Background: Nonalcoholic fatty liver disease (NAFLD) has become the most prevalent chronic liver disorder worldwide and is associated with obesity, insulin resistance, and metabolic syndrome. Timely identification and surveillance are essential to avert advancement to cirrhosis or hepatocellular carcinoma. In clinical practice, ultrasonography remains the most accessible imaging technique.To assess the diagnostic value of ultrasound in detecting hepatic steatosis and to evaluate its utility in monitoring treatment response and identifying complications in patients with NAFLD. Methods: This prospective study was carried out at the Women and Children's Hospital, Abbottabad from January 2022 to January 2023. Seventy-nine adults with NAFLD were diagnosed and clinical workup, including liver function tests and abdominal ultrasonography, were performed. Steatosis grades were based on echogenicity, while associated findings such as hepatomegaly, splenomegaly, and cirrhosis changes were documented. Patients were re-evaluated at months 3, 6, and 12 for changes following lifestyle or pharmacological interventions. Results: Moderate to severe hepatic steatosis was present in over half the participants. Metabolic comorbidities, including diabetes and dyslipidemia, were common. Ultrasound demonstrated a sensitivity of 85% and specificity of 78% compared to MRI/biopsy in a subset of patients. Steatosis regression was observed in 36.2% of those on lifestyle intervention and 57.9% of those receiving additional pharmacotherapy. Cirrhotic changes developed in 7.6% during follow-up, with significant associations seen in patients with metabolic syndrome and elevated BMI. Conclusion: Ultrasound is an effective tool for both diagnosis and follow-up in NAFLD. Its affordability and wide availability make it especially valuable in routine clinical care and resource-constrained settings. Timely intervention and sustained weight loss are key to reversing disease progression.