Metabolic dysfunction-associated steatotic liver disease (MASLD), formerly known as non-alcoholic fatty liver disease (NAFLD) [1], is the most common chronic liver disease, affecting an estimated 32.4% (95% CI 29.9–34.9) of the global population, with great variation among countries [2]. Despite its strong association with obesity, type 2 diabetes (T2D), and other metabolic conditions and risk factors, MASLD remains widely underdiagnosed and undertreated [3]. A key challenge in addressing MASLD is the low level of awareness among healthcare providers, particularly primary care providers (PCPs), who are often the first point of contact for many patients at risk or living with undiagnosed disease.
Given the growing burden of MASLD and the potential progression to complications such as cirrhosis and hepatocellular carcinoma, PCPs play a critical role in early identification and intervention [4]. However, existing research on PCPs' knowledge, screening behaviors, and treatment approaches for MASLD remains limited. Communication gaps, including low disease awareness, inconsistent discussions of risk with patients, and disparate use of patient-reported outcomes, can weaken early detection efforts and impact clinical management [5,6]. Measuring these domains helps illuminate where primary care interactions fall short in addressing MASLD. Understanding the extent to which PCPs recognize MASLD risk factors, incorporate liver disease assessments into routine care, and implement evidence-based management strategies is essential for improving early detection and patient outcomes.
This study evaluates PCPs’ awareness, risk assessment practices, and management strategies in the four most populous cities in the U.S.—New York City (NYC), Los Angeles (LA), Chicago and Houston, respectively [7]—to identify gaps in clinical practice and to inform targeted interventions aimed at enhancing MASLD treatment and care.
2Materials and MethodsAs a part of the Global Think-tank on Steatotic Liver Disease’s MASH Cities initiative, a survey was conducted from 5 to 13 September 2024 among 800 randomly selected PCPs (n = 200 per city) via online panels provided by Consensus Strategies, USA [8]. Participants were recruited via river sampling (recruitment through online activity), telephone recruitment, direct mail invitations, and opt-in options with characteristics by city reported in Table 1. The questionnaire covered five areas: (1) awareness of MASLD and fatty liver disease, (2) routine assessment practices for MASLD risk, (3) discussion of MASLD with at-risk patients, (4) management approaches, including lifestyle recommendations, pharmacotherapy, specialist referrals, and awareness of the fibrosis-4 (FIB-4) index, and (5) the use of patient-reported outcome (PRO) measures. Methodological details, including recruitment and questionnaire, are published elsewhere [9].
Participant characteristics by city.
Caption: Percentages are weighted from N = 200 per city. Group Ns are calculated as percentage*200.
Descriptive statistics summarize sample demographic characteristics. Frequency distributions and percentages estimate awareness of MASLD and fatty liver disease, assessment practices, discussion with patients, and management approaches. Chi-square tests evaluate differences between groups. Regression analysis assessed awareness of the terms MASLD and fatty liver disease each with gender, age, professional role, practice type, and years in practice.
2.1IRB approvalThe Emerson College (USA) Institutional Review Board approved this study in August 2024 (protocol 25–003-F-E-8/21). Written, informed consent was obtained from all participants prior to enrollment.
3ResultsAmong surveyed PCPs, 54.7% reported awareness of MASLD, while 86.6% were aware of fatty liver disease (Table 2). Physicians reported the highest levels of awareness—91.5% for fatty liver disease and 81.3% for MASLD—compared to physician assistants, nurse practitioners, and other healthcare professionals.
Awareness of MASLD and fatty liver disease.
Caption: Yes, No, and Unsure values represent percentages of the n values.
Routine MASLD risk assessment among high-risk patient groups varied by city: 66% of PCPs in Houston (highest) reported assessing patients with diabetes compared to 56.3% in LA (lowest), and 47.9% of PCPs in NYC assessed patients who report low levels of physical activity (Supplementary Table S1). Similarly, discussions about MASLD risk in patients with diabetes also varied: 64.9% of PCPs in Chicago and 52.7% in LA reported having these conversations (Supplementary Table S2).
