When recruiter Hannah Fewtrell began feeling constantly exhausted at 49, with dark circles under her eyes no matter how much she slept, she assumed menopause was to blame.
Although she was carrying some extra weight, she was otherwise healthy.
She walked miles every day with her dog, spent weekends cooking for her extended family and had no reason to suspect something more serious was going on.
But in October last year, a scan revealed the shocking truth: her symptoms weren’t hormonal after all, but the result of a common yet often overlooked liver disease.
Hannah was diagnosed with metabolic dysfunction-associated steatotic liver disease (MASLD), formerly known as nonalcoholic fatty liver disease (NAFLD) – a condition thought to affect up to one in three Americans, or roughly 80 million people.
Despite its name, the disease isn’t caused by heavy drinking – the liver problem most people associate with alcohol. Instead, MASLD develops when excess fat builds up inside the liver. It is becoming increasingly common in the U.S., fueled by rising rates of obesity and type 2 diabetes.
Experts warn that sedentary lifestyles and diets high in ultra-processed foods, sodium, saturated fat and added sugar are also driving the disease in increasingly younger adults.
Professor Penny Manousou, who leads the Fatty Liver Research Group at Imperial College London, says: ‘It’s a lifestyle issue.’
Last year, Hannah Fewtrell was diagnosedd with a common and often overlooked liver condition – non-alcoholic fatty liver disease
‘A generation of children has grown up inactive, sitting in front of video games and eating ultra-processed foods – and as a result, we’re seeing obesity in younger and younger age groups.
‘Children with obesity are more likely to remain obese as adults, and that’s when liver problems really begin to take hold.’
Where liver disease was once largely associated with older adults and heavy drinkers, it is now rising rapidly among younger people.
Cases in children have doubled over the past two decades. Experts estimate the condition may now affect up to one in three Americans, though Professor Manousou says the true figure could be as high as 40 percent.
Worryingly, about 80 percent of people with the disease remain undiagnosed because it often causes no obvious symptoms – or symptoms that are easily mistaken for less serious health problems.
In many cases, it is only discovered during routine blood work or liver function tests performed for unrelated reasons.
While not everyone with excess fat in their liver will go on to develop serious complications, the buildup can interfere with the organ’s normal function and trigger inflammation.
Over time, healthy liver tissue is replaced by scar tissue – a process that can ultimately lead to cirrhosis and liver failure.
However, if caught early, there is now strong evidence that the damage can be halted – and in some cases even reversed. Studies show that weight loss can transform the disease from a silent killer into a manageable condition.
Professor Philip Newsome, a liver specialist at King’s College London, says: ‘We used to believe that cirrhosis was permanent, but we now know that if you tackle the cause of the injury – whether that’s fat, alcohol or viral infections such as hepatitis B – the scarring can decrease. When the disease is caught before cirrhosis develops, we can absolutely see it reverse.’
Hannah is living proof. A FibroScan – a specialized ultrasound that measures liver stiffness to detect scarring and excess fat – showed she had stage 3 fatty liver disease, just one step away from cirrhosis.
‘I was in shock,’ she says. ‘I’m not that old, and I thought I was taking good care of myself. I wasn’t significantly overweight, my partner and I only drank on weekends, and I was walking 10,000 steps a day.’
At Hannah’s most recent scan in March, she was told the condition of her liver had improved massively
‘But my skin was dry, I had dark circles under my eyes and I looked permanently exhausted, even after a full night’s sleep.
‘I was feeling down and constantly arguing with my partner. The diagnosis completely changed my mindset.’
She was referred to a registered dietitian and lost about 14 pounds. At her most recent scan in March, she was told her liver had improved dramatically.
‘I feel so much better,’ she says. ‘I have so much more energy. I’m sleeping better and I’m much less bloated. I recently went on vacation and felt so much more confident.’
The science is clear about what drives these remarkable improvements. Studies suggest losing at least 5 percent of your body weight can reduce fat and inflammation in the liver.
Experts say there are certain approaches that are particularly effective.
The landmark DiRECT trial, which showed that type 2 diabetes could be put into remission using meal replacement shakes and soups to place participants on an 800-calorie-a-day diet for 12 to 20 weeks, also found a significant reduction in liver fat.
Professor Manousou says that while some patients may find very low-calorie diets helpful as an initial jump-start to lose weight, they are not the best long-term solution.
‘They work, but they’re difficult to sustain over the long term,’ she says. ‘What has consistently been shown to help is the Mediterranean diet. We know that even if you don’t lose weight, it can still reduce liver fat.’
The eating plan emphasizes lean meats and fish, whole grains such as brown rice and whole-wheat pasta, nuts and seeds, beans and lentils, healthy fats such as olive oil, and plenty of fruits and vegetables.
‘Whatever you eat, it should be as minimally processed as possible,’ she adds. ‘Avoid fast food and sugary snacks.’
Although the disease isn’t caused by alcohol, even moderate drinking may make it worse, so experts recommend cutting back or avoiding alcohol altogether.
One major review of the evidence found that the most effective way to reverse fatty liver disease is to combine dietary changes with exercise – particularly aerobic activities such as brisk walking, running, cycling or swimming alongside resistance training, such as lifting weights or doing yoga or Pilates.
Professor Newsome says: ‘While studies show that exercise alone isn’t a particularly effective way to lose weight, people who exercise more tend to have less liver fat.
‘That’s true even if they don’t lose weight. It may be because improving muscle function increases the body’s ability to burn fat for energy, making it less likely to accumulate in the liver.’
