Fatty liver is one of the most common findings in Indian OPDs. But the name has changed, the diagnostic framework has been updated, and a drug has now been FDA-approved specifically for MASH. If you are still telling patients they have NAFLD, this guide brings you current. MASLD & MASH: 2026 OPD-Ready Guide for Indian Doctors Why this matters now Fatty liver is one of the commonest incidental and syndromic findings in Indian OPDs. The terminology has changed (NAFLD → MASLD, NASH → MASH), the diagnostic framework is updated, and resmetirom is now FDA-approved for MASH with fibrosis. This summary is designed so you can update your OPD practice immediately. 1. New Terminology: MASLD and MASH Old term: NAFLD (Non-Alcoholic Fatty Liver Disease) New term: MASLD – Metabolic dysfunction-Associated Steatotic Liver Disease Focuses on metabolic drivers instead of just absence of alcohol. Key drivers: obesity, T2DM, hypertension, dyslipidaemia, insulin resistance. Especially relevant in India where MASLD appears at lower BMI and in lean/thin-fat phenotypes. MASH – Metabolic dysfunction-Associated Steatohepatitis Replaces NASH. MASLD with inflammation and hepatocyte ballooning. Progressive form → fibrosis → cirrhosis → HCC. 2. Burden of MASLD in India Estimated 100–120 million Indians with MASLD. Urban adults: ~25–35% prevalence. T2DM patients: 70–80% have MASLD. Thin-fat MASLD (lean MASLD) Normal BMI (18.5–22.9 kg/m²) but high visceral fat and insulin resistance. Common in Indians, frequently missed because BMI appears normal. Screen normal-BMI patients if they have T2DM, central obesity, or high triglycerides. 3. OPD Diagnosis: Step-by-Step Step 1 – Whom to Screen Screen any patient with: Central obesity / increased waist circumference T2DM Hypertension Dyslipidaemia Features of metabolic syndrome Step 2 – Ultrasound First-line imaging: USG abdomen. Diagnostic clue: increased hepatic echogenicity vs right kidney. Detects steatosis when ≥20–30% hepatocytes are fatty. Detects steatosis but cannot grade fibrosis. Use with fibrosis risk scores. Step 3 – Fibrosis Risk Stratification FIB-4 Score (calculate from age, ALT, AST, platelets): Available free online. Low risk < 1.30; indeterminate 1.30–2.67; high risk > 2.67. NAFLD Fibrosis Score (NFS): Low < -1.455; indeterminate -1.455 to 0.675; high > 0.675. Use to triage referral. Low FIB-4: Reassure, lifestyle intervention, annual monitoring in primary care. Indeterminate or high FIB-4: Refer to hepatologist or gastroenterologist for FibroScan (transient elastography) or liver biopsy to stage fibrosis accurately. 4. Management Lifestyle: The Most Powerful Intervention Weight loss: 5% reduces steatosis; 7–10% reduces inflammation; >10% may reverse fibrosis. The most effective treatment currently available. Diet: Calorie-restricted (500–1,000 kcal/day deficit), low GI, avoid added sugar and refined carbohydrates. Mediterranean dietary pattern shows the best evidence. Exercise: 150–300 min/week moderate aerobic + resistance training. Both aerobic and resistance exercise independently reduce liver fat. Alcohol: MASLD diagnosis requires no significant alcohol use (≤30 g/day men, ≤20 g/day women). However, any alcohol accelerates fibrosis progression — advise complete abstinence in MASH.