Physicians' Perceptions and Practices on Metabolic Dysfunction-Associated Liver Disease: An Exploratory Survey

Keywords

metabolic dysfunction-associated liver disease (MASLD) - nonalcoholic steatohepatitis (NASH) - elastography - Enhanced Liver Fibrosis (ELF) - Fibrosis 4 (FIB 4) - Middle East and Africa - physicians perceptions

Introduction

Metabolic dysfunction-associated fatty liver disease (MASLD) is one of the most common causes of chronic liver disease worldwide.[1] MASLD is increasingly recognized as an epidemic among different populations. MASLD encompasses a group of hepatic diseases that range in severity.[2] [3]

MASLD substantially burdens Asia, the Middle East, and North Africa, accounting for about half of the global burden.[4] The prevalence of MASLD in the Middle East is increasing in parallel to the increase in associated risk factors such as obesity, metabolic syndrome, and type 2 diabetes (T2D). Furthermore, about 20 to 30% of the patients progress, causing a substantial burden on health care systems. Therefore, appropriate strategies must be discussed at a regional level to facilitate effective management tailored to the regional needs.[5] [6] [7]

Treatment options for MASLD are still limited. Lifestyle modifications, including exercise and diet, have proven their benefit in reducing liver fibrosis beyond doubt.[8] [9] Prevention is the cornerstone in curbing MASLD. Public health measures to reduce obesity and combat insulin resistance are, at present, the most promising treatment modalities for preventing MASLD.[8] [9] Since prevention is one of the principal management strategies for the progression of MASLD, doctors must have adequate knowledge about the disease and its diagnosis. However, resmethrin gained conditional approval from the Food and Drug Administration (FDA) as the first pharmacotherapy for metabolic dysfunction-associated steatohepatitis (MASH) with moderate to severe hepatic fibrosis.[10]

Nongastroenterologists see most patients with MASLD. Several studies have shown a low knowledge and awareness of MASLD among physicians.[11] [12] [13] Consequently, many MASLD cases may pass unrecognized, and lifestyle modifications to correct risk factors could be missed despite good clinical practice guidelines.[14] [15] [16] [17] Knowledge assessment helps formulate appropriate policies for implementing educational programs to help enhance the quality of care.[14] [15] [16] [17] Nonetheless, data on the knowledge and attitudes of the Middle East and Africa (MEA) physicians toward MASLD are limited. Hence, this explorative exercise is worthwhile.

Methods

Study Design

A cross-sectional online survey study was conducted between 2020 and 2021. The electronic questionnaire service Survey Monkey (SVMK Inc., San Mateo, California, United States) was used to create, disseminate, and analyze the questionnaire. The survey was sent to a convenience sample of physicians primarily residing and practicing in the MEA region.[18] [19] [20]

Survey Questions

The questions were based on previously published studies.[11] [12] [13] It was served in English and French. Additional questions were included to characterize the demographic and professional profiles of the respondents, which were similar to those of our previous studies.[18] [19] [20] The survey questionnaire included five domains. First, consent; second, basic demographic and professional data; third, awareness of the MASLD in respondents' country/practice; fourth, knowledge of risk factors, complications, methods of diagnosis, management options, progression, and screening of MASLD; and finally, reflection of respondents on their clinical practice. Most questions were in multiple-choice format, and a few responses were open-ended. At the end, a space was provided for a free-text comment. The survey text, including the stem questions and response options, is provided in [Supplementary Material S1], available in the online version. The questionnaire content was tested by doing a pilot study on 12 clinicians. The questionnaire used the older nomenclature, but the article uses the updated nomenclature.

Collection and Summary of Responses

Survey responses were collected anonymously and stored electronically by the survey service, accessible only to the lead investigator, and password-protected. Responses from those who met the inclusion criteria only were included. Survey management service tools were used to examine the results and perform descriptive analysis. No information is available on nonrespondents due to the nature of the original database. Responses with substantially missing information were excluded. A reliable response rate could not be calculated due to the nature of the invited pool and convenience sampling.

Statistical Analysis

The descriptive analysis was prepared using the online survey software tools prepared for responses to each question. Because not every participant answered all questions, the percentage of respondents providing a given answer was calculated individually for each question, using the number of respondents to that question as the denominator. Continuous variables were summarized as mean (standard deviation of the mean) or median (range).

Results

Characteristics of the Respondents

One hundred twenty-eight eligible clinicians completed the survey. Respondents were from the Arabian Gulf (48.4%), the Middle East (72.6%), and Africa (27.3%). Over half (49.3%) were older than 50, and 17.2% were younger than 40. There were slightly more males than females (58.6% vs. 41.4%). The majority was senior adult endocrinologists (43.8%), followed by internists (27.3%) and primary care doctors (10.2%), whereas gastroenterologists and others accounted for a minority (6.3 and 12.5%, respectively). They practiced mainly in public services (65.6%) in large cities (75.8%), and over half (56.3%) were in tertiary centers.

