Hepatosteatosis is one of the many obesity-associated metabolic diseases (adiposopathy) and a leading cause of cirrhosis and liver transplants in the United States. The recent nomenclature updates related to fatty liver removed the “nonalcoholic” and replaced it with “metabolic-associated” to better represent the underlying process. This blog will focus on the highlights that the ABOM will require you to know including definitions, screening, and treatment.

Metabolic dysfunction–associated steatotic liver disease (MASLD, formerly NAFLD) is the umbrella term that includes hepatic steatosis involving more than 5% of the liver, occurring in individuals with at least one cardiometabolic risk factor (such as obesity or dyslipidemia), in the absence of other causes of fatty liver disease and with minimal or no alcohol intake. Progressive processes of MASLD include the following severity stages:

  • Metabolic dysfunction–associated steatohepatitis: MASH is a progressive form of MASLD characterized by hepatic steatosis accompanied by inflammation and hepatocellular injury (ballooning), with or without fibrosis.
  • MASH cirrhosis: MASH cirrhosis refers to cirrhosis that has developed as a consequence of longstanding MASH, defined by advanced fibrosis with nodular regeneration, architectural distortion, and progressive loss of normal hepatic function.

The premise of this cascade of progressive events is that dysfunctional or ‘sick’ fat accumulation, because of lipogenesis and increased fatty acid delivery, disrupts normal liver function. This increased fat leads to oxidative stress, resulting in the production of reactive oxygen species that damage cells and contribute to ongoing inflammation. This inflammation triggers cytokine release and immune cell recruitment to the liver, perpetuating hepatocellular injury and amplifying the inflammatory cascade. Untreated, in the setting of this chronic oxidative stress, hepatocellular injury and apoptosis occur, progressing the severity of the disease to fibrosis and, ultimately, cirrhosis.

Like other diseases, understanding the screening and diagnostic algorithm is vital. Although a liver biopsy is considered the gold standard for diagnosis, it would hardly be practical to pan-screen patients in this fashion and is often reserved for those seeing a hepatologist, unless it is being utilized to rule out other secondary causes. An evaluation with liver enzymes, with ALT being considered the most specific liver enzyme for MASLD, is generally the first step. The updated pediatric guidelines recommend that initial screening with ALT should be completed in children 10 years and older with obesity and may be completed in the presence of risk factors for diabetes or MASLD in this age range with pre-obesity (overweight) (key action statements 3, 3.1, and 7). In adults, it is a little less granular. Those with obesity or metabolic abnormalities (hyperlipidemia, central obesity, insulin resistance, hypertension) should be screened. Importantly, insulin resistance is nearly universal in those with MASLD and is the most important risk factor for its development.

What if you discover an elevated ALT? A thorough history of medications, alcohol intake, etc., is important to guide secondary workups. Once chronic viral hepatitis is ruled out, further non-invasive testing, such as utilizing the FIB-4 score, can risk-stratify patients to see if further imaging is necessary. For imaging, ultrasound is not sensitive enough, and vibration-controlled transient elastography, such as Fibroscan®, is often utilized. Numerous other imaging modalities, including MRI and CT, are available but may be limited by their cost, availability, and radiation exposure (CT).

The ABOM is a test for primary obesity management. Although the complexities of MASLD are vast, further diagnostic approaches and new imaging would likely be deferred to a hepatologist, ideally, and thus likely beyond the scope of this exam. However, one final component to be familiar with regarding this topic is treatment.

A new pharmacologic treatment, resmetirom, is now available as of March 2024 for those with noncirrhotic MASLD with moderate to advanced fibrosis. Significant weight loss has always been the mainstay of treatment, with 10-40% being required to make a significant improvement. In addition to healthy eating and increased aerobic physical activity, metabolic and bariatric surgery options and/or GLP-1-based pharmacotherapy often are preferred based on their robust weight-loss potential. GLP-1 receptor agonists, including semaglutide (now FDA-approved for MASLD with fibrosis), demonstrate benefits that extend beyond weight loss, improving hepatic steatosis, inflammation, and fibrosis markers. In addition, thiazolidinediones may reduce hepatic fat and the anti-inflammatory Mediterranean eating plan tends to show some benefit. Finally, reducing cardiac disease risk factors is vital, as this is the number one cause of death in patients with MASLD.

MASLD is a broad topic, and it should be expected to come up a few times on the exam, with a primary focus on diagnosis and treatments. In addition to being prevalent on boards, it will be prevalent in your practice. For more information, check out the American Association for the Study of Liver Disease practice guidelines here.

Sample Question

An 11-year-old girl presents to her pediatrician for a follow-up regarding weight management. The patient’s weight is in the 95th percentile, and blood pressure was elevated on the prior visit. Her mother has end-stage cirrhosis secondary to metabolic dysfunction-associated steatotic liver disease (MASLD). Given the above findings, what is the best initial screening test for this patient?

A. AST: ALT ratio

B. ALT

C. AST

D. MASLD fibrosis score

Next Week: Monthly Knowledge Check. This is a review checklist of must-know items for ABOM exams based on the previous four blog topics (Weight gain in pregnancy, measuring dietary intake, viral etiology of obesity, metabolic-associated steatohepatitis). In addition, this will include a brief explanation of the correct answers to previous sample questions.

Upcoming: Single anastomosis gastric bypass, Alstrom’s disease, ketogenic diet, and everything to know about metformin

For more practice questions, check out the following:

  • Obesity Medicine Board Review Questions (2026): Qs 46, 102, and 151.
  • Obesity Medicine Practice Tests (2026): Qs 48, 95, 100, and 129.

(Copyright 2026) Obesity Medicine Board Review Questions, LLC: obesitymedicinereview.com

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