There are several stages of NAFLD. Having one stage does not mean you will definitely develop the next one. Treating NAFLD with a healthy diet, physical activity and weight loss can slow or even reverse your NAFLD especially if it is at an earlier stage.
The amount of scarring (fibrosis) in your liver is the main sign of how advanced your NAFLD is. Go to the section about fibrosis tests and scores.
- Fatty liver (fibrosis stage 0): There is a build-up of fat in your liver but it has not been damaged and there is no scarring. At this point, NAFLD can be fully reversed.
- NASH with mild fibrosis (Non-alcohol related steatohepatitis) (fibrosis stage 0 or 1): Fat (steato means related to fat) is causing inflammation and damage in your liver (hepatitis). There is no or very little scarring. Healthy living can undo the damage and reverse your NAFLD.
- NASH with moderate fibrosis (fibrosis stage 2): Inflammation and damage have caused some scarring. Your liver is probably still working well and the damage can mostly be repaired.
- NASH with advanced fibrosis (fibrosis stage 3): There is a lot of scarring. At this stage it is very important to stop further damage and scarring so your NAFLD doesn’t get worse. And it is still possible to repair some damage.
- Cirrhosis (fibrosis stage 4): There is so much scarring it changes the shape of your liver. Your liver can keep working and even repair some damage at this point. But if too much of it becomes scarred, your liver may not be able to carry out its job properly.
Cirrhosis can lead to life-threatening conditions including liver cancer and liver failure.
What causes NAFLD?
NAFLD is estimated to affect up to 1 in 5 people in the UK. Rates are increasing with rising levels of obesity. Although most cases of NAFLD are linked to excess weight, you can develop the disease if you have a healthy weight.
These things increase the risk of NAFLD:
- A weight in the overweight or obese range
- A high waist measurement
- Type 2 diabetes
- A diet with too many unhealthy foods and drinks
- Low levels of physical activity or spending a lot of
- time sitting down
- High blood lipids such as cholesterol
- High blood pressure
- Other conditions linked to insulin resistance for example polycystic ovary syndrome
Other diseases can make your liver fatty – either directly or as a side effect of some medicines. Your doctor will check if these things could play a role.
Medicines linked to fatty liver include nonsteroidal anti-inflammatory drugs, amiodarone, corticosteroids, diltiazem, methotrexate and tamoxifen. Do not stop taking any medicine your doctor has prescribed. Speak to your doctor if you have any questions or concerns.
NAFLD is one of a cluster of conditions that are linked to how the body produces, uses and stores energy from food (metabolism). This includes heart and circulatory diseases, type 2 diabetes, and other conditions linked to insulin resistance.
These conditions often develop together and the same person can have several of them. If you are diagnosed with NAFLD or any other metabolic condition talk to your GP. They can monitor your risk of developing a related condition and help you to reduce it.
What are the symptoms of NAFLD?
NAFLD often has no specific symptoms, even if the disease is at a later stage. You may not show any symptoms for many years. If you have NAFLD you may have:
- Tiredness, fatigue or a general feeling of lethargy or having no energy
- Discomfort on the upper right side of your tummy (where your liver is)
If you develop any of the following symptoms tell a doctor straight away:
- yellowness of the eyes and skin (jaundice) – this may be harder to notice if you have black or brown skin
- bruising easily
- dark urine
- swelling of the tummy area (ascites)
- vomiting blood
- dark black tarry poo
- periods of confusion, forgetting things, mood changes or poor judgement (encephalopathy)
- itching skin
Even if you have no symptoms if you are at risk and are worried ask your doctor for a test.
NAFLD might only be diagnosed when it has become serious. Or you might only find out you have it during tests for another health problem.
If your doctor thinks you have any form of liver disease they will try to find out what is causing it and how damaged your liver is. Doctors use a range of tests to get different information and build up an overall picture of what is happening. This often includes:
- Blood tests, especially for alanine aminotransferase (ALT) and aspartate aminotransferase (AST)
- Ultrasound or transient elastography such as FibroScan™
As part of diagnosing NAFLD, your doctor needs to rule out other causes of liver disease. They will ask you about:
- the amount of alcohol you drink
- any other medical conditions
- any medicines you take including ones your doctor has prescribed and over-the-counter medicines you buy for things like pain relief, coughs and colds, or stomach upsets
- homeopathic or alternative supplements or remedies
- recreational drugs
- your diet and the foods you usually eat
- how physically active you are
It is important to give your doctor as much information as you can. This will help them to diagnose your condition correctly and give you the right care.
It is very important that the amount of scarring in your liver is tested as part of your NAFLD diagnosis. This is the main sign of how advanced your liver disease is.
Fibrosis is the medical term for scarring. It is measured on a scale of 0 to 4. The higher the number, the more fibrosis there is and the more severe it is.
There are 2 main ways to check if you’re likely to have advanced fibrosis (stage 3 or 4) without doing a biopsy – blood tests or a liver scan (transient elastography eg FibroScan™).
Many doctors use a scoring system that pools results from several routine blood tests. Common fibrosis scoring systems include:
- The Fibrosis (FIB)-4 score which uses 3 blood tests and your age
- The NAFLD Fibrosis Score which uses 4 blood tests and information about your age, weight (BMI) and whether you have diabetes
- The Enhanced Liver Fibrosis (ELF) test which uses a combination of 3 blood tests.
