Despite the hepatoprotective effects of Spirulina supplementation on our study population, a US change of steatosis among NAFLD patients was not revealed. This finding was not surprising considering that although a US is a widely available and low-cost technique, it is not quantitative or strongly correlated with histopathologic steatosis assessment; nor is it able to display variations across steatosis grades [65,66]. Only a liver biopsy before and after Spirulina supplementation could demonstrate a change on the histopathologic grading of hepatic steatosis. Among imaging techniques, T1-weighted dual-echo MR imaging and 1H MR spectroscopy appear to have the best diagnostic accuracy in depicting hepatic steatosis, in contrast to US and CT [65]. Unfortunately, they were not available in our hospital.