Editor's note: Liver diseases, primarily viral hepatitis, metabolic-associated fatty liver disease (MAFLD), and alcoholic liver disease, affect approximately 400 million people in China. With the increasing pace of life, unhealthy lifestyle habits are contributing to a rise in the incidence of various types of hepatitis. The prevention and control of liver diseases require widespread public awareness and proactive support. Recently, the Academic Forum of the Liver Disease Committee of the World Association of Chinese Doctors was held in the beautiful city of Qingdao. At the forum, Dr. Lai Wei from Beijing Tsinghua Changgung Hospital affiliated to Tsinghua University, represented the guidelines update drafting committee to provide an in-depth interpretation of the 2024 Edition of the Chinese Guidelines for the Prevention and Treatment of Metabolic (Non-Alcoholic) Fatty Liver Disease. Hepatology Digest conducted a deep-dive interview with Dr. Lai Wei, and the following content has been compiled for readers' reference.Hepatology Digest: Metabolic-associated fatty liver disease (MAFLD) is one of the most prevalent liver diseases globally, posing a severe threat and burden. Can you discuss the current epidemiological status of MAFLD in China?
Dr. Lai Wei: As history has progressed, we have gradually come to understand that many metabolic factors contribute to metabolic abnormalities, leading to fat deposition in the liver, followed by liver fibrosis, cirrhosis, and even liver cancer. This has prompted a re-evaluation of the term “non-alcoholic fatty liver disease” (NAFLD), with many international organizations and societies recommending the name change to “metabolic-associated fatty liver disease” (MAFLD). In the real world, when we include metabolic abnormalities in the diagnosis, the prevalence of MAFLD is higher than that previously estimated for NAFLD. In China, about 30% of adults have varying degrees of MAFLD.
Patients with MAFLD are present across different specialties and medical institutions. I would encourage liver specialists to engage more with non-hepatology colleagues to help raise awareness of liver abnormalities associated with metabolic conditions in other medical fields.
Hepatology Digest: Could you elaborate on the philosophy and process behind the revisions in the 2024 edition of the guidelines? How do you assess the significance of the new guidelines in guiding the prevention and treatment of MAFLD?
Dr. Lai Wei: The 2024 edition includes several major updates:
1. Philosophical Update: In the previous edition, the disease was termed “non-alcoholic fatty liver disease.” The new edition adopts the name “metabolic-associated (non-alcoholic) fatty liver disease,” emphasizing that metabolic abnormalities are the primary cause, and individuals with metabolic abnormalities are at high risk for MAFLD.
2. Understanding of Disease Progression: The previous guidelines focused more on the progression from NAFLD to liver fibrosis and liver cancer. With the inclusion of metabolic factors, the new guidelines emphasize a more holistic approach. Apart from reducing the occurrence of cirrhosis and liver cancer, attention is also given to the control, monitoring, and treatment of metabolic factors. Additionally, given that metabolic factors are associated with cancer development, the new guidelines highlight the need to monitor for extrahepatic cancers, not just hepatocellular carcinoma.
3. Treatment Updates: Previously, treatment focused mainly on liver-related issues. The new guidelines expand the focus to managing metabolic conditions such as hypertension, type 2 diabetes, metabolic syndrome, and dyslipidemia. While we currently lack comprehensive studies on whether controlling these factors can reverse liver damage, managing them can reduce the clinical endpoints associated with metabolic abnormalities, such as cardiovascular disease and extrahepatic cancers.
4. Monitoring and Follow-Up: The new guidelines emphasize specific monitoring and follow-up strategies, including how to monitor liver fibrosis in patients without cirrhosis and how to assess liver cancer risk in those with cirrhosis.
Overall, the new guidelines reflect the broader understanding of the disease and encourage collaboration across departments, including liver specialists, primary care centers, and community health centers, to monitor and treat people with metabolic abnormalities, particularly those at risk of liver fibrosis due to fatty liver.
Hepatology Digest: What are the challenges and key areas of focus for China in the prevention and treatment of MAFLD going forward?
Dr. Lai Wei: The primary preventive measure remains the control of metabolic factors. China’s preventive strategy is divided into three levels—primary, secondary, and tertiary prevention. The most critical focus now is on primary prevention, which involves adopting a healthy lifestyle, exercising regularly, and maintaining a healthy diet. This includes reducing the consumption of processed foods, carbonated drinks, and high-sugar beverages. Regular physical activity can help to burn off excess energy, reduce fat accumulation, and maintain energy balance—this is the most important preventive measure.
For those who already have the disease, lifestyle improvements, including dietary adjustments and increased exercise, are crucial to slowing disease progression. For overweight and obese individuals who are unable to improve their lifestyle, metabolic surgery may be an option to control dietary intake. However, metabolic surgery must be managed with the collaboration of multiple disciplines to minimize its impact on the body’s metabolism.
At present, the international research on drugs for treating metabolic-associated steatohepatitis is booming. These studies focus on the mechanisms of metabolic causes, liver inflammation, liver fat deposition, oxidative stress, and fibrosis. Some drugs have already been approved in the United States. We hope that, in the near future, with joint efforts from Chinese hepatologists, domestic pharmaceutical companies, and regulatory bodies, we can also develop and approve local medications for treating MAFLD in China.
