Lana Pine is the editor of HCPLive Rheumatology. She is an experienced editor and technical writer with a demonstrated history of working in the banking and publishing industries. In her free time, she enjoys cooking, yoga, listening to podcasts, and drawing. She can be reached via email at LPine@mjhlifesciences.com.

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As the global burden of fatty liver disease continues to rise, clinicians are increasingly turning to nutrition-based interventions as frontline management. In this final installment of our liver health series in partnership with the 

, Jennifer Lai, MD, transplant hepatologist and Physician Nutrition Specialist at the University of California, San Francisco (UCSF), shares evidence-based strategies clinicians can use to counsel patients on the role of diet and lifestyle in liver disease prevention and management.

Why Nutrition Is Foundational in Liver Care

“The liver is the body’s metabolic hub,” says Lai. “While the intestine is the first organ to encounter food, the liver is where all of that food gets processed, detoxified, and converted into essential proteins.”

Lai emphasizes that clinicians should frame dietary counseling in simple, relatable language. “I often tell my patients: If you eat junk, your liver has to process junk. But if you eat well, you’re bathing your liver in nutrients that help it stay strong and functional.”

Hidden Dietary Risks Beyond Alcohol: The Role of Fructose

While the hepatotoxic effects of alcohol are well known, Lai highlights that excessive fructose — particularly from high-fructose corn syrup and ultra-processed foods — poses a significant but underrecognized threat to liver health.

“Many patients unknowingly consume large amounts of fructose through sugary beverages, snacks, and packaged foods,” she explains. “Like alcohol, the liver can handle some fructose, but chronic high intake contributes to steatosis and inflammation.”

For clinicians, counseling patients on reading food labels and identifying hidden sugars is a critical step in reducing liver disease risk.

Practical Nutrition Counseling: Focus on Polyphenols and Fiber

Lai advises physicians to focus on achievable dietary targets:

 Coffee, green tea, fruits, vegetables, and whole grains are all associated with hepatoprotective effects. “Coffee remains the most studied, but fruits and vegetables offer similar benefits,” she notes.

 Recommending 25 to 30 grams of fiber per day supports gut health and reduces the liver’s inflammatory burden. “Fiber feeds the gut microbiome, helping neutralize toxins before they reach the liver.”

Lai encourages gradual increases in fiber intake to minimize gastrointestinal side effects.

Label Literacy: Teaching Patients to Read Nutrition Facts

When counseling time is limited, Lai suggests focusing on two key points from food labels:

 Advise patients to check the “added sugars” line on the Nutrition Facts panel. A sustainable long-term goal is <50 grams/day, but incremental monthly reductions of 10% are often more achievable for patients starting from higher baselines.

 Encourage choices with higher fiber, aiming toward the 25–30 grams/day target.

“When in doubt, remind patients: The best foods often don’t have labels at all — fruits, vegetables, legumes, and whole grains,” says Lai.

Addressing Asymptomatic Disease and Public Awareness

Lai stresses that most patients with early fatty liver disease are asymptomatic, making patient education even more critical.

“Until recently, we had no FDA-approved medications for fatty liver disease,” she says. “Lifestyle intervention remains the most evidence-based ‘treatment’ we can offer.”

For clinicians, this means reinforcing that weight loss, dietary improvements, and increased physical activity remain the cornerstone of fatty liver management, especially for metabolic dysfunction-associated steatotic liver disease (MASLD).

Integrating Movement with Nutrition Counseling

Lai advocates for pairing nutrition advice with achievable physical activity goals.

“If patients walk within 30 minutes after eating, they can blunt postprandial glucose spikes,” she explains. “For those starting exercise routines, I tell them: Add 10 extra minutes of walking each day. Small steps build momentum.”

The key message for providers: Encourage sustainable, incremental lifestyle changes. Tracking tools, step counters, and motivational interviewing techniques can help patients stay engaged.

Screen for ultra-processed food and added sugar consumption in at-risk patients.

Provide targeted label-reading education during nutrition counseling.

