Closing the Liver Detection Gap in Obesity Care

Routine screening for metabolic dysfunction–associated steatotic liver disease (MASLD) remains inconsistent across primary care and obesity medicine, despite the availability of a low-cost, guideline-supported calculation that can flag high-risk patients before irreversible liver damage occurs. That gap was the focus of a conversation between Naim Alkhouri, MD, chief medical officer at Summit Clinical Research and director of the Steatotic Liver Disease Program at the Clinical Research Institute of Ohio, and Chika Anekwe, MD, obesity medicine clinical director at the Massachusetts General Hospital Weight Center and an instructor in medicine at Harvard Medical School, for the third episode of The American Journal of Managed Care^®'s Beyond the Silo podcast series.

How the Liver Fits Into the Cardio-Renal-Metabolic Continuum

MASLD, and its more aggressive form, metabolic dysfunction–associated steatohepatitis (MASH), share the same drivers as cardiovascular and kidney disease, Anekwe explained, including insulin resistance, obesity, and lipotoxicity. "MASLD...is really just the hepatic manifestation of systemic metabolic dysregulation," she said, noting that the heart, kidneys, and liver are all damaged simultaneously by the same underlying metabolic dysfunction.

Alkhouri added that because most patients with liver disease present first in obesity, endocrinology, or primary care settings rather than hepatology clinics, proactive identification by nonhepatologists is critical to preventing progression.

Why the FIB4 Index Remains Underused

The conversation centered on the fibrosis 4 (FIB4) index, a noninvasive calculation using a patient's age, liver enzymes, and platelet count, which both speakers compared with the urine albumin-to-creatinine ratio used in chronic kidney disease screening. Anekwe described FIB4 as "guideline-supported and noninvasive," yet "notoriously underutilized" in both primary care and weight management settings.

At her own weight center, she explained that implementing FIB4 is an evolving clinical discussion, though they now routinely take ownership of the calculation for referred patients, with elevated results triggering secondary testing such as transient elastography or referral to hepatology.

How Treatment Approvals Are Raising the Urgency of Screening

The FDA approvals of resmetirom and semaglutide for MASH have shifted the calculus around early detection, Anekwe said, since having an actionable treatment "makes more urgent and more necessary the need to more proactively screen and monitor for illness."

She noted that finding and treating fibrosis early is far more cost-effective than managing the astronomical health care costs of end-stage liver disease or transplants—a point Alkhouri strongly agreed with, echoing that catching the disease while it remains reversible is critical.

Addressing Equity Gaps in Liver Disease Screening

Anekwe also addressed disparities in access, pointing to noninvasive blood tests, point-of-care imaging, and telemedicine as ways to extend screening to patients in underserved or rural communities. Alkhouri discussed using artificial intelligence platforms to generate culturally tailored dietary and meal-planning guidance for patients. He agreed with Anekwe on the importance of culturally sensitive lifestyle interventions, citing the disproportionate impact of MASLD on Hispanic patients linked to the PNPLA3 gene variant.

Both speakers closed by emphasizing that screening should be considered a routine part of care for any patient with elevated metabolic risk.

"Screening...should no longer be optional for patients at high metabolic risk," Anekwe said, while Alkhouri summarized his approach with what he called the "3 S's": screen, stage, and start treatment.

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