Pilates for fatty liver (MASLD): liver fat, strength work and what to add

Common and usually silent

NICE says MASLD affects about 30% of adults and about half of people with type 2 diabetes. The NHS says it doesn't usually cause symptoms, and most people only ever have the first stage.

Sources 1, 2

Being active lowers liver fat, even without weight loss

In trials using MRI scans, exercise cut liver fat by about 3 percentage points. About 150 minutes a week of brisk walking made a meaningful fall in liver fat 3.5 times as likely, whether or not people lost weight.

Sources 4, 5, 6

Strength work counts

Resistance exercise lowered liver fat in trials, and guidelines prefer cardio and strength together. The NHS lists Pilates among muscle-strengthening activities, so it fits as the strength half of the week.

Sources 7, 8, 4, 9

Pilates itself has hardly been tested

We found four tiny Iranian studies, none with an MRI scan, and the only one in the main medical database found no change in liver blood tests. A US sports medicine roundtable calls the place of yoga and Pilates uncertain.

Sources 10, 13, 15, 17

Weight and scarring matter most

If you're overweight, losing weight does more for inflammation and scarring than exercise alone. NICE recommends a test for liver scarring for everyone with MASLD, because routine liver blood tests are often normal.

Sources 4, 1

No move detoxes the liver

Liver UK says no complementary or alternative medicine has been shown to treat or prevent MASLD. Twists and tummy work don't massage or cleanse the liver.

Source 18

The names

The NHS page is still called NAFLD and says: "It's also known as metabolic dysfunction-associated steatotic liver disease (MASLD)." The new names were agreed in 2023, partly because many people found the old ones stigmatising, and NICE renamed its guideline in July 2026.

Sources 2, 3, 1

Who's more likely to have it

The NHS lists being overweight, "particularly if you have a lot of fat around your stomach and waist", type 2 diabetes, polycystic ovary syndrome, high blood pressure or cholesterol, being over 50 and not being very active. NICE says about 46% of people with obesity and 53% of people with type 2 diabetes have it.

Sources 2, 1

The stages

Fat without damage, then inflammation (MASH), then scarring (fibrosis), then cirrhosis. "Most people only have the 1st stage, which does not usually cause any problems."

Source 2

Blood tests and scarring

NICE says "more than 80% of patients with MASLD have normal routine liver blood tests", so they don't rule it out, and asks for a scarring test for everyone with MASLD.

Source 1

The heart and the muscles

NICE says MASLD is a risk factor for type 2 diabetes, high blood pressure and kidney disease, and in type 2 diabetes for heart attacks and strokes. In 29 studies, about 1 in 4 people with MASLD had low muscle mass and strength, one reason strength work matters.

Sources 1, 20

How hard Pilates is

Mat Pilates is about 1.8 METs and Pilates in general 2.8, against 4.8 for brisk walking. The liver fat trials point to about 750 MET-minutes a week: roughly 4 to 7 hours of Pilates, or about 2.5 hours of brisk walking (our arithmetic). So walking does most of the dose, and Pilates is the strength half.

Sources 21, 22, 23, 6

Exercise lowers liver fat with little or no weight lossStrong evidence

In 12 controlled trials, the benefit for liver fat came "with minimal or no weight loss". In 19 trials with MRI scans (745 people), interval and steady exercise each cut liver fat by about 3 percentage points. The European guideline says exercise alone reduces liver fat.

Sources 24, 4, 5

How muchEmerging evidence

In 14 trials (551 people), exercisers were 3.5 times as likely to see a 30% fall in liver fat, the size linked with improvement on biopsy, with at least 750 MET-minutes a week (for example 150 minutes of brisk walking). A 2026 analysis of 24 trials found the benefit levelled off at about 630 to 850 MET-minutes a week.

Sources 6, 25

Cardio, strength or bothEmerging evidence

Aerobic and resistance exercise both lowered liver fat, and resistance work used less energy, so it may suit people who find cardio hard. In 11 trials of resistance training, 7 of 8 that scanned the liver found less fat. In one trial, machine resistance training lowered liver fat more than home stretching. Guidelines prefer cardio and strength combined.

