Screening someone who isn't at risk or doesn't have existing comorbidities likely isn't warranted. But I don't think any kind of parenchymal liver changes happen in isolation devoid of affecting the rest of the system. The problem is with finding fatty liver disease... what to do next? Improve lifestyle, which should be happening regardless. My patients are welcome to have any test they like in this commoditized healthcare system but without the basics of lifestyle optimization, the advice will be boringly the same ... let's focus on the right calorie deficit, energy balance, movement, stress, sleep.
Great read. For commenters I would just say if you haven’t already done it read the doctors opinion in the AA big book. Stop looking at obesity like a moral problem and look at it like you would look at any addiction. Medical school does not teach us how to treat addiction. Other addicts are much better at treating it. There is a solution – the problem is physical, the causes emotional, the cure is spiritual. Have a great day, everybody.
The new "big factor" that will drive up the testing for MASLD is trying to get GLP1 drugs covered by a patient's insurance! I see a big increase in the testing being done - ultrasound (has always been a starting point), but now we're seeing a surge in FibroScan, ELF test, Fib-4, elastography. Until we have definitive data that this approach is beneficial, I hate to see insurance coverage for a drug drive up health care costs like this!!
Hopefully, the price comes down on those drugs and we can stop the unnecessary hoops. These drugs are in demand and they are going to be prescribed. Having artificial (and costly) gatekeeping is not helpful.
The risk factor paradigm of disease causation has no basis in science and never did. For starters, most all of the assertions about "lifestyle factors" are unfalsifiable. Many maintain that the population is "sicker than ever" due to lack of exercise, obesity, poor diet with too many processed foods, etc. Is there any real evidence of this? It is probably logistically impossible to carry out a scientific study over the great amount of time involved and the unreliability of the data employed to quantitate these factors. Cause of death statistics are completely unreliable as anyone with more than a passing acquaintance with death certificates will verify. That leaves age related mortality as about the only remotely reliable index for the health of a population. In the US and most other modern societies, the figure for age related death has been progressing steadily upward from the early 1900s to the present. It is an asymptotic curve approaching whatever the biological limit of life may be. There was a small dip in the curve around the time of the covid episode---possibly due to the near shutdown of normal society. But, as near as I can tell, it has moved back to its normal level and slow rate of increase. This pattern has persisted over the last several generations when all of these destructive changes in lifestyle have been taking place.
This year marks the 50th anniversary of a seminal opinion article by two cardiologists (Dr. Eliot Corday and his son) in the American Journal of Cardiology. The title of the article was "Prevention of Heart Disease by Control of Risk Factors: The Time Has Come to Face the Facts". I think the time has come to apply this dictum to other conditions and "diseases" as well.
I'm not sur about the futility or risk factor control. Probably depends on individual risks and what is most important to patients. NNTs are huge nowadays, we have to be clear with people about their personal odds.
When I teach chronic 'disease' though, I always start by showing the prevalence increase in all chronic conditions. We are sicker than ever! Then I transition to despite being sicker, the good news is : we live longer now, the bad news : mortality is 100%. Totally agree that the most important risk factor - the one we can't control (?yet) - is age!
Fatty. Liver. Hepatic steatosis. We don’t NEED more 4/5 letter abbreviations. And also, there’s no mystery. Most of the ‘MaSLSdxyZ’ individuals are OBESE.
No million-dollar workup needed. Why not just have an entry door at the hepatologists’ office that’s 30 inches wide: If you can’t fit through it without turning sideways, or if Mr Potbelly can’t fit through WHEN turning sideways: You’re fat, you need to lose weight, and odds are you have fatty liver.
I see it all the time, due to leukopenia, thrombocytopenia and either monocytosis or macrocytosis.
“I think this patient requires a bone marrow biopsy and cytogenetics, because maybe he’s got leukemia…”
No. He needs to walk more, knock off the doughnuts, and maybe find a primary clinician with better diagnostic skills.
Always easier said than done, but exactly. We know the problem is obesity and lifestyle in >90% of cases of MASLD. Do we need to individualize care, if the prevalence of obesity is > 30%? We don't need sophisticated tests to see people are overweight and are more at risk of adverse outcomes. Lifestyle counseling (eat healthy, exercise more, don't smoke,...) applies to all patient strata. This being said, not all patients with obesity are unhealthy.
