Fatty liver in Singapore: what the scan and the bloods show
Fatty liver affects roughly one in three adults. Most have no symptoms, and in Asian populations it appears at weights that look perfectly normal.
What fatty liver is
Fat builds up inside liver cells. Past about five percent of liver weight, it is called fatty liver. Most people who have it feel completely well.
It is usually found by accident. A scan ordered for something else, or a liver enzyme slightly raised on a routine panel.
Around one in three adults worldwide has it. Across Asia the figure is comparable, and in some regional studies higher.
When a normal BMI misleads
Many people have a normal BMI, but may still have fatty liver. It is a common misconception that fatty liver does not occur in individuals with a normal bodyweight or BMI.
Fatty liver appears at lower body weights in Asian populations than in Western ones. Singapore recognises this: the threshold where risk climbs is a BMI of 23, not 25.
Waist measurement is often the better signal, as central adiposity, or a large amount of belly fat, can contribute to metabolic disease. Above 90cm for men or 80cm for women is where metabolic risk climbs.
The name changed in 2023. International groups renamed it metabolic dysfunction associated steatotic liver disease, or MASLD. Your report may still say NAFLD or fatty liver. They describe the same thing.
What the blood tests show
Fatty liver cannot be diagnosed by a single blood test. The presumptive diagnosis of fatty liver relies upon interpretation of several markers of liver function, as well as tracking patterns in liver markers.
| Marker | What it shows |
|---|---|
| ALT and AST | Liver enzymes. In fatty liver, ALT is usually the higher of the two. |
| GGT | Rises with fatty liver, alcohol, and several common medications. |
| Lipids | Fatty liver usually comes together with elevated cholesterol, in particular elevated LDL or triglycerides. |
| HbA1c and fasting insulin | Insulin resistance drives most cases. Insulin often rises years before glucose does, so fasting insulin is worth measuring. |
Although elevated liver enzymes are very commonly associated with fatty liver, it is worth noting that some cases of fatty liver may still have normal liver function tests.
What the scan shows
Ultrasound is the usual first look (yet it can miss mild steatosis). It detects fat reliably once a reasonable amount is present. It is quick and involves no radiation.
However, an ultrasound may miss out on early fibrosis, or scarring, in the liver. This may be better measured via a Fibroscan or CT scan.
Fat alone is largely reversible. Fibrosis, the scarring that can follow years of inflammation, is much harder to undo. A small minority progress to significant fibrosis, and those people need closer follow-up.
With hepatitis B
Chronic hepatitis B is relatively more common in South East Asia, compared to Europe or North America, and a significant number of people carrying it do not know.
Fatty liver with chronic hepatitis B is a different clinical situation, which warrants closer monitoring and follow-ups.
Say you have fatty liver but have never had your hepatitis B status checked. That is worth doing once. If you already know you are a carrier, tell whoever is managing your liver results. It changes the follow-up plan, not just the diagnosis.
What actually changes it
Fatty liver responds to remarkably few things, but it responds well.
- Weight loss of seven to ten percent resolves liver fat in most people. The effect often appears well before the target is reached.
- Reducing refined carbohydrate and fructose lowers liver fat. Sweetened drinks are a large contributor in our population. Nutri-Grade labelling makes this easy to act on. A, C, or D grade drink taken daily is a real load on the liver, and moving to A or B is a change most people can sustain.
- Both resistance and aerobic training reduce liver fat, even if your weight stays the same.
- Alcohol intake has a direct impact on fatty liver, aim for a reduction of alcohol intake, as much as possible.
GLP-1 medications can achieve significant weight loss progress and reverse fatty liver changes. This is a conversation you can have with your doctor, who has seen your full picture.
If your ALT is raised
- A single raised reading is not enough. Most doctors will repeat the test before acting. Enzymes move with recent alcohol, exercise, illness and several common medications.
- Ultrasound is usually the next step. Available at polyclinics on referral and at private clinics directly. It is quick and involves no radiation.
- FibroScan is not routine. Available privately and in hospital hepatology clinics. If your enzymes stay raised, ask whether it is warranted.
What to ask for
- If your liver enzymes have been flagged more than once, ask whether an ultrasound is warranted.
- Ask for fasting insulin alongside HbA1c to screen for insulin resistance.
- Retest after six months of lifestyle modifications, giving your liver panel sufficient time to improve.
What we published, what we read, and the one thing worth changing. Nothing to buy.
Insulin moves years before glucose does.
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metabolic markers in the Core Health Test