This vault conversation looks back to our coverage of International NASHDay 2023, the predecessor title to this year's Global Fatty Liver Day.

Thursday, June 8 was International #NASHDay 2023 and the podcast hosted a special session featuring patient advocates Gina Villiotti Madison (NASH kNOWledge), Marko Korenjak (European Liver Patients'​ Association) and Michael Betel (Fatty Liver Alliance). With co-hosts Louise Campbell and Roger Green, the group shares both a positive and sobering discussion around the Fatty Liver public health epidemic and its impact on younger generations now and into the imminent future.

Roger starts this conversation by asking Louise to provide more information about the U.K. Parliament debate that had just commenced. Louise notes that MPs from all parts of the UK participated and that they were extremely well-informed on childhood NAFLD and other issues. She notes that members told stories of their own weight loss and government promise to brief MPs on liver disease on an interim basis going forward. One MP said he did not like the term living with obesity, which is considered patient sensitive, because it implies that obesity is a permanent condition. This leads to Roger's closing question which asks each panelist to envision what their organizations' key 2024 International #NASHDay activities might be. While their answer are aligned with what they did for the International #NASHDay 2023, listen for some different twists and new directions.

This is a particularly important and moving episode that captures a range of topics pertinent to the patient perspective and, more broadly, stepping up to NASH.

This closing conversation introduces two new concepts: the idea that MASH has so many facets that it is comparable to the metaphor of blind people touching an elephant, and the provider mandate to "rule the liver out" when assessing patients with metabolic diseases.

Roger cites the parable of the blind people touching the elephant as a metaphor for liver disease, which is a precursor for multiple seemingly unrelated diseases (cardiovascular and extra-hepatic cancers, to name two). He says the point is to teach liver disease to healthcare professionals as "the elephant," not its different parts. Louise agrees and suggests that the simple action point for liver disease-as-elephant is to "rule the liver out" when assessing the various related diseases. The test for this must be "cheap" and "accessible;" it does not exist anywhere in the world today.

Roger suggests that the "Keep It Simple, Stupid" approach to liver disease incorporate the two simple action items discussed in this episode. For patients, act now, get screened. For providers, rule the liver out.

In lieu of a final question, Roger asks panelists to describe one specific initiative they know of that is part of Global Fatty Liver Day. Mike describes a screening activity in Calgary. He describes a "mistake" last year in letting patients eat healthy food before being scanned. Louise assures him that eating healthy foods will affect scan outcomes less than 1% of the time. Jeff discusses the successes of street teams around the world, who screened 77,000 patients as part of International NASH Day 2023.

Jeff McIntyre uses the discussion between Louise Campbell and Mike Betel as a jumping-off point for discussing some of the larger care challenges and barriers associated with MASH patient care.

Jeff says the previous conversation between Louise and Michael provides "a really great synopsis" of the challenges and barriers to patient diagnosis and care. He reports that the Global Liver Institute is planning to release its first "Best Practices in LIver Health Policy" report. For GLI, these challenges are more complex due to the need to find solutions that will work in countries around the world. He also states that GLI believes the system needs to be intentional not only about diagnosis but also health system follow-through. This requires patient access and country systems set up for success. Roger raises the issue of having safe spaces for people to exercise in less developed countries. Louise recommends tier systems so that the solution for each country reflects the country's economics. Roger discusses a recent study showing a link between food insufficiency in 4-year-olds and MASLD and MASH later in childhood. Jeff describes the Stockdale paradox: policymakers cannot get caught up in the big picture without dealing with the short-term issues ahead of longer-term success.

Jeff describes two US health policy cases that reflect the Stockdale paradox: the VA's initial decision (later reversed) to require biopsy for Rezdiffra and lobbying by the giant food companies to have added sugar included in the list of attributes of healthy food.

Louise describes "a big to-do" in the UK about children's teeth and access to dentists because poor dental health drives a 7x increase in the risk of liver cancer. She would like to see a generalized dietician who can work with patients on the range of metabolic issues. Mike says it "scares" him about where to start small. Louise gives an example of boiling water before dressing wounds and taking other health actions in Angkor Wat, which led to dramatic declines in diarrhea and the spread of many diseases.

This conversation focuses on what happens after or around patient screening, addressing the challenges caused by using GLP-1s and dual incretin agonists to treat concomitant conditions before looking at the patient's liver, and then the opportunities that can come from on-site scanning and immediate feedback.

