Liver Disease and Diabetes: An Overlooked Complication

Key takeaways:

MASLD is a very common type of early-stage liver disease that affects many people with diabetes and may progress to MASH, which is when scarring occurs.
Treating metabolic conditions as soon as possible is the best way to protect your liver health and avoid more advanced liver disease.
Two medications have now been approved to treat advanced liver disease, and experts are hopeful that more are on the way.

The liver is a vital organ. It filters toxins from your blood, produces bile to help digest fats, helps regulate blood sugar levels, and manufactures essential proteins for blood clotting and immunity. It’s also one of the body’s main storehouses for sugar, but it struggles to fulfill this role when a person lacks insulin or develops insulin resistance.

One of the primary drivers of insulin resistance is a buildup of fat in the liver. Fat may build up there for a variety of reasons, but some of the most common are obesity, diabetes, and related metabolic conditions. Over time, excess fat can cause significant stress for liver cells, leading to inflammation and damage.

Liver damage often goes unnoticed for many years, and by the time it causes symptoms, it is already quite serious. Fortunately, there are now treatment options for more advanced liver disease, but blood sugar and weight management are the best strategies for protecting liver health in people with diabetes.

Types of liver disease in diabetes

Liver disease progresses through stages. When metabolic conditions like obesity and diabetes are a primary driver, the earliest stage is called metabolic-associated steatotic liver disease (MASLD). The intermediate stage is called metabolic-associated steatohepatitis (MASH). Regardless of the cause, late-stage liver disease is called cirrhosis.

MASLD

MASLD is when excess fat builds up in the liver. This condition used to be called nonalcoholic fatty liver disease (NAFLD), but experts decided to change the name to focus more attention on the role of metabolic health in disease progression and to avoid stigmatizing language.

A MASLD diagnosis requires evidence of fat in the liver and at least one metabolic risk factor, such as obesity, type 2 diabetes, high blood pressure, or high lipid levels. However, a person who meets these criteria may be given a different diagnosis if other factors contributed to liver damage. For instance, a person with type 2 diabetes and a damaged, enlarged liver might be diagnosed with metabolic dysfunction and alcoholic-associated liver disease (MetALD) if they also regularly consume large amounts of alcohol. This diagnosis would help the person and their healthcare team recognize that improving liver health will require addressing alcohol use disorder as well as treating diabetes.

MASLD is common. In 2020, it was estimated to affect a third of all adults around the world, and projections suggest that its prevalence has grown since then. It is particularly common among people with type 2 diabetes, which makes sense given that diabetes can be used as a diagnostic criterion for MASLD and that MASLD progression is often heavily involved in worsening insulin resistance. A study from 2021 found that more than 70% of people with type 2 diabetes have MASLD.

Although type 1 diabetes is not used in making a MASLD diagnosis, research suggests that people with type 1 are also more likely to have it than people without diabetes. A 2025 study estimated that the condition affects over a third of people with type 1.

MASH

Many people don’t progress beyond MASLD, but in a significant number, liver cells exposed to excess fat for too long become damaged. At this point, MASLD turns into MASH, which was formerly called nonalcoholic steatohepatitis (NASH).

In people with MASLD, liver cells are often stressed and inflamed. MASH is when liver cells have reached their limit and start to die. As a result, the liver develops fibrosis, which is when tissue thickens and scars.

Although some amount of scarring has occurred, the early stages of MASH are still generally symptom-free. The liver is a big, resilient organ, and it can keep on doing its job even as parts of it go offline.

Late-stage liver disease

No current medications or technology can turn scar tissue back into healthy, functional cells, but the liver can regenerate on its own if you alleviate the stress on it before scarring has become too extensive. Historically, cirrhosis has been defined as the point at which the body can no longer reverse the damage that has occurred.

When MASH progresses to cirrhosis, scarring has become so extensive that it interferes with liver function. The scarring may also interfere with the liver’s blood supply, causing portal hypertension (high pressure in the portal veins in the liver), which can accelerate liver damage. Ultimately, the entire liver may fail.

In these later stages, liver disease may start to cause noticeable symptoms, ranging from mild fatigue and nausea to jaundice and excessive fluid in the abdomen called ascites, which can interfere with daily life. Ultimately, liver transplantation may become necessary.

How fast does liver disease progress?

How quickly liver disease progresses varies from person to person. On average, it takes decades for someone to go from early MASLD to cirrhosis and liver failure. Progression is typically slower before MASH and speeds up after fibrosis begins.

However, liver disease can progress more rapidly in some people, especially those with more severe and difficult-to-manage cases of diabetes or other health conditions. Genetics, age, and sex can all play a role as well. Overall, men are more likely to experience MASLD and later stages of liver disease, but the risk rises for women with Polyendocrine Metabolic Ovarian Syndrome (PMOS), formerly called polycystic ovary syndrome (PCOS), and after menopause.

