When Bruce Dimmig, 68, was diagnosed with stage 3 (III) metabolic dysfunction-associated steatohepatitis (MASH) in 2022, he was determined to turn his life around.
“I went through my entire pantry and refrigerator and measured the amount of sodium, fat, and fiber in each food,” says Dimmig, a MASH patient advocate, who lives in Surprise, Arizona. “The diagnosis itself was overwhelming. This was something I could do on my own to actively improve my health.”
About a third of people in the U.S. live with some form of metabolic dysfunction associated-steatotic liver disease (MASLD). But only 5 people out of 100 have metabolic dysfunction-associated steatohepatitis (MASH), a more serious form of the condition.
Fortunately, both MASLD and MASH can get better and even be reversible through changes in eating habits and exercise, says Amon Asgharpour, MD, a liver specialist at Virginia Commonwealth School of Medicine in Richmond.
“The liver is an amazing organ,” Asgharpour says. “A lot of patients, when they are first diagnosed with MASH, blame themselves. But I stress that their liver is very forgiving."
Research backs his words up. Recent studies show that people with MASLD were able to greatly improve liver fibrosis, also called scarring, by:
"If you commit to making healthy lifestyle changes, a lot of the inflammation, fat buildup, and even scarring can be reversed,” says Asgharpour.
Why Lifestyle Matters for MASH
MASH is caused by a buildup of fat in the liver. Anything you can do to reverse that will help the condition, says Supriya Rao, MD, a liver specialist and medical director of the Obesity Medicine Program at Lowell General Hospital in Lowell, Massachusetts.
“A healthy lifestyle will help to reduce fat everywhere in your body, including your liver,” Supriya says. “It also helps to reverse some of the metabolic changes and inflammation that worsen MASH.”
Having a healthy lifestyle is most effective in the early stages of MASH, although people will benefit at any stage.
Three key lifestyle steps
Supriya suggests three steps to improve liver health for all her patients with MASH:
- Focus on eating a healthy diet.
- Get active and move.
- Find time to sleep.
Eat a Healthy Diet
After Dimmig was first diagnosed with MASH, his nutritionist suggested a Mediterranean style diet. This type of eating pattern is rich in:
- Fruits
- Vegetables
- Whole grains
- Seafood
- Beans
- Nuts
If you have MASLD or MASH, the Mediterranean diet can help you lose weight loss and support your liver health.
Breakfast. Most days of the week, Dimmig’s breakfast is an egg white omelette filled with veggies and topped with salad. “I try to get as much protein into my diet as I can, as advanced MASH may lead to muscle loss,” he says.
Lunch. A salad topped with lean animal protein, such as chicken, or beans provides nutrients for lunchtime.
Dinner. At night, chicken, steak, or fish, with an occasional pasta tossed in helps Dimming stay healthy.
What's a serving size?
“One thing that struck me when I met with the nutritionist was I didn’t have a clue what a serving size was,” he says. “I have a half cup or cup of pasta now, rather than a whole bowl.”
When it comes to healthy eating, Asgaurpour suggests that you take the word diet out of your vocabulary. “I tell my patients it’s a four letter word,” he says. “The goal is to get people to change their relationship with food.”
Take a picture
To start, Asgaurpour has patients take a picture of everything they eat and drink for two to three days. “Our food recall is horrible, but with photos, you get a clear visual to help you understand your daily caloric intake,” he says. “Once you see how much — and what — you eat, you can take steps to reduce it, whether it’s cutting out sodas and juice or cutting your ice cream portion in half.”
Skip the alcohol
All people with MASH can cut down — or even eliminate — alcohol. “It’s like pouring gasoline onto the fire when it comes to your liver,” says Don Rockey, MD, a liver specialist and chair of the department of medicine at the Medical University of South Carolina in Charleston.
Stay Active
Exercise is an important part of managing MASH. One review found that exercise not only helps you lose weight but can also:
- Lower liver fat
- Lower inflammation
- Boost overall heart health
Exercise also seems to help you at whatever stage of MASH you are in, whether it’s an early stage 1 (I) or advanced cirrhosis.
Short bursts of activity
Dimmig walks for 20-30 minutes most days a week. He also tries to add short bursts of activity into his daily routine.