Sources 7, 8, 27, 25, 4

Scarring and inflammation need moreEmerging evidence

In 3 small trials (72 people), exercise alone didn't improve liver biopsies. If you're overweight, the European guideline's targets are at least 5% of your weight to reduce liver fat, 7% to 10% for inflammation and 10% or more for scarring, and in a study of 293 people the more weight people lost, the more their liver improved.

Sources 19, 4, 28

Liver blood testsMixed evidence

Exercise alone didn't reliably change ALT, a liver enzyme, in reviews, so a normal or unchanged blood test doesn't mean exercise isn't working.

Sources 24, 26

New medicinesStrong evidence

Semaglutide and resmetirom improved inflammation and scarring on biopsy in large trials of people with MASH and scarring. They are specialist treatments; exercise goes alongside them.

Sources 29, 30

A handful of tiny studies, none with MRIStrong evidence

Our searches of PubMed, Crossref and ClinicalTrials.gov in November 2026 found four small Pilates studies in fatty liver that we could read, all from Iran and all 8 weeks long, one of them an unpublished thesis. None measured liver fat with an MRI scan or a biopsy, and ClinicalTrials.gov had no registered Pilates trial in fatty liver.

Source 16

One trial in men, reported three timesMixed evidence

Twenty men with fatty liver did mat Pilates 3 times a week for 8 weeks or no exercise. Their ultrasound grade and a liver enzyme (ALT) improved, but the Pilates group also lost about 3.7 kg, so the change can't be put down to Pilates alone. Three papers in different journals appear to report these same participants (our inference), so we count them as one trial.

Sources 10, 11, 12

One trial in women, reported twiceMixed evidence

Twenty women with fatty liver did Pilates for 8 weeks; the first paper reports blood fats, blood sugar and blood pressure, and the liver wasn't scanned again. A second paper, which appears to report the same participants (our inference), found liver enzymes fell only when Pilates was combined with a herbal supplement.

Sources 13, 14

The one in the main medical database: no changeMixed evidence

In 32 women with fatty liver, 8 weeks of Pilates with or without broccoli sprout extract didn't change liver enzymes.

Source 15

What guidance saysStrong evidence

The US sports medicine roundtable: "The appropriateness of other types of physical activity including yoga and Pilates remains uncertain." Its Pilates evidence is the trial in 20 men above.

Source 17

The weekly target

More than 150 minutes of moderate activity or 75 minutes of vigorous activity a week, plus strength work twice a week. Liver UK: "Aim for at least 2½ hours (150 minutes) of moderate intensity activity every week." and "It's also important to do activities that strengthen your muscles twice a week."

Sources 4, 18, 2

Pilates as the strength half

Count 2 Pilates sessions a week as strength work, and make them work: standing strength moves, a band and short rests. The effective resistance programmes in trials ran about 45 minutes, 3 times a week for 12 weeks.

Sources 9, 7

Walking for the cardio

Brisk walking was the dose behind the 30% falls in liver fat. Our walk and Pilates class puts a 20-minute brisk walk and a Pilates circuit in one session (our editorial structure).

Source 6

Keep going

The effective programmes in trials ran for about 12 weeks, and the gains fade if you stop, as our exercise for fatty liver guide says.

Source 7

Cirrhosis with fluid in your tummy

Ask your liver team first. Leave out lying face down (swimming, the swan and the kick series), moves that squash your tummy (rolling like a ball, the seal and the moves that take your legs over your head) and long held planks, and keep breathing rather than straining (our suggestion). The NHS lists weak bones among the complications of cirrhosis, so the osteoporosis cautions on the rolling and curl-up moves apply too.

Source 32

Type 2 diabetes

Keep hypo treatment nearby if you take insulin or a sulfonylurea, and wear shoes for standing work if your feet are numb, as our Pilates for diabetes guide says.

A bigger body or sore knees

Start with the standing moves and our chair-to-mat class for bigger bodies, which has a chair-only option. Use a sturdy chair rated for your weight, as the sit to stand's own caution says.

Call 999

Call 999 for any of these, and don't drive yourself to A&E:

• You're vomiting blood (it can look bright red, brown or black, or like coffee granules) and feel unwell, confused, faint or dizzy, have rapid or shallow breathing, cold, clammy, pale skin, tummy pain or black poo.
• You have cirrhosis and you're vomiting blood, your poo is very dark or black, or you suddenly become confused or have slurred speech.
• Chest pain that feels tight or like squeezing, or spreads to your arms, neck or jaw, or severe difficulty breathing.

