The liver disease most people don’t know they have

When most people think about liver disease, they think about alcohol or hepatitis. What many don’t realize is that the most common cause of chronic liver disease in the United States today has nothing to do with alcohol at all.

The largest driver of chronic liver disease is something called Metabolic Dysfunction–Associated Steatotic Liver Disease (MASLD) — what many people still know as “fatty liver disease.” And it is everywhere.

Current estimates suggest that nearly one in every three American adults has fatty liver disease. Among people with type 2 diabetes, the share climbs to 50–70%. About one-fifth of those with fatty liver will develop inflammation and progressive scarring over time, and some will go on to develop cirrhosis.
MASLD is now the leading cause of chronic liver disease in the United States, one of the fastest growing causes of cirrhosis, and the leading indication for liver transplantation in women.

For decades, hepatitis C and alcohol were the primary drivers of cirrhosis. But with curative treatments for hepatitis C now widely available, hepatitis C–related cirrhosis has declined significantly. Alcohol-related liver disease remains serious and prevalent, but metabolic liver disease has surged alongside rising rates of obesity and diabetes.

One of the most dangerous aspects of MASLD is that it is usually silent. Fat can accumulate for years without causing pain or presenting red flags. Even inflammation and early scarring often cause no noticeable symptoms. Many patients feel completely well.

It is not uncommon for someone to discover they have cirrhosis only after developing a serious complication, such as an upper gastrointestinal bleed, fluid accumulation in the abdomen (ascites), leg swelling, confusion from toxin buildup known as hepatic encephalopathy, or jaundice.

By the time those events occur, the disease has often been present and progressing for decades.

Beyond its classification as a liver disease, MASLD is also a metabolic disease affecting multiple organs. At the center of this issue is metabolic syndrome, which is characterized by conditions like abdominal obesity, high blood pressure, elevated blood sugar or diabetes, high triglycerides, and low HDL cholesterol. More than one in three U.S. adults meets criteria for metabolic syndrome, and many do not know it.

Patients with MASLD are actually more likely to die from cardiovascular disease than from liver failure. The same metabolic dysfunction that injures the liver also fuels heart disease, stroke, and kidney disease. The liver is, in many ways, a barometer of overall metabolic health.

Because it is silent and because routine screening is not universally performed, MASLD remains significantly underdiagnosed. Millions of Americans likely have advanced fibrosis and do not know it.

The good news is that we do not need invasive testing to begin evaluating risk. Simple blood work, platelet counts, and validated scoring systems such as FIB-4 can help identify patients who need closer monitoring. Ultrasound can detect fat accumulation, and elastography can estimate liver stiffness and help stratify fibrosis risk without biopsy. All of these tests are available locally in eastern Idaho and Idaho Falls.

Weight reduction of 7–10% of body weight has been shown to significantly reduce liver fat and inflammation. Improved blood sugar control, better lipid management, and regular physical activity all improve liver health.

Cirrhosis can creep up on people for years without them even knowing it. If you have diabetes, high blood pressure, elevated triglycerides, or central weight gain, talk to your provider about an evaluation of not only your heart, but your liver as well.