High metabolic dysfunction-associated steatotic liver disease prevalence in type 2 diabetes: Urgent need for integrated screening and lifestyle intervention

Abstract

This letter discusses the recent study by Mukherjee et al, which identifies a significant prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) among newly diagnosed type 2 diabetes mellitus (T2DM) patients in Bihar, India, and underscores the pressing need for integrated MASLD management within T2DM care. With 72.3% of the study cohort affected by MASLD, implementing routine liver function tests and ultrasound screenings is recommended as a standard practice in diabetes care, especially in regions with high prevalence rates. The study also advocates for dietary and lifestyle modifications, particularly the reduction of saturated fats, to slow MASLD progression. Patient education on monitoring body mass index and waist circumference, coupled with the integration of these metrics into digital health records, could enhance patient involvement and support proactive health management. Moreover, the letter emphasizes the advantages of developing a region-specific MASLD risk model that incorporates local dietary patterns and socioeconomic factors. Continued research into genetic and environmental determinants of MASLD remains essential for advancing our understanding of its etiology and informing targeted public health strategies.

Key Words: Body mass index; Dietary intervention; Fatty liver; Genetic factors; Liver health; Metabolic dysfunction-associated steatotic liver disease; Type 2 diabetes mellitus

Core Tip: The high prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) in newly diagnosed type 2 diabetes mellitus patients emphasizes the importance of regular liver health assessments in diabetes care. Screening should include liver function tests and ultrasound imaging for early detection. Dietary changes, such as reducing saturated fat, along with lifestyle interventions, can improve liver health. Educating patients on monitoring body mass index and waist circumference promotes proactive health management. A region-specific MASLD risk model could enhance screening accuracy, while further research into genetic and environmental factors may reveal the disease’s mechanisms and guide prevention strategies.

TO THE EDITOR

I am pleased to offer commentary on the recent study by Mukherjee et al[1], published in the World Journal of Hepatology. This important cross-sectional analysis reveals a notably high prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) among newly diagnosed type 2 diabetes mellitus (T2DM) patients in Bihar, India, and underscores the impact of metabolic factors such as body mass index (BMI), waist circumference, and lipid profiles. By illuminating the strong association between T2DM and MASLD within a population experiencing rising rates of obesity and related metabolic disorders, this study highlights the urgent need for early diagnosis and effective management of MASLD in diabetic patients to help mitigate the risk of severe complications.

The study’s finding that 72.3% of the sample had MASLD is particularly concerning and underscores the need for an integrated approach to MASLD screening within T2DM management. Based on the insights from this study, I recommend several practical, evidence-based strategies to enhance patient outcomes.

Routine screening and early diagnosis

The high prevalence of MASLD among T2DM patients in this study highlights the importance of integrating routine liver health assessments into diabetes care protocols. For newly diagnosed T2DM patients, initiating baseline liver function tests such as alanine aminotransferase (ALT) and aspartate aminotransferase alongside liver ultrasound can provide a thorough evaluation of liver health. In high-prevalence regions like Bihar, establishing an efficient screening process is essential. Utilizing existing telemedicine platforms for follow-up assessments could facilitate early detection and ongoing liver health monitoring for diabetic patients, even in rural areas with limited access to specialized care.

Targeted dietary and lifestyle interventions

The author highlights a significant link between high fat intake and MASLD. Nutritionists and healthcare professionals should advise patients with T2DM to decrease their consumption of saturated fats and transition to healthier alternatives, such as polyunsaturated and monounsaturated fats. Saturated fats are primarily derived from animal products (including red meat, processed meats, and full-fat dairy), certain plant oils (like palm oil and coconut oil), and processed foods (such as fast food and pastries)[2,3].

To effectively lower saturated fat intake, it is recommended to substitute high-saturated fat foods with options that are low in saturated fat or rich in unsaturated fats, such as lean meats, low-fat dairy products, and plant oils[3]. Additionally, increasing the consumption of plant-based foods-like fruits, vegetables, whole grains, nuts, and legumes, which are generally lower in saturated fats and high in fiber is beneficial. It is also important to be mindful of food labels to select products low in saturated fats and to enhance public awareness about the risks associated with saturated fats through health education initiatives that promote healthier eating habits[4].