The score doesn’t say exactly how much scarring there is in your liver. Your doctor or nurse will interpret the result to decide what to do.
There are 3 possible results:
A low risk means advanced fibrosis can be safely ruled out.
This means you don’t have later stage NAFLD including cirrhosis. Your GP will continue to manage your care. They should do a fibrosis test every 3 years to check your condition hasn’t got worse.
Indeterminate risk means it doesn’t say for sure whether you have advanced fibrosis or not.
You should be offered further tests to find out. These could include scans or a liver biopsy.
A high risk means that you probably have advanced fibrosis.
It’s likely you have later stage NAFLD and you may have cirrhosis. You will be referred to a specialist liver doctor (hepatologist or gastroenterologist) who will do further tests and manage your care from then on.
Treatment for NAFLD has 2 main aims:
- To stop the condition getting worse, so that it does not lead to liver cancer or liver failure.
- To help your liver repair as much of the damage as possible and reverse your NAFLD.
The main treatment for NAFLD is eating a healthy diet, being more physically active and (if needed) losing weight. This might seem like very general advice, but these steps all reduce liver fat and inflammation. For example, for people who are overweight, evidence shows losing 5 to 10% of their bodyweight can stop and sometimes even reverse liver damage.
There are currently no medicines to specifically treat NAFLD. But there is a lot of research being done to develop some. You can help by taking part in research. Ask your clinical team about clinical trials in your area or visit the Be Part of Research website.
How your care is managed depends on how serious your NAFLD is and how much scarring (fibrosis) there is in your liver.
Who will manage my care?
GPs manage care for earlier stage NAFLD (primary care)
This can include fatty liver and NASH with mild or moderate fibrosis.
Your liver has little or no long-term damage or scarring and is probably still working well. By eating healthily, doing plenty of physical activity and keeping your weight in a healthy range you have a good chance of repairing any damage and reversing your NAFLD.
Your doctor or nurse will have a conversation with you about your weight, the foods you eat, and how physically active you are. They’ll give you information and help you decide and plan the changes you want to make.
The aim is to build healthy habits that will fit in with your life and help you stay well in the future.
You should have a check-up for NAFLD at least once a year. This should include checks on your risk of developing a condition related to NAFLD.
Your GP can check your:
- weight and body mass index (BMI)
- blood glucose
- blood pressure
- blood lipids (cholesterol and triglycerides).
Every 3 years you should have testing for advanced fibrosis. This is to check that your condition is stable and not getting worse. This is important because there are often no symptoms to tell you or your clinical team that your liver is getting more damaged.
Hospital specialists manage care for later stage NAFLD (secondary care)
This can include NASH with moderate or advanced fibrosis, and cirrhosis.
The level of scarring in your liver means you are at higher risk of liver failure or liver cancer. To reduce this risk it is very important to keep your weight in the healthy range, eat healthily and be physically active. As well as stopping your condition getting worse, it can still be possible to reverse some liver damage.
The main person in charge of your care will be a doctor who specialises in either the digestive system (gastroenterologist) or the liver (hepatologist). They may write you a care plan, which sets out what appointments you have and who else is in your Multidisciplinary Team (MDT).
Your MDT are there to give you any help you need to improve your NAFLD. They can also help you to manage some other medical conditions alongside your NAFLD. Your MDT could include:
- a specialist liver nurse
- a dietitian
- a psychologist
- a physical activity specialist.
People with cirrhosis should be offered scans to check for liver cancer every 6 months. This is called surveillance.
If you have or develop cirrhosis your clinical team will advise on what other treatment you need. Read more about cirrhosis.
Whatever your weight, eating healthily and being more physically active can each help reduce liver fat and improve NAFLD. And for most people these are the best ways to lose weight, if you need to.
Reducing liver fat takes away the root cause of NAFLD. By doing this, you reduce the strain on your liver and give it a chance to repair itself. Research shows all 3 of these things can slow, stop and even reverse NAFLD.
Make small changes that you can stick with in the long term. Your clinical team are there to help you. And we have information and advice to support you every step of the way.
Keep a healthy weight
If you are overweight, the most important thing you can do to improve your NAFLD is to lose weight. Research shows that losing 5 to 10% of your body weight can control and in some cases reverse NAFLD.
If you are a healthy weight, it’s important to avoid gaining weight. This can make your NAFLD worse. Read more about keeping a healthy weight.
Eat a well-balanced diet
There is no magic diet or specific list of foods and drinks that will cure you or to avoid completely. Instead for most people a well-balanced diet is the best way to stay healthy and manage your weight.
The aim is to generally eat and drink healthily most of the time and not have too much or too little of anything. The overall picture is more important than any one small detail. If you are struggling to change your diet, ask to be referred to a dietitian. Find out more about how to eat a well-balanced diet.
Be more physically active
Aim to do at least 2½ hours of physical activity every week that gets you a bit out of breath. Brisk walking, team sports, swimming and dancing all count. You can break it down into smaller bouts of 10 minutes at a time.
Also do activities to strengthen your muscles twice a week. This could be things like yoga, chair exercises, working with weights or even carrying heavy shopping.
Don’t worry if you can’t do the target amount at first. Start small and build up the amount you do over time – remember that any activity is better than none.
Your doctor can advise you on types of activity that would suit you. Find out more about physical activity and exercise.
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