Fatty liver disease is getting a name change. After years of discussion and review, an international working group including members of the American Association for the Study of Liver Diseases and other hepatology societies has come to a consensus, announcing recently that they will refer to fatty liver disease as steatotic liver disease.

Nonalcoholic fatty liver disease will now be called metabolic dysfunction–associated steatotic liver disease, or MASLD, and nonalcoholic steatohepatitis will now be called metabolic dysfunction–associated steatohepatitis. The group also has created a new subcategory, MetALD (pronounced met A-L-D), which is MASLD in the setting of moderate alcohol consumption (140 g/4.76 fluid ounces and 210 g/7.14 fluid ounces per week for women and for men, respectively).

New Name Is More Precise, Avoids Stigma

The nomenclature change, which was announced at the European Association for the Study of the Liver (EASL) 2023 annual meeting and in an article in Hepatology (2023;78[1]:3-5) “stems from a growing need to describe the conditions with more accuracy, while also addressing stigma that some patients may feel from the wording—stigma that can cause patients to avoid treatment. The term ‘fatty’ is perceived by many patients as being stigmatizing and thus hinders disease awareness and patient desire to engage with healthcare services.”

Working group member Mazen Noureddin, MD, told Gastroenterology & Endoscopy News that “this new nomenclature carries the same definition [as] NAFLD. However, it allows the providers to use patient-friendly terms such as ‘metabolic’ and ‘steatosis’ instead of ‘fatty’ or including the previous word ‘nonalcoholic.’” In addition, if patients have MASLD, the new term will allow clinicians to explain the connection more easily between metabolic-associated factors and the disease, said Dr. Noureddin, the director of the Cedars-Sinai Fatty Liver Program, in Los Angeles.

The overarching terminology is now more precise, according to the societies. For instance, as metabolic factors, such as high body weight, visceral obesity, insulin resistance and dyslipidemia, are the main drivers of MASLD, it is more accurate to name the disease for those factors than the absence of alcohol.

They also noted that for some patients, it can be a mix of metabolic factors and alcohol driving the disease, and these name changes can reflect that combination. This new term MetALD, was applauded by all experts who spoke to Gastroenterology & Endoscopy News about the changes. There were always patients who fell in between the previous diagnoses of nonalcoholic or alcohol related, explained Nadege T. Gunn, MD, CPI, the medical director of Impact Research Institute, in Waco, Texas. “We were already recognizing that there was overlap between people with metabolic disorders and excess alcohol use, ... What was reassuring about the terminology change is that now we’re giving a definition to it, and we’re acknowledging that there’s a marriage between these two entities,” she said.

These changes in verbiage are similar to what some have already been using in practices and clinics for years. Ashwani Singal, MD, the medical director of liver transplantation at the University of Louisville, in Kentucky, told Gastroenterology & Endoscopy News that he had incorporated the term metabolic into his patient interactions five or six years ago. He said he’s seen a 180-degree change in patient consultations using the term “metabolic” instead of “fatty.” “When you explain the same thing to the patients, ‘This is due to your metabolism being slow or being different than another individual, that it puts more fat into the liver [and] puts you at risk of diabetes and heart disease,’ the patient’s attitude is more positive as they feel to not be judged by the provider.

“Although replacing the word ‘metabolism’ for ‘fatty’ still brings fat into the discussion, patients remain more accepting of the whole discussion and are more motivated for a change in lifestyle.”

Ripples Never Come Back

The working group stressed that it took great pains to have stakeholders represented for the agreement and employed the Delphi process, but some have criticized the announcement as coming at an inopportune moment in the disease’s time line of research and discovery. Others have said it creates the need for costly new resources to support materials and education with the new names: Everything from ICD-10 codes to pamphlets to names of entire healthcare centers, departments and foundations will need to be changed.

Among members of the Fatty Liver Foundation polled about the change, there was a 60/40 split in favor of having the disease names stay the same, according to Wayne Eskridge, the organization’s CEO.