I am also super annoyed that any overweight teen that has abnormal liver functions gets told it is fatty liver with no other work up? Is this the new Diagnosis to allow a doctor to do nothing but tell people to lose weight? I have a kid on depakote, we check his liver enzymes, when they came back high mom was told "it is fatty liver".......so.....do we stop his depakote? or leave it? Seems like I need more info......
Agree that current screening algorithms have high rate of false positives and lead to
unnecessary burden of more diagnostic work up when indiscriminately applied to large populations at low risk of the disease. However, respectfully disagree with your premise that it is not a disease. MASH, the more severe inflammatory form, carries a high risk of liver fibrosis. Stage 2 or higher is predictive of higher risk of progression to MALO over 10-20 years and is silent clinically. About 25% of children with MASH have stage 2 or worse fibrosis. In recent large cohort studies in US and Sweden, over a 10-15 year period, children with MASH had an >11-40 fold higher risk of early mortality, including liver related deaths as primary cause in the US study. Though it may seem like only a risk factor to you, it is a progressive liver disease for a large subset of affected patients. Overscreening and identifying individuals with fibrosis remains a huge problem in both adults and childen. We need much more precise screening tests to identify those with fibrotic MASH. But same problem exists for other screening tests such as mammography and PSA, which have many false positives, leading to more diagnostic work up and overtrearment. I think there is a bias against liver disease being a problem because it is so silent, until suddenly it is not but at that point cirrhosis and ensuing problems are often irreversible. Lifestyle itnervention is the cornerstone of treatment, but isn't enough to reverse MASH or fibrosis in majority of affected patients. It remains to be seen in ongoing clinical trials if early intervention in adults with fibrotic MASH will reduce CVD and MALO mortality
MASH cirrhosis is a disease, I agree, and there is a considerable disease burden. The problem is identifying the correct patients to treat to prevent adverse outcomes. But screening protocols and treatment at the present time don't allow us to identify correctly who will benefit and how to treat them. Rolling out guidelines on mass screening in primary care population is premature. I certainly don't want to minimize importance of MASH cirrhosis. This is a true problem of ressource utilisation, overdiagnosis and low-value care, as with PSA and mammography like you say. But all these low value care add up. Be it in patients perceiving themselves as ill, health care expenditure or clinician time. This is what the focus of this article is about.
I guess I am not comforable telling my 12 year old patient with cirrhotic MASH that they have a "risk factor" that may lead to later cardivascular events, and not an actual liver disease. Have found several adolescent patients with silent cirrhosis, with modestly elevated live enzymes the only sign that prompted referral, and have many more with stage 2 and stage 3 fibrosis. This doesnt address the considerable flaws in current screening tests, of course, but why cant we recognize it as a chronic liver disease?
Are doctors ever going to be brave enough to just call people FAT? I'm 61, the amount of overweight people around today is horrifying. Many of them are my age and they go to the doctor and get meds and this and that....and NONE of them are ever motivated to lose weight and exercise. You don't have to run a marathon, but can we quit coming up with novel 'new' disease when all it is FAT. If doctors got a little crueler and called things Fat Syndrome or Eating too much diease....shame can be a good thing. America is eating itself to death......and those of us who don't do are having to help foot the bill.
I'd say rather than "fat phobia", this is just not medically correct thinking in many ways. Not all overweight or "fat" people have the same degree of metabolic dysfunction. Some people have a definite "metabolic syndrome" with many lab value derangements. Their risks for more problematic conditions (diabetes, heart disease, liver problems) is much higher than an overweight person who just doesn't have the same genetic predispositions.
Shaming has never been a useful or effective tool for anything, and certainly not habit-change.
And if you think doctors do not bring up weight as an issue that affects health, you're mistaken. As we prescribe medicines for joint pain and cholesterol and heartburn, etc you can bet the vast majority of us are discussing that weight loss would cure most of these things. But that kind of discussion needs to be done by someone the patient has some rapport with and in a motivating, respectful manner. If anything works, that does!
No, overall today, most fat people are fat because they eat too much and exercise too little AND eat all the wrong stuff.