Awareness of MASLD Prevalence

Note that 53.2% of respondents estimated the prevalence of MASLD in the general population to be between 10 and 30%, while 33.3% expressed uncertainty (see [Table 1]). In contrast, 44.5% believed that the prevalence of MASLD among individuals with obesity falls between 50 and 70%, with 25% being unsure ([Table 1]). Reflecting on their patient populations, 24.2% of respondents estimated that 20 to 30% of their patients are likely to have MASLD ([Table 1]). Several barriers to effective MASLD management were identified (see [Table 2]), with the two most prominent barriers being the cost of evaluation and treatment (59.5%) and time limitations (38.1%). Additionally, fewer than half (42.2%) of respondents knew of specific “Professional Society Guidelines” regarding MASLD.

Table 1 Participants' awareness of the MASLD burden in their country and practice

Concepts and perspectives	Details (response options)[a]	Results
The prevalence of MASLD in the general population [N = 126]	Less than 5% Approx. 10% Approx. 30% Approx. 50% Not sure.	7.9% 29.4% 23.8% 5.6% 33.3%
The prevalence of MASLD in the obese population (BMI > 30 kg/m2) [N = 128]	Less than 10% Approx. 25% Approx. 50% Approx. 70% Unsure	9.4% 21.1% 27.3% 17.2% 25.0%
The proportion of “own” patients that are likely to have MASLD [N = 128]	None ≤ 5% 5–10% 10–20% 20–30% 30–40% 40–50% > 50%	0.0% 18.0% 21.9% 12.5% 24.2% 12.5% 7.0% 3.9%
What are the main barriers to optimal MASLD management? (the 3 most important only) [N = 126]	Lack of compliance by the patient Cost of evaluation and treatment Time constraints Lack of confidence Not comfortable discussing obesity	61.9% 59.5% 38.1% 18.3% 9.5%
Awareness of “Professional Society Guidelines” on MASLD [N = 128]	Yes No	42.2% 57.8%

Abbreviations: BMI, body mass index; MASLD, metabolic dysfunction-associated liver disease.

^a Some are more elaborate in the survey text ([Supplementary Material S1], available in the online version).

Table 2 Participants' perceptions of MASLD risk factors and comorbidities

Concepts and perspectives	Responses
	True	False	Unsure
1. The following conditions are strongly associated with MASLD: [N = 128]
Metabolic syndrome [125]	100.0%	0.0%	0.0%
Overweight/obesity [123]	98.4%	0.8%	0.8%
Type 2 diabetes [N = 126]	97.6%	0.0%	2.4%
Hypertriglyceridemia [N = 124]	91.9%	3.2%	4.8%
Hypertension [N = 118]	50.8%	20.3%	28.8%
Alcohol consumption [N = 115]	47.8%	40.0%	12.2%
Chronic obstructive airways disease [N = 113]	30.1%	28.3%	41.6%
Renal impairment [n = 114]	24.6%	32.5%	43.0%
2. Isolated (simple) steatosis is associated with: [N = 128]
Future development of type 2 diabetes [N = 122]	77.9%	5.7%	16.4%
Increased incidence of cardiovascular disease [N = 120]	70.0%	10.8%	19.2%
Increased liver-related mortality [N = 117]	65.0%	12.0%	23.1%
Cirrhosis. [N = 117]	58.1%	30.8%	11.1%
Liver fibrosis in many cases [N = 117]	53.0%	35.0%	12.0%
3. MASH is associated with: [N = 128]
Increased liver-related mortality [N = 119]	87.4%	4.2%	8.4%
Cirrhosis [N = 119]	84.9%	7.6%	7.6%
Future development of type 2 diabetes [N = 125]	84.0%	4.0%	12.0%
Liver fibrosis in many cases [N = 122]	83.6%	11.5%	4.9%
Increased incidence of cardiovascular disease [N = 121]	78.5%	6.6%	14.9%

Abbreviations: MASH, metabolic dysfunction-associated steatohepatitis; MASLD, metabolic dysfunction-associated liver disease.

