Survey Finds Physicians Lack Necessary Knowledge About NAFLD

A survey of global physicians found a gap in knowledge of non-alcoholic fatty liver disease (NAFLD) despite the growing burden of the disease worldwide.

While the prevalence of non-alcoholic fatty liver disease (NAFLD) is rapidly increasing, there is a significant knowledge gap for diagnosis and management of NAFLD among providers, according to a new study published in Clinical Gastroenterology and Hepatology.

The increasing prevalence of NAFLD is being driven by rising rates of obesity and “is on track to become the most common indication for liver transplantation in the United States,” the authors explained. However, less than 20% of patients are diagnosed.

The researchers developed 2 NAFLD awareness and knowledge surveys and distributed them globally to assess physician knowledge of NAFLD across different medical specialties. One is a 59-item survey for gastroenterology and hepatology specialists and the other is a 54-item survey for endocrinology and internal medicine/primary care physicians (non-specialists).

The gastroenterology and hepatology practices primarily see patients with advanced NAFLD or with cirrhosis related to non-alcoholic steatohepatitis (NASH), which is a severe form of NAFLD. However, primary care and endocrinology practices often see the patients who are at increased risk for NAFLD.

The surveys asked questions about NAFLD, as well as about the respondents, their practice, and the patients they see. They also included multiple-choice questions (32 in the specialist version and 24 in the non-specialist version). There were 3 knowledge domains: epidemiology/pathogenesis; diagnostics; and treatment.

Over 24 months, 2202 physicians completed the survey: 488 hepatologists, 758 gastroenterologists, 148 endocrinologists, and 808 primary care providers (PCPs). Hepatologists had practiced for the longest duration and reported seeing the greatest number of patients with NAFLD each year.

The majority of hepatologists (73.6%) believed that fewer than 10% of patients with NAFLD had any symptoms compared with 66.4% of gastroenterologists, 58.5% of endocrinologists, and 40.3% of PCPs.

Hepatologists had the highest proportion of correct answers and PCPs had the lowest proportion. In the specialist survey, hepatologists had higher mean knowledge scores compared with gastroenterologists, and in the non-specialist survey, endocrinologists had higher scores than PCPs.

Respondents who had a practice affiliated with a hospital saw a greater number of patients with NAFLD each month, and those who used medical journals or international conferences as their primary source of NAFLD all had higher total NAFLD knowledge scores.

A large majority of endocrinologists (79.7%) and PCPs (66.2%) reported screening patients with diabetes for NAFLD. Only 27% of endocrinologists and 20.2% of PCPs reported screening everyone and 9.2% of PCPs reported not screening for NAFLD at all.

“Approximately 5% of all physicians (3% endocrinologists) reported that they would do nothing if they incidentally found fatty liver on imaging,” the authors noted.

For patients suspected to have NAFLD:

  • 64.9% of endocrinologists and 55.0% of PCPs tried to exclude other liver diseases
  • 56.8% of endocrinologists and 51.9% of PCPs sent a patient for a biopsy only if they thought the patient was at risk for steatohepatitis and cirrhosis
  • 58.8% of endocrinologists and 47.5% of PCPs sent patients for a biopsy if other causes of liver disease could not be excluded
  • 72% said they would refer patients to a specialist if they were at risk for steatohepatitis or cirrhosis
  • 50% would refer patients to a specialist if they had a high NAFLD Fibrosis Score

The researchers found that more than half of PCPs were not familiar with NAFLD Fibrosis Score, were not aware cardiovascular disease was the leading cause of death in NAFLD, and were not familiar with NASH pathologic criteria.

“Since PCPs play an important role in management of NAFLD metabolic risks, education to aggressively manage these comorbidities as well as to refer patients at high risk for NASH to specialty care will likely be beneficial,” they wrote.

Heterogeneity of current practice guidelines may be a cause for some confusion among providers. There is a guideline that does not recommend any screening, while another recommends it as part of routine work-up in patients with diabetes and metabolic syndrome, and another recommends screening in at-risk populations.

The author noted that one limitation of the study is a potential bias toward respondents interested in and familiar with NAFLD.

“Since these providers are at the front line of seeing patients with NAFLD, targeted educational programs which would cover those who are most at risk for NAFLD are warranted,” the authors concluded. “Education on alcohol consumption and liver biopsy and their role in NAFLD diagnosis would likely be beneficial among all providers.”


Younossi ZM, Ong JP, Takahashi H, et al, and the Global NASH Council. A global survey of physicians knowledge about non-alcoholic fatty liver disease. Clin Gastroenterol Hepatol. Published online July 3, 2021. doi:10.1016/j.cgh.2021.06.048