All this apology is putting them in the grave faster.....REALLY we gonna go with 'it's my glands' Haven't heard that golden oldie since I was a kid.
Of course some are worse than others, but the bottom fucking line is this....TOO much food in, not enough exercise and voila---fat.
You can put lipstick on a pig all day long but it's still a damn fat pig.
And this is not an assault on these people as human beings....The entire fucking world has become fat people codependents....
Doesn't anyone see this?
It's the same as 'soft bigotry of low expectations.' Well, Suzie can't really lose weight, poor thing, I'll we'll just have to watch her eat herself into an early grave....
Of course people are overweight (or fat) due to lifestyle habits: consuming too many calories. Exercise has less to do with it, but plays a role as well. In the 1980s, snack food and snacking became big business. Highly palatable foods started filling the grocery store shelves, commercials encouraging every snack imaginable; the focus was more on "low fat" and foods became filled with sugar. Eating this modern American diet is what is killing most of us. Of course it is not a "glandular" thing.
I think some of us are getting too medically nuanced here; we're not all talking about the same thing.
The solution to this problem is going to come at a societal level with public awareness, marketing, and economic pressures (similar to how smoking became much less common and attractive to people). This is not going to be done patient-by-patient, one-on-one with doctor/patient to provide the "fix" here. Again, this is societal level stuff!
And of course, most physicians have this front and center to discuss with patients - most of us are not pretending this is a glandular problem that is out of the person's control. (I have never heard another doctor mention "It's just your glands!")
Hopefully, most of us are professionals who are skilled in motivational habit change discussions. Shaming doesn't play a big role here, but honest discussion certainly does.
Lately, public awareness is increasing. The US needs to take a hard look at what we serve our kids and make big changes asap.
I have to say that I am quite surprised and concerned with the level of fat phobia in a lot of these comments. Obesity is a complex and multifactorial problem. I agree that we don't need new diagnoses, however, we do need to think about where the appropriate target is for intervention. Individuals haven't changed that much in the last 50 years, but society has. Fat shaming patients will not lead to weight loss. We need to focus efforts on public health and systems issues in order to tackle this epidemic. This is a bigger issue than the patient in front of us (pun intended).
This is EXACTLY the problem today. It's not 'fatphobia.' That is an UTTERLY idiotic word. The fact is this FAT PEOPLE are not healthy. Shielding them from criticism is not helping them. I have recently lost 40lbs. Without drugs, without special diets. Just exercise and commitment. I am now 61 years old and feel better than I have in years. It took me over a year to lose the weight. I didn't do it to get thin and I am STILL not thin, but I did it to FEEL BETTER. Making excuses for people who overeat is not helping them. Let's be 'kind' and give them some more KFC, poor babies...not their fault. Yes, it almost universally IS their fault. Until THEY decide to take control, nothing will work, period. I hate it when people say 'I can't lose weight.' Well, what aren't you doing? If I can do it, so can everyone. Also, didn't go to a gym or have a trainer or dietician or any of that shit. I just started exercising in an organized fashion. Slowly at first, but now I am up to 30 minutes a day before work. I don't do it on the weekends because I am very active when not at work. 30 minutes is not a lot of time.....get off social media, turn off the TV or exercise in front of the TV. I listen to podcasts while I work out. It's funny that as soon as we stopped fat shaming, the % of fat people increased......but I'll bet you'll say correlation doesn't equal causation. Bottom line is this, I am sick and damn tired of being expected to support all the medical costs associated with addiction of any kind. The medical costs to this country for food addiction is astronomical. And most of these really fat people are disabled on top of it so they just suck off the public teat, meaning people like me who go to work every day.....while they sit at home and order more DoorDash and lament about not being able to lose weight. Stop babying these people. They are addicts. They need to be treated like addicts. I was married to an alcoholic/addict for over 20 years....all the behaviors are the same. The only difference is that we are trying to make food addiction acceptable in society. It should not be. They are an incredible drag on the system in all ways. Make THEM pay for it, just like addicts have to pay for their meth, etc, lets not support these people in their addiction. If they won't commit to weight loss, kick them off assistance. Whomever came up with the 'phobia' suffix has really ruined things.