MASLD-Associated Morbidity/Mortality

More than 90% of respondents recognized that metabolic syndrome, overweight/obesity, T2D, and hypertriglyceridemia were strongly associated with MASLD. A proportion of respondents considered other risk factors ([Table 2]). Respondents were aware that simple steatosis is associated with the future development of T2D (77.9%) and an increased incidence of cardiovascular disease (70.0%); in contrast, the relative absence of liver-related outcomes associated with simple steatosis was not as well appreciated. Note that 65.0% of respondents considered that simple steatosis is associated with increased liver-related mortality, and 58.1% considered these subjects at significantly higher risk of cirrhosis. Most respondents were aware of the increased risk of cirrhosis and liver-related mortality in subjects with MASH (84.9 and 87.4%, respectively) ([Table 2]). In their practices, respondents estimated that just under half (43.3, 26.6%) of their patients had T2D, 43.0 (24.8%) had dyslipidemia or hypertriglyceridemia, 36 (23.8%) had hypertension, and 43.6 (24.1%) were overweight (body mass index 28–30 kg/m²). Only a small proportion (6.8, 9.9%) consumed excess amounts of alcohol.

MASLD Diagnosis and Risk Stratification

Many responding clinicians incorrectly felt that a diagnosis of MASH could be made using serum liver enzymes (72.7%), liver imaging (87.4%), or FibroScan (76.4%). Of concern, 28.6% of respondents felt that liver enzymes (alanine transaminase [ALT] and aspartate transaminase [AST]) are sufficiently sensitive to detect underlying MASLD–MASH, and 15.2% were unsure. The majority of respondents agreed that MASLD fibrosis score (91.8%), FibroScan (83.2%), abdominal ultrasound (76.2%), liver enzymes (ALT, AST) (74.0%), serum albumin (74.0%), prothrombin time (68.3%), and platelet count (65.3%) can help to identify MASLD patients with advanced fibrosis/cirrhosis ([Table 3]). However, too many respondents needed clarification on whether the Enhanced Liver Fibrosis (ELF) score (54.5%) or Fibrosis 4 (FIB-4) score (29.1%) could help to identify advanced fibrosis or cirrhosis. Nearly 3 out of 4 respondents (74.3%) felt that six monthly liver enzyme tests could help monitor disease progression in patients with MASLD, while 80.0% thought that annual FibroScan and 78.3% thought that scores could also help with monitoring. Many clinicians needed clarification on whether the ELF score (54.5%) or the MASLD FIB-4 test (29.1%) can help monitor disease progression ([Table 3]).

Table 3 Diagnosis and evaluation of MASLD

Diagnostic and management approach	Responses
	True	False	Unsure
1. A diagnosis of MASH can be made using [N = 113]
Liver biopsy [N = 109]	93.6%	5.5%	0.9%
Liver imaging (ultrasound, CT, or MRI) [N = 111]	87.4%	9.0%	3.6%
FibroScan [N = 106]	76.4%	10.4%	13.2%
Serum liver enzymes [N = 110]	72.7%	24.5%	2.7%
2. Diagnostic values of liver enzymes (ALT and AST):
Are they sufficiently sensitive to detect underlying MASLD-MASH? [N = 112]	28.6%	56.3%	15.2%
3. What tests/scores can help identify MASLD patients with advanced fibrosis/cirrhosis: [N = 113]
MASLD fibrosis score [N = 110]	91.8%	0.0%	8.2%
FibroScan [N = 107]	83.2%	1.9%	15.0%
Abdominal ultrasound [N = 105]	76.2%	18.1%	5.7%
Liver enzymes (ALT, AST) [N = 104]	74.0%	20.2%	5.8%
Serum albumin [N = 104]	74.0%	13.5%	12.5%
FIB-4 score [N = 103]	68.9%	1.9%	29.1%
Prothrombin time [N = 101]	68.3%	15.8%	15.8%
Platelet count [N = 101]	65.3%	20.8%	13.9%
ELF score [N = 101]	43.6%	2.0%	54.5%

Abbreviations: ALT, alanine transaminase; AST, aspartate transaminase; CT, computed tomography; ELF, Enhanced Liver Fibrosis; FIB-4, Fibrosis 4; MASH, metabolic dysfunction-associated steatohepatitis; MASLD, metabolic dysfunction-associated liver disease; MRI, magnetic resonance imaging.

Note: Some are more elaborately phrased in the survey text ([Supplementary Material S1], available in the online version).

Clinical Practices

The survey asked participants about the tools they use to evaluate patients with MASLD in their clinical practice. Note that 99 and 96.2% of respondents employed abdominal ultrasound and liver enzyme tests, respectively. However, approximately half of the clinicians reported not utilizing FibroScan and the MASLD fibrosis score. At the same time, even fewer indicated that they used the FIB-4 score, AST to Platelet Ratio Index score, or ELF test ([Table 4]). Regarding clinical management, the majority of clinicians expressed their intention to provide information on optimizing diet and exercise (100%), refer patients to a dietician (95.0%), and create a general practitioner (GP) management plan along with team care arrangements (91.1%).

