TO THE EDITOR
Metabolic dysfunction-associated steatotic liver disease (MASLD) has become the most common chronic liver disease worldwide, affecting about 38% of the global population[1]. In the Middle East and North Africa, the prevalence is as high as 46%. As one of the countries with the heaviest disease burden in this region, Egypt has a MASLD prevalence of 45%, with about 25.7 million cases nationwide[2]. However, these figures need to be viewed critically. Some epidemiological data from Egypt originate from small-scale or single-center studies, which may not fully represent the true national disease spectrum. This severe situation is closely related to the high rates of obesity and the epidemic of type 2 diabetes mellitus in Egypt. The review by Abdelhamed et al[2] published in the World Journal of Gastroenterology systematically elaborates on the epidemiology, risk factors, and management challenges of MASLD in Egypt, providing a valuable perspective for understanding the complexity of this disease in resource-limited environments. Building upon this foundation and incorporating evidence from China, this article explores the commonalities and specificities in MASLD prevention and control across regions, aiming to inform standardized management strategies for MASLD in Asian countries and even globally.
EPIDEMIOLOGY: COMMONALITIES AND DISPARITIES BETWEEN EAST AND WEST
China and Egypt exhibit certain similarities in the epidemiology of MASLD. According to the latest research, the prevalence of MASLD in China has reached 29.2%, comparable to the global average, and shows a continuous upward trend[3]. Similar to Egypt, China also faces the dual challenges of obesity and diabetes, which have reached a prevalence of 16.4% and 11.2%, respectively[4]. Both countries have the phenomenon of “lean MASLD”, which suggests that we need to look beyond traditional body mass index standards and focus on visceral fat and metabolic abnormalities[5]. This suggests that conventional BMI-based screening strategies may have limitations and should incorporate some indicators more sensitive to metabolic abnormalities. However, significant differences exist between the two nations. The MASLD epidemic in Egypt interacts with residual liver injury from previous hepatitis C virus (HCV) infection, with 30%-70% of chronic HCV patients exhibiting concomitant hepatic steatosis[6]. In contrast, hepatitis B virus (HBV) infection is more common in China[7], and the interaction mechanism between HBV and MASLD differs from that of HCV. Therefore, in Egypt, long-term monitoring of metabolic and liver health among the HCV-cured population should be implemented, while in China, enhanced screening for MASLD within the large HBV-infected population is warranted. The prevalence of MASLD is significantly higher in Egyptian females than in males (79.4% vs 71.2%)[8], whereas in China, the prevalence is typically higher in males. This gender difference stems from the complex interplay of hormonal levels, lifestyle, and sociocultural factors. We recommend that national prevention and treatment strategies should take such gender differences into account, with health promotion programs in Egypt prioritizing women, and lifestyle interventions in China focusing more on men.
RISK FACTORS: THE CENTRAL ROLE OF METABOLIC SYNDROME
Research from Egypt clearly identifies obesity, type 2 diabetes mellitus, dyslipidemia, and hypertension as the primary metabolic risk factors for MASLD. This conclusion has also been validated in Chinese populations. A multicenter study in China showed that the prevalence of metabolic syndrome among MASLD patients is as high as 64.3%, and the risk of liver fibrosis increases with the number of metabolic syndrome components[9]. Particular attention should be paid to shifts in dietary patterns[10]. Egypt has undergone a rapid transition from traditional diet to those high in sugar, fat, and ultraprocessed foods. China is experiencing a similar change. The traditional plant-based diet is gradually being replaced by a western diet, and the consumption of sugar-sweetened beverages is increasing annually. This nutritional transition is a common driver of the MASLD epidemic in both countries. This challenge requires national-level policy interventions in the food environment, such as taxing sugar-sweetened beverages, regulating processed food labeling, and promoting healthy dietary guidelines. Additionally, genetic variations specific to the Chinese population (such as PNPLA3, TM6SF2, etc.) play a crucial role in the development and progression of MASLD. Relevant genome-wide association studies have confirmed the association between these gene polymorphisms and the risk of hepatic steatosis and fibrosis[11].
