Back in 2019, I wrote about the challenge of diagnosing NASH and the frustrating reality that tools like FibroScan, MRE, blood-based scores, and other non-invasive diagnostics were promising but still too disconnected from everyday care. At the time, the problem felt largely technological. We needed better tools, clearer answers, and a path away from relying so heavily on liver biopsy.
That is still true, but it is no longer the whole story.
Today, the more uncomfortable reality is that we do not just have a diagnostics problem. We have an implementation problem.
We already have more tools than we used to. FibroScan is no longer some exotic research device. Risk scores like FIB-4 are simple and inexpensive. Doctors know a lot more now about who is at risk. They have also spent years showing that fatty liver disease is closely tied to obesity, insulin resistance, prediabetes, type 2 diabetes, and broader metabolic dysfunction.
“This consensus report is a call to action to screen for liver fibrosis and risk stratify people with prediabetes or type 2 diabetes.”
American Diabetes Association consensus report, 2025
That is a very different mindset from the older era, when liver disease screening still felt like a side issue in routine metabolic care.
And yet far too many people are still being missed.
For years, the conversation around fatty liver disease sounded like the main problem was scientific uncertainty. We did not know enough. We did not have enough precision. We did not have enough ways to identify the right patients without putting a needle in their liver.
Now the problem looks different. It looks less like a lack of options and more like a lack of follow-through.
Patients with obvious metabolic risk factors still move through primary care without anyone calculating a fibrosis score. People with abnormal liver enzymes are still too often told to lose weight and come back later. Fatty liver findings on imaging still get buried in reports or treated like background noise. Many patients do not reach a hepatologist until fibrosis is already advanced enough to become frightening.
That is not because the medical community has no tools. It is because the tools are still not being used consistently where they matter most.
That matters because the burden is not small. The ADA consensus report notes that liver steatosis affects approximately two out of three people with type 2 diabetes. If a risk this common is still being treated like a specialty issue, then the system is not built around where the disease actually shows up.
I have heard versions of the same concern from hepatologists for years: if widespread screening suddenly started working the way it should, and every at-risk patient got referred straight to hepatology, the system would be overwhelmed almost immediately. That is not an argument against screening. It is an argument for building smarter front-line risk stratification, clearer referral pathways, and better tools in primary care so specialists are not forced to absorb the entire burden alone.
One of the biggest shifts in recent years is that fatty liver disease is finally being treated as part of the larger metabolic health crisis, not just a niche issue for hepatologists. If MASLD and MASH are closely tied to diabetes, obesity, insulin resistance, cardiovascular risk, and metabolic dysfunction, then earlier identification should be happening in the same places where those problems are already being managed.
That disconnect is dangerous because awareness without action is mostly theater. It is good to publish guidance. It is encouraging to talk about better diagnostics and treatment progress. But none of that means much for the person who is never identified in the first place.
To be fair, there are real reasons this has been hard. Primary care is overloaded. Many clinicians are juggling too many priorities. Reimbursement and workflow do not always reward deeper liver risk assessment. There is still uncertainty about exactly who should be screened, how often, and with which tools.
But those realities cannot keep serving as an excuse for inertia.
What should happen next is not mysterious. Checking liver risk needs to become a more normal part of caring for patients with metabolic dysfunction. That does not mean every primary care office suddenly becomes a liver specialty center. It does mean clinicians need practical ways to identify who needs more workup and who does not.
“More awareness about the health risks associated with MASLD and broad adoption of screening for liver fibrosis as a new standard of care hold promise for a future without cirrhosis…”
American Diabetes Association consensus report abstract, 2025
And those paths are clearer now than they used to be. Doctors now recommend starting with a simple first-line score like FIB-4, then following borderline or elevated results with a better second-line test such as liver stiffness measurement by transient elastography. The problem is not that no path exists. The problem is that it still is not routine enough.
One possible way to ease that burden is to use AI tools more intelligently in primary care. Not as a substitute for clinical judgment, and not as hype, but as a way to flag risk patterns, calculate fibrosis scores automatically, and make it harder for obvious warning signs to get missed. Emerging work on machine learning for advanced fibrosis screening in MASLD at the primary care level points in that direction. So does the broader case for AI-augmented stratification when current workflows depend too heavily on provider awareness and follow-through. If primary care is too overloaded to catch every case manually, then part of the answer may be building better systems that do more of that first-pass triage automatically.
That would not solve everything. But it would be better than pretending that an overloaded system will somehow start identifying patients earlier on its own.
I wrote years ago about the challenge of diagnosing NASH because it was obvious even then that delayed recognition was costing people precious time. What is striking now is how much the challenge has changed. We are no longer waiting for diagnostic science to begin. We are at a stage where many of the right pieces already exist, but they are still not being used consistently enough to protect patients.
That is the real test now. Not whether we can keep talking about MASLD and MASH, but whether the healthcare system will actually build screening and follow-up into routine care before it is too late.
Sources: American Diabetes Association consensus report; PubMed abstract; Diabetes Care screening study; Karger ML implementation study; AI-augmented stratification analysis.
