Metabolic Liver Disease (MASLD/MetALD): The New Name for NAFLD — What Indian Patients Must Know

Metabolic Liver Disease (MASLD/MetALD): The New Name for NAFLD — What Indian Patients Must Know

By Dr. Chetan Kalal — DM (Hepatology) · MD (Medicine) · MRCP (UK) First DM Hepatologist of Maharashtra · Associate Director, Hepatology & Transplant Medicine, Gleneagles Mumbai

You may have been told you have a fatty liver. Your reports may say NAFLD, or non-alcoholic fatty liver disease, or steatohepatitis. You may have found this article searching for what your diagnosis actually means, or because you read something about a name change and are not sure if it applies to you.

It does. And the name change matters for reasons beyond terminology.

In 2023, the major international hepatology societies — AASLD, EASL, and ALEH — formally retired the term NAFLD and replaced it with MASLD: Metabolic Dysfunction-Associated Steatotic Liver Disease. NASH became MASH: Metabolic Dysfunction-Associated Steatohepatitis. A new category, MetALD, was created for patients who have both metabolic liver disease and increased alcohol intake, sitting between pure MASLD and alcohol-associated liver disease.

This is not a bureaucratic name change. It reflects a fundamentally more precise understanding of what drives liver disease in people who are not heavy drinkers — and it has direct consequences for how patients are diagnosed, treated, and monitored in India.

Why the old name — NAFLD — was retired

The old terminology defined the disease by what it was not — "non-alcoholic" — rather than what it actually is. This was clinically imprecise, stigmatising for patients, and obscured the underlying metabolic mechanism.

There was a more fundamental problem. "Non-alcoholic fatty liver disease" implied that the disease was simply the absence of alcohol in a person with liver fat — a negative definition that gave physicians and patients no useful framework for understanding why the liver was accumulating fat or what needed to change to reverse it. The disease was being named by exclusion rather than by mechanism.

The new name — Metabolic dysfunction-Associated Steatotic Liver Disease — names the disease by its actual cause: cardiometabolic dysfunction. It signals that the liver is a metabolic organ, and when the metabolic environment — insulin resistance, dyslipidaemia, hypertension, excess adiposity — is sufficiently disrupted, the liver accumulates fat and, in susceptible individuals, progresses to inflammation and fibrosis.

For Indian patients, this shift in framing is particularly consequential, because the metabolic factors driving MASLD in Indians are frequently present even at body weights that Western clinical thresholds would classify as "normal."

The five diagnostic criteria — and why the Indian BMI cutoff matters

MASLD is now defined by the presence of hepatic steatosis (fat in the liver, detected on imaging or histology) plus at least one of five cardiometabolic risk factors. Those with no metabolic parameters and no known cause are classified as having cryptogenic steatotic liver disease — a separate, uncommon category.

The five criteria are: central obesity defined by BMI or waist circumference; elevated fasting glucose, prediabetes, or type 2 diabetes; elevated blood pressure or antihypertensive use; elevated triglycerides or lipid-lowering therapy; and reduced HDL cholesterol.

The MASLD criteria incorporate BMI ≥23 kg/m² as the South Asian cutoff — finally codifying what Indian hepatologists have observed for years. This is the single most important practical implication of the new definition for Indian patients. The old NAFLD threshold used Western BMI cutoffs — overweight at 25, obese at 30 — which consistently failed to capture metabolic risk in Indians, who develop insulin resistance and visceral fat accumulation at substantially lower body weights. A lean Indian with a BMI of 23–24, elevated triglycerides, and borderline fasting glucose now formally meets diagnostic criteria for MASLD under the updated framework, even if they would have been considered metabolically low-risk by Western BMI thresholds.

This is not a minor adjustment. It is the nomenclature catching up to what Indian hepatologists have been observing in clinical practice for over a decade.

What is MetALD — and why it matters for Indian social drinkers

MetALD describes patients who have metabolic dysfunction-associated steatotic liver disease and who consume greater amounts of alcohol per week — specifically 140–350 g/week for females and 210–420 g/week for males. This category sits between pure MASLD and alcohol-associated liver disease (ALD).

To translate those thresholds into recognisable terms: 140g of alcohol per week for a woman corresponds to approximately 10–14 standard drinks per week — roughly two drinks per day on average. For a man, the MetALD range begins at approximately 15 standard drinks per week. Above the upper thresholds of these ranges, the classification shifts to alcohol-associated liver disease.