Screening someone who isn't at risk or doesn't have existing comorbidities likely isn't warranted. But I don't think any kind of parenchymal liver changes happen in isolation devoid of affecting the rest of the system. The problem is with finding fatty liver disease... what to do next? Improve lifestyle, which should be happening regardless. My patients are welcome to have any test they like in this commoditized healthcare system but without the basics of lifestyle optimization, the advice will be boringly the same ... let's focus on the right calorie deficit, energy balance, movement, stress, sleep.
Great read. For commenters I would just say if you haven’t already done it read the doctors opinion in the AA big book. Stop looking at obesity like a moral problem and look at it like you would look at any addiction. Medical school does not teach us how to treat addiction. Other addicts are much better at treating it. There is a solution – the problem is physical, the causes emotional, the cure is spiritual. Have a great day, everybody.
The new "big factor" that will drive up the testing for MASLD is trying to get GLP1 drugs covered by a patient's insurance! I see a big increase in the testing being done - ultrasound (has always been a starting point), but now we're seeing a surge in FibroScan, ELF test, Fib-4, elastography. Until we have definitive data that this approach is beneficial, I hate to see insurance coverage for a drug drive up health care costs like this!!
Hopefully, the price comes down on those drugs and we can stop the unnecessary hoops. These drugs are in demand and they are going to be prescribed. Having artificial (and costly) gatekeeping is not helpful.
The risk factor paradigm of disease causation has no basis in science and never did. For starters, most all of the assertions about "lifestyle factors" are unfalsifiable. Many maintain that the population is "sicker than ever" due to lack of exercise, obesity, poor diet with too many processed foods, etc. Is there any real evidence of this? It is probably logistically impossible to carry out a scientific study over the great amount of time involved and the unreliability of the data employed to quantitate these factors. Cause of death statistics are completely unreliable as anyone with more than a passing acquaintance with death certificates will verify. That leaves age related mortality as about the only remotely reliable index for the health of a population. In the US and most other modern societies, the figure for age related death has been progressing steadily upward from the early 1900s to the present. It is an asymptotic curve approaching whatever the biological limit of life may be. There was a small dip in the curve around the time of the covid episode---possibly due to the near shutdown of normal society. But, as near as I can tell, it has moved back to its normal level and slow rate of increase. This pattern has persisted over the last several generations when all of these destructive changes in lifestyle have been taking place.
This year marks the 50th anniversary of a seminal opinion article by two cardiologists (Dr. Eliot Corday and his son) in the American Journal of Cardiology. The title of the article was "Prevention of Heart Disease by Control of Risk Factors: The Time Has Come to Face the Facts". I think the time has come to apply this dictum to other conditions and "diseases" as well.
I'm not sur about the futility or risk factor control. Probably depends on individual risks and what is most important to patients. NNTs are huge nowadays, we have to be clear with people about their personal odds.
When I teach chronic 'disease' though, I always start by showing the prevalence increase in all chronic conditions. We are sicker than ever! Then I transition to despite being sicker, the good news is : we live longer now, the bad news : mortality is 100%. Totally agree that the most important risk factor - the one we can't control (?yet) - is age!
Fatty. Liver. Hepatic steatosis. We don’t NEED more 4/5 letter abbreviations. And also, there’s no mystery. Most of the ‘MaSLSdxyZ’ individuals are OBESE.
No million-dollar workup needed. Why not just have an entry door at the hepatologists’ office that’s 30 inches wide: If you can’t fit through it without turning sideways, or if Mr Potbelly can’t fit through WHEN turning sideways: You’re fat, you need to lose weight, and odds are you have fatty liver.
I see it all the time, due to leukopenia, thrombocytopenia and either monocytosis or macrocytosis.
“I think this patient requires a bone marrow biopsy and cytogenetics, because maybe he’s got leukemia…”
No. He needs to walk more, knock off the doughnuts, and maybe find a primary clinician with better diagnostic skills.
Always easier said than done, but exactly. We know the problem is obesity and lifestyle in >90% of cases of MASLD. Do we need to individualize care, if the prevalence of obesity is > 30%? We don't need sophisticated tests to see people are overweight and are more at risk of adverse outcomes. Lifestyle counseling (eat healthy, exercise more, don't smoke,...) applies to all patient strata. This being said, not all patients with obesity are unhealthy.
Not all people who drink, drive and don’t wear seatbelts get in wrecks.
