This week’s vault comes from our first episode with Shira Zelber-Sagi. She and Ken Cusi joined us during US Thanksgiving Week 2022 to discuss nutrition and behavioral issues related to MASLD. The episode’s original writeup explains:

Surfing the MASH Tsunami hosts its first episode dedicated to nutrition and NASH with distinguished guest, Prof. Shira Zelber-Sagi. Alongside this rich discussion are Ken Cusi, Jörn Schattenberg, Louise Campbell and Roger Green.

This final conversation starts with Jörn recalling Shira's statement that “diet is every day.” He notes that for patients whose serious medical issues are related to poor diet and lifestyle choices, behavior and diet can play an integral role in improved patient self-care and overall health. Roger highlights that a combination of medications and self-management can be a powerful, reinforced and effective treatment solution. This leads Shira to provide a step-by-step vision of how to work with patients on improving bad habits. In the end, she notes, clinicians and leaders need to appreciate the importance of policy in supporting clinical goals. The conversation continues with the group discussing what Louise calls “fun facts” about common unhealthy foods. For the final question, Roger asks the panelists for one piece of advice to be utilized by providers seeking to push behavioral change in their patients. Surf on for their key takeaways.

This final conversation focuses on shared experience and holistic MASLD support programs. It starts with Tom suggesting that shared experience is a pivotal factor in patient support groups and patient-based supportive care. He goes back to viral hepatitis, where many of the patients had common background challenges related to the disease. In viral hepatitis, patients who have been treated successfully become integrated into the care community. Nothing like that happens in MASLD at this time. Louise comments this would be particularly useful due to stigma around the disease, stigma that successfully treated patients have overcome.

Louise points out that Michael makes extensive use of shared experience video, such as this month, when he has invited patients to follow him on a "30-day glucose challenge." Michael says that he gets unsolicited notes about how helpful the approach is, along with diet recipes. He agrees with Tom that a viral hepatitis model might provide help here.

Mike discusses the idea of metabolic disease support programs that take a more holistic approach and place MASLD in a broader, multi-disease context. Shire likes the holistic approach as well, including a focus on mental health. Tom agrees with the basic approach, commenting that the multitude of possible issues is what makes MASLD so tricky.

As the conversation wraps up, two final themes emerge: (i) physicians needs to be actively curious in exploring each patient's needs if therapy is to succeed; and (ii) joint goal setting is an excellent strategy to drive incremental changes in behavior.

Co-chairs Shira Zelber-Sagi and Mike Betel and panelists Tom Marjot and José Willemse, all from the EASL Congress session "Patient Experiences in Clinical Settings," join Louise Campbell to discuss ways that socioeconomic and psychological issues impact the dynamic of the physician-patient consult, and, as a result, often patient adherence to therapy.

This conversation starts with Shira asking Tom whether he addresses diet with his patients and, more importantly, whether he does so in the context of socioeconomic challenges, such as not recommending food that is too expensive for the patient. Tom says "Yes" to the first part, about diet and nutrition discussions and encouraging all patients to adopt a more healthy lifestyle, but, he says, not enough about socioeconomic issues. He feels that may be changing, though, based on the increasing discussion of food insecurity at conferences. The two agree that sensitivity in the topic is growing and needs to grow more in the years ahead, and also that while they are tailoring their discussions to address these issues, they can do more. Shira has begun to simplify her recommendations: fewer foods and less preparation time. Tom agrees this is a good idea.

Tom notes that he is focusing more these days on unemployment, social isolation and what he describes as social "unmet needs." He cites figures that 80% of the patients in a liver clinic have unmet needs and that improving social engagement can affect health. Mike asks whether the providers consider mental health, particularly given how important behavioral support is to treatment. Does Shira or Tom recognize mental struggle when the patient is sitting in front of them? Tom says this is an excellent question and identifies the three items patients in large studies say they seek in this realm: (i) education, (ii) reduction of stigma, and (iii) better psychosocial support. Mental health challenges are linked to unmet needs which, again, are linked to poor liver health. Tom believes the UK system does a good job of identifying this issue at the primary care level. Shira agrees this is important and, in her case, involves using quiet, probing questions in a sympathetic tone.

Louise asks whether Tom or Michael have observed MASLD-specific patient support groups in their regions. Both report that there are liver support groups, but nothing yet as specific as MASLD.