In terms of MASLD management, recommended lifestyle modification ranged from 62.7% (highest) of PCPs in LA to 41.3 % (lowest) in Chicago, 57.6 % (highest) of PCPs in Chicago and 43.4% (lowest) in LA recommended pharmacotherapy, and specialist referrals were reported by 42.5% (highest) of PCPs in NYC and 28.6 % (lowest) in Chicago (Supplementary Table S3). Awareness of the FIB-4 index was limited, with fewer than half of PCPs overall (48.5%) reporting having heard of the test; awareness varied by city, ranging from 36.7% in Houston to 55.6% in Los Angeles (Supplementary Table S4).
The use of PROs also varied across cities: 67.1% (highest) of PCPs in LA and NYC reported using symptom severity scales compared to 48.4 % in Houston (lowest); 64.2% (highest) in LA (health-related) quality of life tools compared to 42.1% (lowest) in Chicago; and 25.5% (highest) of PCPs in Houston and 8.1% (lowest) in LA reporting no use of PROs (Supplementary Table S5).
The logistic regression results indicate that hospital-based practitioners are more likely to be aware of the term MASLD compared to those in solo private practice (OR = 2.02, 95% CI: 1.02–4.02, p = 0.05) (Supplementary Table S6). Nurse practitioners (OR = 0.21, 95% CI: 0.09–0.49, p = 0.00) and other non-physician professionals (OR = 0.18, 95% CI: 0.09–0.36, p = 0.00) have lower odds of being aware of MASLD compared to physicians. No significant associations held for professional roles for the term fatty liver disease (Supplementary Table S7).
For demographics, the model assessing the term fatty liver disease suggests that older PCP age is associated with higher odds of being aware of fatty liver disease (OR = 1.04, 95% CI: 1.00–1.08, p = 0.03) (Supplementary Table S7). Black or African American respondents have lower odds of awareness compared to White or Caucasian respondents (OR = 0.25, 95% CI: 0.09–0.65, p = 0.00). The model assessing MASLD showed no significant differences by demographic groups (Supplementary Table S6).
4DiscussionThe adoption of the term MASLD in mid-2023 marked a pivotal shift in the nomenclature of liver diseases, emphasizing metabolic dysfunction as the primary driver and underpinning an expansion of the community of practice. While this change aimed to reduce stigma and enhance clarity, it also introduced a new disease name and definition to PCPs. Lack of awareness of the new terminology may hinder early detection and intervention efforts. Awareness of MASLD lags behind that of “fatty liver disease”, a term that has been used for over four decades, as evidenced by this study’s findings. This low level of awareness has communication implications, including that recent clinical terminology and guidance updates have not yet fully diffused into primary care practice. Efforts to improve provider understanding of MASLD should focus on clear, consistent messaging delivered through trusted educational platforms.
Furthermore, logistical challenges—such as updating electronic health records and coding systems like ICD—complicate the transition. Recent efforts to incorporate MASLD/MASH as equivalent terms in ICD-10 will likely help [10]. Educational deficits also play an important role, with many PCPs lacking access to updated training materials that explain MASLD’s diagnostic criteria and management strategies. Structured training and continuing education could accelerate awareness and reduce variability in MASLD-related communication with patients [11]. Addressing these barriers will require multidisciplinary educational campaigns, enhanced communication about the implications of this terminology shift for patient care, and systemic support for integrating MASLD into clinical workflows. Such efforts are critical to supporting PCPs to confidently adopt the new terminology and improve early detection and management of this prevalent condition.
PCPs play a key role in early detection and management of MASLD/MASH. Given the very high prevalence of MASLD and its strong ties to obesity and T2D, proactive screening and intervention by PCPs are crucial to reducing cardiovascular and liver-related mortality (Box 1).