Implementing community-based dietary programs that promote balanced nutrition and physical activity can be particularly advantageous. Research indicates that even moderate weight loss can lead to significant improvements in liver health[5,6]. Therefore, creating structured lifestyle intervention plans for T2DM patients can help reduce the incidence of MASLD and slow disease progression in those already affected.

Furthermore, communities play a vital role in decreasing the prevalence of MASLD. Effective strategies for mobilizing and utilizing community resources include forming partnerships with local health departments, non-profit organizations, and community leaders to collaboratively develop health promotion programs aimed at high-risk populations; conducting targeted outreach campaigns through various channels to raise awareness about the importance of healthy diets and lifestyles; and providing personalized support to assist high-risk individuals in overcoming barriers to participation in health programs[7,8].

However, several challenges may arise during the implementation of dietary and lifestyle interventions, including poor patient compliance, cultural differences, and resource limitations. Patient compliance can be adversely affected by a lack of social support, inadequate time management, and insufficient understanding of health information. Thus, ongoing support and guidance are essential to enhance self-management skills[9]. Additionally, varying cultural backgrounds may influence individuals' receptiveness to health advice; therefore, interventions should be tailored in collaboration with community leaders to ensure they resonate with the cultural practices of the target population[10].

Finally, during the project design phase, it is crucial to conduct a thorough assessment of available resources and devise appropriate strategies to address implementation challenges. By adopting these comprehensive measures, community resources can be more effectively mobilized to increase participation in MASLD prevention interventions among high-risk populations, ultimately improving overall health outcomes[11].

Patient education on self-monitoring

The study underscores associations between BMI, waist circumference, and MASLD, suggesting that routine self-monitoring of these parameters may aid in early detection. Teaching patients to measure and record their waist circumference and track weight changes at home could boost their engagement in managing their health. Incorporating this data into digital health records, accessible to both patients and healthcare providers, would facilitate timely interventions in response to early signs of worsening metabolic parameters. Additionally, clinics could establish support groups where patients can share experiences, creating a supportive environment for sustainable lifestyle changes[8].

Development of a region-specific MASLD risk model

Given the study’s findings and the distinct socioeconomic and dietary patterns in Bihar, a predictive model tailored to the Indian population could improve the accuracy of MASLD screening among T2DM patients. A risk model that integrates factors such as waist circumference, BMI, dietary habits, and biochemical markers like ALT and triglycerides would enable clinicians to more effectively stratify patients by risk level, prioritizing high-risk individuals for focused monitoring and intervention[1]. Such a model could be refined through longitudinal studies, offering a valuable tool adaptable to both urban and rural healthcare settings.

Future research on genetic and environmental influences

There is a significant distinction between environmental factors and individual dietary factors. Environmental factors refer to external conditions that influence dietary habits, such as socioeconomic status (SES), food availability, cultural background, and community support, all of which impact an individual’s dietary choices on a macro level. For instance, low SES can limit access to healthy foods, adversely affecting diet quality. Research indicates that children from low SES families are more likely to choose foods high in saturated fats and sugars, closely linked to the food availability in their surroundings[12,13].

In contrast, individual dietary factors emphasize personal choices and behaviors, including preferences for specific foods, dietary knowledge, and self-control abilities. When designing interventions, addressing environmental factors can be accomplished through improvements in community resources and policies, while interventions targeting individual dietary factors necessitate behavior change and education to foster healthy eating habits.

The relationship between genetic susceptibility and environmental factors is complex and significant, particularly regarding the connection between SES and diet[13,14]. SES not only influences an individual’s access to healthy foods but also affects their health awareness and dietary choices. Low SES groups often face a higher risk of unhealthy eating patterns due to limited economic resources and inadequate nutritional knowledge[15-17]. Furthermore, genetic susceptibility may cause certain populations to exhibit varying metabolic responses under similar environmental conditions, complicating risk assessments for MASLD[13,15].

Consequently, future research should establish a clearer framework for systematically analyzing the relationships among genetic susceptibility, environmental factors, and dietary factors. This approach will enhance our understanding of the mechanisms underlying MASLD development and provide a foundation for effective public health strategies. The study by Mukherjee et al[1] underscores the urgent need to actively manage MASLD in patients with T2DM. Addressing MASLD within the broader context of T2DM care not only aligns with best practices in patient-centered medicine but is also essential for reducing the burden of liver disease in high-prevalence areas. I look forward to future research building on these findings, which may guide the integration of MASLD screening and management into routine diabetes care.