Editor's Note: July 28 is "World Hepatitis Day," and this year's theme in China is "Eliminate Hepatitis: Act Now." While the focus remains on viral hepatitis, the prevention and treatment of Metabolic Associated Fatty Liver Disease (MAFLD) should not be overlooked. In honor of World Hepatitis Day, Hepatology Digest invited Dr. Yuemin Nan from the Hebei Medical University Third Hospital to share valuable insights on MAFLD.

Hepatology Digest: With the latest updates in guidelines, what are the new diagnostic criteria for MAFLD? Which biomarkers or metabolic indicators are useful in predicting disease progression and the risk of complications in MAFLD patients?

Dr. Yuemin Nan: The new diagnostic criteria primarily encompass imaging and metabolic risk factors. First, imaging techniques such as ultrasound, CT, MRI, and elastography are used to diagnose fatty degeneration in the liver. Beyond imaging, metabolic risk factors must be considered: 1) Signs of overweight or increased waist circumference indicating obesity or central obesity; 2) Abnormal glucose metabolism, including type 2 diabetes, patients using antidiabetic drugs, and those with impaired glucose tolerance; 3) Metabolic syndrome, which includes weight changes, blood sugar variations, hypertriglyceridemia, reduced HDL cholesterol levels, and hypertension. It is also crucial to rule out other factors that could cause liver steatosis, such as alcohol consumption, malnutrition, and specific genetic metabolic liver diseases like Wilson’s disease.

Additionally, assessing liver fat content is important. Techniques like MRI-PDFF (Proton Density Fat Fraction) and elastography, and liver biopsy when possible, are used to accurately determine the degree of hepatic steatosis, as well as to assess inflammation and fibrosis.

Currently, non-invasive biomarkers for assessing liver fibrosis include both imaging and serological indicators:

1. Imaging: Techniques like ultrasound-based or MRI-based elastography, such as Vibration-Controlled Transient Elastography (VCTE), Magnetic Resonance Elastography (MRE), and 2D Shear Wave Elastography (SWE), are used to evaluate liver stiffness and determine the degree of fibrosis.

2. Serological Indicators: Biomarkers such as hyaluronic acid, serum PIIINP, type IV collagen, and laminin—often referred to as the “liver fibrosis four”—as well as scoring systems like APRI, NFS, and BARD, can help assess the extent of liver fibrosis.

Recently, studies have proposed models that combine elastography with biochemical indicators, such as FAST, MAST, and MEFIB. These comprehensive evaluation models provide a more thorough and accurate basis for early detection of liver fibrosis, enabling timely intervention to reduce the risk of disease progression and complications.

Hepatology Digest: MAFLD often coexists with other metabolic diseases like type 2 diabetes and cardiovascular disease. How should treatment strategies be adjusted for these patients? How can different treatment needs be balanced in the context of multiple coexisting diseases to maximize therapeutic efficacy?

Dr. Yuemin Nan: When MAFLD coexists with other metabolic diseases such as type 2 diabetes and cardiovascular disease, treatment strategies must be holistic and multi-faceted. The first step in diagnosis is to evaluate the extent of liver steatosis and use elastography to assess liver damage.

Given that MAFLD is fundamentally a metabolic disease, the primary intervention should be lifestyle modifications. Patients should be encouraged to shift away from sedentary habits and adopt a Mediterranean diet rich in low-fat, low-sugar, high-fiber, and high-protein foods. Individualized exercise prescriptions, combining aerobic and resistance training, should be developed, along with recommendations for regular sleep patterns and avoidance of late-night eating. Psychological support should also be integrated to improve treatment adherence and quality of life.

In terms of medication, treatment plans should be tailored to the patient’s specific conditions, such as overweight, obesity, diabetes, or hypertension. For overweight and obese patients, medications that improve insulin resistance, such as metformin, or weight-loss drugs like GLP-1 receptor agonists (e.g., semaglutide) and SGLT2 inhibitors (e.g., empagliflozin, canagliflozin), can be considered to reduce weight and regulate glucose metabolism. Hypertensive and hyperlipidemic patients should be treated with antihypertensive drugs (e.g., calcium channel blockers, ACE inhibitors) and lipid-lowering agents (e.g., statins, fibrates).