Jeff starts this conversation by noting the popularity and widespread discussion around anti-obesity medications, which also have effects on MASH. He says this could "lead to a tricky couple of years" if results include decreased willingness to participate in clinical trials and/or decreased demand for fatty liver drugs from patients already on incretin agonists like semaglutide or tirzepatide. Generally, he expresses a concern that all this will lead to a decline in focus on the liver.

Louise discusses activities in her two home countries, UK and Australia. She starts by noting that interest in the healthcare system picks up when patients go to their primary care physicians seeking care for a given disease, in this case, liver disease. She goes on to note that "liver disease is a small portion of poor liver health," which leads to cardiovascular disease and extra-hepatic cancers. Thus, she says screening should identify patients with poor liver health in order to educate and intervene with these non-hepatic conditions. She describes data in her possession that says 33% of Australians who believe they are healthy have poor liver health, and that most of these are post-menopausal women. She says there is a mismatch between patient needs, perceived resource demand, and funds available to support these resources.

Mike asks Louise to comment on scanning as an educational activity. Before answering his question directly, she discusses the value of on-site patient questionnaires in improving the quality and perceived value of the overall visit. Next, she discusses how she uses the sharing of scan results with the patient to generate a deeper patient understanding of the disease and activate conversation on how patients can help themselves better. Mike agrees based on his experience learning about his high CAP score, then lowering the level. Louise discusses steps treaters can take if the first intervention doesn't work.

This conversation centers around the Global Fatty Liver Day 2024 theme and the rationale behind focusing on screening.

It starts with Jeff describing how much has changed in MASLD in the past year and why this calls for a new focus. Jeff identifies the breadth of the global challenge of treating MASLD and related conditions, which is far broader than "just having one medicine for one aspect of the disease in one country." To Jeff and GLI, the best immediate path forward is to bring more patients into the system through screening, which provides the rationale for GLI's theme for the day, "Act Now. Get Screened."

Roger states that this effort will drop a large number of patients "in the top of the funnel," and notes that earlier podcasts demonstrate limited adoption of clinical care pathways or other ways to manage an increased patient volume. He asks Jeff where the care pathway issue fits in the "Act Now. Get Screened" vision. Jeff states this is an issue for the entire field, not just patients, and that the field needs to collaborate on a turnkey way for PCPs to screen easily.

Roger describes the concern raised Naim Alkhouri (Season 4, Episode 50.3) that the current clinical care pathway approach might create chaos in the system. Also, Roger asks whether US reimbursement policy is far enough along for the various actors to participate. Roger asks about the most effective action that patients and advocates can take. Jeff replies, "Get Screened."

Mike Betel suggests that while this may be an issue for the entire field, he believes the onus for keeping this issue in front of providers must come from patients assertively asking questions and seeking support. Jeff agrees, but describes the relationship between patient and provider in this case as "symbiotic."

On April 23, the global MASLD community lost one of its giants when SurfingMASH Co-founder Stephen Harrison passed away unexpectedly. Co-hosts Louise Campbell and Roger Green and guests Jeff McIntyre and Mike Betel each share a memory of Stephen.

Jeff McIntyre starts this conversation by remembering Stephen as a fellow Southerner and, in addition to his many professional accomplishments, a person who could cut through high-level discussions with a "pithy little West Texas saying" that would make a complex or abstract concept clear. Mike Betel starts his comments by talking about Stephen's older brother, Ken, who wrote personal messages back to every comment he could find on social media, which was a remarkable task in its own right. Mike discusses how often he heard Stephen speak and how many times he interviewed Stephen for various Fatty Liver Alliance posts or events. Mike concludes with a story about Stephen talking for five minutes while Mike's audio was malfunctioning and then doing a second take remarkably similar to the first. Louise discusses being on the podcast with Stephen for years and regrets that he will never cook her a deep-fried turkey. She recalls his hobby of building elaborate sand structures on the beach with his family while he ran around the world, putting a large dent in MASLD. Roger starts by describing the first time he saw Stephen at NASH-TAG 2019 and how his larger-than-life presence and exceptional energy suffused a room of 200 people. He continues by using a favorite "Harrisonism" about being thankful that they didn't stop after WD-39 because WD-40 was the 40th effort to create the product we know today, and comments that for Stephen as Principal Investigator, Rezdiffra was his WD-40. Finally, Roger says he "just lost it" when reading the Walt Whitman poem "O Captain, My Captain," which Scott Friedman posted on LinkedIn as a tribute to Stephen.

After the personal comments, Roger says that next week's episode will be a tribute to Stephen from some of his closest friends in the global MASLD community.

Fatty Liver Alliance Founder and President Mike Betel and Global Liver Institute Vice President for Liver Programs Jeff McIntyre join Louise Campbell and Roger Green to preview the premier MASH event for patient advocates, now known as Global Fatty Liver Day, which falls on June 13.

