Surfing the MASH Tsunami

Send us Fan Mail

This week, Surfing the MASH Tsunami looks back on interviews Roger Green conducted during the EASL Congress itself. This conversation with SurfingMASH co-host and Tawazun Health Founder and Clinical Director Louise Campbell took place on the last day of the Congress This portion of the conversation was not included in the original S5 E19 but instead was reserved for a special conversation at a later time (now).

The specific focus of this conversation is on how practice patterns and guidelines are likely to change over the next several years. One driving factor involves the need to get primary care not only involved but actively committed to playing a leading role in treatment, given how quickly the identified patient population might grow. Louise points out that the overall rate of growth might be one longer-term issue, but in the short term, dramatic increases in the number of patients with cirrhosis will be a more immediate concern. She questions how staffing and training will address both challenges, with more patients being diagnosed in earlier-stage MASLD patients, coupled with more late-stage fibrosis and cirrhosis. She speaks specifically about a poster looking at liver disease as a factor for cardiac arrhythmias and the seemingly confounding idea that play three, while a genetic target to predict muscle, might also be cardioprotective within the muscle population. However, it has no effect on muscle progression or other just related diseases. This leads Louise to one more optimistic conclusion this time that we will see broader collaboration between specialties over time as we appreciate the scope and complexity that comes from viewing muscle as part of the broader metabolic disease continuum.  

Send us Fan Mail

This week, Surfing the MASH Tsunami looks back on interviews Roger Green conducted during the EASL Congress itself. This conversation with Hepatology Key Opinion Leader and EASL Educational Councillor Sven Francque took place 90 minutes after the EASL Congress closed. The discussion focuses on plans and hopes for the future, both the future of MASLD diagnosis and treatment and of the EASL Congress itself.

The conversation starts with Sven discussing all the positive energy coming from the Congress, not only for MASLD but for the entire Liver community. He describes the ambiance of the meeting as feeling "vibrant," and with a lot of interaction. He goes on to discuss the CPG guideline committee on which he was a member. (See Season 5 Episode 21 for a fuller discussion of CPG). Sven goes on to share the vision of disease that led to this broad, forward-looking guideline update.

From there, we discuss positive results from a set of early-stage clinical trials, with Sven commenting specifically on tirzepatide, efruxifermin and an array of positive phase two trials, one of which is lanifibranor, which presented its results previous year. Sven also finds two studies that use different methodologies but evaluated the prognostic value of liver stiffness to be important. He discusses the value of the new nomenclature and how it allows researchers to look more broadly at the entire steatotic liver disease category. We close by talking once more about the positive body of drug development studies, which Surfing MASH discusses in greater detail in Season 5 Episode 20.

Send us Fan Mail

This week, Surfing the MASH Tsunami looks back on interviews Roger Green conducted during the EASL Congress itself. This conversation with SurfingMASH co-host and Tawazun Health Founder and Clinical Director Louise Campbell took place on the last day of the Congress.

This conversation centered on three major topics addressed at the EASL Congress, each of which made Louise "quite enthusiastic."

The first of these was the presentation of the new EASL/EASD/EASO Clinical Practice Guidelines and their practical implications (Season 5 Episode 21). Louise described this session as having "blown her mind" with its forward-thinking style and recommendations. She termed it a "leap of faith" that we all need to think differently about diabetes and obesity given how quickly incidence is growing. Her favorite items? The guidelines mentioned resmetirom even before it was approved in Europe.   Also, the guidelines described ways to use several drugs that have not been approved for MASLD to treat patients with other metabolic conditions that are linked to MASLD. Louise also expressed enthusiasm at which three organizations partnered on this document.

Roger suggested that this aligned broadly with the various drug presentations in the Late Breaker and General sessions. Collectively, those presentations highlighted an array of drugs with different modes of action and strengths across the metabolic continuum.  More generally, the two agreed that we are looking at a world where, in just a few years, we will have multiple drugs, most with unique modes and all with specific patient targets.

Roger asked whether Louise believes that over time, the diagnostic focus would stay with liver stiffness and CAP or switch to in-office PDFF. Louise suggested that in a world where clinical trials may not require biopsy, it would be difficult to build a sufficiently robust data set for any new tests.

Send us Fan Mail

This week, Surfing the MASH Tsunami looks back on interviews Roger Green conducted during the EASL Congress itself. This conversation with SurfingMASH co-host and Tawazun Health Founder and Clinical Director Louise Campbell took place on the first day of the Congress.

Roger's first interview with Louise took place at the end of Thursday, the opening day of the formal Congress and the first day of research presentations and posters. She starts by describing the "really nice vibe" of the meeting, dampened by the fact that Stephen Harrison was not there, and is no longer with us.

