A Growing and Often Missed Burden
Metabolic dysfunction-associated steatotic liver disease (MASLD) has emerged as a major public health threat, one that is often under-recognized due to its silent progression. Most patients remain asymptomatic until liver fibrosis or cirrhosis has already developed. By the time MASLD is diagnosed, critical intervention windows may have already closed.
As GI specialists, we are increasingly seeing the downstream consequences of missed early detection, an issue that calls for proactive engagement and leadership from the GI community in reshaping liver screening and care pathways.
Epidemiology and Risk Dynamics
MASLD is now the most common chronic liver disease globally, affecting an estimated 25–30% of the population. In the U.S., it is projected to become the leading indication for liver transplantation. The rise mirrors increasing rates of obesity, type 2 diabetes, dyslipidemia, and hypertension, components of metabolic syndrome.
What is visible clinically is only the tip of the iceberg. A large population remains undiagnosed due to subclinical disease or insufficient risk-based screening. Traditional markers like BMI may miss “lean MASLD” patients with metabolic dysfunction. A broader screening lens incorporating metabolic health markers, beyond weight, is critical.
Disparities in Access and Outcomes
MASLD does not affect all communities equally. Patients in underserved or rural settings face barriers to early diagnosis and effective management due to limited access to liver specialists, imaging tools, and supportive care services.
To address these inequities, a systemic approach is needed: community-based screening initiatives, telehepatology, and expanding non-invasive diagnostic access through primary care. GI physicians should champion policies that support equitable access to liver screening and education.
Current Challenges
Despite the urgency, several challenges persist:
- Rising incidence of obesity and metabolic syndrome.
- Low awareness among both patients and non-GI clinicians regarding MASLD and emerging diagnostic technologies.
- Difficulty implementing lifestyle changes due to resource limitations.
The Role of GI Physicians in Population Health
Early detection and prevention of progression to fibrosis or cirrhosis are achievable goals. GI physicians must lead the integration of MASLD screening into routine practice. This includes designing and deploying evidence-based screening algorithms for at-risk patients, collaborating with primary care, and coordinating with other specialists such as endocrinologists and bariatric surgeons.
Strengthening the Primary Care-Specialist Interface
Primary care physicians are well positioned to identify at-risk individuals but need support in the form of structured guidance. GI specialists can provide clinical decision tools for MASLD risk assessment (e.g., FIB-4 scoring), training on non-invasive technologies like FibroScan or MRE, and clear criteria for specialist referral.
Lifestyle and Modifiable Risk Factors
Lifestyle is at the core of MASLD management. Poor dietary patterns, physical inactivity, alcohol consumption, and ultra-processed foods all contribute to disease progression. A holistic care model should include access to registered dietitians, behavioral support for stress management, fitness counseling, and alcohol cessation programs, especially for patients with Met-ALD overlap.
Therapeutic Advances and Emerging Tools
Several tools are transforming the MASLD care landscape:
- AI and EHR-integrated screening algorithms to identify at-risk patients.
- Non-invasive fibrosis staging (FIB-4, transient elastography, MRE).
- Pharmacotherapy options including GLP-1 receptor agonists and Resmetirom for patients with F2–F3 fibrosis.
- Coordinated care models integrating GI, endocrinology, behavioral health, and bariatric surgery when appropriate.
Bridging the Awareness Gap
Compared to cardiovascular disease or diabetes, liver disease lacks public and policy visibility. Gastroenterologists can play a vital advocacy role, educating both the public and policymakers. Coverage for preventive screenings, nutritional counseling, and behavioral health services is essential to support sustainable lifestyle interventions, particularly for underserved populations.
Final Thought: Seize the Window
Liver disease may be silent, but our collective response shouldn’t be. MASLD is reversible in its early stages. By incorporating systematic screening, facilitating multi-specialty coordination, and addressing barriers to lifestyle change, GI physicians can alter the course of this epidemic. Let’s act decisively, before the window closes.
Neelima Reddy, MD, is a gastroenterologist with Gastroenterology Associates, a GI Alliance practice.