Advocate for fiber-rich, polyphenol-containing foods that support liver and gut health.

Encourage gradual increases in both physical activity and dietary improvements to enhance adherence.

With new therapeutics for MASH on the horizon, Lai’s guidance serves as a timely reminder that lifestyle remains a first-line, low-cost intervention that every clinician can support.

Articles

Clinicians are increasingly using nutrition-based interventions to manage fatty liver disease, emphasizing the liver's role as a metabolic hub. Excessive fructose intake, particularly from high-fructose corn syrup and ultra-processed foods, poses a significant risk to liver health. Practical dietary counseling should focus on polyphenol-rich foods and adequate fiber intake. Teaching patients to read food labels, particularly for added sugars and fiber content, is crucial. Lifestyle interventions, including diet and physical activity, remain the cornerstone of managing fatty liver disease, especially in the absence of FDA-approved medications.

Jennifer Lai, MD, shares science-backed strategies for clinicians to counsel patients on nutrition and liver health.

Jennifer Lai, MD, on Counseling Patients About Liver-Healthy Nutrition

For many clinicians, metabolic dysfunction-associated steatohepatitis (MASH) — formerly known as NASH — presents a diagnostic and management challenge. Dianne Gillard’s story, a U.K.-based patient advocate, highlights the real-world consequences of missed diagnostic opportunities and underscores the need for earlier detection, patient-centered communication, and system-wide changes in fatty liver disease screening.

Gillard’s experience reflects the growing global burden of MASH, with more patients progressing silently toward cirrhosis before diagnosis.

Nearly Two Decades of Missed Opportunities

Although Gillard was officially diagnosed with MASH in 2021, her symptoms began nearly 19 years earlier. In 2002, she presented with leg swelling — a non-specific symptom that could suggest liver dysfunction among other causes. Instead of further investigation, her physician recommended weight loss and referred her to a commercial weight loss program.

“My doctor told me to lose weight and gave me a voucher for 20 weeks at Weight Watchers,” Gillard recalled. “But that was the start of nearly two decades of being overlooked.”

Her case illustrates a common scenario in primary care: Liver enzyme abnormalities and radiologic findings that go unflagged or under-addressed. Between 2008 and 2013, Gillard’s records revealed multiple missed opportunities: abnormal liver function tests, a scan showing fatty liver, splenomegaly, and gallstones—all of which were not followed up.

By the time she underwent FibroScan and further evaluation at King’s College Hospital in 2021, she was diagnosed with Stage 4 MASH with cirrhosis and fibrosis.

Following her diagnosis, Gillard described feelings of shock, anger, and mistrust toward the healthcare system.

“Looking back, the signs were there, but they were ignored,” she said. “I was treated like just another overweight patient who didn’t take care of herself.”

Her story reflects a broader patient perception issue in MASH care: Weight bias, diagnostic inertia, and fragmented follow-up often create long-term emotional scars and distrust of the medical system.

Clinical Trial Participation and Ongoing Management

After diagnosis, Gillard entered a clinical trial at King’s College Hospital, receiving investigational infusions for three years with close monitoring.

“The trial saved my mental health as much as my physical health,” she said. “Regular scans, blood tests, and follow-up made me feel safe and seen.”

Her experience underscores the psychosocial benefits of care continuity and patient engagement in clinical research — especially for chronic conditions where disease-modifying therapies remain limited.

Despite her commitment to change, Gillard admits that lifestyle modification remains a challenge.

“With two sick parents, a disabled husband, and kids at home, I often put myself last,” she said. “Takeout was quick and easy.”

This patient reality aligns with clinical evidence showing that social determinants — such as caregiving burden, food insecurity, and emotional stress — often hinder lifestyle adherence in MASH patients.

Today, Gillard uses food labeling as a personal guide, targeting foods with “yellow and orange” nutritional content instead of red-flagged options. She also highlights the difficulty of making healthy choices in an environment where fast food is accessible, affordable, and aggressively marketed.

