Table 1. A Summary of the NAFLD quality standard recommendations.

Management of people with, or at risk of, NAFLD before the gastroenterology or liver clinic	Quality of evidence	Agreement	Responses
1. Services should have an agreed local clinical pathway for the investigation of suspected liver disease that includes an assessment for liver fibrosis using available non-invasive liver fibrosis tests	Low	100%	100% SA
2. Consider the possibility of liver fibrosis due to NAFLD in those with Type 2 diabetes (T2DM) or the metabolic syndrome	Low	96%	70% SA, 26% A, 4% N
3. Do not rely on abnormal liver blood tests to prompt consideration of liver disease. However, persistently unexplained abnormal liver blood tests should always be investigated.	Low	96%	67% SA, 29% A, 4% N
4. The finding of liver steatosis on ultrasound, or unexplained abnormal liver blood tests, should prompt risk assessment for liver fibrosis.	Low	100%	89% SA, 11% A
5. Use validated widely available non-invasive tests (e.g. FIB-4 score or NAFLD fibrosis score) with high negative predictive value to risk assess for significant liver fibrosis in the community.	Moderate	100%	85% SA, 15% A
6. Refer patients stratified as high risk for advanced fibrosis or cirrhosis to a hepatologist. For patients stratified as indeterminate risk, offer further discriminatory tests (such as transient elastography or ELF test) or refer for further evaluation.	Low	100%	67% SA, 33% A
7. Manage those at low risk of significant fibrosis in the community, with focus on lifestyle advice and cardiovascular risk reduction. Reassess fibrosis using non-invasive tests after 3 years.	Low	100%	62% SA, 38% A
8. Secondary care liver services and community services should collaborate on audit, research and education to share knowledge, strengthen links and encourage service and quality improvement and involve patients as part of this as appropriate.	Not graded	92%	SA 69%, 23% A, 8% N
Assessment and investigations in secondary care		Agreement	Responses
9. Patients with NAFLD should be assessed for additional causes of steatosis (e.g., drugs and alcohol) and undergo investigations for other causes of liver disease (i.e., completion of blood aetiology screen) if not already undertaken in primary care.	Low	100%	85% SA, 15% A
10. Patients with NAFLD should have a detailed alcohol history (such as AUDIT-C), illicit drug and smoking history documented.	Moderate	100%	67% SA, 33% A
11. Practitioners should document a treatment history and medicines use review. The rationalisation of medicines that may accelerate disease progression should be considered	Low	100%	65% SA, 35% A
12. An assessment of dietary habits and physical activity levels should be obtained.	Low	93%	67% SA, 26% A, 7% N
13. Patients with NAFLD should undergo sequential use of a simple non-invasive test (e.g. FIB-4) and specialist non-invasive tests (e.g. ELF, transient elastography or ARFI) to assess the severity of fibrosis	Moderate	96%	69% SA, 27% S, 4% D
14. Patients with NAFLD should be considered for a liver biopsy: A. if there is diagnostic uncertainty (other aetiologies/overlap conditions); B. to evaluate the severity of NASH and be considered for potential drug therapies (including clinical trials); or C. to determine the stage of liver fibrosis where non-invasive tests are inconclusive to aid with future management (e.g. F4 for HCC surveillance).	Moderate	92%	50% SA, 42% A, 8% N
15. Liver biopsies should be processed, stained and examined according to the RCPath guidelines and reported by pathologists who participate in the liver EQA scheme using a validated score such as the NASH CRN (NAS) or SAF score.	Low	96%	56% SA, 40% A, 4% N
16. Patients with NAFLD cirrhosis should be offered surveillance for complications of cirrhosis, including HCC and varices, in accordance with national/international recommendations. The Baveno VI exclusion criteria should be considered as a non-invasive tool to rule out the presence of varices requiring treatment.	Moderate	100%	79% SA, 21% A
17. People with NAFLD should undergo systematic assessment of cardiovascular risk factors including use of an objective risk score. (e.g. QRISK-3).	High	96%	55% SA, 41% A, 4% N
18. Patients with NAFLD should be screened annually for Type 2 Diabetes (using HbA1c), hypertension and dyslipidaemia.	Low	85%	46% SA, 39% A, 11% N, 4% SD
Management in secondary care		Agreement	Responses
19. People with NAFLD should be asked about smoking and, if they smoke, should be advised to stop and offered referral to smoking cessation services.	High	100%	67% SA, 33% A
20. People with NAFLD should be advised on benefits of regular exercise; a baseline assessment of physical activity should be made and individualised advice given to increase physical activity.	Moderate	92%	78% SA, 14% A, 4% N, 4% SD
21. Patients with NAFLD should have a regular reassessment of their alcohol consumption.	Low	100%	50% SA, 50% A
22. Abstinence from alcohol should be strongly recommended to patients with NAFLD and cirrhosis. Patients with pre-cirrhotic NAFLD should be advised that alcohol consumption may accelerate disease progression and so should minimise or abstain from alcohol to reduce the risk of disease progression.	Low	100%	69% SA, 31% A
23. Tailored dietary advice should be given with the aim of 5-10% body weight loss through a calorie deficit including, but not limited to, reduction of refined carbohydrates and processed foods, and increased consumption of vegetables, lean protein sources and fish. Referral to weight management services should be considered, especially if weight loss goals have not been achieved.	Low	100%	54% SA, 46% A
24. Referral for consideration of bariatric surgery should be considered in NAFLD patients with obesity who meet the eligibility criteria for bariatric surgery according to national recommendations.	Moderate	96%	50% SA, 46% A, 4% D
25. People with NAFLD who are at significantly increased risk of disease progression and potential risk of liver related complications should continue to be managed in the secondary care setting. Such patients include those with cirrhosis or significant-advanced fibrosis whose liver disease is not outweighed by comorbidities or performance status.	Low	100%	42% SA, 58% A
26. Patients with decompensated liver disease caused by NAFLD should be considered for transplant assessment.	Moderate	96%	78% SA, 18% A, 4% N
27. Patients with hypertension should be managed in accordance with NICE guidelines.	High	100%	76% SA, 24% A
28. Patients who are at increased cardiovascular risk (T2DM and/or QRISK-3 >10%) should be offered HMG-CoA reductase inhibitor (“statin”) treatment in accordance with NICE guidelines.	High	100%	76% SA, 44% A
29. Statins should not be withheld from patients with NAFLD, including patients with compensated cirrhosis, because hepatotoxicity is very rare and the benefits are likely to significantly outweigh the risk.	Moderate	100%	64% SA, 36% A
30. In people with NAFLD and type 2 diabetes, treatment with glucose lowering agents that promote weight loss and reduce cardiovascular risk should be considered.	Moderate	96%	77% SA, 19% A, 4% N
31. Patients with NAFLD should be considered for research studies and offered the opportunity to participate in clinical trials where available.	Not graded	100%	85% SA, 15% A
32. Management of patients with advanced NAFLD in secondary care should be by multidisciplinary teams with expertise in clinical hepatology, management of diabetes and cardiovascular risk factors, lifestyle intervention and health promotion (diet and exercise/physical activity)	Low	92%	58% SA, 34% A, 4% N, 4% D
33. In those discharged to primary care, recommendations should be made on triggers for re-referral back to secondary care liver services.	Low	100%	65% SA, 35% A
34. Patients should be provided with written information about NAFLD and weight management in a format appropriate to their needs and signposted to other credible sources of information such as the NHS and the British Liver Trust	Not graded	100%	65$ SA, 35% A

SA = Strongly Agree; A = Agree; N = Neutral; D = disagree; SD = strongly disagree.