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• W3122647216 abstract "We read with great interest the landmark consensus on the redefinition of fatty liver disease by Eslam et al. This includes a shift in nomenclature from non-alcoholic fatty liver disease (NAFLD) to metabolic dysfunction-associated fatty liver disease (MAFLD) as a more apt term, as well as the adoption of a set of simple and pertinent “positive” criteria to diagnose the disease, independent of alcohol intake or other liver diseases.[1]Eslam M. Newsome P.N. Sarin S.K. Anstee Q.M. Targher G. Romero-Gomez M. et al.A new definition for metabolic dysfunction-associated fatty liver disease: an international expert consensus statement.J Hepatol. 2020; 73: 202-209Abstract Full Text Full Text PDF PubMed Scopus (937) Google Scholar,[2]Eslam M. Sanyal A.J. George J. MAFLD: a consensus-driven proposed nomenclature for metabolic associated fatty liver disease.Gastroenterology. 2020; 158 (1999-2014.e1)Abstract Full Text Full Text PDF PubMed Scopus (872) Google Scholar These twin proposals provide a major advance in the conceptualisation of fatty liver diseases, but given the variation between different health systems, reaching a broad and global consensus is imperative. Sub-Saharan Africa (SSA) has more than half of the Earth's arable land, of which <10% is currently cultivated. The region was home to 13% of the global population in 2017 (over 1 billion) and it is forecasted to account for 35% of the global population by 2100. SSA is confronted by a high disease burden accounting for around 24% of the global disease burden. Although, the burden of disease in this region continues to be dominated by infectious diseases, countries in this region are undergoing a demographic transition characterised by industrialization and urbanization leading to an increasing prevalence of non-communicable diseases (NCDs).[3]Gouda H.N. Charlson F. Sorsdahl K. Ahmadzada S. Ferrari A.J. Erskine H. et al.Burden of non-communicable diseases in sub-saharan Africa, 1990–2017: results from the global burden of disease study 2017.Lancet Glob Health. 2019; 7: e1375-e1387Abstract Full Text Full Text PDF PubMed Scopus (240) Google Scholar The burden of NCDs in SSA regions is higher than the global average and it is projected that by 2020, NCDs will account for 27% of mortality in this region.[3]Gouda H.N. Charlson F. Sorsdahl K. Ahmadzada S. Ferrari A.J. Erskine H. et al.Burden of non-communicable diseases in sub-saharan Africa, 1990–2017: results from the global burden of disease study 2017.Lancet Glob Health. 2019; 7: e1375-e1387Abstract Full Text Full Text PDF PubMed Scopus (240) Google Scholar Adults in these regions face twice the risk of NCD mortality than their counterparts living in high-income countries.[4]Ezzati M. Pearson-Stuttard J. Bennett J.E. Mathers C.D. Acting on non-communicable diseases in low-and middle-income tropical countries.Nature. 2018; 559: 507-516Crossref PubMed Scopus (63) Google Scholar Fatty liver disease associated with metabolic dysfunction has emerged as an important NCD in SSA and available data suggest that this region has one of the fastest growing burdens worldwide. The prevalence of NAFLD in Africa was estimated to be about 13%,[5]Younossi Z. Anstee Q.M. Marietti M. Hardy T. Henry L. Eslam M. et al.Global burden of NAFLD and NASH: trends, predictions, risk factors and prevention.Nat Rev Gastroenterol Hepatol. 2018; 15: 11-20Crossref PubMed Scopus (2033) Google Scholar although this is like to be underestimated because of under-diagnosis and under-reporting. Cirrhosis-related deaths doubled in SSA between 1980 and 2010, and the underlying aetiology of cirrhosis was unknown in 31% of cases.[6]Vento S. Dzudzor B. Cainelli F. Tachi K. Liver cirrhosis in sub-Saharan Africa: neglected, yet important.Lancet Glob Health. 2018; 6: e1060-e1061Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar Similarly, 10% of the underlying aetiology for hepatocellular carcinoma in Africa was unknown,[6]Vento S. Dzudzor B. Cainelli F. Tachi K. Liver cirrhosis in sub-Saharan Africa: neglected, yet important.Lancet Glob Health. 