Five years ago, a 50-year-old businessman walked into my clinic with what, at that stage, was a very manageable problem. He had obesity, diabetes, hypertension and mildly elevated liver enzymes. An ultrasound showed Grade 2 fatty liver, while a FibroScan revealed significant fibrosis — evidence that his liver had already begun to develop scar tissue but had not yet reached a point of no return.I explained his treatment plan. It wasn’t glamorous, but it was backed by solid evidence: lose weight, adopt a Mediterranean-style diet, take medicines to control diabetes and obesity (metformin and empagliflozin cause modest weight loss too), return for regular follow-up blood tests and FibroScans, and monitor for disease progression. He listened carefully but then chose a different path.Instead of following evidence-based treatment, he became convinced that he could “cleanse” his liver naturally. He began taking over-the-counter herbal supplements and liver cleansers purchased online, including products containing milk thistle (Silymarin). He stopped taking his diabetes medication, skipped his follow-up appointments and believed he was protecting his liver naturally.Five years later, he returned. His weight had increased by another 10 kg. His HbA1c (average blood sugar count of three months) had climbed from 7.5% to 9%, reflecting poorly controlled diabetes. His cholesterol remained high. He proudly told me he had continued walking for half an hour every day throughout those years, an effort too little. He had begun experiencing persistent fatigue, abdominal bloating and declining stamina. Blood tests showed his platelet count had fallen to 80,000, a warning sign of advanced liver disease. His liver function tests revealed low albumin, indicating chronic liver dysfunction. A repeat FibroScan showed advanced fibrosis or scarred tissue, far worse than what we had documented five years earlier.An endoscopy demonstrated enlarged veins in his oesophagus or food pipe caused by increased pressure in the liver’s blood vessels and carrying a risk of life-threatening bleeding. His liver disease had progressed to cirrhosis. Yet much of this progression could likely have been prevented.Why ‘liver Detox’ sounds so convincingMy patient’s story is not unique. Increasingly, I see people who postpone proven treatment because they believe herbal supplements and liver detox products offer a safer, more natural alternative. The internet is flooded with advertisements promising to cleanse, regenerate or detoxify the liver using herbal capsules, powders and tonics. Testimonials often sound persuasive, and “natural” is frequently equated with “safe.”But medicine does not work on testimonials. It works on evidence. Recent evidence reviews published in 2025 found that while Silymarin may produce a small improvement in liver enzyme levels in some patients, it has not consistently improved liver fibrosis, liver fat, disease progression or long-term outcomes. Most studies on efficacy of herbal supplements remain small, of low methodological quality or inconsistent, making their conclusions uncertain. At present, there is insufficient high-quality evidence to recommend OTC herbal liver cleansers as improving fatty liver.Story continues below this adEqually important, the quality of supplements sold online is highly variable. Unlike prescription medicines, many herbal products are not subjected to the same rigorous standards of manufacturing, purity and quality control. Some have themselves been implicated in drug-induced liver injury because of contamination, adulteration or unpredictable ingredients.Why treatment delays can be costly?So, every year spent relying on an unproven liver cleanser is another year during which diabetes remains uncontrolled, obesity worsens, cholesterol stays elevated and liver scarring progresses quietly. That is exactly what happened to my patient.His daily walks certainly benefited his overall health but could not compensate for progressive weight gain, poorly controlled diabetes and the absence of medical treatment. Meanwhile, the disease continued advancing silently until cirrhosis had already developed, when the liver loses its ability to function normally.Another misconception is that liver enzyme levels tell the whole story. They do not. Many patients with significant fibrosis have only mildly abnormal — or even completely normal— liver enzyme levels. While liver enzymes may fluctuate, they are poor indicators of how much scarring is actually present. This is why regular monitoring with blood tests, FibroScan and, when appropriate, ultrasound is so important.Story continues below this adWhat actually changes the course of diseaseThe encouraging news is that we already know what works. The single most effective intervention is sustained weight loss. Losing at least 10% of body weight has consistently been shown to reduce liver fat, improve inflammation and, in many patients, reverse fatty liver. This should be accompanied by a Mediterranean-style diet rich in vegetables, fruits, whole grains, legumes, olive oil, nuts and fish; tight control of diabetes; treatment of obesity; management of cholesterol; avoidance of excess alcohol; and regular moderate-intensity exercise.For many patients, weight-loss medications prescribed for obesity or diabetes can be valuable tools to achieve meaningful and sustained weight reduction when lifestyle measures alone are insufficient. These approaches may not promise a dramatic “detox,” but they are the interventions proven to change the natural history of liver disease.Interestingly, drinking two to three cups of coffee a day has consistently been associated with lower liver fibrosis and appears to protect the liver by reducing inflammation. While coffee is not a treatment by itself, it is one of the few dietary factors repeatedly associated with better liver outcomes.The window to reverse fatty liver is not open foreverWhen I think about my patient today, I do not see someone who made a foolish decision. I see someone who wanted to do the right thing for his health but was persuaded by marketing that promised a simple, natural solution. Fatty liver disease often gives us a valuable window during which the liver can heal. But that window does not remain open indefinitely.(Dr Tickoo is senior director, Internal Medicine, Max Healthcare)