run more advanced tests, evaluate how far along the condition is, and work with you on a treatment plan before serious damage occurs. Catching NAFLD early matters — early detection and treatment may prevent it from progressing, and in some cases, even reverse it.