Image for representation.
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You’ve probably come across the term “skinny fat” while scrolling through fitness content. It refers to individuals who appear slim on the outside but carry unhealthy fat deposits internally, particularly around key organs like the liver.
Another term gaining traction is TOFI (Thin Outside, Fat Inside). In clinics across urban India, doctors are increasingly seeing lean, young adults with signs of liver dysfunction. One of the most underdiagnosed and silent consequences of this hidden fat is Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD). Once thought to affect primarily those with obesity or visible weight gain, MASLD is now frequently seen in active, seemingly healthy individuals. That makes it more dangerous because it hides in plain sight.
Why are lean people developing fatty livers?
The liver plays a vital role in metabolism, hormone regulation, and detoxification. When it begins to store fat without excessive alcohol intake or noticeable weight gain, it signals systemic dysfunction. The main contributors include:
Hormonal imbalances: PCOS, thyroid dysfunction, and insulin resistance are increasingly common, even among those with a normal BMI. These hormonal issues can alter how the liver processes sugar, fat, and cholesterol, leading to fat buildup in the liver over time.
Unbalanced nutrition despite fitness: Urban lifestyles present a paradox as people may work out consistently but eat poorly. Diets high in ultra-processed foods, excessive protein supplements, sugary drinks, and extreme regimens like fasting or keto often lack essential micronutrients. Overconsumption of fructose and refined carbs burdens the liver, triggering fat accumulation.
Self-medication & detox trends: The rising use of over-the-counter gym supplements, fat burners, and unregulated detox products is concerning. These “natural” solutions can overwhelm the liver’s detox pathways, disrupt enzyme function, and sometimes even lead to inflammation or fibrosis.
A disease with no alarms
One of the biggest challenges in detecting MASLD in lean individuals is the absence of clear symptoms. There’s often no pain, jaundice, or fatigue until the liver is significantly compromised. It’s rightfully called a “silent” disease.
Mild cues, like persistent sugar cravings, unexplained digestive issues, stubborn belly fat, or subtle hormonal changes, are easily dismissed or blamed on stress. But these signs may be early indicators of liver dysfunction.
Gut health, an overlooked axis
Emerging research points to a strong gut-liver connection. Poor gut health, caused by overuse of antibiotics, low-fibre diets, or irregular eating patterns, can trigger inflammation that quietly damages the liver. For TOFI individuals, this invisible stress accelerates fatty liver progression even without visible symptoms.
A wake-up call for urban youth
The shift from a fit-looking exterior to internal metabolic dysfunction is more than cosmetic; it’s clinical. Increasingly, young adults in their 20s and 30s are being diagnosed with fatty liver during routine check-ups or fertility evaluations. If left unaddressed, MASLD can progress to inflammation (steatohepatitis), scarring (fibrosis), and ultimately, cirrhosis. What’s more alarming is that MASLD in lean individuals often escapes both patient and physician scrutiny, until it’s advanced.
How to protect your liver
The good news? MASLD is largely preventable and reversible with consistent lifestyle changes. Here’s how:
Return to real food: Embrace simple, home-cooked meals rich in vegetables, whole grains, legumes, and good fats. Skip processed “health” bars and artificial juices
Be cautious with supplements: Take them only under professional supervision. Not all “natural” labels guarantee liver safety.
Balance your routine: Don’t overtrain without adequate nutrition and rest. A mix of strength, cardio, and recovery promotes better hormonal and liver health.
Prioritise sleep & stress management: Chronic stress and poor sleep raise cortisol and disrupt insulin sensitivity, both key factors in liver health.
Regular screening: Annual liver enzyme tests and ultrasounds are crucial, especially for those with family histories of metabolic or hormonal conditions.
We often associate liver disease with obesity or alcohol. But today’s reality is more complex. MASLD is becoming common among young, lean Indians who assume fitness equals health. If your regimen includes detox teas, skipped meals, and protein shakes, this is your gentle wake-up call. Sometimes, the body doesn’t scream for help. It whispers. Listen to the subtle signs, and don’t ignore them. Even a simple test could protect your liver for life.
(The author is a senior consultant in HPB & GI Surgery and multi-organ transplant surgery.)