2018; 6: e1060-e1061Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar suggesting potentially a major contributing role of NAFLD. The management of NAFLD in SSA comes with unique challenges. Compared to high-income countries, the changes in SSA countries are occurring abruptly and involving massive populations that have rapidly surpassed the capacity of healthcare systems, which are already fragile, fragmented, under-resourced, and limited in terms of infrastructure and ability to cope.[3]Gouda H.N. Charlson F. Sorsdahl K. Ahmadzada S. Ferrari A.J. Erskine H. et al.Burden of non-communicable diseases in sub-saharan Africa, 1990–2017: results from the global burden of disease study 2017.Lancet Glob Health. 2019; 7: e1375-e1387Abstract Full Text Full Text PDF PubMed Scopus (240) Google Scholar Hence, SSA countries do not have the option of simply copying the protocols that have emerged in high-income countries; examining the existing NAFLD guidelines through the contextualisation lens reveals gaps between policy and implementation. To reach a consensus, the African Middle East Association of Gastroenterology (AMAGE) invited leading members of SSA countries to come to a consensus on this proposal from a local perspective, through a Delphi process. Participating experts have uniformly decided to endorse “MAFLD” as the official term to describe fatty liver disease associated with metabolic dysfunction and be diagnosed by the proposed positive criteria (supported by 100% of participants). We also recommended abandoning the term non-alcoholic steatohepatitis “NASH” and that the single term MAFLD be used, recognising a disease continuum that is dependent on grade of activity and stage of fibrosis. Besides, the consensus reached through the Delphi method displaying a clear support for the MAFLD proposal, from a national perspective, the panel of experts recognized plenty of multiscale advantages that are at play in adopting the MAFLD framework, which include: Value the evidence: To date and in quite a short timeframe, available studies have consistently reached the conclusion that the diagnostic criteria for MAFLD are simple, practical, and superior to the existing NAFLD criteria for identifying high-risk patients with severe liver injury, cardiovascular diseases, and chronic kidney diseases.[7]Fouad Y. Elwakil R. Elsahhar M. Said E. Bazeed S. Ali Gomaa A. et al.The NAFLD-MAFLD debate: eminence vs evidence.Liver Int. 2020 Nov 21; (Online ahead of print)https://doi.org/10.1111/liv.14739Crossref Scopus (41) Google Scholar Placing proof in pragmatism: SSA countries bear a huge, disproportionate, and growing burden of risk factors for MAFLD, which constitutes a threat to development. Efforts to tackle the global burden of MAFLD may need region-specific fine-tuning measures addressing the challenge of scarce resources. In this regard, the obvious ease of implementing the diagnostic criteria of MAFLD,[7]Fouad Y. Elwakil R. Elsahhar M. Said E. Bazeed S. Ali Gomaa A. et al.The NAFLD-MAFLD debate: eminence vs evidence.Liver Int. 2020 Nov 21; (Online ahead of print)https://doi.org/10.1111/liv.14739Crossref Scopus (41) Google Scholar,[8]Fouad Y. Waked I. Bollipo S. Gomaa A. Ajlouni Y. Attia D. What's in a name? Renaming 'NAFLD' to 'MAFLD'.Liver Int. 2020; 40: 1254-1261Crossref PubMed Scopus (130) Google Scholar in contrast to the challenging criteria of the old diagnosis of NAFLD, presents a unique opportunity to bridge these gaps and combat MAFLD despite our limited resources. Turning challenges into moments of opportunity: The redefinition of fatty liver disease associated with metabolic dysfunction presents a unique opportunity to change the perception of MAFLD, engage stakeholders in MAFLD management and rectify the current funding deficit. Increasing awareness and rectifying the funding deficit is partly challenged by a problem of language.