Why does this category exist? Because the old NAFLD framework created a false binary: either you were a non-drinker with fatty liver (NAFLD), or you were a drinker with liver disease (ALD). The reality — which Indian hepatologists see regularly in clinical practice — is that many patients have both significant metabolic risk factors and moderate to moderately heavy alcohol intake, and the liver injury in these patients is driven by additive mechanisms from both exposures simultaneously.

MetALD is the first formal acknowledgement that these patients exist as a distinct clinical population with a distinct risk profile. The clinical implication is important: a patient in the MetALD range who reduces alcohol intake meaningfully may shift back into the MASLD category — where the metabolic interventions are primary. One who continues drinking may progress toward ALD. Managing MetALD requires addressing both levers simultaneously, which is not how NAFLD management was historically conceptualised.

What this means for your "fatty liver" diagnosis in India

If you have been told you have a fatty liver, NAFLD, or steatosis, and you are Indian, here is what the new framework means practically.

Your diagnosis is now more precise. The word "fatty" tells you nothing about mechanism. MASLD tells you that your liver disease is driven by metabolic dysfunction — insulin resistance, excess visceral or ectopic fat, and associated cardiometabolic abnormalities. This gives you a mechanistic framework for what actually needs to change.

Your BMI does not exonerate your liver. The most consequential aspect of the MASLD definition for Indian patients is the BMI ≥23 cutoff. If you have been told your weight is "normal" by a doctor using Western references, but your BMI sits between 23 and 25 and you have any of the five cardiometabolic criteria — elevated triglycerides, borderline glucose, blood pressure at the high end of normal, central adiposity despite low BMI — you formally meet MASLD criteria. This is precisely the lean MASLD pattern I have written about in detail previously: a person who does not "look" metabolically unwell but whose liver has accumulated ectopic fat driven by insulin resistance at the hepatocyte level.

MASH — the inflammatory subtype — requires active investigation. Not everyone with MASLD has MASH. The distinction matters enormously for prognosis and management. MASLD without significant inflammation (steatosis alone or with mild inflammation) has a substantially lower risk of fibrosis progression than MASH, where active hepatocellular injury and ballooning are driving scar tissue formation. The only way to distinguish MASLD from MASH with certainty is liver biopsy, though newer non-invasive blood-based biomarkers and enhanced imaging protocols are being validated as alternatives. If you have been told you have NAFLD without knowing whether you have steatohepatitis (the inflammatory subtype), that question has not been answered — and the answer determines your surveillance and treatment urgency.

If you drink even moderately and have a fatty liver, ask whether you are MetALD. The significance of the MetALD category for India cannot be overstated. A very substantial proportion of Indian patients presenting with "NAFLD" at liver clinics have alcohol intake in the MetALD range — not heavy drinking by social convention, but enough to interact additively with metabolic liver disease through shared pathways of oxidative stress and hepatocellular injury. If your alcohol intake sits in the range described above, your management plan must address both the metabolic and the alcohol components. Treating only one while ignoring the other is incomplete clinical management.

Does this change your treatment?

The fundamental management principles for MASLD remain unchanged from NAFLD management — because the underlying disease is the same, only the naming framework has been updated. What changes is the precision of intervention targeting.

The primary treatment for MASLD remains lifestyle modification directed at the five cardiometabolic criteria. Weight loss of 5–10% reduces hepatic steatosis; 10% or more sustained weight loss can reduce fibrosis stage. But the framing matters: in MASLD, weight loss is a metabolic intervention, not a cosmetic one. For lean Indian patients with MASLD — who cannot and should not aggressively restrict calories — the intervention target shifts toward dietary quality (reduction of refined carbohydrates and fructose, Mediterranean-pattern eating) and resistance training to build skeletal muscle mass and reduce hepatic insulin resistance.

For MASH — the inflammatory subtype with active fibrosis — pharmacological options are now emerging. Resmetirom (a thyroid hormone receptor-beta agonist) received FDA approval in 2024 for MASH with liver fibrosis, the first drug approved specifically for this indication. Its availability and regulatory status in India should be verified with the current prescribing physician. Semaglutide and other GLP-1 receptor agonists have shown benefit in reducing MASLD-related steatosis and liver enzyme elevation, though their approval specifically for MASH fibrosis remains an active regulatory question at the time of writing.

For MetALD specifically, alcohol reduction to below the MetALD threshold — moving the patient back into MASLD territory — is the highest-priority intervention. This frequently requires formal addiction medicine support rather than simple lifestyle advice, and the clinical management of MetALD should involve both hepatology and, where applicable, addiction psychiatry.

