This is war. The Crusades! Two opposing camps are sparring as to what exactly metabolic dysfunction is. The idea of renaming non-alcoholic fatty liver disease (NAFLD) to metabolic (dysfunction)-associated fatty liver disease (MAFLD) has opened a can of worms with regard to the definition of metabolic dysfunction [MD].1 We had previously criticised the MAFLD criterion of MD and had shown that 33.9 % of healthy individuals without fatty liver satisfied two of seven parameters of MAFLD criterion although only 8.8 % had the metabolic syndrome (MS) as per ATP III criteria.2,3 To make things worse, the Global NAFLD nomenclature consensus group have come up with the term ‘metabolic dysfunction-associated steatotic liver disease (MASLD)’ to replace NAFLD.4 MD has been defined as presence of at least one of five cardiometabolic risk factors. This definition of MD too does not have any scientific basis. We, therefore, decided to re-evaluate the criterion for MD in a healthy cohort without fatty liver to see how this applied to healthy individuals.
We retrospectively evaluated clinical and biochemical parameters of the previously described cohort of 171 healthy individuals obtained from the database of Kalinga Gastroenterology Foundation [Table 1].2 While 8.8 % of them were found to have MS as per ATP III criterion3 and 33.9 % individuals satisfied two of seven parameters enumerated in MAFLD criterion for MD(1), 77.2 % individuals could be called ‘dysmetabolic’ according to criterion enunciated by the MASLD proponents4; further, a whopping 94.7 % healthy females were rendered ‘dysmetabolic’ compared to 68.4 % males. In addition, the mean HDL level of females in the cohort was below the normal cut-off of 50 mg/dL.
Table 1.
Anthropometric, Biochemical, and Metabolic Parameters of the Cohort.
| Parameter | All Patients (n = 171) | Males (n = 114) | Females (n = 57) | P value |
|---|---|---|---|---|
| BMI (kg/m2) | 21.61 ± 3.23 | 21.24 ± 2.74 | 22.35 ± 3.96 | 0.06 |
| Waist Circumference (cm) | 78.88 ± 10.80 | 80.25 ± 9.40 | 76.16 ± 13.64 | 0.04 |
| HDL (mg/dL) | 45.34 ± 8.55 | 44.94 ± 8.37 | 46.14 ± 8.91 | 0.39 |
| TG (mg/dL) | 130.98 ± 58.29 | 131.68 ± 61.51 | 129.58 ± 51.74 | 0.82 |
| Dysmetabolism as per MASLD criterion (%) | 77.2 | 68.4 | 94.7 | <0.001 |
| Dysmetabolism as per MAFLD criterion (%) | 33.9 | 28.07 | 45.6 | 0.02 |
| Metabolic Syndrome (%) | 8.8 | 6.14 | 14.03 | 0.07 |
| Alcohol intake (%) | 5.84 | 8.77 | 0 | 0.03 |
∗P value calculated by independent t-test for continuous variables and Chi-square test for categorical variables.
MASLD, metabolic dysfunction-associated steatotic liver disease; MAFLD, metabolic (dysfunction)-associated fatty liver disease.
These results are extremely disconcerting given the fact that the investigators from both the groups chose to impose the definition of ‘metabolic dysfunction’ arbitrarily. Certainly, it would not be wrong to question the rationale of the ‘consensus’ labelling patients having one out of five cardiometabolic factors as ‘dysmetabolic’. It needs no reiteration that South Asian populations have lower HDL and higher TG levels.5 Surely, the authors of this global consensus on NAFLD should have had a more inclusive approach and tried to solve the problem from a global perspective. This implies that there is a need for at least revisiting the definition of dysmetabolism since such random and loose criteria could lead to labelling entire populations of several countries and ethnicities dysmetabolic!
It is very clear that although the consensus committee adopted a very rigorous and painstaking methodology to find a just and politically correct substitute for NAFLD, unfortunately somewhere during the arduous journey, the process itself has gone astray possibly due to a lopsided over-representation of the hepatologists of the West and a disproportionate presence of zealous non-hepatologists with conflict of interest. Besides, even if this name is to stay, this criteria of dysmetabolism is unacceptable and has to be recalibrated. The focus today should be on finding means to tackle the NAFLD pandemic and not on wasting precious time and resources changing names. After all, the rose remains the same!
Conflicts of interest
None to disclose.
Funding
None received.
References
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