The Paradigm Shift From NAFLD to MAFLD

A Global Primary Care Viewpoint

Taghreed M. Farahat; Mehmet Ungan; Josep Vilaseca; Jacqueline Ponzo; Pramendra Prasad Gupta; Andrew D. Schreiner; Wadeia Al Sharief; Kelly Casler; Tafat Abdelkader; Ludovico Abenavoli; Fatima-Zohra Mchich Alami; Mattias Ekstedt; Muntadar S. Jabir; Matthew J. Armstrong; Mona H. Osman; Johannes Wiegand; Dina Attia; Veronique Verhoeven; Ashraf Abdul Qayoum Amir; Nagwa N. Hegazy; Emmanuel A. Tsochatzis; Yasser Fouad; Helena Cortez-Pinto


Liver International. 2022;42(6):1259-1267. 

In This Article

Abstract and Introduction


Half of the global overweight/obese adult population have metabolic-dysfunction-associated fatty liver disease (MAFLD),[1] with prevalence rising, even among non-obese individuals.[2,3] This increase is observed globally and mostly in low- and low-middle-income countries of Africa, Asia and South America and represents a great worldwide burden on healthcare expenditures.[4–7] Lifestyle changes and a healthy diet are still the cornerstone in the clinical management of these patients as approved medications are presently lacking.[4,8]

In clinical settings, most patients with fatty liver disease are first identified and subsequently followed up in the community by primary care practitioners (PCPs).[9] There is unequivocal evidence of the health-promoting influence of primary care and its role in the prevention of illness and death.[10] In addition, in contrast to speciality care, primary care is characterized by a more equitable distribution as a healthcare service for all populations.[10] In this context, primary care is central and may therefore help or hinder optimal chronic disease care. For PCPs, to provide effective and high-quality care, it is crucial to integrate novel knowledge, skills and favourable attitudes towards care that focuses on system reform and interactive patient and primary care team relationships.[11]

In 2020, a group of international experts reached a consensus to comprehensively revisit the current definition of fatty liver disease, including updating the nomenclature from non-alcoholic fatty liver disease (NAFLD) to metabolic-dysfunction-associated fatty liver disease (MAFLD), and more importantly introducing a simple set of 'positive' diagnostic criteria for both adults and children.[12–15] The diagnosis of MAFLD is made if a patient has hepatic steatosis and is overweight or obese, has type 2 diabetes mellitus or two or more of the following: central obesity by ethnic-specific waist circumference cut-offs; blood pressure ≥ 135/85 mmHg or specific drug treatment; plasma triglycerides ≥150 mg/dL or specific drug treatment; plasma HDL-cholesterol <40 mg/dL for men and <50 mg/dL for women or specific drug treatment; fasting plasma glucose ≥100 mg/dL, 2-h post-load glucose ≥140 mg/dL or haemoglobin A1c ≥ 5.7%; homeostasis model assessment of insulin resistance ≥2.5 and plasma high-sensitivity C-reactive protein >2 mg/L. This call received substantial support from hepatologists across the globe, hepatology scientific societies, nursing and allied health leaders, pharma and regulatory science experts and patient associations.[4,5,16–23] Nonetheless, the new nomenclature has also triggered controversy,[24] suggesting the need for a consensus-driven redefinition of NAFLD.[25]

The high prevalence of fatty liver disease and its strong association with conditions traditionally managed in primary care such as obesity, diabetes mellitus, hypertension and hyperlipidaemia, positions general practitioners/family doctors to lead the charge of providing high-quality treatment at the scale that is needed to combat the fatty liver epidemic. Therefore, it is crucial to understand PCP perspectives regarding the proposed redefinition of fatty liver disease as well as the implications for the primary care of patients. In fact, the way PCPs envisage the utility of this change will play a significant role in global consensus building. Thus, the aim of this paper is for an international team of experts in primary care to provide perspective regarding the proposed redefinition of MAFLD. We think that the main role of PCPs is raising awareness, diagnosing cases, follow-up and detection of complications. The role of PCPs is essential in the detection and management of extra-hepatic associations as well as screening and surveillance of hepatocellular carcinoma.

Currently, numerous systemic barriers exist for PCPs who are managing fatty liver disease. These include diagnosis and screening, efficient referral pathway, restrictive policies, disease awareness and continuum of care. We believe that the transformational change from NAFLD to MAFLD can help to overcome some of these barriers and promote widespread active case findings of MAFLD and improvement of care.