Table 4 Reported respondents' approaches to therapy and monitoring of MASLD

Therapy and monitoring approaches	Responses
	True	False	Unsure
1. Current therapeutic management of MASLD involves [112]
Physical exercise [N = 109]	100.0%	0.0%	0.0%
Weight loss [N = 110]	99.1%	0.0%	0.9%
Medical treatment of concurrent metabolic disorders [N = 111]	91.9%	0.9%	7.2%
Pharmacologic therapy directed at weight loss [N = 105]	77.1%	6.7%	16.2%
Bariatric surgery [N = 105]	74.3%	7.6%	18.1%
Specific liver-directed pharmacologic therapy [N = 103]	42.7%	33.0%	24.3%
2. What tests/scores can help to monitor patients with MASLD for disease progression: [N = 112]
Annual FibroScan [N = 105]	80.0%	4.8%	15.2%
6 monthly MASLD fibrosis score and/or FIB-4 score [N = 106]	78.3%	2.8%	18.9%
6 monthly liver enzymes (ALT, AST) [109]	74.3%	17.4%	8.3%
Annual liver ultrasound [105]	68.6%	10.5%	21.0%
6 monthly platelet count [N = 93]	52.7%	20.4%	26.9%
Annual ELF test [N = 100]	50.0%	2.0%	48.0%

Abbreviations: ALT, alanine transaminase; AST, aspartate transaminase; ELF, Enhanced Liver Fibrosis; FIB-4, Fibrosis 4; MASLD, metabolic dysfunction-associated liver disease.

Note: Some are more elaborate in the survey text ([Supplementary Material S1], available in the online version).

Patterns and Barriers to Specialist Referrals

The majority (83.8%) of respondents stated that they would refer a patient to a gastroenterologist/hepatologist if they suspected the patient had MASLD ([Table 5]). Despite this, when asked how many referrals they make to hepatology each month for an opinion regarding suspected MASLD, 20.0% do not make any referrals and 41.8% make less than one to two referrals each month ([Table 5]).

Table 5 Participants' self-reported practices in evaluation management practices

Question	Yes	No
1. In my clinical practice, I utilize the following tools to assess my patients with MASLD [N = 109]
Abdominal ultrasound [103]	99.0%	1.0%
Liver enzymes [N = 106]	96.2%	3.8%
FibroScan [N = 89]	50.6%	49.4%
MASLD fibrosis score [84]	48.8%	51.2%
FIB-4 score [85]	41.2%	58.8
APRI score [N = 60]	26.8%	73.2%
ELF test [N = 80]	26.3%	73.8%
2. If I suspect one of my patients has MASLD, I would do the following: [N = 110]
Provide information on optimizing diet and exercise [N = 106]	100.0%	0.0%
Refer to dietician [N = 101]	95.0%	5.0%
Provide management plan and team care arrangements [N = 101]	91.1%	8.9%
Refer to gastroenterologist/hepatologist [N = 99]	83.8%	16.2%
Refer to weight loss clinic [N = 95]	81.1%	18.9%
Refer to exercise physiologist [N = 93]	69.9%	30.1%
Refer to endocrinologist [N = 87]	55.2%	44.8%

Abbreviations: APRI, Aspartate Transaminase to Platelet Ratio Index; ELF, Enhanced Liver Fibrosis; FIB-4, Fibrosis 4; MASLD, metabolic dysfunction-associated liver disease.

Note: Some are more elaborate in the survey text ([Supplementary Material S1], available in the online version).

Common reasons provided for not referring patients to hepatology included: “I manage them myself by optimizing lifestyle” (54.9%), “There is no specific pharmacotherapy available” (29.3%), “I do not see many patients with MASLD” (26.8%), “The patients do not want referral” (20.7%), “I do not think it is necessary” (12.2%), and “The waiting list is too long” (4.9%). Of concern, 64.5% of clinicians stated they would unlikely refer patients to hepatology unless liver function tests were abnormal ([Table 6]). At the end of the survey, a section was available for free-text comments. Respondents addressed various aspects, including the burden of the disease, the nature of the issue, challenges in management, organization of care, training, and their perspectives ([Supplementary Material S2], available in the online version).