Role of primary care in MASLD detection and management
Screening & risk stratification:
PCPs should screen all patients with T2D or pre-diabetes for MASLD, especially those with obesity, metabolic syndrome, hepatic steatosis on imaging, persistently elevated aminotransferases (>6 months), other cardiometabolic risk factors or established cardiovascular disease. MASLD is often asymptomatic until advanced stages, and liver function tests may be normal. Initial non-invasive risk stratification can use the Fibrosis-4 index (FIB-4), which incorporates age, AST, ALT, and platelet count. *
• FIB-4 of 1.3–2.67 → Indeterminate risk for advanced fibrosis. Next steps, depending on the clinical practice guideline you follow, may include referral to a specialist or second-line testing such as ultrasound, elastography, or the Enhanced Liver Fibrosis (ELF) blood test.
• FIB-4 >2.67 → High risk for advanced fibrosis; immediate referral to a specialist is warranted.
• Reassessment: Patients with T2D, metabolic risk factors or hepatic steatosis should have a repeat FIB-4 test every 1–2 years.
• Additional evaluation: Assess for alcohol intake and secondary causes of liver disease.
Management & Lifestyle Interventions:
• First-line treatment includes a goal of at least 5%, preferably ≥7–10% weight loss, through caloric restriction, physical activity, and a Mediterranean-style diet.
• Pharmacologic options include GLP-1 receptor agonists, GLP-1/glucose-dependent insulinotropic polypeptide (GIP) receptor agonists, pioglitazone, SGLT2-inhibitors, and vitamin E for select patients. Resmetirom and semaglutide are now FDA-approved for MASH with moderate to advanced fibrosis (non-cirrhotic), initiated and monitored under endocrinology or hepatology care.
• Given that cardiovascular disease is the leading cause of premature mortality among people living with MASLD/MASH, optimizing blood pressure and lipid levels is essential. Statins are safe and recommended for cardiovascular risk reduction across the MASLD/MASH spectrum, including in compensated cirrhosis.
• Optimize metabolic health with a multidisciplinary approach including endocrinology, hepatology, nutrition, cardiology, mental health, and bariatric specialists.
Key takeaways:
PCPs should screen and risk-stratify using FIB-4, optimize cardiometabolic health, and refer high-risk patients to hepatology. Standardized guideline implementation in primary care is crucial to prevent progression to hepatic (e.g. cirrhosis, hepatocellular carcinoma) and extra-hepatic morbidity and mortality.
Note: The above recommendations are based on the American Association for the Study of Liver Diseases (AASLD) 2023 guidance [18], the American Association of Clinical Endocrinology (AACE) 2022 guidelines [12], and prior American Diabetes Association (ADA) guidance [19]. *The FIB-4 index has lower sensitivity for patients under 35 years old, and lower specificity with higher age, particularly over 65 years old, leading to more false positives. Some research suggests adjusting thresholds to 2.0 for adults >65 years old, but these adjustments are not universally agreed upon [20].
American Association for the Study of Liver Diseases (AASLD) clinical guidelines emphasize the importance of assessing metabolic risk factors—such as obesity, diabetes, and physical inactivity—for liver disease risk stratification [12]. Our findings indicate variability in clinical practice across the four cities studied. For instance, roughly half of PCPs in Chicago reported routinely assessing patients with overweight or obesity, compared to two-thirds in NYC. Similarly, although diabetes is a major risk factor for MASLD, screening rates remain suboptimal, particularly in Los Angeles and NYC, where just over half of PCPs report screening this patient population for liver disease. Despite FIB-4 being the AASLD-recommended first-line non-invasive test for liver fibrosis risk stratification in primary care [12], fewer than half of PCPs in the study sample reported awareness of the test, highlighting a clear implementation gap and pointing to the need for stronger policy, guideline dissemination, and health-system–level supports to translate MASLD recommendations into routine practice.
