Expert Roundtable: Staging and Treating NASH and MASLD
In part 2 of this video roundtable on NASH (MASH) and MASLD, Drs Alan Bonder, Gordon Jiang, and Hirsh Trivedi discuss the staging of these conditions and lifestyle changes that patients can make to improve outcomes.
Dr Bonder:
So let's just move in this journey of how we stage a patient. So Dr. Jiang, in your clinical practice, how often should we assess the stage of fibrosis? How often should we bring those patients back to clinic? Is there any kind of assessment that we can say one and done this patients can go back to their primary care or should we keep these patients kind of in the hepatology clinics to follow them closely? So what is your suggestion in that aspect?
Dr Jiang:
Yeah, so I think this is a great question and it's always a dilemma for specialists. I think you have to balance the need in your community and the patient population as well and how much resources you have. I think the rule of thumb is that you want to prioritize resources to help the people at the highest risk patients at the highest risk to progress to cirrhosis. I think realistically it's probably not practical to follow every patient with me D in a liver or gastroenterology clinic. I think primary care physicians are very well educated and competent to manage patients with MASLD with many different comorbidities. I think for specialists in GI and hepatology, I think it would be more value to focus on patients already establish moderate fibrosis, I mean stage two to three and above fibrosis or those demonstrating rapid progression on serial examination. In terms of the frequency of accessing liver fibrosis, I think it's a little bit of method dependent.
I mean for tests like FIB-4, you can do it in every visit for fibro scan. Ideally if you have access you can do it every year, but if the access is more limited, you can do it every couple of years, you certainly cannot do liver biopsy. Likely MRI is also not something that you usually do every year, but based on the resources available, you can do it every few years. And I also think this should be customized to the specific patient. If somebody is really young age already developing pretty moderate fibrosis, you probably want to watch that patient a bit closer or somebody is in their seventies and having stage two liver fibrosis, they already demonstrated the data throughout a long period of time they have stage two fibrosis. Maybe they can have a bit of leeway in terms of how close you want to watch them.
Dr Bonder:
That's great. So Dr. Trivedi, I know there was a big kind change in the nomenclature of what it used to be fatty liver and now it's called MASLD. Any kind of, I would say key words about the changes in the nomenclature that we need to be aware that we need to communicate to primary care. And I think we are going to also ask you, now that we use the alcohol word, is how do we differentiate between someone who has MASLD with just fatty alcoholic liver disease complicated with 2 different conditions. So can you comment on those two things please?
Dr Trivedi:
Yeah, no, I think that's a good point to bring up. I think the nomenclature change was really important in my opinion for two main reasons. Number one, destigmatized a couple of the terms like fatty liver, for example, or nonalcoholic liver. And it also highlights or re-emphasizes the importance of the pathophysiology of the condition, which is really surrounded by metabolic dysfunction as the cause of the liver disease. And it really highlights that by using this new term. So I think those are really the two main reasons that we should all be adopting this new terminology. And in the future using this new terminology will not only help us treat our patients better, but it will also help us uniformly research the causes of MASLD in a more cohesive way.
In terms of the alcohol component, the umbrella term that encompasses MASLD is really liver disease and stenotic liver disease includes MASLD as well as on the other end of the spectrum of alcohol-related liver disease, which is caused predominantly by excessive alcohol intake. But there is this sort of overlap syndrome where you get an individual with metabolic risk factors who also has a significant amount of alcohol use and that term is called Met-ALD. So this is an important new term. There was no term that denoted this sort of overlap syndrome before, but this highlights the physiology that there can be metabolic risk factors plus significant alcohol use that could be causing the stenotic liver disease. So these patients, we call them Met-ALD.
Dr Bonder:
Right. So Dr. Jiang, in your experience, I mean we have a patient who is already staged, who despite of you recommending maybe lifestyle modifications, the patient continues to advance or has advanced stage of fibrosis. So can you explain to me what's kind of your thought process about who should be treated and at what point do we decide, okay, this patient needs to be treated at this moment before there are complications of liver disease?
Dr Jiang:
Yeah, so I think this is a great question for 2025 because just 5 years ago we probably don't have many treatment options and now we have a few treatment options and there are several more in the pipeline. I think in general there are two camps of treatment strategies that is currently FDA-approved. One is focusing on weight loss in these treatments achieves the goals of addressing not just steatotic liver disease but also overall metabolic disease burden. So for people, for patients who are at a very high BMI, I think this will be a very good treatment strategy and there are reasons that they approve the specific treatment that will have more liver-specific metabolic benefits and it has clinical evidence of reducing the fibrosis. I think this type of treatment is also beneficial, particularly for those advanced liver fibrosis and maybe does not have a high BMI or already on weight loss treatment but still has a high BMI, this can be added and used together.
Dr Bonder:
This is great. So Dr. Trivedi, there's going to be a very simple question because we talk about lifestyle modifications. I mean, I don't know, how do you explain this to patients, but can you go over quickly is what are the general, I would say measurements or general principles, that you actually talked with patients about what they should do to start really trying to improve their MASLD?