“I do different chores on different days of the week — Monday I vacuum, and on Saturday, I water my backyard,” he says. “I get up and move around every 30 to 60 minutes, even if it’s just to walk from my office to my bedroom and then into my kitchen.”
He keeps a pedometer and aims to log anywhere between 5,000 and 10,000 steps each day, depending on how he feels.
Start slowly
With MASH, try to get 30-60 minutes of moderate- to vigorous-intensity exercise, such as very brisk walking, three to five days a week. That may sound like a lot. Start off slow, and gradually work your way up, Asgharpour says.
Build muscle with strength training
It’s important to strength train, too, because it helps you build muscle, which may also reverse MASH, Asgharpour says.
“I had one patient come to see me six months later, and I didn’t recognize him because he’d become so muscular,” Asgharpour says. “He went down four pant sizes in half a year. When we did a FibroScan — an ultrasound test to check the liver — we found all the fat in it had disappeared.”
Focus on Sleep and Stress
You may be surprised to learn that sleep can help you better manage your MASH. In one study, people who didn’t get enough sleep were more likely to get MASH. And those who didn’t go to bed until after midnight, were more at risk to see their liver disease progress to fibrosis (scarring).
Because lack of sleep may lead to weight gain, not getting enough rest at night may worsen your liver disease, Rockey says. When you’re sleep-deprived, you’re also less likely to eat right and stay active, which can make your MASH harder to control.
MASH and sleep apnea
People with MASH who are overweight or have obesity are more likely to have an underlying sleep condition such as sleep apnea, Rockey says. If you snore at night or are frequently sleepy during the day, even though you get enough rest, ask your doctor if you should have a sleep study.
Mood disorders and MASH
If you have MASH, you’re also more likely to have symptoms of mood disorders such as depression or anxiety.
“It can be hard because the condition often seems to take over your life,” says Dimmig, who had to retire early because of his liver disease. He’s also no longer able to drive due to hepatic encephalopathy. It’s a buildup of toxins in the brain because the liver is no longer able to filter them all out.
Dimmig’s advice? Stay as active as possible.
Dimmig volunteers as a spokesperson for the American Liver Foundation and often travels to Washington DC to advocate for patients with MASH.
“Don’t give in to the temptation to stay home and throw yourself a pity party,” he says. “Find motivation and encouragement where you can. For me, it’s advocacy.”
The Power of Lifestyle and Medication for MASH
While many people with MASH are able to manage the condition with lifestyle changes, for others, it’s not enough.
There are two medicines approved to treat MASH:
- Resmetirom (Rezdiffra), a medication that targets a liver receptor
- Semaglutide (Wegovy), the weight loss medicine
Jennifer Berg, 53, struggled with stage 2 (II) MASH for over a decade, even though she led a healthy life. “I cut out all added sugar and ate very few carbohydrates — I lived mainly on lean proteins like chicken and fish and non-starchy vegetables,” says Berg, a MASH patient advocate and speaker at Metabolic multi Organ Science Accelerating Innovation in Clinical Trials (MOSAiC), who lives in San Antonio.
But her liver enzyme levels barely budged. “I remember being told that my liver was more than 30% fat, which was shocking to me as I barely had any fat in my diet,” Berg says.
Then, in August of 2024, she started resmetirom, which had gotten FDA-approved to treat MASH just a few months earlier. Resmetirom helped her:
- Liver function get better
- Lose 70 pounds
- Revert her MASH to stage 1 (I)
Berg credits both lifestyle and medication for her health, too. “Once I went on Rezdiffra, I had more energy, so I was able to get up for a morning walk before work and just move more in general,” she says.
While modifying your lifestyle is usually the first treatment for MASH, if you don’t see results within a few months, it’s important to speak to your doctor about medication.
“I see one or two patients a month with advanced cirrhosis from MASH, who were told by their doctor 20 years ago that they had fatty liver but they didn’t need to worry about it,” Asgharpour says. “It’s critical that patients use both lifestyle and medication to make an impact early, not later in the game when the condition is almost impossible to reverse.”
The sooner you embrace a healthy lifestyle to manage your MASH, the better off you’ll be. And remember, the liver is forgiving. So, healthy changes now to lower fat buildup can help reverse your MASH and keep your liver healthy.