[8]Fouad Y. Waked I. Bollipo S. Gomaa A. Ajlouni Y. Attia D. What's in a name? Renaming 'NAFLD' to 'MAFLD'.Liver Int. 2020; 40: 1254-1261Crossref PubMed Scopus (130) Google Scholar This is not the case for more defined areas of health, such as HIV/AIDS or diabetes. One regional lesson from HIV/AIDS that may be useful for MAFLD is to involve local communities actively during national scale-up programmes.[9]Narayan K.V. Ali M.K. del Rio C. Koplan J.P. Curran J. Global noncommunicable diseases—lessons from the HIV–AIDS experience.N Engl J Med. 2011; 365: 876-878Crossref PubMed Scopus (36) Google Scholar An inability to understand the risk of NAFLD and the use of the negative prefix “non” does not give a sense of importance.[8]Fouad Y. Waked I. Bollipo S. Gomaa A. Ajlouni Y. Attia D. What's in a name? Renaming 'NAFLD' to 'MAFLD'.Liver Int. 2020; 40: 1254-1261Crossref PubMed Scopus (130) Google Scholar MAFLD could provide a useful alternative that better reflects risk and may encourage metabolically healthy lifestyle changes. Various studies in other diseases have shown the positive implications of changing disease names on improving the lay perception and beliefs about management and health outcomes.[10]Shiha G. Korenjak M. Eskridge W. Casanovas T. Velez-Moller P. Högström S. et al.Redefining fatty liver disease: an international patient perspective.Lancet Gastroenterol Hepatol. 2021 Jan; 6: 73-79Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar Enhancing management of multimorbidity in low-income context: Multimorbidity is a growing concern in SSA countries.[11]Odland M.L. Payne C. Witham M.D. Siedner M.J. Bärnighausen T. Bountogo M. et al.Epidemiology of multimorbidity in conditions of extreme poverty: a population-based study of older adults in rural Burkina Faso.BMJ Glob Health. 2020; 5e002096Crossref PubMed Scopus (12) Google Scholar In contrast to the previous criteria of NAFLD that solely relied on exclusion of other liver diseases, the positive criteria for MAFLD will encourage the recognition of dual burdens of liver disease. A multi-sectoral, integrated approach to healthcare that accounts for all diseases appears to be the way forward, particularly considering the significant burden of HIV in the region. This change would also represent the pillar for establishing HIV-metabolic clinics which are currently needed in many countries in the region. This will also be an opportunity to encourage physicians to evaluate the hepatic manifestation of metabolic disorders. Strengthening primary healthcare systems: One of the major problems with NAFLD care is that it is primarily hospital-centred and tends to be concentrated in large urban hospitals.[12]Tesema A.G. Ajisegiri W.S. Abimbola S. Balane C. Kengne A.P. Shiferaw F. et al.How well are non-communicable disease services being integrated into primary health care in Africa: a review of progress against World Health Organization’s African regional targets.PloS one. 2020; 15e0240984Crossref PubMed Scopus (12) Google Scholar This dire situation is aggravated by an extreme shortage of specialists in these centres,[13]Kinfu Y. Dal Poz M.R. Mercer H. Evans D.B. The health worker shortage in Africa: are enough physicians and nurses being trained?.Bull World Health Organ. 2009; 87: 225-230Crossref PubMed Scopus (172) Google Scholar causing problems with referrals and counter-referrals, which in turn leads to undiagnosed and untreated diseases. In addition, in 2019, the World Health Organization estimates that out-of-pocket expenditure exceeded 40% of total healthcare expenditure in low-income countries, mainly in SSA. Hence, it is not surprising that studies have shown a high prevalence of undiagnosed NAFLD in real life, even among high-income countries.