Not everyone who smokes a pack per day for 30 years gets cancer.
But odds are, they will.
And so it is, with obesity.
Truth isn’t convenient, nor polite, nor mean. It’s truth.
I am also super annoyed that any overweight teen that has abnormal liver functions gets told it is fatty liver with no other work up? Is this the new Diagnosis to allow a doctor to do nothing but tell people to lose weight? I have a kid on depakote, we check his liver enzymes, when they came back high mom was told "it is fatty liver".......so.....do we stop his depakote? or leave it? Seems like I need more info......
Agree that current screening algorithms have high rate of false positives and lead to
unnecessary burden of more diagnostic work up when indiscriminately applied to large populations at low risk of the disease. However, respectfully disagree with your premise that it is not a disease. MASH, the more severe inflammatory form, carries a high risk of liver fibrosis. Stage 2 or higher is predictive of higher risk of progression to MALO over 10-20 years and is silent clinically. About 25% of children with MASH have stage 2 or worse fibrosis. In recent large cohort studies in US and Sweden, over a 10-15 year period, children with MASH had an >11-40 fold higher risk of early mortality, including liver related deaths as primary cause in the US study. Though it may seem like only a risk factor to you, it is a progressive liver disease for a large subset of affected patients. Overscreening and identifying individuals with fibrosis remains a huge problem in both adults and childen. We need much more precise screening tests to identify those with fibrotic MASH. But same problem exists for other screening tests such as mammography and PSA, which have many false positives, leading to more diagnostic work up and overtrearment. I think there is a bias against liver disease being a problem because it is so silent, until suddenly it is not but at that point cirrhosis and ensuing problems are often irreversible. Lifestyle itnervention is the cornerstone of treatment, but isn't enough to reverse MASH or fibrosis in majority of affected patients. It remains to be seen in ongoing clinical trials if early intervention in adults with fibrotic MASH will reduce CVD and MALO mortality
MASH cirrhosis is a disease, I agree, and there is a considerable disease burden. The problem is identifying the correct patients to treat to prevent adverse outcomes. But screening protocols and treatment at the present time don't allow us to identify correctly who will benefit and how to treat them. Rolling out guidelines on mass screening in primary care population is premature. I certainly don't want to minimize importance of MASH cirrhosis. This is a true problem of ressource utilisation, overdiagnosis and low-value care, as with PSA and mammography like you say. But all these low value care add up. Be it in patients perceiving themselves as ill, health care expenditure or clinician time. This is what the focus of this article is about.
I guess I am not comforable telling my 12 year old patient with cirrhotic MASH that they have a "risk factor" that may lead to later cardivascular events, and not an actual liver disease. Have found several adolescent patients with silent cirrhosis, with modestly elevated live enzymes the only sign that prompted referral, and have many more with stage 2 and stage 3 fibrosis. This doesnt address the considerable flaws in current screening tests, of course, but why cant we recognize it as a chronic liver disease?
Are doctors ever going to be brave enough to just call people FAT? I'm 61, the amount of overweight people around today is horrifying. Many of them are my age and they go to the doctor and get meds and this and that....and NONE of them are ever motivated to lose weight and exercise. You don't have to run a marathon, but can we quit coming up with novel 'new' disease when all it is FAT. If doctors got a little crueler and called things Fat Syndrome or Eating too much diease....shame can be a good thing. America is eating itself to death......and those of us who don't do are having to help foot the bill.
I'd say rather than "fat phobia", this is just not medically correct thinking in many ways. Not all overweight or "fat" people have the same degree of metabolic dysfunction. Some people have a definite "metabolic syndrome" with many lab value derangements. Their risks for more problematic conditions (diabetes, heart disease, liver problems) is much higher than an overweight person who just doesn't have the same genetic predispositions.
Shaming has never been a useful or effective tool for anything, and certainly not habit-change.
And if you think doctors do not bring up weight as an issue that affects health, you're mistaken. As we prescribe medicines for joint pain and cholesterol and heartburn, etc you can bet the vast majority of us are discussing that weight loss would cure most of these things. But that kind of discussion needs to be done by someone the patient has some rapport with and in a motivating, respectful manner. If anything works, that does!