Advocacy and the Push for Early Screening

 — including her attendance at the European Association for the Study of the Liver (EASL) Congress and GLI’s Advanced Advocacy Academy — has empowered her to speak publicly about MASH, patient stigma, and the need for screening reforms.

Her biggest call to action: Screen earlier — starting in adolescence.

“I watch kids buying fried chicken and chips after school every day,” she said. “We should be screening starting at 13. If we wait until adulthood, it may be too late.”

Gillard even calls for policy changes that mirror public health strategies used against tobacco. “Why not put warning labels or diseased liver images on fast food packaging?” she asked.

Act on abnormal LFTs and imaging findings, even in patients without classic risk profiles.

Screen at-risk populations proactively, including younger patients with obesity or metabolic syndrome.

Address patient stigma and weight bias during liver disease discussions.

Refer early for hepatology consultation and consider FibroScan use where available.

Recognize barriers to lifestyle change and offer practical, personalized support.

Dianne Gillard’s story is not just a patient narrative — it’s a call for earlier action and better communication across healthcare settings.

Metabolic dysfunction-associated steatohepatitis (MASH) poses significant diagnostic and management challenges, as illustrated by Dianne Gillard's experience. Her nearly two-decade journey to diagnosis highlights the consequences of missed diagnostic opportunities and underscores the need for earlier detection and patient-centered communication. Gillard's case reflects the global burden of MASH, with many patients progressing to cirrhosis before diagnosis. Her participation in clinical trials and advocacy efforts emphasize the importance of early screening, addressing patient stigma, and recognizing barriers to lifestyle changes in managing MASH effectively.

This case study underscores how fragmented care and weight bias can contribute to late-stage MASH diagnosis.

Beyond Weight Bias: Lessons from a Patient’s Progression to Stage 4 MASH

Fatty liver disease is a growing public health crisis — yet it often remains undetected until catastrophic events force a diagnosis. Jerry Rosenberg’s story is a powerful reminder of this reality and offers key takeaways for physicians working at the intersection of primary care, hepatology, critical care, and transplant medicine.

Without traditional risk factors or a known diagnosis, Rosenberg went from a healthy, active lifestyle to a coma and liver failure within days — his first real sign that something was wrong.

A Silent Disease with Deadly Consequences

Before his health crisis, Rosenberg was thriving. He co-owned a nightclub, exercised regularly, maintained a healthy weight, and traveled extensively. Despite his active lifestyle and lack of alcohol consumption, he unknowingly had advanced fatty liver disease.

“I had just received a clean bill of health from my doctor,” Rosenberg said. “I didn’t drink. Liver disease wasn’t something I was ever told to worry about.”

The turning point came while on vacation, after a suspected case of food poisoning. Within days, Rosenberg collapsed and entered hepatic coma. Local doctors in Bermuda offered little hope of survival. Only after multiple international care coordination efforts was he airlifted to Florida, and later accepted into Mayo Clinic’s transplant program.

Delayed Diagnosis and Missed Screening Opportunities

Rosenberg’s experience reflects a broader pattern seen across healthcare settings. Nonalcoholic fatty liver disease (NAFLD) and its progressive form, nonalcoholic steatohepatitis (NASH), now affect 

Multiple studies show that NAFLD often goes undetected in primary care, even when patients have risk factors like obesity, diabetes, or metabolic syndrome. However, Rosenberg didn’t fit even those profiles — further underscoring the need for more nuanced risk assessment and screening tools beyond conventional assumptions.

Critical Care, Transplant Readiness, and Multidisciplinary Coordination

Rosenberg’s journey also highlights challenges in transplant triage, especially for patients presenting with acute liver failure without a clear etiology.

With few hospitals willing to accept him, Rosenberg’s case required rapid, cross-border coordination between emergency medical teams, hepatologists, transplant centers, and intensive care specialists.

Post-transplant, his rehabilitation was extensive. Prolonged ICU stays led to muscle atrophy, requiring inpatient rehab and nursing home care to regain basic mobility.

“Learning to walk again was one of the hardest parts,” Rosenberg recalled. “My brother, who was also my caregiver, pushed me every day.”

