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Rebranding Fatty Liver Disease: What’s in a Name?
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Released: January 03, 2025

Neeraj Mistry
Neeraj Mistry, MD, MS

What’s in a Name? Understanding the Terminology Shift for Fatty Liver Disease

 

[00:00:07] Neeraj Mistry, MD: Good day and welcome to episode two of Solving the Fatty Liver Mistry. My name is Dr. Neeraj Mistry. I'm the chief medical officer of the Fatty Liver Foundation and I'm delighted to be joining you once again for the second episode in this newsletter series.

 

[00:00:25] So in our first episode, we talked very broadly about fatty liver disease, about how fat accumulates in the liver, and then, induces a state of inflammation, which then leads to fibrosis, and leads to cirrhosis and end stage liver disease.

 

[00:00:40] But something interesting happened last year. There was a change in the nomenclature around fatty liver disease, and we're going to go through that. And it feels very nerdy at some points because it's long terminology, but bear with me because it makes a lot of sense, so we firstly had nonalcoholic fatty liver disease, which then progressed to form nonalcoholic steatohepatitis, or NASH. So NAFLD and NASH. The terminology change went to metabolic associated steatotic liver disease or MASLD, and the more advanced form of that disease was metabolic associated steatohepatitis or MASH. Now the reason why this happened. was to address a few key questions, so firstly, what are the issues with current nomenclature and how can they be addressed with a change in the name? So nonalcoholic was naming a disease on something that it's not. So that was the first thing that was being addressed. The second, the term alcoholic had a lot of stigma associated with it. Further to that, fatty was a pejorative term which referenced people as being lazy and not taking charge of their own health. So, there was a lot of stigma around these terms and certainly naming a disease on something that it's not was also not indicative of what the disease is.

 

[00:02:06] The second question they wanted to ask is what is the importance of steatohepatitis in disease definition and endpoints? When we're looking at disease and the fact that it is fat accumulation with the inflammatory process and there are various stages of it, they certainly wanted the terminology to reflect those changes. When we look at real patient experiences and how we live our lives, we don't live it in categories in medical texts. And certainly, people who have poor diets also have some level of alcohol consumption. So, we needed a disease definition that included both those lifestyle factors with diet, type 2 obesity, metabolic syndrome, that impacted steatotic liver disease, but also, factored in the use of alcohol. And so that was a really important inclusion in this broad umbrella of MASLD. We wanted to look at how the disease changed awareness, clinical trials, regulatory pathways, et cetera. And it was interesting looking at a disease that didn't have much awareness and we were changing its name to a, a new disease name that still didn't have awareness. So, this was an opportunity that many of us in the advocacy and awareness communications world felt it was opportune to raise and inject a new level of energy in the new terminology. And then finally, can an alternate name reduce the heterogeneity and allow for future advances? And this was quite interesting from a patient perspective. Because there are several etiologies, but sort of a common patient journey in terms of lifestyle, their doctor visits, their dietary changes. And so, how could we homogenize the patient’s journey, irrespective of the etiology that they came from? So those were all the questions that we addressed. When we were looking at changing the terminology, it was a really complex process and there were many stakeholders involved from the patients to understanding the impact of stigma, that the terminology was having on them to policy makers on allocation of resources for research, for programs. To the medical experts who wanted accuracy and precision in defining the characteristics as well as the social perception, not to marginalize groups. And there's been many diseases that have actually caused marginalization of communities by virtue of the name.

 

[00:04:36] What is this new nomenclature? We have an overarching umbrella of steatotic liver disease. And when you look at the left that goes down into metabolic dysfunction associated steatotic liver disease, or MASLD, the advanced form of which is metabolic dysfunction associated steatohepatitis or MASH. And that's your vast majority of patients, who will fall into this category with those risk factors and comorbidities that we talk about. The second category is MetALD, and this is massive with increased alcohol intake. And what they said is, well, it's not just about increased alcohol intake with those comorbidity risk factors, but can we quantify the level of alcohol consumption? So, we have a MASLD-predominant MetALD, and then we have an ALD or alcohol associated liver disease, predominant, MetALD. And so, there's a spectrum of alcohol use. together with the co morbidities, associated with MASLD. We then have the ALD category, which is alcohol associated liver disease. and we use the term alcohol associated instead of alcoholic, because of those stigmatization factors. Then we have specific etiology SLD, which is drug induced monogenic miscellaneous and cryptogenic SLD. And I think when we come to those categorizations of diagnosis, we are looking at very small proportion of the overall incidence.

 

[00:06:09] So this is the MASLD diagnostic criteria. So overall, there's steatotic liver disease, and then we look at, does the patient meet any of the cardiometabolic criteria? And I'll show you what those criteria are. But if they do meet those criteria, then we need to find out, are there any other causes of steatosis? And this is the left pathway. If there aren't any other causes of steatosis, then we can comfortably say, yes, this is metabolic dysfunction-associated steatotic liver disease or MASLD. They are other courses, then we're going to move down the path of MetALD, looking at the inclusion of alcohol as a risk factor together with the other, comorbidities. The key decision point is looking at those cardiometabolic criteria. And if they're not present, then we go down into the much lower prevalence pathway, we look at BMI, and if we don't have the BMI or we feel that's not accurate, we also look at things like the waist circumference. And so, this is our indicator for overweight or obesity. We then look at the fasting glucose. So, look at prediabetes or type two diabetes. We look at the blood pressure, we look at plasma triglycerides, and then we look at cholesterol. And so, with those cardiometabolic criteria, we can then look at the risk profile for the patient and then put them on the diagnostic criteria pathway to classify their disease.

 

[00:07:36] And later on, we'll go into what those tests are for staging the disease. So, this was a lot of information, but I hope it was clear in organizing this nomenclature and all those criteria we look at on the cardiometabolic profile that helped fulfill those criteria in getting us towards a diagnosis.

 

[00:07:55] For the next episode. We're going to be looking at the staging and critical to the staging are the screening as well as the diagnostic tests that we use that will lead us to a more accurate and precise staging of our patients, which influence the management.

 

[00:08:11] In our future episodes, I'll be talking about the data that was presented at the liver meeting in San Diego, where the GLP 1 agonists had a huge showing on its impact on the comorbidities and its implications for fatty liver disease.

 

[00:08:26] So welcome to the world of steatotic liver disease, and our new journey has begun. Look forward to seeing you in episode three.

 

[00:08:33]

This transcript has been lightly edited for clarity.