I have a question for the docs here. I was diagnosed with NAFLD (just steatosis, no confirmed NASH) about 2 years ago. My PCP has been tracking my ALT which hovers around 55-65 U/L. FibroScan showed CAP 312 but stiffness was only 5.8 kPa (F0-F1). My PCP says I don't need treatment because my fibrosis score is low. He told me to lose weight and come back in a year. But I'm worried about progression. I'm 39, BMI 34, pre-diabetic (HbA1c 5.9%). Am I wrong to want more aggressive treatment? The "lose weight" advice isn't helpful when I've been trying to do exactly that for 15 years.

You're not wrong, and this is a systemic problem in how we manage early-stage fatty liver disease. Your numbers tell a story: CAP 312 (moderate-severe steatosis), persistently elevated ALT (55-65), pre-diabetic, BMI 34, age 39. You don't have significant fibrosis YET, but you have all the risk factors for rapid progression. Your FIB-4 score (which uses age, AST, ALT, and platelet count) is probably low because you're young. FIB-4 is biased toward older patients — it systematically underestimates fibrosis risk in people under 45. What I'd recommend: 1. Ask for a hepatology referral. PCPs often don't appreciate the progression risk in young patients with metabolic NAFLD. 2. A GLP-1 RA is justified based on your pre-diabetes and obesity alone (cardiovascular risk reduction), and the liver benefit is a major bonus. 3. Get a comprehensive metabolic panel including insulin level, HOMA-IR calculation, lipid panel, and uric acid. 4. Repeat FibroScan in 6-12 months to establish a trajectory. The patients who progress fastest from F0 to F3 are exactly your phenotype — young, metabolically unhealthy, persistently elevated ALT. Intervening now while you have no fibrosis is enormously easier than trying to reverse F3 later. "Lose weight" is a treatment goal, not a treatment plan. You deserve a plan.