In the last quarter of 2023, the American Association for the Study of Liver Diseases, the European Association for the Study of the Liver, and the Sur Medical Clinic Foundation jointly released a Delphi consensus statement [1]. These organizations recognized the significant limitations of the current terms, nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH). As a result, a new nomenclature for fatty liver disease was introduced and published in the Journal of Hepatology [2]. The term chosen to replace NAFLD is metabolic dysfunction–associated steatotic liver disease (MASLD) [2]. The changes to the previous terminology will be integrated into this research compilation, while maintaining the original terms as referenced. In addition, the new nomenclature, acronym, and diagnostic criteria received broad support and are expected to enhance awareness and patient identification [2].

Even though NASH was first used in 1989, it required another 10 years for its inclusion in the clinicopathologic spectrum of MASLD, which includes subtypes with varying likelihood for progression [3]. The term MASLD refers to the buildup of fat in the liver, specifically when the amount of fat in the liver exceeds 5% of the hepatocytes [4]. In addition, MASLD is characterized by progressive steatosis and related pathology, such as cirrhosis, hepatitis, or hepatocellular carcinoma. Patients with MASLD can display a diverse range of histological features, including simple steatosis, NALFD, or NASH [5]. Over the years, the prevalence of chronic liver diseases has risen, leading to concerning increases in liver-related morbidity and mortality rates globally [6]. MASLD is one of the primary contributors to chronic liver diseases and has escalated to a worldwide epidemic, impacting approximately 1 in 4 adults, with an estimated prevalence of 25% to 30% [6,7]. This trend seems to correlate with the rising incidence of metabolic syndrome and its associated factors, such as obesity, type 2 diabetes mellitus (T2DM), and dyslipidemia [6].

The diagnostic criteria of MASLD include invasive and noninvasive tests. Noninvasive fibrosis tests should be used to rule out advanced fibrosis in low-prevalence populations and patients at risk of advanced liver fibrosis, such as those with metabolic risk factors or harmful alcohol use. These tests are part of routine investigations in primary care for suspected liver disease. Automatic calculation and systematic reporting of simple noninvasive tests, such as Fibrosis-4, is recommended to improve risk stratification and care linkage [8]. However, liver biopsy continues to be the most reliable method for diagnosing this condition. However, there are a variety of noninvasive methods, such as imaging tests and biomarkers, that are becoming more widely used for the assessment of fibrosis [9].

In Saudi Arabia, the prevalence of MASLD is expected to increase through 2030, parallel to projected increases in the prevalence of obesity and DM. By 2030, there would be a pre-estimated 12,534,000 MASLD cases in Saudi Arabia [10].

It is assumed that 30% of the people aged ≥15 years in 2015 had MASLD. The prevalence of MASLD among older adults in Saudi Arabia is estimated at 24.8% [10]. The prevalence of MASLD continues to rise and is now becoming one of the most frequent causes of cirrhosis (advanced liver disease) and liver transplantation in Europe [11].

Unless patients with MASLD are identified and diagnosed, they are denied the knowledge and opportunity to make the necessary changes. It is important to identify and risk-stratify patients with MASLD in order to implement therapeutic interventions [11]. The latter statements are the major incentives to initiate this research to identify patients with MASLD among T2DM attending King Saud Medical City (KSMC), Riyadh. Patients with MASLD have an increased risk of dying from liver disease, cardiovascular disease, and most causes of cancer, with modeling suggesting that the annual predicted economic burden of MASLD in Europe would be more than €35 billion (approximately US $40) of direct cost and further €200 billion of societal cost [12]. Primary care practitioners are central to the management of patients with NAFLD, but data on the knowledge and attitude of primary care practitioners toward MASLD are lacking. Future guidelines should emphasize strategies for screening vulnerable populations (obese and diabetics) [13].

It has been emphasized in recent relevant literature that MASLD is strongly linked with an unhealthy lifestyle. This is an area where improvement strategies could be designed and implemented in communities, including schools. Another important drive to conduct this research is the close relationship between MASLD and T2DM, and the management of the latter will go far in arresting the progression of MASLD. Family medicine and primary care practitioners are in a central position to provide timely screening and early diagnosis of MASLD and possible reduction in the future prevalence rates, as these practitioners serve as gatekeepers and are the primary health care professionals providing most of the care for these patients. The main aim of this study is to identify patients with T2DM who have MASLD attending KSMC, Riyadh, under the care of Family Medicine Department health care professionals.