Ethnicity was not significantly associated with awareness of MASLD, but it was with fatty liver disease, perhaps because the former is a new term with lower overall awareness. Data from NHANES 2017–2018 indicate that severe MASLD is most common among Mexican Americans (46 %), compared to 22.7 % in Black individuals, 29.9 % in other Hispanic groups, and 32.1 % in Whites [13]. These findings highlight the need to enhance public health messaging around MASLD and promote liver fibrosis screening for populations at higher risk, while also addressing the terminology gap that may contribute to differences in disease awareness across ethnic groups.
We found notable variation in MASLD management strategies across the cities. While lifestyle modification was the most commonly recommended strategy overall, its use ranged widely, highlighting missed opportunities for consistent first-line interventions [4,14,15]. The use of patient-reported outcomes (PROs), a key communication tool for understanding patient experiences, was inconsistent in the four cities. While PROs can support shared decision-making and enhance patient engagement, their limited use in our sample suggests that communication about MASLD may focus more on clinical metrics than patient perspectives [14,16].
This study has several limitations. Findings are based on self-reported data, which may not reflect actual clinical practice. The survey was conducted in four large U.S. cities and may not be generalizable to non-urban or resource-limited settings. In addition, while the survey assessed awareness of MASLD and related tools such as FIB-4, it did not evaluate the accuracy of knowledge or adherence to guideline-recommended risk stratification and referral pathways. Finally, the cross-sectional design limits causal inference and captures awareness during an early phase of diffusion following the 2023 MASLD nomenclature change.
5ConclusionsThese findings underscore the need for more standardized implementation of MASLD guidelines, with an emphasis on early screening, comprehensive management, and the integration of PROs into routine care to support holistic patient-centered approaches [4]. Bridging existing awareness gaps requires more than targeted educational initiatives for PCPs. It also requires a stronger focus on communication within clinical interactions, particularly around risk factors, lifestyle changes, and the importance of MASLD as a chronic disease. Enhancing how MASLD is discussed in primary care could support more timely diagnosis, appropriate referrals, better outcomes and, ultimately, end this public health threat [17].
FundingThe creation of the MASH Cities initiative and this study were funded by the CUNY Graduate School of Public Health and Health Policy (SPH), New York City, NY, USA. Some authors are faculty at the CUNY SPH and had a role in the study design and implementation and manuscript drafting.
Author contributionsJVL contributed to Conceptualization, Methodology, and Supervision. JVL, TMW, AM, SP, and NA contributed to Methodology. TMW contributed to Data curation, Formal analysis, and Visualization. MB, AA, and MER contributed to Formal analysis and Validation. TMW contributed to Writing – original draft. JVL, AM, SP, NA, MB, AA, MER, MM, BEF, YH, NT, MC, MN, IJ, and SK contributed to Writing – review & editing. All authors reviewed and approved the final manuscript and agree to be accountable for all aspects of the work.