No, overall today, most fat people are fat because they eat too much and exercise too little AND eat all the wrong stuff.
All this apology is putting them in the grave faster.....REALLY we gonna go with 'it's my glands' Haven't heard that golden oldie since I was a kid.
Of course some are worse than others, but the bottom fucking line is this....TOO much food in, not enough exercise and voila---fat.
You can put lipstick on a pig all day long but it's still a damn fat pig.
And this is not an assault on these people as human beings....The entire fucking world has become fat people codependents....
Doesn't anyone see this?
It's the same as 'soft bigotry of low expectations.' Well, Suzie can't really lose weight, poor thing, I'll we'll just have to watch her eat herself into an early grave....
Of course people are overweight (or fat) due to lifestyle habits: consuming too many calories. Exercise has less to do with it, but plays a role as well. In the 1980s, snack food and snacking became big business. Highly palatable foods started filling the grocery store shelves, commercials encouraging every snack imaginable; the focus was more on "low fat" and foods became filled with sugar. Eating this modern American diet is what is killing most of us. Of course it is not a "glandular" thing.
I think some of us are getting too medically nuanced here; we're not all talking about the same thing.
The solution to this problem is going to come at a societal level with public awareness, marketing, and economic pressures (similar to how smoking became much less common and attractive to people). This is not going to be done patient-by-patient, one-on-one with doctor/patient to provide the "fix" here. Again, this is societal level stuff!
And of course, most physicians have this front and center to discuss with patients - most of us are not pretending this is a glandular problem that is out of the person's control. (I have never heard another doctor mention "It's just your glands!")
Hopefully, most of us are professionals who are skilled in motivational habit change discussions. Shaming doesn't play a big role here, but honest discussion certainly does.
Lately, public awareness is increasing. The US needs to take a hard look at what we serve our kids and make big changes asap.
I have to say that I am quite surprised and concerned with the level of fat phobia in a lot of these comments. Obesity is a complex and multifactorial problem. I agree that we don't need new diagnoses, however, we do need to think about where the appropriate target is for intervention. Individuals haven't changed that much in the last 50 years, but society has. Fat shaming patients will not lead to weight loss. We need to focus efforts on public health and systems issues in order to tackle this epidemic. This is a bigger issue than the patient in front of us (pun intended).
This is EXACTLY the problem today. It's not 'fatphobia.' That is an UTTERLY idiotic word. The fact is this FAT PEOPLE are not healthy. Shielding them from criticism is not helping them. I have recently lost 40lbs. Without drugs, without special diets. Just exercise and commitment. I am now 61 years old and feel better than I have in years. It took me over a year to lose the weight. I didn't do it to get thin and I am STILL not thin, but I did it to FEEL BETTER. Making excuses for people who overeat is not helping them. Let's be 'kind' and give them some more KFC, poor babies...not their fault. Yes, it almost universally IS their fault. Until THEY decide to take control, nothing will work, period. I hate it when people say 'I can't lose weight.' Well, what aren't you doing? If I can do it, so can everyone. Also, didn't go to a gym or have a trainer or dietician or any of that shit. I just started exercising in an organized fashion. Slowly at first, but now I am up to 30 minutes a day before work. I don't do it on the weekends because I am very active when not at work. 30 minutes is not a lot of time.....get off social media, turn off the TV or exercise in front of the TV. I listen to podcasts while I work out. It's funny that as soon as we stopped fat shaming, the % of fat people increased......but I'll bet you'll say correlation doesn't equal causation. Bottom line is this, I am sick and damn tired of being expected to support all the medical costs associated with addiction of any kind. The medical costs to this country for food addiction is astronomical. And most of these really fat people are disabled on top of it so they just suck off the public teat, meaning people like me who go to work every day.....while they sit at home and order more DoorDash and lament about not being able to lose weight. Stop babying these people. They are addicts. They need to be treated like addicts. I was married to an alcoholic/addict for over 20 years....all the behaviors are the same. The only difference is that we are trying to make food addiction acceptable in society. It should not be. They are an incredible drag on the system in all ways. Make THEM pay for it, just like addicts have to pay for their meth, etc, lets not support these people in their addiction. If they won't commit to weight loss, kick them off assistance. Whomever came up with the 'phobia' suffix has really ruined things.