00:00:00 - Surf's Up: Season 5 Episode 13
Episode introduction, including brief quotes taken directly from panelists.

00:02:37 - Introduction/Remembering Stephen Harrison
Roger introduces the podcast. Each panelist shares a memory of Stephen Harrison.

00:11:44 - Groundbreaker
Each panelist shares one piece of good news from the previous week.

00:15:18 - Jeff Discusses Global Fatty Liver Day
Jeff starts by discussing how GLI came to its 2024 theme: "Act Now. Get Screened." Roger comments that this will require health systems to expand in scale and sophistication and shares Naim Alkhouri's critique (Season 4, Episode 50.3) of the current approach. He asks if US reimbursement policy is sufficiently developed and what patients can do. Jeff replies, "Get Screened."

00:25:46 - Fatty liver and obesity
Jeff notes the popularity and widespread discussion around anti-obesity medications, which also have effects on MASH. He expresses concerns that all this will lead to reduced focus on the liver.

00:26:43 - UK and AUS
Louise discusses activities in her two homes. Rather than focusing on liver disease, she prefers "poor liver health," which leads to cardiovascular disease and extra-hepatic cancers.

00:31:10 - Scanning patients as educational tool
Mike asks Louise to comment on scanning as an educational activity. Louise discusses the ability to generate an effective description and activate conversation when she delivers scan results right at the time of the patient visit. She then discusses the next steps if the first one doesn't work.

00:35:40 - Challenges and barriers for patients
To Jeff, the previous conversation between Louise and Michael provides "a really great synopsis" of the challenges and barriers to patient diagnosis and care. He announces that the GLI is planning to release its first Best Practices in Policy report. These challenges are more complex due to the need to find solutions for diagnosis and health system follow-through that will work around the world.

00:43:10 - Battles around healthy lifestyle policies
Jeff describes two challenging US health policy cases: the VA's decision (later reversed) to require biopsy for Rezdiffra and giant food companies lobbying to include added sugar as a healthy food item. Louise links the sugar question to "a big to-do" in the UK about children's teeth and access to dentists because poor dental health drives a 7x increase in the risk of liver cancer and advocates for generalized dietician training.

00:47:56 - The liver as elephant
Roger cites the parable of the blind people touching the elephant as a metaphor for a myopic view of liver health. He advocates teaching "the whole elephant" to healthcare professionals. Louise proposes an action point of "rule the liver out" before testing for related diseases. Roger suggests this is a dual mandate. For patients: Act Now. Get Screened. For providers, Rule the Liver Out.

00:51:21 - Initiatives for Global Fatty LIver Day and wrap-up
In lieu of a final question, Roger asks panelists to describe one specific initiative that is part of Global Fatty Liver Day. Mike and Jeff each describe screening activities.

00:58:13 - Question of the Week
Roger asks what listeners can do in their work to support the two simple mandates: act now, get screened, and rule the liver out.

00:58:44 - Business Report
This week's news on audience metrics, future episodes and this week's Vault conversation.

One theme in this week's episode involves different ways to use NITs in drug development and assessing the value of older drugs in MASH. This conversation, from our review of last September's FDA workshop on NITs, considers two additional roles that NITs might play in drug development.

The conversation includes Jörn Schattenberg, Louise Campbell, Roger Green, and guest Laurent Castera. The original post has an excellent description:

This conversation begins with a discussion of a point from a previous episode in 2022 about the difference between NITs to qualify patients for trials versus to evaluate the efficacy of drugs. This point stems from the idea that the way disease regresses may not be the same way it progresses. Laurent notes that NIMBLE and LITMUS have demonstrated important results with large data over the last two years. Jörn comments on the limits of using transaminase as a key NIT and Laurent replies by discussing a study over time that shows faster early declines on liver stiffness and slow declines over time as therapy might shift from reducing inflammation to regressing fibrosis. Louise shifts focus to ask about the relationship between kilopascal drops related to lifestyle change, specifically to ask whether these are false positives or real effects. Laurent notes that BMI is a confounder for liver stiffness and that CAP might help assess this issue. Finally, in response to a question from Louise, Laurent answers that we do not know about some of the key changes in test scores, and need to know more.

Plenty more ideas are explored as this is both a fascinating and pivotal workshop which covers a range of topics on NITs with presentations by the some of the field's most innovative and knowledgable contributors. If you have questions or comments around the workshop, NITs, drug development or any other themes addressed in this episode, we kindly ask that you submit reviews wherever you download the discourse.