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.