The questions your doctor should be answering

If you have a MASLD/NAFLD diagnosis and these questions have not been explicitly discussed, they need to be.

Which of the five cardiometabolic criteria do you meet, and are they being actively managed? Is your liver disease simple steatosis, or is there active inflammation (MASH)? What is your current fibrosis stage — has a fibroscan or biopsy been performed? Are you in the MetALD range based on your alcohol intake, and has this been explicitly factored into your management? Is your waist circumference being monitored alongside your BMI? And — critically for Indian patients — has your insulin resistance been formally assessed even in the absence of frank diabetes?

These are not optional questions. They determine the clinical trajectory of a disease that, left incompletely managed, can progress silently from steatosis to cirrhosis over years.

The honest summary

The new name — MASLD — was chosen by a multisociety Delphi consensus endorsed by 236 panellists across 56 countries. It is not a rebranding exercise. It is a precision upgrade to a disease framework that was always mechanistically incomplete.

For Indian patients, the upgrade is especially meaningful: the BMI ≥23 cutoff formally recognises the thin-fat Indian phenotype that Indian hepatologists have been trying to communicate to the broader medical community for years. Lean MASLD is real, it is common in India, and it now has a diagnostic framework that explicitly captures it.

If you have a fatty liver diagnosis — under any name — the question that matters is not what the label is called. It is whether you understand the mechanism driving your disease, whether your cardiometabolic risk factors are being managed, whether your fibrosis has been staged, and whether your management plan is complete.

If your fatty liver report is more than 12 months old, has never been followed up with a Fibroscan, or has never been reviewed by a DM Hepatologist — that gap in your care deserves to be closed.

Book a consultation with Dr. Chetan Kalal at drchetankalal.com — in-person in Mumbai or via virtual consult internationally.

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Frequently asked questions

What is MASLD? MASLD stands for Metabolic dysfunction-Associated Steatotic Liver Disease. It is the new name for what was previously called NAFLD (non-alcoholic fatty liver disease), adopted by the major international hepatology societies in 2023. It is diagnosed by the presence of liver fat plus at least one of five cardiometabolic criteria: overweight/central obesity (BMI ≥23 in Indians), elevated fasting glucose or diabetes, high blood pressure, elevated triglycerides, or low HDL cholesterol.

What is the difference between MASLD and MASH? MASLD is the overarching diagnosis — fatty liver with metabolic risk factors. MASH (Metabolic dysfunction-Associated Steatohepatitis) is the inflammatory subtype, characterised by active hepatocellular injury and ballooning in addition to fat accumulation. MASH carries significantly higher risk of fibrosis progression and cirrhosis. The distinction requires liver biopsy or validated non-invasive testing for definitive classification.

What is MetALD? MetALD is a new disease category introduced in the 2023 nomenclature consensus for patients who have MASLD and also drink alcohol at increased levels — 140–350 g/week for women and 210–420 g/week for men. Above these thresholds the diagnosis shifts to alcohol-associated liver disease. MetALD is not the same as ALD, but it is also not the same as pure MASLD — it requires managing both metabolic and alcohol-related injury pathways.

Does NAFLD still mean the same thing as MASLD? The underlying disease is the same. The definition has been refined: MASLD now requires the presence of at least one of five specific cardiometabolic criteria, which NAFLD did not formally require. Most patients previously diagnosed with NAFLD will meet MASLD criteria. The key practical difference is that the BMI threshold for South Asian populations has been explicitly set at ≥23 kg/m² in the MASLD definition.

What is the Indian BMI cutoff for MASLD? The MASLD consensus incorporates a BMI ≥23 kg/m² cutoff for South Asian populations, including Indians, reflecting the well-documented metabolic risk at lower BMI values in this population compared to Western BMI standards. This means lean Indians with a BMI of 23–24 may meet MASLD criteria if any other cardiometabolic risk factor is present.

Source: Rinella ME et al. "A multisociety Delphi consensus statement on new fatty liver disease nomenclature." Journal of Hepatology 2023;79(6):1542–1556. DOI: 10.1016/j.jhep.2023.06.003. Also published in Hepatology 2023;78(6):1966–1986. DOI verified via PubMed. The AASLD 2023 practice guidance updates referenced in this article are available via AASLD.org. Resmetirom FDA approval status and GLP-1 agonist indications should be verified with current regulatory databases before clinical application — drug approval timelines vary by jurisdiction.