Mechanisms of SGLT2 Inhibition in Pediatric Steatotic Liver Disease

Inclusion Criteria: For clinical referral to screening visit: * BMI \>30 kg/m2 or \>95th BMI-Percentile * Weight Range of 75kg to 150kg * Age 16 to \<21 at baseline * Elevated alanine aminotransferase (ALT) more than twice the upper limit of normal by gender (≥ 44 U/L for girls, ≥ 50 U/L for boys)63 within 3 months prior to screening (used for historic ALT value) OR diagnosis of NAFLD from ultrasound, MRI, or participants with biopsy-proven NASH within 12 months of screening. * History of lifestyle modification to treat obesity or NAFLD. * Tanner stage \>2 * Normal fasting glucose (fasting blood glucose \<100 mg/dL) To be obtained at screening visit: * Confirmation of obesity; * Tanner stage 2,3,4 or 5; * Normal fasting glucose tolerance (fasting blood glucose \<100 mg/dL); * If Screening ALT is used as inclusion criteria (if \> 2x historic ALT value (historical value obtained clinically within 12 months of screening visit), repeated after 4 weeks \[unable to randomize until completed\]. If the repeat ALT is more than 50% increased or decreased over the screening ALT, a third ALT should be obtained. If a third ALT is not within 50% of the previous value, then the subject is ineligible but may be rescreened at a later date. If ALT is not used: * An ultrasound will be done to diagnose NAFLD if the diagnosis has not previously been made by ultrasound, MRI or biopsy. * A MRI-derived HFF ≥ 5.5% * Willingness to adhere to lifestyle considerations throughout the study Exclusion Criteria: * ALT \> 250U/L at screening * History of significant alcohol intake or current use * Impaired fasting glucose (\>100 mg/dL) * Diabetes (type 1 or 2) * Current or recent (\<6 months prior to enrollment) use of weight loss medication(s) * Vitamin E supplementation or use of metformin -washout period 30 days * Previous bariatric surgery * Prior use of empagliflozin * Lower limb infection/ulceration within 3 months of screening * Metal or magnetic implants, devices or objects inside of or on the body, which are not MRI compatible * Structural and functional urogenital abnormalities, that predispose for urogenital infections * Recent initiation (\<3 months prior to enrollment) of anti-hypertensive or lipid medication(s) * Major psychiatric disorder * Known hypothalamic or pituitary dysfunction * Current pregnancy or plans to become pregnant * Females unwilling to be tested for pregnancy * Females who are sexually active and not protects by an effective method of birth control (e.g. UID or medication or patch) -can re-screen 30 days after getting on birth control * Tobacco use * Significant liver dysfunction (levels \>5 times the upper limit of normal (ULN)): * ALT (ULN = 50 U/L) * AST (ULN = 48 U/L) * GGT (ULN = 48 U/L) * ALP (ULN = 115 U/L) * Platelets \< 150,000 cells/mm3 * Total bilirubin \> 1.3 mg/dL * INR \> 1.3 * Albumin \<3.2 g/dL * Gilbert's Syndrome * Any known causes of liver disease (except NAFLD and NASH) * Significant renal dysfunction (estimated glomerular filtration rate \[eGFR\] \< 80 mL/min/1.73 m2), * Diagnosed monogenic obesity * History of cancer * Untreated thyroid disorder * History of decompensation events (ascites, variceal bleeding, hepatic encephalopathy, or hepatocellular carcinoma) * Current or recent (\<6 months prior to enrollment) use of medication(s) associated with weight gain (e.g. atypical anti-psychotics).