Mr. Eskridge noted that as a part of the working group, he and his organization support the name change, but he acknowledged there will be aftereffects of the nomenclature shift. Organizations, foundations, healthcare centers, departments and the like will probably have to change their names in the near future, incurring costs for new signage, updates to webpages, and labor incurred making the various changes. For some, that is just the cost of doing business, but for others, they will have to search for new revenue streams to fund the changes, “which can be very challenging.”

An AASLD representative said they are working to help organizations and patient groups that need support with the change.

“We … understand that the implementation will be challenging for some in the medical community,” wrote AASLD in a written comment sent to Gastroenterology & Endoscopy News. “AASLD is convening conversations with key stakeholders in our community, including membership groups, regulatory groups, industry groups and patient organizations. These conversations will help inform our roll-out strategy,” the association wrote. Noting that the upcoming Liver Meeting will be “a key vehicle for communication with the broader global community,” the AASLD statement indicated that in the meantime, the association is developing clinical tools, such as “an SLD decision tree, infographics, and presentations to help those in our community better understand the new nomenclature and how to use it.”

The ripples of the name change continue out from there. Paperwork will have to be updated, especially living documents that are still in process for things such as grants, clinical trials or FDA review. Mr. Eskridge told Gastroenterology & Endoscopy News that he has worried that these changes will slow down bureaucracy that, in turn, could hinder speedy approvals for new drugs, for instance, when we are on the precipice of new approvals for treatment of steatotic liver disease. “My fear is ... if anything at all in [regulators’] world changes, they’re so cautious that they’ll have a hard time coping with it,” he said. However, he said other members of the working group got assurances from the FDA specifically that name changes would not hamper new drug approvals.

The timing for this name change may not be ideal, Dr. Gunn told Gastroenterology & Endoscopy News. Although Dr. Gunn conceded that no time may be the best time, changing a name as new understanding of disease mechanisms and novel therapies are on the horizon is a bit chaotic. “It’s the timing,” she said. “It’s like, we don’t really even understand the disease fully. We’re still learning. We’re trying to find treatments, and then in the heat of all of that, in the midst of all of that, here’s this name change that we now have to wrap our minds around.

“It also is going to take a lot of time and resources—both financial and just sweat equity, if you will—to try and reeducate everyone around this name change. In the midst of this, we’re still trying to educate people around fatty liver, period. And now we’re trying to explain to them that it’s now called metabolic dysfunction–associated steatotic liver disease.”

Explaining the changes to patients has been time-consuming, Dr. Gunn said, often leading to confusion on what the name change means for the disease, as if the change denotes a new change in understanding of their disease states. And it’s not just patients who need to learn the new verbiage, she said, but also referring physicians like primary care and family providers. The news of the name change hasn’t reached many providers outside of GI and hepatology, she explained. “So we’re having to really go down to ground zero, to explain to them that this is a name change,” she said.

Not Our First Rodeo

Researchers will have to remember to use NAFLD and MASLD as search terms when reviewing the literature. ICD-10 codes will have to be updated, as well as electronic health record systems. Payors will have to update their verbiage. But this isn’t the first time this has happened—let alone the first time this has happened in hepatology.

Primary biliary cholangitis was formerly known as primary biliary cirrhosis, Dr. Gunn said. Alcohol-associated liver disease was called alcoholic liver disease, Dr. Singal said. Both were changed to use more inclusive and accurate wording for patients. Those name transitions have been largely incorporated but are ongoing. “I still see patients being referred to and the charts and the medical documents being filled with the diagnosis, writing ‘alcoholic liver disease,’” Dr. Singal said. “Even some of the family physician and PCP [primary care provider] talks and conferences use the word ‘alcoholic,’” he added. “It always takes time. I’m sure this similarly will be naturally replaced by the new word. And time will tell how quickly that gets adopted by the community.”

—Meaghan Lee Callaghan

The sources reported no relevant financial disclosures. Dr. Singal is a member of the Gastroenterology & Endoscopy News editorial board.