A post hoc analysis of the NASHFit randomized clinical trial found that moderate-intensity aerobic exercise substantially improved noninvasive markers of metabolic dysfunction-associated steatohepatitis (MASH) resolution, even without clinically significant weight loss. The analysis included 23 adults with biopsy-confirmed MASH who completed a 20-week intervention involving either supervised aerobic exercise or standard clinical care. Using the MASH Resolution Index (MASH-RI), researchers found that 33% of participants in the exercise group met the biomarker-based threshold for MASH resolution, compared with 13% receiving standard care. Additionally, 53% of exercisers achieved a clinically meaningful reduction in alanine aminotransferase (ALT) level of at least 17 U/L, compared with 13% of controls. A reduction in liver fat of at least 30%, measured by magnetic resonance imaging-proton density fat fraction (MRI-PDFF), occurred in 36% vs 13%, respectively. These improvements in noninvasive biomarkers occurred largely independently of clinically significant weight loss (≥5%).

The findings reinforce the importance of prescribing structured exercise as part of routine MASH management, regardless of whether patients achieve substantial weight loss. The intervention consisted of 150 minutes of moderate-intensity aerobic activity weekly, divided into five 30-minute sessions, demonstrating a practical approach consistent with current physical activity recommendations. The study also highlights the potential value of MASH-RI, which combines ALT, aspartate aminotransferase, and MRI-PDFF measurements to assess treatment response without repeat liver biopsy. However, the small sample size, short study duration, and absence of follow-up biopsies mean that biomarker-defined improvement cannot be equated with confirmed histologic resolution. Larger studies are needed to determine whether these improvements translate into sustained fibrosis regression and better long-term outcomes.

Reference:  Channapragada T, Batra S, Hummer BL, et al. Aerobic exercise training leads to MASH resolution as defined by the MASH Resolution Index. Dig Dis Sci. 2026;71(2):628-635. doi:10.1007/s10620-025-09361-9

A new review highlights growing evidence that exercise can improve metabolic dysfunction-associated steatotic liver disease (MASLD), even without significant weight loss. Findings from randomized trials and meta-analyses show that aerobic exercise, resistance training, and high-intensity interval training (HIIT) can reduce liver fat, improve liver enzymes and insulin sensitivity, and support cardiometabolic health. Notably, patients who meet recommended physical activity levels are more than 3.5 times as likely as inactive individuals to achieve meaningful improvements in liver fat and markers of hepatic inflammation and fibrosis. Both HIIT and moderate-intensity continuous exercise can reduce liver fat by approximately 3%, although HIIT may achieve similar benefits in less time. Resistance training offers additional advantages for patients with sarcopenia or myosteatosis, conditions associated with poorer outcomes in MASLD. Although exercise may improve noninvasive fibrosis markers, evidence demonstrating fibrosis regression through exercise alone remains limited.

The findings support prescribing exercise as a core component of MASLD management rather than focusing exclusively on weight loss. Current guidelines recommend at least 150 minutes of moderate-intensity aerobic activity weekly, combined with resistance training targeting major muscle groups 2 to 3 days per week. Exercise programs should be individualized according to cardiovascular risk, physical limitations, muscle strength, and patient preferences, with gradual progression and efforts to reduce prolonged sitting. The review also introduces Rehabilitation for Metabolic and Hepatic Dysfunction (REMEDHE), a proposed multidisciplinary framework combining structured exercise, nutrition, behavioral support, and medical management. Although this approach requires further validation, it emphasizes monitoring measurable outcomes, including liver fat, liver enzymes, fibrosis markers, and physical fitness. These findings reinforce the importance of incorporating practical, sustainable exercise counseling into routine MASLD care, including for patients who struggle to achieve or maintain weight loss.

Reference: Martinez Rodriguez LA, Guevara Olivera MR, Gutierrez Espinosa CS, et al. Prescribing exercise in MASLD: from evidence to a structured, measurable intervention. Curr Hepatol Rep. 2026;25:24. doi:10.1007/s11901-026-00740-y

As treatment options for metabolic dysfunction–associated steatohepatitis (MASH) expand, identifying patients with significant liver fibrosis is increasingly important. In a Medscape educational discussion, liver disease specialists Meena Bansal, MD, and Zobair Younossi, MD, reviewed current recommendations for noninvasive fibrosis assessment, emphasizing targeted screening of patients with type 2 diabetes, obesity with cardiometabolic risk factors, or persistently elevated liver enzymes. The Fibrosis-4 (FIB-4) index remains the recommended first-line assessment, with a score below 1.3 generally indicating low risk and a score of 1.3 or higher prompting additional evaluation. Second-line testing with vibration-controlled transient elastography (VCTE/FibroScan) or the Enhanced Liver Fibrosis test can help identify patients with clinically significant fibrosis. A VCTE liver stiffness measurement below 8 kPa generally indicates low risk, while measurements of 8-15 kPa may suggest fibrosis stages F2-F3, the primary population considered for MASH-directed treatment.

The discussion highlights a practical, stepwise approach to identifying patients who need further testing, specialist referral, or treatment. FIB-4 interpretation requires particular attention in older adults and patients with diabetes, while magnetic resonance elastography may offer greater accuracy when VCTE results are uncertain. Liver biopsy is no longer routinely necessary for fibrosis assessment but may be appropriate when noninvasive findings are discordant or when additional histologic information would influence management. Patients with noncirrhotic MASH and moderate to advanced fibrosis (F2-F3) may be candidates for therapies approved by the US Food and Drug Administration, including resmetirom and semaglutide, depending on clinical characteristics and treatment eligibility. The experts emphasized that noninvasive testing can support not only initial risk stratification but also treatment selection, monitoring, and long-term management.

Reference: Bansal M, Younossi ZM. Noninvasive assessment of MASH fibrosis. Medscape Education.  May 15, 2026. Accessed October 19, 2026. https://www.medscape.org/s/viewarticle/noninvasive-assessment-mash-fibrosis-2026a10007a4