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Lancet Reg Health Am
Lancet Reg Health Am
Lancet Regional Health - Americas
2667-193X
Elsevier

S2667-193X(24)00192-3
10.1016/j.lana.2024.100865
100865
Editorial
Steatotic liver disease and diabetes: prolific nomenclature, insufficient data, and poor treatment options
The Lancet Regional Health – Americas
12 8 2024
8 2024
12 8 2024
36 100865© 2024 The Author(s)
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
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pmcNearly 550 million people worldwide have diabetes. However, the prevalence of diabetes across the world is heterogenous. For example, the age-adjusted prevalence of diabetes exceeds 10% in the Middle East, and it is greater than 15% in many countries, including Qatar. By contrast, the prevalence of diabetes in African countries is the lowest, at less than 3%. In South America, Guyana is the country with the highest prevalence, exceeding 14%, whereas Peru reports the lowest prevalence in the region (below 4%). It is unknown whether the high heterogeneity in diabetes prevalence across countries could be explained by underreporting, undiagnosed diabetes, genetic predisposition, or differences in lifestyle. Nevertheless, individuals who have diabetes are at high risk of severe complications including stroke, blindness, coronary artery disease, kidney failure, amputations, or even death. One condition that commonly remains silent is fatty liver disease associated with metabolic dysfunction.

There has been much discussion about the most appropriate nomenclature for lipid accumulation in the liver associated with cardiometabolic disease, also called non-alcoholic fatty liver disease (NAFLD). Changes to the term NAFLD have been proposed in recent years, to metabolic dysfunction-associated fatty liver disease (MAFLD) and, more recently, to metabolic dysfunction-associated steatotic liver disease (MASLD). MASLD is particularly common in individuals with advanced age, obesity, and diabetes, but also in the general population. It is estimated that 3 out of 10 adults in the USA have MASLD. While estimates for Latin America appear to be similar (∼25%), the numbers are based on the definition of NAFLD, which does not require the presence of metabolic dysfunction as diagnostic criteria, as opposed to MAFLD or MASLD. In addition, no data are available for most countries in Latin America and the Caribbean using the latest definitions. The prevalence of MASLD in patients with type 2 diabetes can be as high as 65%. The impact the suggested changes to the nomenclature will have on prevalence estimates and clinical outcomes of non-alcoholic fatty liver disease remains unclear. What is clear is that advanced MASLD represents a serious threat to people with diabetes who are already at high risk of multiple organ failure. MASLD can progress to severe liver fibrosis, also called cirrhosis, which can lead to liver failure and ultimately require liver transplantation, further complicating the treatment of patients with advanced diabetes.

In June, 2024, the American Diabetes Association held its 84th Scientific Sessions, in Orlando, FL. One of the sessions discussed the epidemiology of diabetes and liver disease. A straightforward message was the use of numerous surrogate biomarkers and imaging (eg, ultrasound and MRI) as alternatives to invasive techniques (such as liver biopsy) to screen for advanced liver fibrosis. In the same session, experts discussed that MASLD is not associated with increased mortality when adjusting for cardiometabolic risk factors, which puts the usefulness of massive screening for MASLD into perspective. However, current guidelines do recommend screening for MASLD in individuals with type 2 diabetes or prediabetes, particularly those with underlying obesity, cardiovascular disease, and cardiometabolic risk factors. Although treatment for MASLD at early stages is not recommended, primary prevention should not be moved to second place.

MASLD and cardiovascular disease share similar modifiable risk factors. Therefore, adopting a healthy lifestyle is essential for preventing MASLD, especially as MASLD is asymptomatic at early stages. Slowing or even stopping the progression of this disease could avoid severe consequences of MASLD, namely non-alcoholic steatohepatitis (NASH; now proposed to be called metabolic dysfunction-associated steatohepatitis [MASH]) and liver failure. For patients with advanced MASLD, there is some hope with the discovery and very recent US FDA conditional approval of resmetirom, the only drug currently available for the treatment of moderate to severe MASH. Consequently, early diagnosis of MASLD in individuals at high risk is paramount as options for treatment of advanced MASLD are extremely limited and not fully effective.

As the number of people with type 2 diabetes increases, so does the number of individuals with MASLD (or MAFLD), MASH (or NASH), and liver failure. Prevention measures are key, including early screening of people at high risk. Progress has been made in identifying steatotic liver disease, and the suggested repeated changes to the nomenclature of NAFLD will hopefully pay dividends. However, more research is needed to inform policy makers about the actual burden of steatotic liver disease and steatohepatitis in people with diabetes and other predisposing diseases, particularly in Latin America and the Caribbean. Further research is also urgently needed to better understand the impact of early MASLD on health and to identify new therapeutic drugs for advanced MASLD. Public health authorities should foster prevention campaigns to increase awareness of MASLD and MASH and advocate for healthier lifestyle choices. The Lancet Regional Health — Americas invites scholarly contributions to further explore these critical areas and to advance knowledge and innovation to safeguard the health of those at risk.
