Clinicians Debate the Usefulness of NAFLD Name Change

Marilynn Larkin

August 03, 2023

Some clinicians say it's "confusing" and "ridiculous" to change the name and diagnostic criteria of an established liver disease, while others bemoan the seemingly political reasons why it happened. Yet recently, 236 panelists from 56 countries decided that the terms nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) rely on "exclusionary confounder terms and the use of potentially stigmatizing language."

In a report published June 24 in Hepatology, the panelists, members of the NAFLD Nomenclature Consensus Group, determined that steatotic liver disease (SLD) would be used as an "overarching term to encompass the various etiologies of steatosis."

Metabolic dysfunction-associated steatotic liver disease (MASLD) was chosen to replace NAFLD, and the definition was changed to include at least one of five cardiometabolic risk factors.

Metabolic dysfunction-associated steatohepatitis (MASH) replaces NASH. 

Those with no metabolic parameters and no known cause will be diagnosed with cryptogenic SLD.

A new category, MetALD, now describes those with MASLD who drink more alcohol per week — 140-350 g for men and 210-420 g for women.

The changes did not sit well with Medscape readers from diverse specialties, including family practice, critical care, and gastroenterology.

In its report, the consensus group writes that 74% of respondents to its rounds of surveys felt the current nomenclature "was sufficiently flawed to consider a name change."

The terms "nonalcoholic" and "fatty" were felt to be stigmatizing by 61% and 66% of respondents, respectively, according to the group, a multi-stakeholder effort under the auspices of the American Association for Study of Liver Disease and the European Association for Study of the Liver, in collaboration with the Asociación Latinoamericana para el Estudio del Hígado.

Consensus was defined a priori as a supermajority (67%) vote. 

"The new nomenclature and diagnostic criteria are widely supported, non-stigmatizing and can improve awareness and patient identification," the group concluded.

"No way" sums up many of the almost 60 reader comments received on Medscape's story covering the change. Readers must share medical credentials to publicly comment on stories.

"Confusing" and "Ridiculous"

A number of readers questioned how the changes will help practice.

"Once again, the specialists and other experts are changing the nomenclature to make the subject even more confusing for us primary care practitioners," an HIV/AIDS physician wrote. "They obviously have no idea what [primary care practitioners] have to put up with day in and day out. All such revisions do is increase the cynicism and anger so many [primary care practitioners] have."

Similarly, an internist commented, "These new terms are going to confuse both doctors and patients. When you give a patient a diagnosis like this, they will not understand it, and will not be able to act as they should to correct it."

"‘Fatty liver' is a jargon-free diagnosis, easy to understand and easy for patients to know what they need to do," the internist continued. "You think patients are gonna be educated when you tell them they have a 'metabolic disease'? 100% they will not know what you're talking about."

Yet another wondered, "If SLD is the 'umbrella' term, why (are) MetALD and ALD not MetASLD and ASLD, respectively? Furthermore, efforts to 'de-stigmatize' terminology will inadvertently condemn cryptogenic SLD (CSLD) as the new 'closet alcoholic.' "

"Perhaps a subclassification, CSLD-HDIRDD (CSLD-Honest, Doc, I Really Don't Drink)," the reader added.

"Everything about this is ridiculous," a family physician exclaimed. "How long will it be until the experts change obesity to 'gravitationally challenged' as a diagnosis!"

"I was thinking of 'circumferentially challenged,'" a reader in Canada chimed in. "But that would be 'body shaming' would it not?"

This reader continued, asking, "What about returning to the old practice of using Latin names patients don't understand so there is no 'shame' attached to them? Or what about this revolutionary idea: to just say it as it is - fat?"

Acceding to "Wokeness"

A sizable number of readers felt the name changes were motivated by a "woke" awareness.

"The effect of this new 'woke' clarity is ridiculous and simply not worth it! Can we justify the cost of this? Patients will have to learn all over again how to discuss their condition," commented one reader.

The reader continued, saying, "The internet and social media freely use the term 'fat' — and despite not wanting to offend — there seems to be universal agreement that FAT, in certain conditions or places, is unhealthy and undesirable."

"Why is the medical community so afraid to tell it like it is? I might hurt your feelings, but I could save your life," concluded the reader.

Defending Change

One commentator, a hepatologist in France, defended the changes and responded to some of complaints.

"Maybe people who comment here should read the article, reflect and understand the reasons why the old nomenclature and definition were scientifically inaccurate and needed to be changed," the commentator wrote.

"It was an exclusionary, negative definition not recognizing the root of the disease (adipose tissue dysfunction with insulin resistance — instead defining it by what it is not...) and not allowing the recognition of a large segment of the population [that] accumulates metabolic risk factors and moderate alcohol consumption. These patients were left out of all studies. Those were the main reasons for change and not the stigma part — with the word 'fatty' only being an issue in English-speaking countries, not elsewhere," the commentator continued.

"Calls for change have been voiced for 20 years and a first comprehensive attempt (called MAFLD) was introduced three years ago (J Hepatol. 2020;73:202-9). Please, a little bit of respect and restraint in the comments recognizing the research efforts and publications for those that contributed to the field over the past 25 years..." the hepatologist wrote.

The reader added, "Clinicians and researchers were dissatisfied for a long time, but it took years to gather overwhelming evidence demonstrating what causes the disease and then to kickstart a process under the auspices of several multinational scientific societies and come up with something consensually agreed upon by a large number of clinician researchers."

"Now you can tell your patient that he has metabolic liver disease instead of telling him that the problem at the root of his disease is that he is not drinking alcohol (nonalcoholic steatohepatitis). So, again, it is not so much about changing a name but about redefining diagnostic criteria and a nosological framework," the reader wrote.

Other readers responded to the defender:

"This nomenclature issue has been churned for 20+ years? Well, the mountain has labored heavily, and given birth to a mouse," one said.

"Still, how is this going to help in the clinical management? The whole gamut of conditions are evaluated and treated as a whole, not in isolation," a general practitioner in India said. "If someone has a risk factor or not, continuous follow-up is required as a whole, whether it's nonalcoholic or alcoholic, or whatever term is coined up."

Finally, a family practitioner commented, "It just rolls off the tongue, doesn't it? But I have to admit, it's the one place where 'persons' from 56 countries can get together and agree on something. Not even politicians can do that! Me, I'm sticking with NAFLD."

Follow Marilynn Larkin on Twitter:  @MarilynnL

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