Sources 34, 32

Urgent GP appointment or NHS 111

• Your skin or the whites of your eyes turn yellow (jaundice), perhaps with itchy skin, darker pee and paler poo.
• You have cirrhosis and you're more short of breath than usual, or your tummy, legs, ankles or feet are swelling.
• You vomited blood, but it has stopped and you have no other symptoms.

Sources 33, 32, 34

Signs of more advanced liver disease

Liver UK lists these signs of more advanced liver disease:

• Yellowing of the skin and the whites of the eyes.
• Bruising easily.
• Dark urine.
• A swollen tummy (ascites), or swollen legs, ankles or feet.
• Weight loss you can't explain.
• Vomiting blood, or dark, black, tarry poo.
• Confusion, memory problems, mood changes or poor judgement.
• Itchy skin.

Source 18

See a GP

• You think you might have MASLD, or you're at higher risk: overweight, especially around the waist, type 2 diabetes, PCOS, high blood pressure or cholesterol, or over 50.
• You've been told you have fatty liver but haven't been offered a test for scarring (NICE recommends one for everyone with MASLD).
• You're worried about how much you drink, or want help to stop.

Sources 2, 1

Chest pain or fainting: call 999

Call 999 if:

• You get sudden pain or discomfort in your chest that doesn't go away; it can feel like squeezing or pressure, burning or indigestion.
• The pain spreads to your left or right arm, or your neck, jaw, stomach or back.
• You have chest pain and feel sweaty, sick, light-headed or short of breath.
• Someone faints while exercising, can't be woken within 1 minute, or has chest pain or a pounding, fluttering or irregular heartbeat.

Sources 35, 36, 37

Breathlessness

Call 999 or go to A&E (accident and emergency) straight away for severe difficulty breathing (gasping, choking or not able to get words out), a chest that feels tight or heavy, pain that spreads to your arms, back, neck and jaw, lips or skin turning very pale, blue or grey, or sudden confusion. If you're more short of breath than usual, or your heart is racing, fluttering or skipping beats, contact NHS 111.

Source 38

Cirrhosis, diabetes and stopping

With cirrhosis, ask your liver team what exercise suits you before starting or stepping up (our suggestion), and talk to your doctor before trying to lose weight, as Liver UK advises. With type 2 diabetes on insulin or a sulfonylurea, follow the hypo advice in our type 2 diabetes guide. Stop and rest if you get chest pain, unusual breathlessness, dizziness or palpitations (our suggestion).

Source 18

Statins

NICE: "Be aware that people with MASLD who are taking statins should keep taking them."

Sources 1, 31

Stop the session if

You feel any pain or become unwell, as the NHS advises for its Pilates videos, and especially for chest pain or pressure, unusual breathlessness, dizziness or fainting. If you have a health problem, an injury or any symptoms, get advice from a healthcare professional, such as a GP, before you start.

Source 39

Before you start

The NHS advises getting advice from a healthcare professional first if you have a health problem, an injury or symptoms, or have recently had a heart attack or an operation.

Source 39

"Pilates melts liver fat"Mixed evidence

Only a handful of tiny trials, by ultrasound grade or blood tests, and the one in the main medical database found no change. The US roundtable calls Pilates' place uncertain.

Sources 10, 15, 17

"Twists or tummy work detox the liver"Strong evidence

No study tests it, and Liver UK says no complementary or alternative medicine treats MASLD. Our yoga for fatty liver guide says the same about poses.

Sources 16, 18

"Exercise only helps your liver if you lose weight"Strong evidence

Exercise lowered liver fat with little or no weight loss. Weight loss adds more for inflammation and scarring.

Sources 24, 6

"Only cardio counts"Emerging evidence

Resistance exercise lowered liver fat too, and guidelines prefer cardio and strength combined.

Sources 7, 4

"Normal liver blood tests mean a healthy liver"Strong evidence

NICE says more than 80% of people with MASLD have normal routine liver blood tests.

Source 1