Obesity and MASH: What You Should Know

Keep reading to learn about the link between obesity and MASH and how to reduce your risk of this disease.

“MASH is a dysfunction of the liver caused by excess fat cells,” says Mir Ali, MD, a general surgeon and the medical director of MemorialCare Surgical Weight Loss Center at Orange Coast Medical Center in Fountain Valley, CA.

Excess fat in the liver is known as steatotic liver disease (SLD) in the medical field. There are several types of SLD. The most common one, metabolic dysfunction-associated steatotic liver disease (MASLD), is related to abnormal metabolism. MASH is an advanced stage of MASLD. “That fatty deposition affects liver function and leads to inflammation of the liver,” says Dr. Ali. And chronic inflammation causes damage that has the potential to progress to fibrosis (scar tissue, which can affect liver function), cirrhosis, liver failure, or other complications, including liver cancer. A liver transplant may be required in advanced liver disease stemming from MASH.

Although alcohol use can lead to chronic liver disease, MASLD and MASH are not related to alcohol consumption. In fact, until recently, they were known as nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH).

• Diabetes or insulin resistance
• High blood pressure
• High cholesterol
• Metabolic syndrome
• Polycystic ovary syndrome
• Underactive pituitary gland
• Underactive thyroid

• Over age 40
• Postmenopausal
• Asian or Latino (Asians are also considered to have overweight or obesity at a lower body mass index than the rest of the population)

As far as physical symptoms, MASH can present as mild pain on the right side of the abdomen (where the liver is located) or general fatigue, says Ali. But more often than not, people don’t experience symptoms at all — or at least none that can easily be directly attributed to liver disease.

“Most patients don’t even realize they have it,” Ali says. “The liver doesn’t make itself known until it’s progressed beyond mild inflammation. If someone’s experiencing symptoms, their MASH tends to be advancing.”

For this reason, the first signs of MASH usually show up on routine blood work that you might get during an annual physical or as part of an ER visit. It’s called a comprehensive metabolic panel, which includes liver enzymes. “If results are abnormal, it usually warrants further investigation,” he explains.

From there, your doctor may order imaging studies, such as an ultrasound, CT scan, or MRI scan, which can uncover some liver changes. For a definitive diagnosis, a biopsy used to be done. Now, newer, noninvasive tests, such as a FibroScan or blood-based biomarker test, are often used instead.

Waiting to screen for MASH until symptoms appear isn’t the best strategy, as symptoms often don’t occur until the disease is severe, says Ali. Make sure you see your doctor for regular checkups, and ask for routine lab work that includes a liver function test, so you can catch liver disease before it advances to more serious complications.

Once liver damage worsens to cirrhosis, each complication needs to be treated individually. The only option for a cure is a liver transplant, says Ali. “It’s important to make a MASH diagnosis early on to address the causes of it and treat it,” he says.

Here are some additional tips to help you achieve lasting weight loss and lower your MASH risk.

• Eat a Mediterranean diet. This eating plan emphasizes fresh produce; lean proteins, such as fish and poultry; and omega-3 fatty acids from foods such as nuts and olive oil. The diet is also considered heart healthy, Ali notes.
• Stay active. Aim for 150 minutes of moderate-intensity aerobic exercise or 75 minutes of vigorous activity, such as cycling or jogging, spread throughout the week. Brisk walking counts, so get outside! You should also try to supplement aerobic activity with two days of resistance training a week.

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• Consider medication. “GLP-1 medications are effective for weight loss, but if cost or supply are an issue, other medications that are a little bit older may be used instead,” says Ali. For example, topiramate, phentermine, or Xenical could be a good fit, he adds. If you have MASH, your doctor may prescribe a drug called resmetirom (Rezdiffra), which is the only FDA-approved treatment for MASH with moderate-to-advanced liver scarring.

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• Talk to your doctor about surgery. “Gastric bypass or a gastric sleeve surgery are often the best long-term solution for maintaining weight loss and resolving the secondary effects of obesity like MASH, diabetes, and high blood pressure,” Ali says. Your doctor may recommend an endobariatric procedure, such as a gastric sleeve or intragastric balloon, which are done with an endoscope and reversible.
• Avoid alcohol. Although this version of liver disease, MASH, is not primarily attributed to alcohol, drinking — especially more than 21 alcoholic drinks per week for men or 14 for women — can increase your risk.

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   It’s especially important to avoid alcohol if you have stage 2 liver fibrosis or more advanced disease.

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• MASH is a severe form of liver disease that can lead to liver damage if unmanaged. It’s often asymptomatic, so understanding your risk and monitoring your health are important.
• Obesity is a leading risk factor for MASH, and having other related health conditions, such as high cholesterol, diabetes, or metabolic syndrome, can further increase your risk.
• If you have obesity, taking steps to lose weight through diet, exercise, medication, or surgery can help lower your risk of MASH. Additionally, staying on top of regular health checkups can help your doctor monitor your liver function and protect your health.