The overall prevalence of MASLD in our study population was 54.5% (n=159). Table 1 provides an overview of the sociodemographic and clinical characteristics of the participants in the study, which included 292 individuals. The total response rate was 85%. Of 292 participants, there were 138 (47.3%) males and 154 (52.7%) females. Regarding age groups, the majority of participants fell within the 41‐59 years category (192/292, 65.8%), followed by those aged 60 years and older (94/292, 32.2%), with a smaller proportion in the 30‐40 years group (6/292, 2.1%). The vast majority of participants were married (243/292, 83.2%) and had received at least an elementary education (79/292, 27.1%). In terms of physical activity, 30.8% (90/292) reported being physically active. The study population exhibited various comorbidities, with dyslipidemia being the most prevalent (218/292, 74.7%), followed by hypertension (209/292, 71.6%). Other comorbidities included cardiac disease (108/292, 37%), hypothyroidism (32/292, 11%), and bronchial asthma (19/292, 6.5%). The duration of diabetes was relatively evenly distributed, with 28.4% (83/292) having diabetes for less than 5 years and 71.6% (209/292) for 5 years or more. In terms of current treatment for diabetes, the majority were on oral hypoglycemics only (179/292, 61.3%), followed by a combination of oral hypoglycemics and insulin (92/292, 31.5%). In addition, most participants were taking antihypertensive medications (216/292, 74%) and lipid-lowering agents (226/292, 77.4%). However, only 46.9% (137/292) were taking aspirin. The majority of participants were nonsmokers (218/292, 74.7%), with a smaller proportion being current smokers (30/292, 10.3%) or ex-smokers (44/292, 15.1%). Regarding WC, a considerable proportion of males (110/292, 37.7%) and females (141/292, 48.3%) exceeded the recommended thresholds of 94 cm and 80 cm, respectively. Furthermore, the distribution of BMI classifications varied, with the majority falling within the overweight and obese categories (BMI 25‐39.9 kg/m²).

Table 2 presents the laboratory findings of the participants in the study. The majority of participants (251/292, 86%) had normal ALT levels, while a smaller percentage (34/292, 11.6%) had high ALT levels. As for AST, most participants (273/292, 93.5%) had normal levels, with a small proportion (17/292, 5.8%) having high levels. For gamma-glutamyl transferase (GGT), the majority had normal levels (177/292, 60.6%), while some had high levels (22/292, 7.5%). In terms of glycated hemoglobin (HbA_1c) levels, the largest proportion fell within the range of 6.4‐10.0 (173/292, 59.2%), followed by >10 (55/292, 18.8%), indicating suboptimal glycemic control in a significant portion of the participants. Regarding triglyceride levels, most participants had normal levels (197/292, 67.5%), while a smaller percentage had borderline high (44/292, 15.1%) or high levels (46/292, 15.8%). Similarly, for low-density lipoprotein (LDL), the majority had normal or optimal levels (184/292, 63%), with smaller percentages in the borderline high, high, and very high categories. Vitamin D levels varied, with a considerable portion of participants having either deficiency (104/292, 35.6%) or insufficiency (71/292, 24.3%). Vitamin B₁₂ levels and glucose levels were mostly high (201/292, 68.8% both). Insulin levels were also predominantly normal (171/292, 58.6%), with a notable percentage of participants having high levels (28/292, 9.6%). The HOMA-IR indicated that nearly half of the participants had high insulin resistance (143/292, 49%). Ultrasound reports revealed that the majority of participants had either normal or unremarkable findings (133/292, 45.5%), while 54.5% (159/292) were diagnosed with MASLD based on ultrasound reports.

Table 3 presents the association using the chi-square test between sociodemographic and clinical characteristics and MASLD stages among the study participants. There were no significant associations observed between MASLD stages and age groups, gender, physical activity, hypertension, dyslipidemia, hypothyroidism, bronchial asthma, cardiac disease, stroke, epilepsy, depression, kidney disease, treatment of diabetes mellitus, or antihypertensive medications. However, a significant association was found between high WC and MASLD, with 60.3% (85/141) of females and 54.5% (60/110) of males with WC greater than the normal range having MASLD (P=.02), as well as a significant association regardless of gender (P=.003). In addition, obesity (BMI >30 kg/m²) was significantly associated with MASLD (P<.001), as well as increased BMI, where higher BMI categories showed higher prevalence of MASLD (P<.001). These findings suggest that factors such as WC, obesity, and BMI may play crucial roles in the development of MASLD among patients with T2DM.

