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Background & Aims: Large prospective studies to establish the prevalence of non-alcoholic fatty liver disease (NAFLD) and steatohepatitis (NASH), are lacking. We prospectively assessed the prevalence and severity of NAFLD/NASH in a cohort of asymptomatic middle-aged Americans attending a colonoscopy class at a gastroenterology clinic., Methods: Screening for NAFLD was performed using magnetic resonance (MR)-based LiverMultiScan® proton density fat fraction (LMS-PDFF). MR exams also included corrected T1 and elastography for liver stiffness measurement (LSM). FibroScan® was also used to measure LSM. Participants with predetermined abnormal imaging parameters were offered a liver biopsy. Biopsies were read in a blinded fashion with results based on the consensus by 2 expert pathologists. The prevalence of NAFLD was determined by PDFF ≥5% or by histological diagnosis of NAFLD (if biopsy data were available). The prevalence of NASH was defined by biopsy., Results: Of 835 participants, 664 met the inclusion and exclusion criteria. The mean age was 56 ± 6.4 years, 50% were male, the mean BMI was 30.48 ± 5.46 kg/m 2 , and 52% were obese. The prevalence of NAFLD was 38% (95% CI 34-41%) and the prevalence of NASH was 14% (95% CI 12-17%). While no patient had cirrhosis on biopsy, significant fibrosis (F ≥2) was present in 5.9% (95% CI 4-8%) and bridging fibrosis in 1.6% (95% CI 1-3%). In a multivariable analysis, factors associated with the presence of NASH were race, obesity, and diabetes., Conclusion: Using state-of-the-art liver imaging modalities and reference biopsy, this study establishes an overall prevalence of NAFLD of 38% and NASH by biopsy of 14% in this cohort of asymptomatic middle-aged US adults., Lay Summary: There are no prospective studies to determine how common is nonalcoholic steatohepatitis (NASH), the severe form of non-alcoholic fatty liver disease (NAFLD). In a large number of asymptomatic middle-aged Americans, we used a combination of state-of-the-art liver imaging methods and liver biopsy to prospectively determine the prevalence of NAFLD and NASH. NAFLD was diagnosed in 38%, NASH in 14%, and significant liver fibrosis in 6% of asymptomatic middle-aged Americans., Competing Interests: Conflict of interest Dr. Harrison-SAH reports grants from Bristol Myers Squibb, Pfizer, Second Genome, Tobira/Allergan, and Genentech; grants, personal fees, and stock/equity from Akero, Axcella Health, Cirius Therapeutics, Galectin Therapeutics, Genfit, Madrigal Pharmaceuticals, Metacrine, NGM Biopharmaceuticals, and NorthSea Therapeutics; grants and personal fees from Cirius Therapeutics, CiVi Biopharma, CymaBay Therapeutics, Conatus Pharmaceuticals, Galmed Pharmaceuticals, Gilead Sciences, Hepion Pharmaceuticals, High Tide Therapeutics, Intercept Pharmaceuticals, Novartis, Novo Nordisk, Sagimet Biosciences, and Viking Therapeutics; personal fees and stock/equity from HistoIndex; and personal fees from Altimmune, Blade Therapeutics, Chronic Liver Disease Foundation, Corcept Therapeutics, Echosens, Foresite Labs, Gelesis, Indalo Therapeutics, Innovate Pharma, IQVIA, Lipocine, Medpace, Perspectum, Poxel, Prometheus, Prometic, Terns Pharmaceuticals, and Ridgeline Therapeutics outside the submitted work. Dr. Gawrieh consulting: TransMedics, research grant support: Cirius, Galmed, Viking and Zydus. Dr. Roberts has nothing to disclose. Dr. Lisanti receives royalties for the book MRI: The Basics, from Wolters Kluwer. Dr. Schwope has nothing to disclose. Dr. Cebe has nothing to disclose. Dr. Paradis consulting: Servier. Dr. Bedossa reports personal fees from Genfit, Intercept Pharmaceuticals, Allergan, Inventiva Pharma, Echosens, HistoIndex, Madrigal Pharmaceuticals, Cymabay, Pfizer, Cirius Therapeutics, Histoindex and Diafir outside the submitted work. Ms. Aldridge Whitehead has nothing to disclose A. Labourdette is a full-time employee of Echosens. Dr. Miette is a full-time employee of Echosens. Dr. Neubauer is a current shareholder and previous non-executive director and consultant for Perspectum. Outside the submitted work: Research grants from Cytokinetics and Boehringer Ingelheim, consultancy from Cytokinetics, shareholder, consultant and non-executive director, Caristo Diagnostics. Dr. Fournier is a full-time employee of Echosens. Dr. Paredes has nothing to disclose. Dr. Alkhouri serves on advisory boards for Allergan, Gilead, Intercept, Pfizer, and Zydus; he serves as a speaker for AbbVie, Alexion, Gilead, Intercept, and Simply Speaking; and has received research support from Akero, Albireo, Allergan, Axcella, BI, BMS, Celgene, Gilead, Galmed, Galectin, Genfit, Enanta, Enyo, Hanmi, Inventiva, Madrigal, Merck, Novartis, Novo Nordisk, Pfizer, Poxel and Zydus. Please refer to the accompanying ICMJE disclosure forms for further details., (Copyright © 2021 European Association for the Study of the Liver. All rights reserved.)