Fatty Liver Disease: The Damage You Cannot Feel

Last updated 31 July 2026

The screening report comes back and most of it looks acceptable. Blood pressure is fine, and the cholesterol is only borderline. Then there is one line near the bottom, in the ultrasound section: fatty liver, mild. The doctor mentions it in passing. Watch your diet, she says, and cut down on the sweet drinks. Nothing hurts, and nothing feels different from last week. The report goes into a drawer.

That single line is easy to file away and forget, but it deserves rather more attention than it usually gets. Fat in the liver is not simply fat sitting quietly in storage. In a substantial minority of people, it begins a slow process of inflammation and scarring. That process can run for twenty years without producing a single symptom.

It is also common here, and the National Health and Morbidity Survey 2023, run by Malaysia’s Institute for Public Health, measured it across the country for the first time. Almost three in ten adults in Malaysia have fat accumulating in the liver linked to metabolic problems. That works out to roughly 6.7 million of us. It was more common in men, at 32 percent, than in women, at 25 percent. Most of those millions have no idea that anything is happening.

The name changed in 2023, and the new name explains the disease

For years, doctors called this non-alcoholic fatty liver disease, usually shortened to NAFLD. The name carried two problems. It described the condition by what it was not, which told a patient nothing useful. It also leaned on the word “fatty”, which many patients found shaming.

In 2023, an international panel of liver specialists agreed on a replacement. The condition is now called metabolic dysfunction-associated steatotic liver disease, shortened to MASLD.

The word “steatotic” simply means that fat is being stored inside the liver cells. The other half of the name is the important half. To qualify as MASLD, you need fat in the liver plus at least one sign of metabolic trouble. That could be a wide waist, raised blood glucose, hypertension, elevated triglycerides or low HDL cholesterol. The new name describes what the disease is, rather than what it is not. It is a liver condition driven by the way your body handles sugar and fat.

Two other terms arrived alongside it. NASH, the inflamed form of the disease, has been renamed MASH. People who have the same metabolic problems but who also drink a moderate amount of alcohol are now classified separately, under the label MetALD.

You will still meet the older names in clinics and on laboratory reports, and Malaysia’s national survey used MAFLD, another term from the same period. The labels differ a little in their small print, but the liver is indifferent to what we call it.

What fat actually does inside a liver

A healthy liver holds almost no stored fat, because it is a chemical factory rather than a warehouse. It processes glucose, manufactures proteins, produces bile and clears medications from your circulation.

Fat begins to collect when more of it arrives than the liver can burn or export. Doctors call this steatosis, and it is counted once fat appears in more than about five percent of the liver cells. That threshold sounds small, and it is surprisingly easy to cross.

The difficulty is that certain fat molecules are actively toxic to liver cells. The cells come under stress and some of them die. Immune cells arrive to clear up the damage, and inflammation sets in. That inflamed stage is MASH. Every round of repair leaves a little scar tissue behind, much as a healing wound on your skin does. Scar tissue filters nothing and does nothing. It simply occupies the space where working liver used to be.

Four stages, and most people stop at the first

Stage	What is happening	Can it be reversed?
Steatosis	Fat is stored inside the liver cells, without significant inflammation.	Yes, and often completely.
Steatohepatitis (MASH)	Fat plus inflammation, meaning liver cells are being injured.	Yes, in many people.
Fibrosis	Scar tissue is accumulating, and it is graded from mild to advanced.	Partly, if the cause is removed early enough.
Cirrhosis	The liver is heavily scarred and beginning to fail.	No, because damage at this stage is permanent.

Most people with a fatty liver never leave the first stage, and that is good news, worth stating plainly. A meaningful share do progress, however, and there is no way to sense which group you belong to.

Of everything on that table, the fibrosis stage is the one that matters most, because the amount of scarring is the strongest predictor of serious liver trouble later on. Inflammation can settle down, but scarring is considerably harder to undo.

Why you feel nothing at all

The liver contains no pain nerves inside its tissue. Only the thin capsule around it can hurt, and only when something stretches it, so the damage itself is silent by design.