Table 4 provides insights into the association using the chi-square test between biochemical findings and MASLD stages among the study participants. High levels of ALT were significantly associated with MASLD, with 41.2% (14/34) of participants in stage 2 having high ALT levels. Similarly, high AST levels were significantly associated with MASLD, with 29.4% (5/17) of participants in stage 2, and 11.8% (2/17) in stage 4 having high AST levels. However, there was no significant association between GGT levels and MASLD. Regarding insulin resistance markers, high HOMA-IR levels were significantly associated with MASLD, with 31.5% (45/143) of participants in stage 2 having high HOMA-IR levels. However, no significant associations were found between MASLD and HbA_1c levels, total cholesterol, triglycerides, albumin, LDL levels, vitamin D levels, and vitamin B₁₂ levels. When comparing the mean (SD) values of glucose and insulin according to stages, no significant differences were observed with glucose levels according to MASLD stages (P=.69), whereas significantly higher insulin levels were observed among patients with stage 2 and 3 compared with patients without MASLD (P=.008).

Table 5 provides insights into the association between sociodemographic characteristics and MASLD regardless of severity among the study participants. Variables including age groups, marital status, and educational level did not show significant associations with MASLD. However, when grouped by sex, females showed a significantly higher prevalence of MASLD compared with males (94/154, 61% vs n=65/138, 47.1%). Similarly, there were no significant associations between MASLD and physical activity. However, a significantly higher proportion of patients with high WC have MASLD (146/253, 57.7%) compared with those with normal WC (13/39, 33.3%). In addition, BMI showed a significant association with MASLD, with higher proportions of MASLD observed among patients with BMI 30-34.9 kg/m² (64/99, 64.6%), 35‐39.9 kg/m² (25/33, 75.8%), and >40 kg/m² (24/30, 80%).

Figure 1 shows the relationship between various clinical characteristics and MASLD among the study participants. Results indicate no significant association between MASLD and hypertension, dyslipidemia, hypothyroidism, bronchial asthma, cardiac disease, stroke, epilepsy, depression, kidney disease, and smoking history. However, there was a significant association between MASLD and obesity (P<.001), with a higher proportion of patients with obesity (113/162, 69.8%) exhibiting MASLD compared with those without obesity (46/130, 35.4%). In addition, patients on lipid-lowering medications (P=.047) and those taking aspirin (P=.006) showed significant associations with MASLD, with higher proportions of MASLD among those not taking these medications. Furthermore, no significant association was found between MASLD and the duration of diabetes or the use of antihypertensive medications.

Categorical variables were represented as numerical variables, and collinearity diagnostics were performed by calculating the variance inflation factor and tolerance. Variance inflation factor for ALT was 1.36, AST was 1.36, HOMA-IR was 1.04, lipid-lowering drugs was 1.14, aspirin was 1.16, gender was 1.11, and WC was 1.08. This signifies that there was a moderate correlation, but it was not severe enough to warrant corrective measures.

Table 6 shows the series of sequential logistic regression models. Unadjusted logistic regression showed a significantly increased risk associated with male sex, high WC, presence of obesity, high ALT, and high HOMA-IR on MASLD, and with a significantly decreased risk associated with MASLD for patients who used insulin (refer to OR in Table 6). When adjusted for age, gender, and obesity, high ALT and high HOMA-IR remained to significantly increase the risk for MASLD (model 2). When adjusted for age, gender, obesity, and the use of lipid-lowering drugs and aspirin, high ALT and high HOMA-IR remained significant risk factors for MASLD (model 3).

In addition to the associations mentioned, the analysis reveals several other noteworthy findings regarding the relationship between biochemical findings and MASLD. When MASLD was compared with ALT, AST, GGT, HbA_1c, and albumin levels (regardless of stage), no significant associations were found (P>.05). However, a higher proportion of patients with MASLD had significantly elevated levels of total cholesterol (P=.01), triglycerides (P=.03), and LDL (P=.04). In addition, there was no significant association between MASLD and vitamin D (P=.92) or vitamin B₁₂ (P=.92) levels. Furthermore, HOMA-IR exhibited a significant association with MASLD, with many patients with high HOMA-IR having MASLD compared with those with normal or low HOMA-IR (P<.001). The analysis also showed that glucose level was not significantly associated with MASLD (correlation coefficient r=0.03, P=.63). However, insulin level exhibited a significant positive correlation with MASLD (r=0.24; P=.001), indicating that as insulin levels increased, the likelihood of having MASLD also increased.