Liver steatosis, known as non-alcoholic fatty liver disease (NAFLD) is common among obese children. Deposition of lipid within the liver represents part of an abnormal lipid partitioning pattern, most commonly associated with increased intra-abdominal fat. Lipid deposition in the liver can be a cause of peripheral insulin resistance via local acceleration of lipogenesis and a cause of hepatic insulin resistance leading to further compensatory hyperinsulinemia. The typical obese child with NAFLD will usually manifest other components of the insulin resistance syndrome such as dyslipidemia, hypertension and altered glucose metabolism. As liver steatosis itself is usually asymptomatic, a high index of suspicion for its presence should be present in obese insulin resistant youth who present with dyslipidemia or altered glucose metabolism or manifest anamnestic or physical signs that suggest the presence of insulin resistance.