Geraldine Frank was looking forward to celebrating her 62nd birthday when her son noticed some yellowing in her eyes. He wasn’t too concerned but wanted her to see a doctor.
It turned out that Frank’s eyes were showing signs of jaundice. She had cirrhosis, severe scarring of the liver that usually takes years, or even decades, to develop.
Frank had been overweight and saw doctors for other conditions, her son David Frank said, but she never mentioned hearing any concerns about her liver. “How is it possible, with all the medical advances, that nobody knew this was a problem?” he said.
Cirrhosis can occur in the late stages of metabolic dysfunction-associated steatotic liver disease, or MASLD, which happens when fat builds up in the liver and can lead to inflammation and scarring. MASLD, which was known until recently as nonalcoholic fatty liver disease, is estimated to affect nearly 4 in 10 people worldwide. It is the fastest-growing reason that people require liver transplants in the United States.
It’s possible to stop its progression or even reverse the damage, but patients often aren’t diagnosed until it’s too late to do so.
“It’s largely asymptomatic until it’s not,” said Meena B. Bansal, chief of the division of liver diseases at the Icahn School of Medicine at Mount Sinai in New York. “And usually when it’s symptomatic it’s quite advanced.”
What is MASLD?
People with MASLD have excess fat in their liver and one or more metabolic risk factors, which include obesity, high blood sugar, and high blood pressure.
About 1 in 4 patients has a more advanced form called metabolic dysfunction-associated steatohepatitis, or MASH. In this condition, fat buildup has led to inflammation, cell damage, and, in some cases, liver scarring. Up to 1 in 5 people with MASH will progress to cirrhosis, which can lead to liver failure and increase the risk of liver cancer, Bansal said.
Even with cirrhosis, patients may not feel sick for years, said Dr. Mary Rinella, director of metabolic and fatty liver disease at the University of Chicago Medicine. When liver function starts to decline, though, patients can accumulate fluid in the abdomen, develop jaundice, or experience confusion caused by a buildup of toxins in the bloodstream.
Who is at risk?
Patients with Type 2 diabetes or obesity — particularly those with excess fat around the abdomen — are at greatest risk, liver experts said. In these patients, insulin resistance and excess calorie intake, especially from saturated fats and carbohydrates, can lead to fat buildup in the liver that makes it susceptible to injury. Fat itself releases chemicals that cause inflammation and damage liver cells.
Latino people are at heightened risk because they are more likely than the general population to have metabolic issues and to carry a genetic variant that can lead to fat accumulation in the liver, said Dr. Arun Sanyal of the Stravitz-Sanyal Institute for Liver Disease and Metabolic Health at the Virginia Commonwealth University School of Medicine.
The liver tries to heal the damage by producing collagen, which scars the injured tissue.
If the fat and inflammation continue to damage the liver, though, “you’re going to gradually accumulate more and more scar,” Bansal explained. This is called fibrosis, which doctors categorize on a scale of 0 to 4, with stage 4 being cirrhosis. (Cirrhosis can also be caused by excessive alcohol consumption over time.)
Clinicians can identify which patients may be at risk of advanced disease using a FIB-4 score, which is calculated using routine lab tests. But because such screening isn’t widespread, Sanyal said, patients often aren’t diagnosed until they experience complications of cirrhosis. “This person did not wake up with cirrhosis,” Sanyal said. “It takes 20-plus years to develop.”
By the time Geraldine Frank was diagnosed, the condition was no longer treatable. She died five weeks later.
How, can you reverse it?
Early-stage MASLD can be reversed through weight loss and dietary changes. If fat buildup and inflammation stop damaging the liver, the organ can return to normal.
Doctors recommend the Mediterranean diet, along with at least 150 minutes per week of aerobic exercise and resistance training.
Bariatric surgery has been shown to reverse fibrosis, and many doctors are hopeful that weight-loss drugs like Ozempic could also help stop the progression of liver disease. The Food and Drug Administration recently approved a drug, resmethrin, which can treat Stage 2 or 3 fibrosis by stopping inflammation and reducing scarring in the liver.
Lifestyle changes helped Shawanna James-Coles, 54, a school district administrator in Pennsylvania, manage her condition. After being diagnosed with nonalcoholic fatty liver disease and Stage 2-3 fibrosis in 2021, she began working with a doctor and nutritionist to make small changes, like doing chair yoga before work and taking daily walks. She monitored her carbohydrate and sugar intake, swapping out the sweet instant oatmeal she loved to eat for breakfast for an omelet instead.
James-Coles lost 50 pounds, and her fibrosis is now Stage 0-1. “It’s the maintaining that’s going to be critical,” she said.
This article originally appeared in The New York Times.
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