Despite his medical history, Rosenberg frequently encountered stigma—both in the hospital and in his community.

“There was an automatic assumption that my liver failure was alcohol-related,” he said. “That stigma was hurtful and it’s still something I speak out about.”

For clinicians, this highlights an important care gap: Addressing biases and misconceptions when communicating with patients about liver disease. Not all patients with liver failure have a history of alcohol misuse. This is especially true as NAFLD/NASH continues to rise as a leading cause of transplantation.

Advocacy, Education, and the Physician’s Role

Today, Rosenberg is a vocal advocate with the 

. He speaks at medical schools, health fairs, and policy events to raise awareness about fatty liver disease and the need for increased organ donation.

Screen proactively, even in patients without obvious risk factors.

Educate without bias, avoiding stigma-laden assumptions.

Encourage patients to understand their liver health, especially those with metabolic risk factors.

“I want doctors to know that their words matter,” Rosenberg said. “You could catch this early for someone else.”

NAFLD/NASH can progress silently — even in lean, low-risk individuals.

Acute liver failure without prior warning signs presents unique diagnostic and triage challenges.

Multidisciplinary coordination is essential for successful transplant outcomes.

Stigma remains a significant barrier in liver disease care—clinician communication can help address this.

Early screening and patient education can prevent late-stage crises.

As Rosenberg’s story makes clear, liver disease is not always visible — but its consequences can be life-altering.

Fatty liver disease, particularly nonalcoholic fatty liver disease (NAFLD) and its progressive form, nonalcoholic steatohepatitis (NASH), is a significant public health issue often undiagnosed until severe complications arise. Jerry Rosenberg's case exemplifies the silent progression of this disease, even in individuals without traditional risk factors. His experience underscores the necessity for improved screening, multidisciplinary care coordination, and addressing stigma in liver disease management. Physicians are encouraged to proactively screen, educate without bias, and advocate for increased awareness and organ donation to mitigate late-stage liver disease crises.

A patient’s near-fatal journey from undiagnosed fatty liver disease to liver transplant highlights the urgent need for better screening and stigma-free communication.

From Asymptomatic to Acute Liver Failure: A Wake-Up Call for NAFLD Screening

Two Gout Journeys That Reveal the Cost of Delayed Specialist Care

In the final episode of the Managing Uncontrolled Gout series, two patient narratives—Joe and Stacy—offer powerful, real-world insights into the long-term consequences of undertreated gout. Their stories underscore a pressing clinical reality: many patients continue to suffer needlessly due to delays in specialist referral and persistent misconceptions about gout as an episodic rather than chronic condition.

Joe, a railroad industry worker, was diagnosed with gout in 2001 and managed his condition for more than two decades using a static, ineffective treatment plan. Despite debilitating pain that interfered with his physically demanding job, Joe was not connected with appropriate specialty care until much later. Once he began working with informed providers, his condition markedly improved, illustrating the impact of guideline-based treatment and patient engagement.

Stacy’s case further highlights the systemic under-recognition of gout’s severity. Experiencing his first flare at age 24, Stacy endured over 25 years of progressive joint damage and severe disability, despite attempting various lifestyle interventions and acute treatments. Only in 2019, after finally seeing a rheumatologist, did he receive effective disease-modifying therapy through infusion treatment. Since then, he has remained gout-free. His experience reveals not only the therapeutic potential of modern interventions, but also a concerning lack of awareness—even among some healthcare professionals—regarding optimal gout management strategies.

Both cases illuminate the clinical importance of timely referral to rheumatology and comprehensive care grounded in urate-lowering treat-to-target principles. Patients with recurrent flares or inadequate response to oral therapies should be reevaluated promptly to prevent irreversible joint damage and comorbidity escalation.

Clinicians are urged to move beyond the “flare-and-forget” model and treat gout as the chronic systemic disease it is. Proactive management, patient education, and interdisciplinary coordination remain central to improving outcomes.

Videos

Delayed specialist referral can result in decades of unnecessary pain and joint damage for patients with gout.