The first session Louise chose to discuss was the previous day's Patient Advocate session. To her, the key point was to learn a key question that every provider should share with every patient once a year. She mentioned briefly the one presentation from the day's General Session she was able to attend, a retrospective analysis of the predictive value of VCTE.

Next, Louise discussed two sessions she attended that delivered powerful, somewhat novel messages. The first was a symposium sponsored by Novo Nordisk that looked at using the liver "to manage cardiometabolic side" through the liver "rather than focusing on liver disease." The second was the "Healthy Livers, Healthy Lives" presentation that presented "very startling figures" about healthcare costs and lack of productivity in the US and how and why India has targeted this disease aggressively. 

After Louise and Roger both commented on the building momentum in MASLD and mentioned why they believe this is happening, Louise noted how many conversations about AI and quicker population detection were occurring despite the lack of ability to act on these today. This let Roger recall his major takeaway from the Preview episode (S5 E17), which was the emerging importance of data development and large datasets. He mentioned a paper from the Karolinska Institute that Hannes Hagstrom discussed in that episode.

Send us Fan Mail

This week, Surfing the MASH Tsunami looks back on interviews Roger Green conducted during the EASL Congress itself. This conversation with Fatty Liver Alliance Founder and CEO Mike Betel took place Wednesday of Congress week, a day for special sections and industry presentations, but one day before the General Session opened.

The first part of the conversation centered  on the Patient Advocate session that Mike chaired with Shira Zelber-Sagi. (This is the focus of Season 5 Episode 23.) The goal of this session was to discuss barriers to addressing unmet needs in a clinical setting and explore potential solutions. He listed the speakers and their topics, and then went straight to his key takeaway: patients around the world are having challenges getting personal attention and time from their treaters. He mentions one panelist who once told a doctor, "I know you're listening  but you're not hearing me." The conversation also touched on stigma and how it comes into these discussions.

The rest of this interview touched briefly on the Opening Session and a couple of industry-sponsored sessions Mike attended. His final point was to emphasize the exceptional opportunities for networking at an event like this one.

Send us Fan Mail

This week’s vault comes from our first episode with Shira Zelber-Sagi. She and Ken Cusi joined us during US Thanksgiving Week 2022 to discuss nutrition and behavioral issues related to MASLD. The episode’s original writeup explains:

Surfing the MASH Tsunami hosts its first episode dedicated to nutrition and NASH with distinguished guest, Prof. Shira Zelber-Sagi. Alongside this rich discussion are Ken Cusi, Jörn Schattenberg, Louise Campbell and Roger Green.

This final conversation starts with Jörn  recalling Shira's statement that “diet is every day.” He notes that for patients whose serious medical issues are related to poor diet and lifestyle choices, behavior and diet can play an integral role in improved patient self-care and overall health. Roger highlights that a combination of medications and self-management can be a powerful, reinforced and effective treatment solution. This leads Shira to provide a step-by-step vision of how to work with patients on improving bad habits. In the end, she notes, clinicians and leaders need to appreciate the importance of policy in supporting clinical goals. The conversation continues with the group discussing what Louise calls “fun facts” about common unhealthy foods. For the final question, Roger asks the panelists for one piece of advice to be utilized by providers seeking to push behavioral change in their patients. Surf on for their key takeaways. 

Send us Fan Mail

Co-chairs Shira Zelber-Sagi and Mike Betel and panelists Tom Marjot and José Willemse, all from the EASL Congress session "Patient Experiences in Clinical Settings," join Louise Campbell to the need for resources that allow MASLD patients to access shared experience programs and holistic MASLD support programs. 

This final conversation focuses on shared experience and holistic MASLD support programs. It starts with Tom suggesting that shared experience is a pivotal factor in patient support groups and patient-based supportive care. He goes back to viral hepatitis, where many of the patients had common background challenges related to the disease. In viral hepatitis, patients who have been treated successfully become integrated into the care community. Nothing like that happens in MASLD at this time. Louise comments this would be particularly useful due to stigma around the disease, stigma that successfully treated patients have overcome. 
 
Louise points out that Michael makes extensive use of shared experience videos, such as this month, when he invited patients to follow him on a "30-day glucose challenge." Michael says that he gets unsolicited notes about how helpful the approach is, along with diet recipes. He agrees with Tom that a viral hepatitis model might provide help here. 
 
Mike discusses the idea of metabolic disease support programs that take a more holistic approach and place MASLD in a broader, multi-disease context. Shire likes the holistic approach as well, including a focus on mental health. Tom agrees with the basic approach, commenting that the multitude of possible issues is what makes MASLD so tricky. 
 
