Food help for fatty liver disease (MASLD/MASH)

Fatty liver disease (renamed MASLD — metabolic dysfunction-associated steatotic liver disease — by AASLD in 2023) affects 80-100 million Americans (25-30% of adults). The progressive inflammatory form, MASH, affects ~20M and can lead to cirrhosis and liver cancer. The good news: diet and weight loss can reverse it in early stages. The best news: Resmetirom (Rezdiffra) received FDA approval in March 2024 — the first drug approved specifically for MASH.

Diagnosis and monitoring

• FibroScan (transient elastography) — non-invasive, in-office, 10 min. Measures liver stiffness (fibrosis). Covered by Medicare CPT 91200, ~$50-200 uninsured.
• FIB-4 score — calculate with AST + ALT + age + platelets. Free at hepatology.org. If >1.3 (60+) or >2.67, refer to hepatologist.
• MRE (MR elastography) — non-invasive gold standard. ~$1,000-2,000.
• Liver biopsy — still definitive gold standard, but rarely needed with FibroScan/MRE.
• Normal ALT/AST does NOT rule out MASLD — 30-40% of patients have normal enzymes with active steatosis.

Mediterranean diet (only level-A AASLD recommendation)

• Extra virgin olive oil — 2-4 tablespoons/day. Reduces steatosis in trials.
• Fatty fish 2-3x/week: salmon, sardines, mackerel, trout. Omega-3 EPA/DHA reduces hepatic inflammation.
• Leafy greens: spinach, kale, chard — nitrate + folate.
• Nuts: 1 oz/day (~24 almonds or 14 walnut halves). Vitamin E + monounsaturated fats.
• Whole grains: oats, barley, quinoa, brown rice.
• Legumes: beans, lentils, chickpeas — 3+x/week.
• Fruits: berries, citrus, apples. Limit very-sweet tropical fruits (mango, pineapple).
• Coffee (unsweetened): 2-3 cups/day reduces fibrosis progression and liver cancer in prospective studies.

Foods to avoid / reduce

• High-fructose corn syrup (HFCS): sodas, commercial juices, candy, bottled sauces. The worst enemy of the liver — goes straight to lipogenesis.
• Added sugar: <25g/day (women), <36g (men) per AHA. Read labels.
• Refined carbs: white bread, white rice, white pasta, baked goods.
• Trans fats: margarines, fried foods, industrial baked goods (read "partially hydrogenated oil").
• Processed meat: bacon, sausage, deli meats, hot dogs.
• Alcohol: reduce/eliminate. AASLD recommends 0 g/day with MASH F2+. MASLD F0-F1 patients: max 1 drink/day (women) or 2 (men).
• Industrial seed oils: soy, corn, canola, sunflower — high omega-6, pro-inflammatory.

Weight loss (primary goal)

Weight loss is the most powerful intervention. Validated targets in literature:

• 5% weight loss — reduces steatosis.
• 7-10% loss — reduces inflammation (NASH resolution).
• >10% loss — can reverse F1-F2 fibrosis.
• Exercise: 150 min/week moderate + 2x strength training. Reduces liver fat INDEPENDENT of weight loss.
• GLP-1 agonists (semaglutide/Ozempic, tirzepatide/Mounjaro) — approved for diabetes/obesity, growing evidence for MASH. Medicare coverage by diabetes dx.

Resmetirom (Rezdiffra) — new MASH drug

• FDA-approved March 2024 — first drug specifically for MASH (F2-F3).
• Manufacturer: Madrigal Pharmaceuticals.
• Mechanism: thyroid hormone receptor β agonist — activates hepatic lipid metabolism.
• List price: ~$47,400/year.
• Assistance: Madrigal Patient Support 1-844-RESMET-1. $5/month copay program for insured, free for uninsured <500% FPL.
• Medicare Part D 2026 coverage — with $2,000/year IRA out-of-pocket cap.
• Requirement: liver biopsy or FibroScan + MRI-PDFF documenting F2-F3.

SNAP, Medicare, Medicaid

• SNAP covers all Mediterranean foods — olive oil, fish, nuts, fruits, vegetables.
• High-omega-3 fish covered by SNAP: canned sardines $1.50, mackerel $2, canned salmon $3, fresh salmon $8/lb.
• WIC (families with kids <5): includes fruits, vegetables, whole grains, dairy — aligned with Mediterranean diet.
• Medicaid + Medicare cover: hepatologist visit, FibroScan, MRI, GLP-1 (with diabetes dx), biopsy, Resmetirom (with criteria).
• Medically Tailored Meals (MTM) programs: God's Love We Deliver, Project Open Hand — some accept liver disease referrals.

Community resources

• American Liver Foundation — liverfoundation.org. Helpline 1-800-465-4837. Spanish materials.
• AASLD (American Association for the Study of Liver Diseases) — aasld.org — clinical guidelines.
• Fatty Liver Foundation — fattyliverfoundation.org. Patient community.
• NASH Education Program — nash-now.org.
• HealthWell Foundation, NeedyMeds, Patient Advocate Foundation — copays.

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