The liver also carries an enormous amount of spare capacity. It can lose a great deal of working tissue and still keep your blood chemistry normal. Your energy and your appetite stay exactly as they were, so nothing raises an alarm.

When symptoms finally do arrive, they arrive late. There may be tiredness that never quite lifts, or a dull ache under the right ribs. By the time anyone develops yellowing of the eyes, a swollen abdomen, confusion or vomiting of blood, the disease has reached the cirrhosis end of the scale.

There is a further point worth knowing. Most people with fatty liver disease do not die of their liver. They die of heart disease instead. The same insulin resistance that fills the liver with fat also damages blood vessels throughout the body. That is why our article on how diabetes increases heart risk belongs in the same conversation as this one.

How it is actually found

A raised ALT on a blood test

ALT is an enzyme that lives inside liver cells, and when those cells are injured it leaks out into the bloodstream. A raised ALT on a routine liver function test is one of the commonest ways that fatty liver disease is discovered accidentally.

It is not a dependable test on its own. Plenty of people with a fatty liver have a perfectly normal ALT, and so do some people with advanced scarring. A normal result does not clear you.

An ultrasound scan

Ultrasound is cheap, quick and painless, and a liver loaded with fat appears brighter on the screen than a healthy one does. This is how most fatty livers in Malaysia are found, usually by accident during a scan arranged for something else entirely.

Its weakness is sensitivity. Ultrasound tends to miss milder degrees of fat, and it cannot tell you whether the liver is inflamed or scarred. It confirms that the fat is present, but it says nothing about what the fat is doing.

The FIB-4 score

This is the useful one, and many people have never heard of it. FIB-4 is not a measure of fat at all, but an estimate of scarring, which is the thing that determines your future.

It is a simple calculation using four numbers you may already have on file. They are your age, your AST, your ALT and your platelet count. No extra blood is needed if you have had a recent full blood count and liver panel.

• A FIB-4 result below 1.3 makes advanced scarring unlikely, and that cut-off applies to adults under the age of 65.
• A result above 2.67 suggests a high probability of advanced fibrosis, and it usually means referral to a liver specialist.
• Anything between those two figures is uncertain, so a further test is normally arranged to settle the question.

That further test is usually transient elastography, a specialised ultrasound probe that measures how stiff the liver has become. A stiff liver is a scarred liver. The scan takes about ten minutes and involves no needles at all.

The company this disease keeps

Fatty liver disease travels with type 2 diabetes and with excess weight, and the relationship runs in both directions. Persistently high insulin levels push the liver into manufacturing and storing fat. A fat-laden liver then handles sugar poorly, which drives insulin higher still.

The same national survey found that 15.6 percent of adults in Malaysia have diabetes and that 54.4 percent have a body mass index of 25 or above. Abdominal obesity, measured by waist size, was present in 54.5 percent of adults. These conditions overlap heavily with fatty liver. That is why the Malaysian Society of Gastroenterology and Hepatology, in its 2022 consensus statement on this disease, sets out a pathway for screening people who already have type 2 diabetes.

If you have diabetes, it is entirely reasonable to ask whether anyone has ever looked at your liver.

You do not need to drink alcohol to get this

This is the most common misunderstanding about the condition. Alcohol is not required, and it never was.

Alcohol causes its own form of fatty liver, but that is a separate disease with a separate name. MASLD is metabolic. It is built out of sugar, refined carbohydrate, surplus calories and insulin resistance. Someone who has never touched alcohol can still finish up with a badly affected liver.

The national survey found this condition in roughly three in ten adults, in a country where only about one adult in ten had drunk any alcohol at all in the previous year. Those two numbers do not leave much room for argument.

What actually works: weight

Weight loss is currently the treatment with the strongest evidence behind it. Not a supplement, not a detox drink, and not a herbal liver tonic.

The amount of weight matters, and knowing the thresholds is useful, because they turn a vague instruction into a target. A landmark study published in the journal Gastroenterology in 2015 followed patients through a year of lifestyle change, with a liver biopsy before and afterwards. The results formed a clear ladder.