Can people with type 1 diabetes get liver disease?

While liver disease is more prevalent in type 2 diabetes, people with type 1 diabetes can also develop it. This is why managing metabolic health is just as important in people with type 1 diabetes as it is in those with type 2 and other related disorders.

As you think about your liver health, it may be helpful to keep in mind that processing fat is part of the liver’s job description. The liver is good at clearing and repairing any damage it’s experienced. Problems arise when it’s exposed to the same metabolic stressors nonstop for a long time (for example, high blood sugar over time). By managing blood sugar levels and body weight, it gives the organ a break so it has time to heal itself.

How to prevent liver disease

Metabolic health issues play a central role in MASLD and MASH. The surest way to avoid either diagnosis is to prevent health conditions like obesity, type 2 diabetes, high blood pressure, and abnormal cholesterol and blood lipids. If you already live with one or more of these conditions, the best way to avoid liver disease is through blood sugar and weight management.

More often than not, this means making some combination of lifestyle changes, which may include reducing body weight, eating more balanced and nutritious meals, exercising more, managing stress, and sticking to a more regular sleep schedule. It’s also important to avoid smoking and drinking alcohol.

For many people, medications are necessary. Metformin, SGLT-2 inhibitors like Jardiance and Farxiga, and GLP-1 drugs like Ozempic and Mounjaro are highly effective treatments that can help people manage their blood sugar and weight, as well as protect other organs like the heart. For some people with obesity, weight loss surgery may also be beneficial.

Because early liver disease may have no symptoms, routine screening is recommended for people with diabetes. Healthcare providers use FIB-4, a score that incorporates your age, liver enzymes and platelet count, to screen for fibrosis from liver disease. A high FIB-4 score indicates a high likelihood of liver fibrosis, but an actual diagnosis of liver disease usually requires a scan. Historically, biopsies were used, but they’re currently less common.

How to treat MASLD and MASH

The American Diabetes Association (ADA) recognizes liver disease as a major concern for people with diabetes. In 2025, ADA issued its most recent guidelines for the diagnosis, management, and treatment of MASLD and MASH. In that document, they stressed the importance of monitoring liver health for people with diabetes, placing it on equal footing with heart, kidney, and eye health.

Managing metabolic health conditions is key to treating MASLD and the early stages of MASH. A new diagnosis of type 2 diabetes, obesity, or high blood pressure can give you ample time to improve liver health, even if you aren’t thinking about it yet. Regardless of when you were diagnosed, it’s still important to monitor your liver health. Some people have particular combinations of genes and environmental exposures that make them vulnerable to liver damage, even if they’re doing everything they can to stay healthy.

For people who test positive for MASLD or early-stage MASH, treating liver disease isn’t much different than trying to prevent it. Healthcare providers will recommend appropriate lifestyle changes and, potentially, more potent treatments for any metabolic conditions you have. Weight loss is often a primary focus.

People who have more advanced fibrosis that hasn’t become cirrhosis may be eligible for Rezdiffra (resmetirom), a daily pill that boosts fat metabolism in the liver. Studies show that Rezdiffra helps most people halt or reverse liver scarring.

Research also shows that GLP-1 medications can help people reverse MASH. In fact, the FDA officially approved semaglutide (specifically for weight loss under the Wegovy brand name) as a treatment for MASH in 2025. If you have type 2 diabetes but aren’t yet taking a GLP-1 and you’ve been diagnosed with MASH, it’s a good idea to talk to your healthcare provider about whether one of them is right for you.

Rezdiffra and Wegovy are currently the only drugs approved in the U.S. to treat MASH, but there are several more being developed. Researchers are also starting to test their treatments in people with cirrhosis, raising hopes that people who don’t find out about their liver disease until very late could one day have treatment options beyond a transplant.

Even now, diabetes medications may help prevent liver failure in people who have cirrhosis. Those who find a successful treatment strategy are sometimes able to manage life with late-stage liver disease for years before a transplant becomes necessary.

The bottom line

Metabolic health problems like type 2 diabetes put stress on the liver, increasing the likelihood of excessive fat buildup in the liver that can lead to inflammation and ultimately scarring. Still, the liver is resilient, and effectively managing blood sugar, weight, and any other related health conditions can be enough to keep it healthier and more functional.

Regular liver health checks are essential because symptoms don’t usually start until liver disease has already become very difficult to treat. If you have developed some scarring on your liver, you may be eligible for treatments that could give your liver a boost and help you avoid more serious problems down the road.

Learn more about diabetes-related complications here:

This content was made possible with support from Madrigal Pharmaceuticals. Sponsored articles are independently written by diaTribe and subject to our standard editorial and medical review process to ensure they meet standards for quality, accuracy, and relevancy. Final editorial authority rests with diaTribe.

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