NAFLD: Putting the spotlight on a hidden public health challenge

“Non-alcoholic fatty liver disease [NAFLD] is an illness many of us have never heard of but it is much more common than cirrhosis and far more baffling.” These are the words of author Bill Bryson in his book The Body and he is right. It seems implausible that an illness which affects an estimated 2 billion people globally, causes a substantial burden of ill health, and has wide ranging social and economic implications, still remains as obscure as NAFLD is today. In fact, this obscurity is not limited to the general public, but also applies to many healthcare professionals and the wider global health community. 

NAFLD is often referred to as the hepatic manifestation of metabolic syndrome due to its close association with obesity and other metabolic conditions, and its complex bidirectional relationship with insulin resistance and type 2 diabetes mellitus. Yet, unlike other highly prevalent non-communicable diseases (NCDs) such as diabetes, heart disease, and obesity, NAFLD is yet to be widely recognised as a major public health challenge worthy of attention.

NAFLD is entirely absent from national health strategies and few countries have specific clinical guidance for the management of the condition. Despite the close association with other major non communicable diseases (NCDs), and the overlapping approaches required to address these conditions, NAFLD is also not explicitly mentioned in key global health documents on the prevention and control of NCDs.  

Over the past 24 months, the EASL International Liver Foundation (EILF) has been collaborating with a wide range of partners, from clinicians and academics, to policy-makers and industry, to shine a spotlight on NAFLD. As part of these efforts, EILF recently engaged the Economist Intelligence Unit to hold a workshop series NAFLD: Sounding the alarm on a global public health challenge with experts from Asia, Latin America, and the Middle East. During 12 workshops throughout 2020, more than 50 experts, ranging from liver disease and diabetes specialists, to primary care providers and public health leaders, explored a diverse range of topics, from improving the diagnosis and care of affected populations to broader public health responses and integration of NAFLD within the NCD agenda. The outcome of these discussions has been distilled into a global call to action covering five key areas.

Several cross-cutting themes emerged throughout the series. The first recognised the critical importance of collaboration between key stakeholders including professional associations, care providers, patient groups, or policy actors. 

People living with NAFLD access care across different parts of healthcare systems, with many requiring services for multiple comorbid conditions. The efficient and effective flow of information and resources between key stakeholders, including clinical teams and patients, is critical. Yet, in many settings there remain silos that inhibit joined-up health system responses. Ultimately what is required is a reorientation of health systems. The challenges and solutions here are not exclusive to NAFLD. There is, however, a compelling case for the NAFLD community to work alongside others, especially those who focus on metabolic disease management, to lead this process and envisage what is required to design and deliver patient-centric healthcare systems fit for dealing with the 21st century’s major health issues, namely NCDs. 

The second emerging theme focused on the need to be bold and ambitious when plotting the course for NAFLD. Like other NCDs, addressing NAFLD will require comprehensive public health responses that address not only the immediate health needs of affected populations, but also the underlying and basic influences that give rise to the condition. The NCD community has been criticised for having a singular focus on Sustainable Development Goal 3, “ensure healthy lives and promote well-being for all at all ages”, and not looking at the multisectoral, whole-of-society responses that can deliver a significant and sustained impact.  The liver health community must take heed of this and consider how to engage broadly across sectors and disciplines as it sets out the vision of addressing NAFLD. This will have to start with a moment of reflection to consider the liver health landscape and consult with others in different sectors and disciplines to identify opportunities for collaboration and integration. 

We remain at ground zero in the public health response to NAFLD. We would urge the global health community to see this blank canvas as an opportunity to leverage its collective knowledge to develop innovative approaches that can benefit not only people living with NAFLD, but the NCD community as a whole. We are in no doubt that transforming NAFLD from a hidden challenge to a public health priority will be challenging, requiring sustained commitment from clinicians, patients, and policy makers alike. We are, however, inspired by the recent workshop series and the vibrant community ready to lead this charge. 

Jeffrey V Lazarus is head of the Health Systems Research Group at the Barcelona Institute for Global Health (ISGlobal), an associate professor at the Faculty of Medicine, University of Barcelona, Barcelona, Spain, and vice-chair of the EASL International Liver Foundation, Geneva, Switzerland. @JVLazarus

Henry E Mark is a Programme Manager with the EASL International Liver Foundation, Geneva, Switzerland. @HenryEMark

Massimo Colombo is Chairman of the EASL International Liver Foundation, Geneva, Switzerland and Director Liver Center IRCCS San Raphael Hospital, Milan, Italy. @mcolombo46

Philip N Newsome is Director of Research and Knowledge Transfer for the College of Medical & Dental Sciences and Director of the Centre for Liver and Gastrointestinal Research at the University of Birmingham, and the Secretary General of the European Association for the Study of the Liver (EASL) @phil_newsome7

Competing interests: Jeffrey V Lazarus reports research grants from Genfit, Gilead and Intercept, outside of the work discussed here. Massimo Colombo reports personal fees from Intercept, Exelyxis, COST, and Target HCC, outside of the work discussed here. Phil Newsome reports receiving grant support from Pharmaxis, Boehringer Ingelheim and Novo Nordisk, donated supplies from Echosens, and consulting fees, paid to the University of Birmingham, from Bristol-Myers Squibb, Gilead, Intercept, Novo Nordisk, Pfizer, and Poxel, outside of the work discussed here. Henry Mark declares no competing interests relevant to this article.