[14]Alexander M. Loomis A.K. Fairburn-Beech J. van der Lei J. Duarte-Salles T. Prieto-Alhambra D. et al.Real-world data reveal a diagnostic gap in non-alcoholic fatty liver disease.BMC Med. 2018; 16: 1-11Crossref Scopus (94) Google Scholar Therefore, decentralized healthcare is needed to ensure more efficient and effective healthcare delivery at all levels in SSA, especially in rural communities. A simple care system based on simple diagnostic criteria and education has been developed and tested in SSA; this approach has been shown to improve population-level health outcomes, reduce all-cause mortality and is a cost-effective strategy for achieving universal health coverage.[15]Pfeiffer J. Montoya P. Baptista A.J. Karagianis M. de Morais Pugas M. Micek M. et al.Integration of HIV/AIDS services into African primary health care: lessons learned for health system strengthening in Mozambique-a case study.J Int AIDS Soc. 2010; 13: 3Crossref PubMed Scopus (115) Google Scholar Hence, the simplified MAFLD diagnostic criteria would likely lead to similar outcomes. In conclusion, the SSA experts enthusiastically endorse the MAFLD proposal. In concert with our work, experts from the Asian Pacific Association for the Study of the Liver (APASL), the Latin American Association for the Study of the Liver (ALEH), and the Middle East and North Africa16Shiha G. Alswat K. Al Khatry M. Sharara A.I. Örmeci N. Waked I. et al.Nomenclature and definition of metabolic-associated fatty liver disease: a consensus from the Middle East and north Africa.Lancet Gastroenterol Hepatol. 2021 Jan; 6: 57-64Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar, 17Mendez-Sanchez N. Arrese M. Gadano A. Oliveira C.P. Fassio E. Arab J.P. et al.The Latin American Association for the Study of the Liver (ALEH) position statement on the redefinition of fatty liver disease.Lancet Gastroenterol Hepatol. 2021 Jan; 6: 65-72Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar, 18Eslam M. Sarin S.K. Wong V.W. Fan J.G. Kawaguchi T. Ahn S.H. et al.The Asian Pacific Association for the Study of the Liver clinical practice guidelines for the diagnosis and management of metabolic associated fatty liver disease.Hepatol Int. 2020 Oct 1; https://doi.org/10.1007/s12072-020-10094-2Crossref PubMed Scopus (172) Google Scholar previously endorsed the same proposal, indicating that a broad consensus is emerging. No funding was required for this study. All authors contributed to the conceptualisation, drafting of the manuscript and approved the final version. The authors declare no competing interests or any conflict of interest. Please refer to the accompanying ICMJE disclosure forms for further details. The following is/are the supplementary data to this article: Download .pdf (.27 MB) Help with pdf files Multimedia component 1 A new definition for metabolic dysfunction-associated fatty liver disease: An international expert consensus statementJournal of HepatologyVol. 73Issue 1PreviewThe exclusion of other chronic liver diseases including “excess” alcohol intake has until now been necessary to establish a diagnosis of metabolic dysfunction-associated fatty liver disease (MAFLD). However, given our current understanding of the pathogenesis of MAFLD and its rising prevalence, “positive criteria” to diagnose the disease are required. In this work, a panel of international experts from 22 countries propose a new definition for the diagnosis of MAFLD that is both comprehensive and simple, and is independent of other liver diseases. Full-Text PDF MAFLD: Now is the time to capitalize on the momentumJournal of HepatologyVol. 74Issue 5PreviewWe thank Abdel Alem et al.,1 Kasper et al.2 Fouad et al.3 and Spearman et al.4 for their interest in our work.5,6 Abdel Alem et al.1 report an important qualitative study that shows a high level of dissatisfaction among patients with the old acronym “NAFLD” and their strong preference for a name change to “MAFLD”. This study in concert with a recent statement by >30 patient advocacy associations led by the European Liver Patients' Association (ELPA) and associations across different disciplines from diabetes to renal medicine and obesity medicine, highlights the increasing traction that MAFLD has received. Full-Text PDF" @default.
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