New name for NAFLD may not be better, process may become ‘endless debate’
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Many health care providers agree the term nonalcoholic fatty liver disease is a bad name because it’s defining a disease by what it is not; however, the challenge has been to find something that would fulfill a number of criteria.
Some patients feel that the term “nonalcoholic” gives them relief because when you tell someone they have cirrhosis, they link it to alcohol. It is difficult to find a term that will encompass the complexity of the disease, and changing the definition of NAFLD would make all prior studies invalid (ie, potentially a different population was studied under NAFLD).
These are the issues in the debate: One is considering a change in the name but also allowing moderate amounts of alcohol intake. The overall consensus is that we want to call this disease “NAFLD” for what it is now. Another change is we include in the definition some features of metabolic syndrome. Changing NAFLD and/or changing its definition will create unnecessary confusion. Some think that we should choose exactly the same definition, so all the work done before holds and we do not have to create new data.
Another issue is stigma. With the recent vote from the committee, we would change fatty liver disease to “steatotic liver disease” and under this big umbrella term of “steatotic liver disease” will be NAFLD, alcoholic liver disease when you have excessive amounts of alcohol and a separate category that is a combination of both. Then there will be other causes of fatty liver — from medications, some genetic diseases, etc.
A big issue is the term “metabolic dysfunction,” because it was generated by a group of hepatologists without the inclusion of endocrinologists. I remember in the early 2000s, we had the debate between using the term ‘insulin resistance syndrome’ or ‘metabolic syndrome’ due to the pathophysiology of obesity and insulin resistance, and hypertension, dyslipidemia and diabetes. If we just say “metabolically-associated” fatty/steatotic liver disease, it is going to generate a lot of debate about these cut-offs and clinical significance.
Regarding NAFLD, my personal concern with including metabolic syndrome or metabolic in the name is that it is broad and it is going to generate some confusion about the precision of the term. The debate has the potential to be a distraction from disease awareness and early diagnosis. I’ve seen this in the diabetes field, after the term ‘metabolic syndrome’ was introduced.
We recently have had major progress with guidelines for the screening of NAFLD among primary care, endocrinology and other health care providers to send people at risk for advanced fibrosis to the specialist early in the course of their disease. We are improving our diagnostic algorithms and we are beginning to have FDA-approved drugs. It will be worrisome if we change the disease definition by adding metabolic features; it would dilute the current effort focused on increasing awareness among non-hepatologists.
Including “metabolic” does not really define what the pathophysiological problems are with the disease, and on top of that, if we change the definition by adding metabolic components, we will need to redefine our prior work and repeat much of the biomarker work as well.
I would say that some people feel that adding “metabolic” is useful to discuss the problem with their patients. I understand the good intention because people who favor the term say it helps focus on metabolic abnormalities and may also help to better explain NAFLD to public health authorities. However, from a scientific perspective, it is fraught with many issues. I do not favor metabolic syndrome in the name. If we are going to change the term NAFLD, which I think the field is inclined to do, if anything I advocate that we keep NAFLD under the same definition as we have today, so our prior work is consistent with the present and future.
The current risk is to end up with a name that is not much better than NAFLD, while submerging the field in an endless debate and not using our energies in the most productive way. My point is that we will go from a bad term to a slightly better one, but still not a great one. I am afraid that there is going to be a lot of futile publications comparing definitions that are not going to lead to better care for patients.
- For more information:
- Kenneth Cusi, MD, FACP, FACE, is professor of medicine and chief of the division of endocrinology, diabetes and metabolism at the University of Florida.
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