DIAGNOSTIC STRATEGIES: STRATEGIC CHOICES UNDER RESOURCE LIMITATIONS
The diagnosis of MASLD in Egypt primarily relies on ultrasonography and noninvasive fibrosis scores [such as fibrosis-4 (FIB-4) and nonalcoholic fatty liver disease fibrosis (NFS) score], but advanced technologies like elastography are insufficiently widespread. This should not be simply viewed as technological backwardness but rather as a pragmatic approach under resource-limited conditions. The experience in Egypt suggests that standardized application of FIB-4/NFS for risk stratification in primary care represents a critical strategy for prioritizing limited advanced resources to patients with the greatest need. This situation is also common in primary care institutions in China. China has made significant progress in the noninvasive diagnosis of liver fibrosis. Transient elastography (FibroScan and FibroTouch) is now widely used clinically, while magnetic resonance imaging-proton density fat fraction and magnetic resonance elastography are being gradually promoted in tertiary hospitals[12]. The Chinese Society of Hepatology recommends using FIB-4 and NFS as initial screening tools[13], which aligns with Egyptian practice. Optimized models based on serum biomarkers (such as the Agile score and FibroScan-AST score) show promising application prospects in resource-limited areas[14,15]. Egyptian research emphasizes the need for continued monitoring of MASLD progression in patients after HCV cure. This experience has some reference value for China, as a large number of hepatitis B patients face similar risks of MASLD after antiviral therapy. We advocate for the integration of liver metabolic health assessment as a core component of long-term follow-up management after viral hepatitis is cured or controlled, representing a paradigm shift from merely eradicating the virus to comprehensively managing overall liver health.
MANAGEMENT STRATEGIES: LIFESTYLE INTERVENTION AND PHARMACOTHERAPY
Lifestyle intervention is the cornerstone of MASLD treatment. Egypt emphasizes the Mediterranean dietary pattern, while China advocates for a balanced diet low in sugar and fat and high in dietary fiber, combined with moderate-intensity aerobic exercise and/or high-intensity interval training[16]. Studies indicate that a weight loss of ≥ 7% can significantly improve steatohepatitis, but long-term adherence is a common global challenge[17]. In terms of pharmacotherapy, Egypt still relies on traditional drugs such as vitamin E and pioglitazone, whereas China has gradually introduced glucagon-like peptide-1 receptor agonists and sodium-glucose cotransporter 2 inhibitors for MASLD patients with concomitant diabetes[18,19]. The US FDA approval of Resmetirom in 2024 for the treatment of metabolic dysfunction-associated steatohepatitis with significant fibrosis has provided a new direction for drug development in MASLD. We foresee that the future therapeutic landscape will be multitargeted and individualized, with the core challenge lying in validating its cost-effectiveness ratio through real-world studies across diverse healthcare settings.
PUBLIC HEALTH POLICY RECOMMENDATIONS
Egypt currently lacks a national-level MASLD prevention and control guideline; therefore, the review by Abdelhamed et al[2] calls for the integration of MASLD into the national noncommunicable disease prevention and control system. China has published multiple editions of guidelines for the diagnosis and treatment of fatty liver disease and is gradually incorporating liver fibrosis screening into metabolic disease management. Future efforts should be strengthened in the following areas: (1) Formulating a national action plan for MASLD and integrating it into the chronic disease prevention and control system to promote community screening and tiered healthcare; (2) Enhancing the training of general practitioners and primary care medical staff to improve the capacity for early identification and management of MASLD; (3) Advancing a multidisciplinary collaborative diagnosis and treatment model that integrates hepatology, endocrinology, nutrition, and mental health services; (4) Increasing public health education to raise public awareness of healthy lifestyle; and (5) Encouraging real-world research and innovative drug development to improve the efficacy evaluation system for MASLD. Particularly, we advocate a targeted, stepwise screening approach - focusing first on high-risk groups using low-cost tools, followed by confirmatory imaging where available. We call for local research to develop context-appropriate, low-cost interventions.
CONCLUSION
Research on MASLD in Egypt provides a valuable perspective from a developing country, and its experiences and lessons hold significant reference value for rapidly transitioning countries like China. Facing the global challenge of MASLD, we need to move beyond the traditional biomedical model and build a comprehensive prevention and control system that integrates social, economic, cultural, and behavioral factors. Through international cooperation and experience sharing, we hope to curb the epidemic trend of MASLD and alleviate the heavy burden imposed by this silent epidemic.
Peer review: Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Gastroenterology and hepatology
Country of origin: China
Peer-review report’s classification
Scientific quality: Grade B, Grade B
Novelty: Grade B, Grade B
Creativity or innovation: Grade B, Grade B
Scientific significance: Grade A, Grade B
P-Reviewer: Su S, Associate Chief Physician, China; Tabll AA, Additional Professor, PhD, Professor, Egypt S-Editor: Bai Y L-Editor: A P-Editor: Wang CH