JVL reports speaker fees from Echosens, Gilead Sciences, Novo Nordisk, Pfizer, and grants from Echosens, Boehringer Ingelheim, Gilead Sciences, Madrigal Pharmaceuticals, Novo Nordisk, Pfizer and Roche Diagnostics, outside the submitted work. YH received research grants, consultant fees and speaker honoraria from 89Bio, Amgen, Applied Therapeutic, Astra Zeneca, Bayer, Boehringer Ingelheim, Corcept, Endogenex, Esperion, Ionis, Lilly, Mankind, Merck, Merck-Pfizer, Novartis, Novo Nordisk, Regeneron, and Sanofi. BEF reports consultant fees from WL Gore, BD Medical and Novo Nordisk. MM has received payments from Doximity for advertising its services for physicians via her social media platforms. SP has received grants from Novo Nordisk for an investigator-initiated trial with payments made to her institution. She has also served as a speaker and advisor for Novo Nordisk and Lilly and owns stock or stock options in Lilly, Novo Nordisk, and Viking. MER has provided scientific consulting for Akero, 89Bio, Boehringer Ingelheim, Intercept Pharmaceuticals, Histoindex, Heptabio, Madrigal, NGM Biopharmaceuticals, Novo Nordisk, Eli Lilly, Sagimet Biosciences, Sonic Incytes, Cytodyn, and GSK. MB has received grants from NIH, CDC/NIOSH, Pfizer, The Kinetix Group, Histoindex, and Siemens, consulting fees from The Kinetix Group, Madrigal, Pfizer, Fibronostics, Novo Nordisk, GSK, Boston Pharma, Merck, Boehringer-Ingelheim, and CurveBio, and has served on advisory boards for Surrozen, Madrigal, GSK, Novo Nordisk, and Boehringer-Ingelheim. AA has received grants from the National Institutes of Health, Novo Nordisk, Pfizer, Target Pharma, Oncoustics, Escopics, and Siemens, and consulting fees from Madrigal, Boehringer Ingelheim, Novo Nordisk, and GSK. NA has received grants from 89bio, Akero, Arbutus Biopharma, AstraZeneca, BioAge, Boehringer Ingelheim, Bristol Myers Squibb, Corcept Therapeutics, CymaBay, DSM, Galectin Therapeutics, Genentech, Genfit, Gilead, Healio, Hepagene, Intercept, Inventiva, Ionis, Ipsen, Lilly, Madrigal, Merck, NGM Biopharma, Noom, NorthSea, Novo Nordisk, Perspectum, Pfizer, PharmaIN, Poxel, Viking, and Zydus, consulting fees from 89bio, Akero, Boehringer Ingelheim, Echosens, Fibronostics, Gilead, Intercept, Ipsen, Madrigal, NorthSea, Novo Nordisk, Perspectum, and Pfizer, and honoraria from AbbVie, AstraZeneca, Echosens, Gilead, Intercept, Ipsen, Madrigal, and Perspectum. NT has received grants from the National Institutes of Health (NIH), GSK, Genentech-Roche, Helio Health, Durect Corp, Eiger Pharmaceuticals, and ImmunoCore for institutional support for clinical trials, royalties from Elsevier, and honoraria for lectures from CASL, EASL, PSSLD, APASL, GUILD, ILTS, and several academic institutions, as well as travel support for lectures from AASLD, INASL, and EASL. MC consults for and received grants from Gilead, Intercept, NGM Bio, Genfit, Conatus, and Novartis. MN has received research support from Allergan, Akero, BMS, Gilead, Galmed, Galectin, Genfit, Conatus, Enanta, Madrigal, Novartis, Pfizer, Shire, Viking and Zydus; MN is a shareholder or has stocks in Anaetos, ChronWell, CytoDyn, Ciema, Rivus Pharma and Viking. IJ has received grant and research support from Akero, Cymabay, 89Bio, Eli Lilly, Gilead, GSK, Intercept, Inventiva, Ipsen, Madrigal, Mirum, Novo Nordisk, and Rockefeller University (NIH funded) and has served as a consultant or advisor for Aligos, Arbutus, GSK, Intercept, Madrigal, Merck, Moderna, Precision Biosciences, Takeda, and Vir, and faculty panel discussant for Gilead. SK consults for and has received speaking fees from Novo Nordisk, Ipsen, Intercept, Gilead, Madrigal and GSK; SK reports speaker fees from Gilead Sciences, Novo Nordisk, Madrigal Pharmaceuticals, Ipsen, GSK, Intercept; consulting fees from Gilead Sciences, Intercept, Novo Nordisk, Madrigal Pharmaceuticals, Ipsen, Boehringer-Ingelheim, GSK. All other authors declare no competing interests.
JVL and TMW acknowledge institutional support to ISGlobal from the grant CEX2023-0001290-S funded by MCIN/AEI/10.13039/501100011033, and support from the Generalitat de Catalunya through the CERCA Program.