• Losing around 5 percent of your body weight reduces the amount of fat stored in the liver.
• Losing around 7 percent can clear the inflammation, which means that MASH resolves.
• Losing 10 percent or more offers the best chance that the scarring itself will improve.

In that study, among the patients who lost 10 percent or more of their body weight, 90 percent had their steatohepatitis resolve and 45 percent had their fibrosis regress. The Malaysian consensus statement advises patients who are overweight or obese to aim for a loss of 5 to 10 percent.

Translate that into real numbers. If you weigh 80kg, then 7 percent is about 5.6kg, which is not a transformation. It is a realistic target over six months to a year, and it is enough to change what is happening inside your liver.

Exercise earns its place here too. It helps even when the number on the scale barely moves, because working muscle pulls fat out of the liver. The Ministry of Health’s Clinical Practice Guidelines on the Management of Obesity, published in 2023 and hosted by the Academy of Medicine Malaysia, ask for at least 150 minutes of moderate activity a week, building towards 300 minutes.

Medicines are beginning to appear. In 2024, a drug called resmetirom became the first medicine approved anywhere for MASH with moderate to advanced scarring. Availability differs between countries, and it is prescribed to a narrow group of patients. Several medicines used for diabetes and obesity also improve the liver. None of them removes the need to change what you eat and how much you move.

What to actually change

These are the changes with the most evidence behind them, translated into everyday Malaysian terms.

• Deal with sweetened drinks first, because they are the fastest win available to you. The liver converts fructose into fat more readily than other sugars, and sweetened drinks deliver it in a rush. Three-in-one coffee sachets, canned drinks, bubble tea, iced malt drinks and teh tarik with condensed milk all belong in this category.
• Ask for kurang manis, and then work your way towards kosong. Reducing the sugar in your drink is good, and removing it altogether is better. Your palate usually adjusts within a fortnight.
• Cut the refined carbohydrate load at your largest meal of the day. You do not need to abandon rice. Take half of your usual portion and fill the gap with vegetables and protein.
• Choose the steamed, grilled or soup version wherever one exists. Deep-fried food carries an enormous number of calories in a way that is very difficult to notice while you are eating it.
• Walk for thirty minutes after dinner, on most days of the week. This is the most repeatable habit available to a working adult in this climate. It also lowers your blood sugar directly after a meal.
• Add some resistance training twice a week, using weights or your own body weight. Muscle is where your body burns glucose, so additional muscle means less insulin resistance.
• Be cautious with supplements and herbal liver tonics. Some of them are hard on the liver. If you are taking one, tell your doctor its full name.
• Get your blood pressure, blood glucose and cholesterol treated properly. They are all part of the same underlying process, and our guides on how much salt, sugar and fat is too much and on foods that help prevent heart disease cover the practical side of that.
• Lose the weight slowly rather than dramatically. Crash dieting and very rapid weight loss can worsen liver inflammation. Half a kilogram a week is a sensible pace.

A note on coffee

Studies have repeatedly linked regular coffee drinking with less liver scarring. The evidence is observational, so it cannot prove cause and effect. Coffee remains a reasonable thing to enjoy, but only without sugar and without condensed milk. A sweetened coffee undoes the point of drinking it.

When to see a doctor

Book an appointment if any of the following describes you.

• An ultrasound or scan report has mentioned a fatty liver at some point, and nothing was done about it afterwards.
• Your ALT or your AST has come back raised on any blood test.
• You have type 2 diabetes and your liver has never been properly investigated.
• You carry your weight around your middle and have never had a liver test.

Ask two questions at that appointment. Ask whether your FIB-4 score can be calculated from the results you already have, because it usually can. Then ask what your target weight should be, expressed in kilograms rather than in percentages.

A fatty liver is not a verdict. Caught at the fat stage, it is one of the most reversible conditions in medicine. The damage you cannot feel is also, for most people, damage that can still be undone. Read more in our nutrition and diet section.