metabolic health, particularly in patients with obesity or type 2 diabetes, says Cusi. The goal of risk assessment is to identify patients with clinically significant fibrosis (typically, stage F2 or higher) before it progresses any further. This stage is associated with increased risk of disease progression. 4 Not only can lifestyle changes help reverse steatosis, but FDA-approved liver therapies have been shown to decrease both steatosis and fibrosis when treated prior to cirrhosis. 6 “Although there are ongoing trials, we have no drugs that are proven to reverse cirrhosis,” says Cusi, a co-author of the 2025 ADA consensus report on MASLD in people with diabetes. “So, the sweet spot is to identify patients at an earlier stage.”
studied and the evolving evidence base, points out Bril. “They all agree that we need to screen ‘at risk’ populations, but there is variability in what is considered ‘at risk,'" he says. "Plus, different guidelines may be targeted to different populations." As evidence evolves, older guidelines may be less comprehensive than more recent updates. Once a person has 5 percent fat in the liver (along with at least one cardiometabolic risk factor, or CMRF), they can be diagnosed with MASLD. Current approaches prioritize fibrosis assessment rather than steatosis, given the high prevalance of hepatic fat in at-risk populations. 1 “We want to know if they have liver damage, whether they are progressing, and whether we need to address that with medications,” says Bril. All guidelines identify individuals with type 2 diabetes and “medically complicated” obesity as high-risk populations warranting screening, though specific criteria vary. AACE and ADA also recommend screening individuals with pre-diabetes; AACE includes
those with obesity with tw0 or more cardiometabolic risk factors, while ADA recommends screening those with obesity and at least one cardiometabolic risk factor. The AASLD recommends screening those with more than mild alcohol use and those with a first-degree relative with MASH cirrhosis. Most guidelines include those with steatosis on imaging and/or elevated ALT and AST. 1,2,3,4 Emerging data suggest that risk may extend beyond traditional populations, including individuals with incidental hepatic steatosis or an enlarged liver on imaging. Risk may also be underrecognized in certain metabolic subgroups. 1,4 "Since type 1 diabetes is more of an insulin-deficiency state, we thought MASLD and MASH would not be a concern, but we found that in the presence of obesity, risk is quite similar to type 2 diabetes," says Cusi. Given the high prevalence of undiagnosed disease, a lower threshold for screening may help identify patients with clinically significant fibrosis at a stage where intervention can alter disease trajectory.
Who should be screened? It depends on which guideline you follow. There are a number of evidence-based clinical guidelines from the AACE, ADA, AGA, AASLD, and others, but they don’t all agree. 1,2,3,4,5,7 Guidelines vary in their recommendations, reflecting differences in populations Prediabetes Type 2 Diabetes Isolated Overweight Isolated Obesity Non-Obese with Two CMRFs Obese + CMRF Steatosis on Imaging Elevated ALT/AST Moderate Alcohol Use Family History MASH-Cirrhosis People Living with HIV Patients to Screen for MASLD-Related Fibrosis
AACE 2022 AASLD 2023 EASL-EASD- EASO 2024
ADA 2025 AGA 2026 15% RULE *
Bril F., Metabolic liver disease: A summary of major guidelines and identifying opportunities to improve future guidelines. Diabetes Obes Metab. 2026;28 Suppl 2(Suppl 2):63-80. *Populations recommended for MASLD-related fibrosis screening across major clinical guidelines and clinical care pathways and proposed evidence-based strategy ("rule of 15%").
Healthful Living Rx 13
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