Has My NAFLD Diagnosis Changed to MASLD? Understanding the Transition

Is NAFLD no more? That’s right – In 2023, the name non-alcoholic fatty liver disease (NAFLD) was switched to metabolic dysfunction-associated steatotic liver disease (MASLD) after extensive review from a scientific panel. So what does this change actually mean? I’m a dietitian who works closely with liver disease patients, and there’s a lot of chat about this new terminology. So, let’s review the new nomenclature and how this might impact your diagnosis and treatment plan.

Table of Contents

• What is MASLD?
• Why NAFLD has Changed to MASLD
• Other New Terms – Different Classifications of Liver Disease
• Does the change to MASLD change your treatment plan?

What is MASLD?

Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) is a term used to describe accumulation of fat (also called steatosis) in the liver. In those who have MASLD, more than 5% of the liver contains fat. This build-up of fat in the liver is associated with having cardiometabolic risk factors, such as cardiovascular disease, diabetes, high cholesterol, or high blood pressure. Overall, we can think of MASLD as the way that metabolic disorders “present themselves” in the liver. To put it simply – having other cardiometabolic risk factors can greatly increase chances of having MASLD. 

MASLD can progress from simple steatosis (fat accumulation) to more severe forms of liver disease, such as fibrosis, cirrhosis, and liver cancer, making it a significant public health concern.

Why NAFLD Terminology Has Changed

One of the primary concerns with the old name is that it uses limiting and stigmatizing language. 

Using ‘non-alcoholic’ as a classifier doesn’t allow for much nuance about the progression and development of the disease. Although someone with fat in their liver may not be classified as ‘alcoholic’, there is still the possibility that alcohol can be a contributor to their disease state. It’s not always black and white! Additionally, some people didn’t quite fit into either group according to the previous characteristics of NAFLD and alcoholic liver disease. Therefore, it was important that the panel of experts come up with a better way of classifying these types of patients. 

The word “fatty” can contribute to stigma because it is often used in a negative or derogatory context, especially when referring to body weight or health conditions. This can further stigmatize those with liver disease and implies blame or moral judgment, suggesting that the condition is solely the result of personal choices. In reality, having liver disease is the result of complex interactions of genetics, environment, and lifestyle factors.

Aside from the stigma of the old terms, one of the other reasons for new terminology is to add new categories of liver disease. As mentioned above, the development of liver disease is complex and doesn’t always ‘fit in a box’, so new classifications needed to be created to accommodate all versions of the disease.

After surveying and interviewing the global liver community, researchers have come up with the following new terms:

• Cryptogenic steatotic liver disease – This is defined as fat accumulation in the liver without known cause or without presence of at least 1 metabolic risk factor. So this term can be used for those who have fat deposits in the liver but don’t have factors such as diabetes, high cholesterol, high triglycerides, or high blood pressure. According to studies, 99% of those with NAFLD fit the criteria for MASLD, but for those that don’t, this is the best term to use. 
• Alcoholic-associated liver disease (ALD) – This now takes the place of the old term ‘alcoholic liver disease. 
• MetALD – This describes those with MASLD who consume greater amounts of alcohol per week – This would be characterized by 140g/week (14 standard drinks) for females or 210 g/week (21 standard drinks) for males. MASLD is not always cut and dry – so this category helps to define the spectrum of alcohol consumption and lifestyle factors that can contribute to liver disease. 
• Metabolic dysfunction-associated steatohepatitis (MASH) replaces Non-alcoholic steatohepatitis (NASH) – This is when there is fat accumulation in the liver AND inflammation and injury to the cells of the liver. This stage of liver disease can progress to fibrosis, which essentially means some of the liver tissue becomes replaced by connective tissue. In more advanced stages,  it can also progress to liver cirrhosis which is more permanent and severe scarring.

The new overarching term used to describe this entire group of liver conditions is now steatotic liver disease (SLD).

Will these changes affect my treatment plan?

It is unlikely that the new MASLD nomenclature should fundamentally change someone’s treatment plan. While the classification may refine diagnostic criteria and provide a clearer understanding of disease progression, treatment strategies for any type of steatotic liver disease typically target underlying risk factors and lifestyle factors.

Therapeutic interventions such as dietary changes, exercise, alcohol reduction, and managing blood sugars, insulin, and cholesterol are common. These strategies are designed to address the metabolic disorders that are a common aspect of developing steatotic liver disease. 

Therefore, while the new MASLD nomenclature may offer valuable insights into disease classification and progression, it is unlikely to significantly alter the treatment approach for most people. Treatment decisions will continue to be based on a comprehensive evaluation of each patient’s clinical presentation, genetic profile, and overall health, with the goal of reducing long-term health risk and finding strategies that are sustainable and realistic.

It is best to discuss all your treatment options with your physician, particularly if you have other cardiometabolic risk factors that could be contributing to your MASLD. If you have been told to lose weight or adjust your diet to manage your liver disease, work with a dietitian to find the best approach.