Diabetes Core Update – Special Edition: MASH Part 1 – Screening

Podcast: Diabetes Core Update
Date: October 8, 2025
Hosts: Dr. Neil Skolnick, Dr. John J. Russell
Guest: Dr. Jay Shubrook, Professor and Diabetologist, Touro University California
Episode Focus: Epidemiology, progression, consequences, and screening of Metabolic Associated Steatohepatitis (MASH)

Episode Overview

In this special episode, the Diabetes Core Update team begins a three-part series on metabolic (dysfunction) associated steatohepatitis, or MASH, formerly known as NASH. MASH has become increasingly prevalent and is now a leading cause of end-stage liver disease. The discussion centers on updated terminology, disease epidemiology, progression, associated risks, and—crucially—practical screening recommendations for clinicians.

1. Understanding the Nomenclature: From NAFLD/NASH to MASLD/MASH

• Terminology Evolution ([01:35]–[03:45])
  • NAFLD: Non-Alcoholic Fatty Liver Disease
  • NASH: Non-Alcoholic Steatohepatitis
  • Reason for Change: Old terminology implied that alcohol was a possible cause; new terms better reflect metabolic etiology and avoid patient stigma.
  • Current Terms:
    • MASLD: Metabolic Associated Steatotic Liver Disease—fat accumulation in >5% of the liver.
    • MASH: Metabolic Associated Steatohepatitis—includes inflammation, fibrosis, ballooning of cells.
  • Patient Communication: Dr. Shubrook relates the disease to "insulin resistance at the level of the liver," helping patients understand the relationship between diabetes and liver disease.
  • Quote:
    “The new term, metabolic associated steatotic liver disease... tells us this is metabolic liver disease as measured by fat and inflammation of the liver.”
    — Dr. Jay Shubrook [02:29]

2. Epidemiology and Populations at Risk

• Prevalence and High-Risk Groups ([04:14]–[06:15])
  • Global Prevalence:
    • 30% of the world’s population has MASLD.
    • 60–70% of people with diabetes have MASLD.
    • Up to 16% of people with diabetes may have the more severe MASH.
  • Risk Factors:
    • Diabetes and obesity are primary risk factors.
    • Overweight/obesity plus any metabolic risk factor (dyslipidemia, HTN, pre-diabetes) confers high risk.
    • Exception: metabolically healthy obese patients, but this is rare.
  • Quote:
    "If we're not diagnosing MASLD every day in our practice, we're probably missing it because diabetes and obesity are the most common risk factors."
    — Dr. Jay Shubrook [04:57]

3. Disease Progression: Stages and Fibrosis

• Progression Timeline and Stages ([06:15]–[07:44])
  • Liver Fibrosis Stages: F0 (fat only) to F4 (cirrhosis), ~7 years per stage on average.
  • Clinical Action Points: F2/F3 are the most actionable stages today.
  • Silent Progression: MASH often develops quietly, mirroring the stealthy progression of diabetes.
  • Quote:
    "There are not symptoms that you can rely on... you actually just have to be aware that this is going on quietly in the background, just like diabetes."
    — Dr. Jay Shubrook [07:19]

4. Clinical Impact: Beyond the Liver

• Liver and Systemic Outcomes ([07:44]–[09:16])
  • Liver-specific: MASH is a leading cause of hepatocellular carcinoma and cirrhosis requiring transplant.
  • Cardiometabolic: Diagnosis of MASLD doubles cardiovascular disease risk.
  • More patients with MASLD/MASH die from CVD or non-liver cancers than from liver complications.
  • Bidirectional Risks: Metabolic disease worsens liver health, and vice versa.
  • Quote:
    "The day you're diagnosed with MASLD, you have double the risk of cardiovascular disease."
    — Dr. Jay Shubrook [08:43]

5. Who Should Be Screened? Recommendations and Rationale

• Screening Necessity and Target Populations ([09:16]–[10:57])
  • Universal for At-Risk Groups: Screening is recommended in all patients with diabetes, adults with obesity or other metabolic risk factors (dyslipidemia, hypertension, prediabetes).
  • Screening Must Be Proactive: Because the disease is silent.
  • Quote:
    “Screening needs to occur by everyone that sees the patient. This is a silent disease, and so we have to be opportunistic and directed in our screening.”
    — Dr. Jay Shubrook [10:02]

6. The Screening Process: Stepwise Approach

Step 1: FIB-4 Score ([10:57]–[12:23])

• Calculation using:
  • AST
  • ALT
  • Platelets
  • Age
• Utilizes labs already available in most settings.
• Easy calculation via EHRs (e.g., EPIC) or online tools (e.g., MDCalc).

FIB-4 Interpretation ([12:23]–[13:10])

• <1.3 (adults <65): Lower risk—focus on metabolic disease and rescreen in 1–2 years.
• ≥1.3 (<65) or ≥2.0 (≥65): Proceed to second-line testing (due to possible overestimation in older adults).

Step 2: Second-Line Testing

a. Transient Elastography (FibroScan) ([13:28]–[15:03])

• Non-invasive, quick test measuring hepatic stiffness.
• Cutoff: KPA >8 signals higher risk and warrants hepatology/gastroenterology evaluation.

b. ELF Test (Enhanced Liver Fibrosis) ([15:07]–[15:28])

• Blood biomarker panel.
• Score >9.2: High risk, warrants further evaluation.

Management After Second-Line Screening

Low-Risk Results ([16:00]–[16:50])

• Emphasize cardiovascular risk reduction:
  • Statins
  • Blood pressure/glucose control
  • Gradual weight loss (≥5% for benefit, up to 10% for reversal)
  • Advise avoiding alcohol

High-Risk Results ([16:50]–[18:04])

• Refer to hepatology/gastroenterology for further workup and management.
• Comanagement—primary care/diabetes team focuses on lifestyle/metabolic management; specialists monitor and treat liver progression.
• Collaboration for disease-modifying therapies, regular surveillance.

7. Notable Quotes and Memorable Moments

• On Prevalence:
  “This is the most common disease you never heard of.”
  — Dr. Jay Shubrook, quoting Dr. Skolnick [04:27]
• On Collaboration:
  "It really becomes team-based care at that point where we all have something to contribute."
  — Dr. Neil Skolnick [18:04]
• Key Takeaway:
  “No matter what stage someone’s at, we have a critical role into the evaluation and treatment of those patients to prevent both liver and non-liver outcomes.”
  — Dr. Jay Shubrook [18:25]

8. Final Takeaways and Next Steps

• MASH is highly prevalent, especially among those with diabetes and metabolic risk factors.
• Silent progression means proactive, stepwise screening is vital in primary care and diabetes practices.
• Use FIB-4 for initial screening; follow up with elastography/ELF if elevated.
• Most patients can and should receive essential metabolic disease management in primary care.
• High-risk patients need specialist referral for assessment and long-term monitoring.
• Team-based care is critical, combining generalist and specialist expertise.

Next Episode Preview:
Part 2 will focus on treatment—both current options and emerging therapies. The third installment will apply this knowledge to patient cases.

For more information:
Visit www.diabetesjournals.org for referenced articles and guidelines.