Studies suggest the ideal amount of exercise is 150 to 300 minutes a week, spread across three to five days.
Ideally, that should include three aerobic workouts and two strength-training sessions. Professor Manousou says the latter may be even more important.
‘We think it has an even greater effect on liver fat than cardio,’ she says.
‘A study we’re about to publish shows that if you ask a patient to sit in a chair and stand up five times, the time it takes them to do it correlates with how severe their disease is. It’s linked to leg muscle function.
‘Once you can do that more quickly, you’ve likely reduced the severity of your disease.’
You don’t need an expensive gym membership, the experts add. Strength training can be as simple as doing squats, lifting cans of beans or walking up and down the stairs.
‘The goal is to raise your heart rate and become slightly out of breath,’ says Professor Newsome. ‘That doesn’t mean running a 5K three times a week. It could simply mean walking to the end of your street and back, then gradually picking up the pace each week.’
Jules Hutton, 54, adopted a Mediterranean diet and started going to the gym four times a week after she was diagnosed with moderate fatty liver disease in 2021, following an ultrasound performed for an unrelated abdominal problem.
The mother of two, from Warrington, England, swapped her usual breakfast cereal for oatmeal or Greek yogurt with fruit, chose omelets or stir-fries instead of sandwiches for lunch, and adapted her family’s dinners to include more vegetables and lean protein.
Her body mass index (BMI) fell from 26.5, which is in the overweight range, to 21, and follow-up scans show she has remained free of the disease four years later.
‘I feel 100 percent better,’ she says. ‘The thing about this disease is that it often has no symptoms, and I thought I was relatively healthy. But now I have so much more energy.’
Liver specialist Professor Manousou says that a Mediterranean diet is clinically proven to help the condition. ‘We know that, even if you don’t lose weight, it will help reduce your liver fat,’ he says
Hannah adopted a similar approach, replacing carb-heavy meals and traditional Sunday roasts with scrambled eggs, homemade soups, grilled meat skewers with salad, and stir-fries and curries packed with lentils and chickpeas.
She also satisfied her sweet tooth by swapping her favorite Cadbury Dairy Milk chocolate for a square of high-quality dark chocolate.
‘If I’d left it any longer, there’s a chance it could have become really serious,’ she says.
‘It’s scary because I felt fine. I was functioning normally – but with liver disease, you don’t know how much damage is already there.’
Not everyone is able to make or maintain the lifestyle changes needed to improve the disease, but there is encouraging news. Drug treatments currently being tested have shown significant benefits, says Professor Newsome, reducing liver fat, inflammation and scarring.
One of those drugs is semaglutide, the active ingredient in the weight-loss medications Wegovy and the diabetes drug Ozempic. Professor Newsome adds: ‘I’m presenting research in the U.S. in November suggesting that it’s not just the weight loss that’s responsible – something else also appears to be reducing liver fat.
‘When we compared people who lost the same amount of weight through diet and exercise with people taking semaglutide, those taking the drug experienced much greater improvements in liver health. We still don’t fully understand why.’
Another drug in late-stage clinical trials is resmetirom, which targets a receptor in the liver to help prevent fat from building up.
It can also reduce inflammation and fibrosis.
Resmetirom, sold under the brand name Rezdiffra, is already approved in the U.S. However, Professor Manousou says it works in only ‘around 20 percent’ of patients and is expensive, costing about £35,000 (roughly $47,000) per patient each year.
A third drug in earlier-stage trials is efruxifermin, which has shown promise in reducing liver scarring and even reversing cirrhosis in some patients.
‘Drugs may help some people, but they’re not the answer,’ Professor Manousou says.
‘The bottom line is that if you exercise regularly and eat a healthy diet, you’re much less likely to develop excess fat in your liver.
‘If you don’t, the disease is more likely to progress.’
DID EXPENSIVE SUPPLEMENT CURE SAM?
Sma Cook claims to have been able to reverse his liver condition with a combination of a herbal product called De-liver-ance, alongside diet and exercise
A host of supplements are marketed as being able to ‘boost liver health,’ but the evidence behind them is shaky at best.
Milk thistle is among the most popular, often promoted as a way to detox the liver or cure a hangover. Other widely marketed supplements include vitamin E, omega-3 fatty acids and plant compounds such as curcumin, silymarin and berberine.
One herbal supplement, called De-liver-ance, has developed a loyal following thanks to claims – based largely on studies in mice – that it can reduce liver fat.
Sam Cook, a father of three from London, was diagnosed with advanced fatty liver disease at 42. Now 55, he credits the supplement – which costs $24.99 for three doses – along with diet and exercise, with helping him reverse the disease and lose more than 28 pounds.
But liver specialists caution that there is currently no strong clinical evidence that any supplement can treat fatty liver disease.
‘The likelihood that it’s simply a placebo effect is high,’ says Professor Penny Manousou, a liver specialist at Imperial College London.
She warns that some herbal supplements may even damage the liver or interact with prescription medications, adding: ‘Long-term use of vitamin E has also been linked to an increased risk of prostate cancer in some men and a higher risk of bleeding.’
Dr. Thomas Drake, a research fellow at the Usher Institute in Edinburgh, says the best way to improve liver health remains straightforward: adopt a healthier lifestyle.
‘If you stick with it, most people can start to see meaningful improvements within just a few months,’ he says.
If you’re concerned about your liver health, experts recommend talking to your primary care doctor, who can order blood tests to assess liver function and determine whether further evaluation is needed.