Dr Trivedi:
Yeah, I think this is definitely should be an individualized approach to the patient you have in front of you because every patient has different weaknesses and strengths. But in general, I think as Dr. Jiang mentioned, weight loss is definitely important. But I do try to remind my patients not to weigh themselves on the scale every single day because they do oftentimes get obsessive about the number that they see on the scale. And I tell them to just start implementing slow, long-term lifestyle changes that you can sustain over time. And that includes even just moderate exercise for someone who hasn't been doing any exercise; if they have been doing some mild exercise, I try to tell them measures to step it up a little bit more. And I do reassure them that even though they may not be seeing the changes that they want on the weighing scale, that exercise in itself does reduce liver inflammation, it does reduce liver steatosis and may potentially even impact fibrosis independent of weight loss. So I think that's very important.
I do try to talk about the concept of body composition rather than weight loss if the patient is the right patient to hear it. And then I talk about nutritional dietary recommendations and in general I tell my patients to reduce carbohydrates, avoid any sugary foods, avoid drinking sodas and juices, and increase their intake of lean meats or lean sources of protein, sometimes even adding supplemental sources of protein if needed. And then the last thing that I mention to my patients is it's not just increasing the level of exercise, but it's also the type of exercise. So there are increasing amounts of studies and research showing that even weight training or resistance training has more of a dramatic impact on reducing liver hepatic inflammation in these patients. So I do try to tailor their regimen based off of what they're already doing and I do give a sort of tailored approach to my recommendations.
Dr Bonder:
Thank you. So Dr. Jiang, now that Dr Trivedi brought a little bit about different types of diets, I mean we get asked all the time in clinics, do you recommend a specific diet? So that would be question number one and number two, he really kind of touched the topic of exercise. Is there a magic number of the amount of exercise that we need to do amounting minutes time to devote it in a week that we need to really kind dedicate to actually achieve a better response in our mazel?
Dr Jiang:
Yeah, so I totally agree with what Dr Trivedi said, that this is something that has to be personalized and whatever intervention you come up with through discussion with patient has to be something that the patient can enjoy and can sort of bring it in the long term, not just a few weeks.
In terms of diets, unfortunately nutritional studies is not very easy to do and what we know is that a Mediterranean diet has been a diet that probably has been the best studied diet in terms of the quality of the research behind it. And it has shown that it has benefited in terms of reducing the metabolic risk factors and the metabolic related outcomes. This diet sort of exemplifies some of the key elements for liver health that we look for — the limited carbohydrate, minimized sugar, and a reasonable amount of protein as well as some healthy fatty acids, especially these unsaturated fatty acids that come from vegetables, that come from seafood, can be very helpful in terms of exercise. Again, this has to be taken into consideration of patient's lifestyle in general. Daily exercise is recommended. I tell my patient that all exercise is good exercise as long as you enjoy it and that you feel your heart rate is going up and you're sweating. And these are always helpful. I tend to emphasize less of the type of exercise, but encourage the patient to do the type of exercise that they enjoy. Even simple walking with families, these can also help them to go outside and have more physical activity in their daily life.
Dr Bonder:
Great. So I just want to throw a question to each one of you with recapping our today's video. So what would be your message to our primary care, our general gastroenterologists, about MASLD, what they should be aware of and what are their concerns?
Dr Trivedi:
Yeah, so I think increasing awareness and having increasing amount of knowledge on this topic is really key. I think that all started by the recent change in nomenclature. I think adopting this new terminology will help primary care physicians and community physicians at every level understand this disease process better and be able to inform and talk to their patients about it in a better way. So that's number one. Secondly, I think just any sort of screening tool that you could use based off of your available resources, even if it's just the FIB-4 score, is better than not screening at all. So there are a number of different articles and papers that talk about all of the different types of tools that we have. Selecting one that is available to you, sticking to that, and using it throughout your patient population is important. And then the last point I have to make is don't be afraid to refer your patient to a specialist. Even if you're not sure if this patient may have an indeterminate or an elevated fibrosis marker, for example, you can always consult with your friendly local hepatologist.
Dr Jiang:
Yeah, I think Dr Trivedi summarized it really well. I may have two points to add. One is that I think we are witnessing a paradigm shift in the management of liver disease. As a hepatologist, we used to take pride of treating cirrhosis, but I think the future is in preventing cirrhosis. MASLD is a disease really, we have the opportunity to prevent the patient getting to the point of cirrhosis and have to face the dreadful complications associated with liver fibrosis. And the second point is that patient can really change their lifestyle. We always say that it's impossible to change the lifestyle. In my practice, I have had numerous occasions that a patient are willing to take the advice and willing to implement changes. And with today's age that we have very helpful medications combined with these therapies, I think we can really achieve the goal of preventing patient developing cirrhosis. It all starts with a conversation with the patient, recognizing the condition and start a conversation about MASLD.
Dr Bonder:
Well thank you both. It was very informative and hope everyone really gets to enjoy and learn something from this video. And again, thank you so much for being here and we'll see you at our next chapter.
