Fatty liver disease, now called steatotic liver disease (SLD), is a condition caused by a buildup of fat in the liver. There are two main types of SLD: metabolic dysfunction-associated steatotic liver disease (MASLD) and alcohol-associated liver disease (ALD). You may have heard these conditions referred to as nonalcoholic fatty liver disease (NAFLD) and alcoholic fatty liver disease (AFLD) in the past, but those terms are no longer used in the medical community.
An estimated 24% of U.S. adults have MASLD, a figure due at least in part to rising rates of obesity and type 2 diabetes – two major risk factors for SLD. While SLD is common, there are some big differences in how it affects people based on race, gender, and socioeconomic status (how much money they make, their education and jobs, where they live, etc.). There may also be differences in how they are diagnosed and treated based on those things. Such disparities are concerning, as timely treatment of SLD is crucial to avoiding complications, such as cirrhosis of the liver, which can lead to liver failure, liver cancer, and other serious conditions.
Factors Influencing Fatty Liver
SLD has many potential causes, though carrying excess weight – particularly around your middle – is a major risk factor. Others include excess alcohol use, type 2 diabetes, and other medical conditions, such as thyroid disease and obstructive sleep apnea.
These factors also raise your risk:
Genetics
The genes you inherit from your parents can have major impacts on your health. Having certain genes can make it more likely you will get SLD. These include genes related to the breakdown of fats (lipids) in the body, inflammation, and fibrosis, which is a buildup of scar tissue in an organ that can lead to organ failure or other problems. In particular, having an abnormal PNPLA3 gene may lead to greater production of fat in the liver and problems with the liver’s ability to break down fat.
Lack of health information
Research shows that more than 90% of U.S. adults with MASLD were unaware they had the condition. This suggests that poor awareness of SLD is a major public health problem. A lack of awareness about the disease was especially significant among non-Hispanic Black people and young adults.
Greater awareness of the disease and its risk factors could help many get checked for SLD before the condition reaches its advanced stages. The later SLD is diagnosed, the harder it is to treat and the greater the chances are you’ll have complications.
Medical bias and discrimination
You may hope that health care providers treat all their patients the same when it comes to preventive care, recommendations for screenings, and treatment. But studies show that some doctors and other health care providers are biased or prejudiced against certain people. This type of discrimination may impact how accurately people are diagnosed and how effectively they are treated. According to research, this type of discrimination has decreased over the years but has not disappeared.
Little access to resources
Many people with SLD may simply lack easy access to doctors and other other medical resources that would help them get diagnosed and treated. Research suggests that a lack of health insurance and having a lower income are common socioeconomic barriers to proper care for many people with chronic liver problems. Black patients and people assigned female at birth were among the groups of people particularly burdened by the cost of liver treatment.
Managing SLD through exercise and weight loss can be just as difficult for some people. Research suggests that some people may not believe they have enough time to exercise or have enough information or education about the best ways to exercise. Others may have physical problems that keep them from exercising. But most people in the study did say they knew physical activity was important for their health.
Cultural factors
Things like diet, lifestyle, and traditions can affect many health conditions. A study on SLD in Latinos highlights several things that might explain why this group has higher rates of the condition. They include limited access to quality health care and higher rates of medical problems like diabetes and metabolic syndrome – a combination of several conditions, such as high blood pressure and high cholesterol.
A separate study of Mexican Americans also noted that they tend to eat more carbohydrates and saturated fats than Anglo Americans. This may have an effect on the higher rates of MASLD among Hispanic people. But other research suggests that Mexican Americans who follow a more traditional Mexican diet have lower rates of MASLD, while U.S.-born Mexican Americans who eat a less traditional Mexican diet may have more of a risk.
Other factors
While obesity is a well-established risk factor for SLD, other conditions can also raise the risk of having liver problems. Alcohol use disorder is a major risk factor for alcohol-associated liver disease. According to the 2023 National Survey on Drug Use and Health (NSDUH), almost 30 million people in the U.S. above the age of 11 had alcohol use disorder (AUD) in the past year. Addressing this public health issue could help lower rates of this form of SLD.
Disparities in Treating SLD
Just as there are some groups of people who are diagnosed more often with SLD, there are also great differences in how different groups are treated. A report by the National Committee for Quality Assurance notes that underserved communities (groups that have limited access to resources like quality health care and other services), especially non-English-speaking people, already face obstacles to getting good care from liver specialists (hepatologists). The report goes on to explain that SLD – and MASLD especially – is probably going to become more common in the years ahead. That means vulnerable populations may face even greater challenges to getting effective treatment for their liver health.
Low socioeconomic status is linked to many long-term health problems. It can interfere with being able to engage in healthy activities and afford medical care, as well as having easy access to quality health care. As for SLD specifically, low socioeconomic status is linked to higher rates of worsening liver disease and greater odds of liver cancer.
People with lower socioeconomic circumstances or who are in certain ethnic groups are also less likely to be considered for liver transplants, compared with people not from underrepresented groups or who have a higher socioeconomic status.
People assigned female at birth (AFAB) also are less likely than people assigned male at birth (AMAB) to get a liver transplant – the final option for people whose SLD has led to liver failure. Research suggests that people AFAB are 30% less likely than people AMAB to get a liver transplant.
The Role of Health Care Providers
Health care providers can play a significant role in reducing the differences in how certain groups of people with SLD are diagnosed and treated. This will be especially important, as the rates of SLD are expected to climb rapidly in the years ahead.
In a recommendation for improved coordinator care for people with SLD, the National Committee for Quality Assurance noted that primary care doctors recommend too few noninvasive SLD screenings for people at high risk of the condition. A more proactive approach might help more people get a diagnosis sooner, so they could start treatment and making healthy lifestyle changes before their condition worsens.
Educating people about their risk factors for SLD and the potential complications if the condition develops may also be useful. Targeting at-risk groups, such as non-English-language speakers and people living in lower socioeconomic status, also may help.
As there is currently only one FDA-approved drug for SLD treatment, new drugs and other treatments are also needed to help manage the rising number of cases. More treatments will also help reduce the health care gaps among groups most affected by this condition.
Takeaways
Ethnic and racial differences, gender, and socioeconomic status all influence how different groups of people with SLD are diagnosed and treated. Without timely treatment, serious complications can develop. Health care providers should consider more than a person’s body mass index or liver enzyme levels when considering whether to have a person evaluated for SLD. As rates of SLD continue to increase, the medical community will need to do more to come up with newer treatments. It will also be important to expand access to liver specialists to all populations, especially underserved groups, such as non-English-speaking people.
FAQs on the Disparities in the Diagnosis and Treatment of Fatty Liver
What causes SLD in young adults?
Though fatty liver disease is more common in middle-aged and older adults, it can happen in young adults. The causes of fatty liver in people in their 20s are much the same as they are for older adults – obesity and excessive alcohol consumption.
Why would a woman have SLD?
While people AFAB may be less likely than people AMAB to get fatty liver disease, certain things can raise the risk of fatty liver in some women. Among those things are menopause and a reduction in estrogen levels, as well as having polycystic ovary syndrome (PCOS).
What is the new treatment for SLD?
One of the newest treatments for fatty liver is an oral medication called resmetirom (Rezdiffra). It was approved by the FDA in March 2024 to treat people in advanced stages of MASLD.
How can I get help for fatty liver?
If you have risk factors for fatty liver, such as obesity, type 2 diabetes, a family history of fatty liver, or alcohol use disorder, talk with your health care provider soon. You may need a blood test to check liver enzyme levels or have other screenings that may be helpful, such as a liver ultrasound.
