Holistic care for fatty liver (MASLD): risk, treatment and teamwork

Summary: Fatty liver disease (MASLD) affects more than 30% of adults worldwide. Most people with it who do not have cirrhosis die not from the liver but from cardiovascular disease and cancers outside the liver. A review from Charité Berlin therefore recommends a stepwise approach: find at-risk patients early, estimate the risk of liver scarring, and tailor lifestyle, medication and care to the person.

State of the evidence: The review was submitted on 15 December 2025 and accepted on 27 January 2026. The trial results it shows date from 2023 to 2025. It does not describe a systematic literature search. This article was written on 17 October 2026; newer studies are not included.

What is it about?

MASLD (metabolic dysfunction-associated steatotic liver disease, formerly NAFLD) means fat in the liver together with at least one metabolic risk factor such as overweight, type 2 diabetes, high blood pressure or abnormal blood fats. It can progress to liver inflammation (MASH), scarring (fibrosis), cirrhosis and liver cancer. The review asks how to care for people so that liver, heart, kidneys and metabolism stay in view together.

How was it studied?

This is a narrative review by Chen, Horn and Tacke (Charité, Berlin), not a new study of patients. It summarises guidelines and studies and proposes a care model.

What does the review show?

• Not every fatty liver is the same: Before menopause, 9 to 18% of women have MASLD, compared with 20.2 to 41% of men; afterwards the share in women rises above 30%. Some courses are liver-predominant (higher risk of cirrhosis and liver cancer), others systemic (higher risk of cardiovascular disease).
• Normal-weight people are affected too: About 13% of the world population has MASLD at normal weight. In an analysis of more than 180,000 people, they had higher risks of liver events, cardiovascular death and death from any cause than people with overweight and MASLD.
• Stepwise case-finding: People with type 2 diabetes, obesity with other risk factors or persistently raised liver enzymes should first get the FIB-4 index (from age, liver enzymes and platelets). Below 1.3 the risk of advanced fibrosis is low; between 1.3 and 2.67 an elastography scan (liver stiffness) or blood test follows; above 2.67, or stiffness of 8 kPa or more, leads to referral to hepatology.
• Measure alcohol properly: In “MetALD”, people drink 20 to 50 g (women) or 30 to 60 g (men) of alcohol per day. Besides questionnaires, the PEth blood test helps: below 20 ng/mL rules out relevant use, from 200 ng/mL it counts as harmful.
• Think of heart, kidneys and cancer: Everyone should have their 10-year heart risk, blood sugar and kidney function checked. With cirrhosis, an ultrasound every six months is recommended to detect liver cancer early.
• Lifestyle remains the foundation: Losing at least 10% of body weight can reverse MASH and fibrosis; even 5 to 7% reduces liver fat. A Mediterranean diet and at least 150 minutes of moderate activity per week are advised.
• New medicines: Resmetirom and semaglutide are approved in the US for MASH with moderate to advanced fibrosis. With resmetirom, MASH resolved in 25.9 to 29.9% (placebo 9.7%), with semaglutide in 62.9% (placebo 34.3%). Weight-loss surgery can make sense at a BMI of 40 or more (or 35 with metabolic complications); MASH resolved in up to 80% after surgery.
• Who looks after whom: With low fibrosis risk, the family doctor's practice is enough, with regular checks. With moderate to high risk, the practice and hepatology share care; with cirrhosis or liver cancer, a specialised team takes over.

Where are the limits?

• The review is not systematic; the authors chose the studies.
• Evidence for multiprofessional care is still weak, as the authors state.
• The split into liver-predominant and systemic courses rests on few studies and is not yet tested in practice. The same applies to AI-assisted tools.
• Drug trials are mostly short; several substances are still in earlier phases.
• Criteria for cancer surveillance without cirrhosis are unsettled.
• Many health systems lack structure and funding for team-based care.

What does this mean for me?

The review does not replace a personal assessment. It does show that people with diabetes, severe overweight or persistently raised liver enzymes can ask their family doctor for a simple fibrosis test (FIB-4). If the risk is raised, closer tests follow, and possibly medicines or surgery. Weight, diet, activity and an open talk about alcohol matter most. Discuss next steps with your doctor.

This article does not replace medical advice.

Source and notes

• Citation: Chen L, Horn P, Tacke F. Providing holistic care for patients with metabolic dysfunction-associated steatotic liver disease/metabolic dysfunction-associated steatohepatitis: Key aspects of clinical assessment and how to develop individualised care plans for surveillance and interventions. Diabetes Obes Metab 2026;28(Suppl 2):46–62. DOI: 10.1111/dom.70545. Open access (CC BY).
• Study type: Narrative review (special issue article).
• Funding: The review was commissioned for a themed issue made possible by an independent medical grant from Boehringer Ingelheim International GmbH; the authors did not know the sponsor before publication. Individual authors are supported by the China Scholarship Council, the German Research Foundation, the Excellence Strategy and the Berlin Institute of Health.
• Conflicts of interest: Frank Tacke and Paul Horn report research grants and fees from pharmaceutical companies, including Gilead, AstraZeneca, MSD, Novo Nordisk and Boehringer Ingelheim. Lanlan Chen reports no conflicts of interest.