Table 6 Patterns and rationale of referrals of patients with MASLD

Questions	Responses
1. Do you refer patients with MASLD to a more specialized physician? [N = 109]:
Yes	70.6%
No	29.4%
2. I am unlikely to refer a patient to hepatology unless liver function tests are abnormal [N = 107]
Yes	64.5%
No	35.5%
3. Pattern: Currently, the number of referrals I make to hepatology each month for an opinion regarding suspected MASLD-MASH is: [N: 110]
None	20.0%
1–2	41.8%
3–5	14.5%
6–10	15.5%
11–20	5.5%
21–30	0.9%
> 30	1.8%
4. Rationale: Reported reasons for not referring many patients to a specialized physician for MASLD/MASH because [N = 82]
I manage them myself by optimizing their lifestyle	54.9%
There is no specific pharmacotherapy available	29.3%
I do not see many patients with MASLD/MASH	26.8%
The patients do not want a referral	20.7%
Other reasons	14.6%
I do not think it is necessary	12.2%
The waiting list is too long	4.9%

Abbreviations: MASH, metabolic dysfunction-associated steatohepatitis; MASLD, metabolic dysfunction-associated liver disease.

Discussion

MASLD is a significant health problem, and the number of patients with this condition gradually increases worldwide.[4] The consequences of MASLD include MASH, liver cirrhosis, and hepatocellular carcinoma. This makes the condition a public health problem that needs urgent attention. This study explores the awareness and knowledge of MASLD among doctors in a developing region with rapidly increasing rates of obesity, diabetes, and metabolic syndrome.[21]

Currently, no definitive treatment options (there is a newly FDA-approved treatment for MASH) are available for MASLD. Therefore, lifestyle modifications—such as increased physical activity and nutritional changes—are essential. It is concerning that only 32.6% of respondents referred their MASLD patients to dietitians. This low referral rate is echoed in a separate study conducted in Poland, which reported a rate of 30%.[4] MASLD is a metabolic disorder that requires lifestyle changes. For patients to successfully modify their lifestyle, particularly their diet, they need the support that dietitians can provide. While fat intake is known to contribute to hepatic fat deposition in animal studies, data from human studies remains inconclusive.[5] Most respondents believed a low-fat diet is more beneficial than a low-calorie diet, highlighting the necessity of enhancing physicians' dietary knowledge.

MASLD is a distinct entity that needs specialist input, as prevention of progression is the key. Another study done among GPs also saw a low referral rate to specialists, as in our study. Seeking specialists' input early could benefit patients, such as identifying those needing specific therapy or a liver biopsy.

Our respondents knew somewhat about the merits of exercise and weight loss. According to the American guidelines,[15] [16] [17] at least 3 to 5% of weight loss and, if possible, up to 10% is indicated, and this seems to be the understanding among most of the study's participants (65.2%). Weight loss reduces hepatic steatosis. Though the participants recognized weight loss as crucial, follow-up actions such as referral to physical activity, dietician, or weight loss clinic were low.

Noninvasive methods are increasingly used to diagnose MASLD. The respondents' knowledge of the availability of noninvasive methods to aid diagnosis was poor. Continuous medical education on emerging modalities of diagnosis needs to be addressed.

The identification of common drugs causing hepatic steatosis was reasonable among the doctors. This contrasts with studies done elsewhere.[6] On the positive side, most respondents identified the association between metabolic syndrome and MASLD. This would lead to more screening for MASLD and, thus, lifestyle modifications. Routine screening of patients with MASLD risk factors is recommended by all major gastroenterology/hepatology associations and guidelines.[14] [15] [16] [17]

As the doctors exhibited, the principal barriers to MASLD management included a lack of knowledge, confidence, and time constraints. This problem seems universal; U.S. doctors have reported similar constraints.[12] Due to limited access, cost, or lack of training, the low-level utilization of advanced diagnostic tools like FibroScan and the ELF score is a recurring theme. Solutions like subsidizing diagnostic tools, promoting telemedicine, or developing continuing medical education programs tailored to regional needs are recommended. The current practices in the MEA align with international guidelines.[14] [15] [16] [17] Regional adaptations of these guidelines with readily available educational materials and events could help bridge this gap brought about by collaboration between endocrinologists and gastroenterologists.

The study has some limitations. The participant count could have been higher to accurately represent MEA physicians. The distribution among regions and countries differs from their populations and the number of medical professionals. Additionally, there could have been a greater representation of endocrinologists, who see most patients with risk factors. Lastly, this study is based on a survey relying on self-reported practices rather than a quality assurance assessment that measures actual processes and outcomes. Furthermore, convenience sampling introduces the potential impact of self-reported data on the reliability of findings.

Conclusion

Although it is acknowledged that these patients are at risk for progressive liver disease, about 45% of primary care clinicians lack awareness. This study emphasizes the need for a greater understanding of MASLD and suggests that ongoing medical education for physicians on this topic is the most effective way to move forward.

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