S4-E48.1 – Reviewing TLM 2023 Part One: A Discussion With Zobair Younossi

S4-E48.1 - Reviewing TLM 2023 Part One: A Discussion With Zobair Younossi
Dr. Zobair Younossi joins Roger Green to kick off our review coverage of TLM 2023. Dr. Younossi discusses the studies he presented at the meeting and discusses other work related to patient quality-of-life, economics of screening and treatment, and how stigma affects both patients and providers.

Dr. Zobair Younossi joins Roger Green to kick off our review coverage of TLM 2023. Dr. Younossi discusses the studies he presented at the meeting and other work related to patient quality-of-life, the economics of screening and treatment, and how stigma affects patients and providers.

The conversation starts with Zobair listing the topics on which he and his group will present data at the TLM2023 meeting. The first of these is an oral presentation regarding health disparities in adolescents. The thrust of this work is that food insecurity is leading to dramatic, increasing rates of MASLD and MASH among adolescents. Food insecurity, which correlates with lower incomes and living in “food deserts” — primarily urban areas where stores sell ultra-processed foods at high prices — emerges from the NHANES database as a correlation and likely cause of MASLD and even MASH with fibrosis in these younger patients.

Zobair cites alarming statistics about the underestimated prevalence of liver diseases in children and teens. Standard estimates put MASLD in children at 10%, but Zobair believes that number to be closer to 18%, with adolescents as high as 24% and the adult US population at 38%! In parallel, there has been a striking increase in liver disease among type 2 diabetics, which was previously estimated at 55%, but he now estimates at 68%! He notes that “food deserts” also tend to be “activity deserts” without facilities that support a healthy lifestyle.

Roger notes that an increase in patients with Type 2 diabetes and MASH will have significant economic implications: they are more likely to develop cardiovascular disease and obesigenic cancers before they progress to cirrhosis. Also, they are more likely to go from advanced fibrosis to cirrhosis than people with MASH and no diabetes. These social and economic realities emphasize the need for cost-effective screening strategies similar to those recommended by professional societies. Zobair mentions another paper he is presenting at TLM that demonstrates cost-effectiveness for screening in all intermediate-risk patients even before MASH drugs come to market.

From here, the conversation focuses on the factors that make MASLD and MASH so costly. Zobair focuses on fatigue, which affects 30-40% of MASLD patients. Many patients consider fatigue something they live with, not an effect of disease, but MASLD can lead to “brain fog,” or cognitive impairment.
Zobair and Roger go on to explore the issue of stigma in the context of conference presentations and Zobair’s own work. After noting that stigma was a significant reason for the recent nomenclature change, Zobair reports that it seems less of an issue for patients (8%) than providers, where the number is higher. Roger notes his experiences in marketing research, where providers frequently blamed patients for their disease and expressed frustration or even contempt that patients could not take better care of themselves. Zobair notes that this translates to patients, who express more significant frustration and sadness about being blamed for the disease than simple name-related stigma. Zobair makes two more points on stigma: (i) patients who feel stigmatized have lower quality-of-life scores, and (ii) to patients, obesity and Type 2 diabetes are far more stigmatizing than “fatty liver disease.”

The final portion of this conversation focuses on cultural differences. Zobair notes that the stigma associated with obesity and MASH is a Western-world phenomenon and a relatively recent one. In much of the world, obesity can appear as a sign of prosperity because the obese person has enough wealth to buy large quantities of food. They conclude that understanding these nuances is crucial for improving patient-provider communication and addressing factors beyond individual control, such as social determinants and health disparities, which heavily influence health outcomes.

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