HealthAndMe, the health vertical of the Bennett, Coleman & Co. group (Times of India), published a bylined article by Dr. Chetan Kalal in its July 25, 2026 edition. The piece — authored under his name and published to a national audience — addresses a clinical question that reaches his outpatient practice with increasing frequency: how does a lean, physically active person with no diabetes end up with fatty liver?
The short answer is that body weight was never the whole story. The longer answer is what the article sets out to explain.
The lean MASLD problem
Fatty liver — formally termed Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) — is still widely assumed to be a condition of the overweight or the metabolically unwell. That assumption is increasingly inadequate. Dr. Kalal notes in the article that lean MASLD accounts for nearly 10–20% of fatty liver cases in Asia, and that the true burden in India may be even higher, given the distinct genetic and metabolic profile of South Asians.
Three mechanisms that do not require obesity
The article identifies three drivers that operate independently of excess body weight.
Genetics. The PNPLA3 gene variant predisposes the liver to fat accumulation regardless of what a person weighs. This variant is significantly more prevalent among South Asians than in Western populations. A patient can be lean, exercise regularly, and eat reasonably well — and still carry a liver primed to store fat because of inherited biology.
Visceral fat at normal BMI. Standard body weight measurements are blunt instruments. Many Indians carry excess fat concentrated around their internal organs — the so-called “skinny fat” pattern — without this being visible on a BMI reading or clinical examination. This visceral adiposity drives the same inflammatory pathways in the liver that obesity does in heavier individuals.
Dietary fructose load. The liver processes fructose through a dedicated metabolic route that leads directly to fat synthesis. A diet built on refined carbohydrates — white rice, maida, packaged biscuits, sugary beverages, fruit juices — keeps this pathway active regardless of whether the person gains visible weight. Over years, the liver accumulates fat while the waistline remains normal.
The clinical takeaway
Routine health check-ups should not bypass liver assessment simply because a patient is lean. Grade 1 fatty liver in a 34-year-old who goes to the gym and has never been overweight is no longer a clinical anomaly; it is a recognisable pattern that warrants a structured workup — dietary history, visceral fat assessment, and, where appropriate, consideration of genetic risk.
Dr. Kalal is Associate Director, Hepatology and Liver Transplant, at Gleneagles Hospital, Mumbai.
Read the full article: You’re Not Overweight. You Don’t Have Diabetes. So Why Do You Have Fatty Liver? — HealthAndMe, July 25, 2026.