As the conversation wraps up, two final themes emerge: (i) physicians must be actively curious in exploring each patient's needs if therapy is to succeed, and (ii) joint goal setting is an excellent strategy for driving incremental changes in behavior.
 
 

Send us Fan Mail

Co-chairs Shira Zelber-Sagi and Mike Betel and panelists Tom Marjot and José Willemse, all from the EASL Congress session "Patient Experiences in Clinical Settings," join Louise Campbell to discuss ways that socioeconomic and psychological issues impact the dynamic of the physician-patient consult, and, as a result, often patient adherence to therapy.

This conversation starts with Shira asking Tom whether he addresses diet with his patients and, more importantly, whether he does so in the context of socioeconomic challenges, such as not recommending food that is too expensive for the patient. Tom says "Yes" to the first part, about diet and nutrition discussions and encouraging all patients to adopt a more healthy lifestyle, but, he says, not enough about socioeconomic issues. He feels that may be changing, though, based on the increasing discussion of food insecurity at conferences. The two agree that sensitivity in the topic is growing and needs to grow more in the years ahead, and also that while they are tailoring their discussions to address these issues, they can do more. Shira has begun to simplify her recommendations: fewer foods and less preparation time. Tom agrees this is a good idea. 
 
Tom notes that he is focusing more these days on unemployment, social isolation and what he describes as social "unmet needs." He cites figures that 80% of the patients in a liver clinic have unmet needs and that improving social engagement can affect health. Mike asks whether the providers consider mental health, particularly given how important behavioral support is to treatment. Does Shira or Tom recognize mental struggle when the patient is sitting in front of them? Tom says this is an excellent question and identifies the three items patients in large studies say they seek in this realm: (i) education, (ii) reduction of stigma, and (iii) better psychosocial support. Mental health challenges are linked to unmet needs which, again, are linked to poor liver health. Tom believes the UK system does a good job of identifying this issue at the primary care level. Shira agrees this is important and, in her case, involves using quiet, probing questions in a sympathetic tone.  
 
Louise asks whether Tom or Michael have observed MASLD-specific patient support groups in their regions. Both report that there are liver support groups, but nothing yet as specific as MASLD. 

Send us Fan Mail

Co-chairs Shira Zelber-Sagi and Mike Betel and panelists Tom Marjot and José Willemse, all from the EASL Congress session "Patient Experiences in Clinical Settings," join Louise Campbell to discuss strategies and questioning styles that can improve the dynamic of the physician-patient consult.

This conversation starts with Tom stating that having multidisciplinary treatment teams would provide tremendous benefits in terms of being prepared for patients and fully responsive to the issues they are likely to raise. Jose agrees but adds that many countries have only a few nurses and no ability to create these kinds of teams. 
 
Shira states that every physician should learn the principles of motivational interviewing. The key to this is asking open questions that allow the patient to respond fully without feeling judged or steered in a specific direction. This enables the patient to share unhealthy behaviors, which they might not do if the physician admonished them in advance. Tom agrees with the positive tone, saying that so much of the physician's role is all about trying to enthuse the patient to take control of lifestyle factors. 
 
Along a similar theme, Mike notes the importance of tailoring care and questions to the individual patient. He points out that while 10,000 steps/day might be a goal, for some patients, it will feel so unattainable as to be demoralizing. Shira points out that an open question would start by asking the patient what goal is reasonable, and Jose follows by sharing an example of a patient who "hated" all exercise. José found a way to motivate the patient with simple, timely reminders that this was for the liver, and that the liver would be appreciative.  Louise adds that changes in activity if the patient can define them as "fun."

Send us Fan Mail

Co-chairs Shira Zelber-Sagi and Mike Betel and panelists Tom Marjot and José Willemse, all from the EASL Congress session "Patient Experiences in Clinical Settings," join Louise Campbell to discuss some of the key dynamics shaping the physician-patient consult.

This conversation starts with Mike asking Tom whether he reviews the patient's history before the visit. Tom says he does so because he considers preparation vital to a successful consult. That said, Tom notes the importance of being responsive to the conversation rather than using the chart review to decide the outcome of the visit. He provides some empathetic detail about how important the visit is to the patient and, as a result, how important that he be responsive as well as prepared. 
 
José agrees, provides more color, and notes what she considers the most important question a physician can ask a patient: "How are you feeling today?" To José, asking that question just one time a year can change he entire dynamic of the relationship. 
 
Tom then notes the scarcity of time and the double-edged demand this creates for each visit: plan in advance to use time as productively as possible, but once the patient is in the consult, give it all the time it needs. 
 
After José makes a point about the importance of using language precisely, Louise joins the conversation to describe the consult as "like speed dating," with both sides having a scare few minutes to make a relationship that will be pivotal to the patient.