Multidisciplinary collaboration is essential for a comprehensive assessment of the patient’s health status and the development of a complete treatment plan based on the various metabolic components involved. For example, while addressing insulin resistance, liver-protective and enzyme-lowering treatments should be provided; during glucose-lowering therapy, attention should be given to changes in lipid levels and liver function, with treatment adjustments made as necessary. Cardiovascular disease patients should receive appropriate medications, and their nutritional status and physical activity levels should be closely monitored to ensure the rationality and effectiveness of the treatment plan.

Throughout the treatment process, it is crucial to closely monitor key indicators such as blood glucose, lipids, blood pressure, and liver function. Monitoring of kidney function and uric acid levels may also be necessary to ensure the normal and stable functioning of the heart, liver, kidneys, and other organs.

Hepatology Digest: In the treatment of MAFLD, lifestyle interventions play a crucial role. Are there specific dietary patterns or interventions that have been proven beneficial for MAFLD patients?

Dr. Yuemin Nan: Lifestyle interventions are undeniably central to the treatment of MAFLD. If patients fail to effectively adjust their lifestyle, even with multiple drug treatments, it is challenging to achieve ideal results. Therefore, we place great emphasis on lifestyle changes.

Diet is at the forefront of lifestyle interventions. We recommend that patients adopt a Mediterranean diet, which emphasizes the intake of low-fat, low-sugar, and high-fiber foods. The Mediterranean diet is rich in whole grains, vegetables, fruits, nuts, legumes, fish, and moderate amounts of olive oil, while strictly limiting the intake of red and processed meats. This dietary pattern not only helps in fat reduction and weight loss but also effectively maintains muscle mass, preventing the onset of sarcopenia.

The DASH diet is another recommended dietary pattern. Designed to prevent hypertension, the DASH diet includes an abundance of fruits, vegetables, whole grains, low-fat dairy products, lean meats, fish, beans, and nuts, while strictly controlling the intake of salt, sugar, and unhealthy fats. By improving cardiovascular health, the DASH diet may indirectly have a positive therapeutic effect on MAFLD.

Hepatology Digest: In recent years, the prevalence of MAFLD has continued to rise, and the age of onset is trending younger. What advice do you have for today’s young people?

Dr. Yuemin Nan: Given the rising prevalence of MAFLD and its increasingly younger onset, I strongly urge young people to take their lifestyle seriously and make adjustments where necessary. Through scientifically sound lifestyle changes, many young people can significantly improve or positively influence their metabolic status.

1. Dietary Adjustments: Adopt a healthy dietary pattern like the Mediterranean or DASH diet. These diets help reduce fat, promote weight loss, and maintain muscle mass.

2. Regular Exercise: Combine aerobic and resistance training with a personalized exercise plan. Aerobic exercises such as brisk walking, jogging, and swimming improve cardiovascular function and promote fat burning, while resistance training like weightlifting and push-ups help build muscle strength. Aim for at least five sessions per week, each lasting 40 minutes or more, for optimal results.

3. Regular Sleep Patterns: Improve daily routines by ensuring sufficient sleep and avoiding late-night eating and staying up late. Regular sleep patterns help regulate the body’s biological clock and improve metabolic levels.

4. Psychological Support: Maintain a positive and optimistic mindset, avoiding excessive stress and anxiety. Psychological support can help patients better adapt to lifestyle changes and improve treatment adherence.

For young people who are already overweight, obese, or have abnormal glucose metabolism, lifestyle changes should be complemented with appropriate medication under medical guidance. For example, SGLT2 inhibitors can aid in weight loss, boost confidence, and enhance control over diet and physical activity. For those who have already developed MAFLD, liver-protective and enzyme-lowering medications should be used alongside lifestyle adjustments to improve liver biochemical markers.

Dr. Yuemin Nan’s Message for World Hepatitis Day

As World Hepatitis Day approaches on July 28, I hope that healthcare professionals, especially those on the clinical frontlines, will pay attention to MAFLD and provide patients with guidance on lifestyle, exercise, and medication. By doing so, we can enhance patients’ treatment adherence, ensure timely follow-up visits, and ultimately improve treatment outcomes. This will enable more patients to reverse metabolic disorders and enhance their quality of life and overall health.

I also urge patients to recognize the health risks associated with metabolic disorders. With their own efforts and the professional support of doctors, they can improve their health, reduce the risks of cardiovascular and kidney diseases, and achieve a better quality of life and a happy family life!