Surfing the MASH Tsunami SurfingNASH.com

The sudden passing on April 23 of our co-founder and colleague Stephen Harrison sent shock waves throughout the global SLD community. This week, Manal Abdelmalek and Naim Alkhouri join Jörn Schattenberg, Louise Campbell and Roger Green to remember and pay tribute to an exceptional leader, role model and human being.

00:00:00 - Surf's Up: Season 5 Episode 14
Episode introduction, including brief quotes taken directly from panelists.

00:03:11 - Introduction
Roger introduces the podcast. The three key opinion leaders, Jörn Schattenberg, Manal Abdelmalek and Naim Alkhouri, discuss their fast-paced, high intensity travel schedules.

00:04:41 - Groundbreaker: a special memory of Stephen
In place of a traditional SurfingMASH groundbreaker, Roger asks each panelist to share a special memory of Stephen. In turn, panelists discuss how they got to know Stephen and/or the role he has played in their lives. Summaries cannot do the emotion of these recollections justice.

00:17:30 - One Harrison accomplishment 
Roger asks the group each to describe an accomplishment that Stephen has left the field. Each panelists provided at least 2 or 3, with no redundancy.

00:23:52 - "Harrisonisms" and wrap-up 
In closing, Roger asks panelists each to provide a favorite "Harrisonism." Answers varied, although every group member recalled Stephen's question, "Is the juice worth the squeeze."

00:33:33 - Question of the Week
Roger asks how listeners feel their lives or work were affected by Stephen Harrison, either directly or indirectly. 

00:33:56 - Business Report 
This week's news on our new newsletter, future conversations, and the Vault, plus more on how we plan to honor Stephen.

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. 

This conversation focuses on what happens after or around patient screening, addressing the challenges caused by using GLP-1s and dual incretin agonists to treat concomitant conditions before looking at the patient's liver, and then the opportunities that can come from on-site scanning and immediate feedback. 

Jeff starts this conversation by noting the popularity and widespread discussion around anti-obesity medications, which also have effects on MASH. He says this could "lead to a tricky couple of years" if results include decreased willingness to participate in clinical trials and/or decreased demand for fatty liver drugs from patients already on incretin agonists like semaglutide or tirzepatide. Generally, he expresses a concern that all this will lead to a decline in focus on the liver. 
Louise discusses activities in her two home countries, UK and Australia.  She starts by noting that interest in the healthcare system picks up when patients go to their primary care physicians seeking care for a given disease, in this case, liver disease. She goes on to note that "liver disease is a small portion of poor liver health," which leads to cardiovascular disease and extra-hepatic cancers. Thus, she says screening should identify patients with poor liver health in order to educate and intervene with these non-hepatic conditions. She describes data in her possession that says 33% of Australians who believe they are healthy have poor liver health, and that most of these are post-menopausal women. She says there is a mismatch between patient needs, perceived resource demand, and funds available to support these resources.


Mike asks Louise to comment on scanning as an educational activity. Before answering his question directly, she discusses the value of on-site patient questionnaires in improving the quality and perceived value of the overall visit.   Next, she discusses how she uses the sharing of scan results with the patient to generate a deeper patient understanding of the disease and activate conversation on how patients can help themselves better. Mike agrees based on his experience learning about his high CAP score, then lowering the level. Louise discusses steps treaters can take if the first intervention doesn't work. 

This conversation centers around the Global Fatty Liver Day 2024 theme and the rationale behind focusing on screening.

It starts with Jeff describing how much has changed in MASLD in the past year and why this calls for a new focus. Jeff identifies the breadth of the global challenge of treating MASLD and related conditions, which is far broader than "just having one medicine for one aspect of the disease in one country." To Jeff and GLI, the best immediate path forward is to bring more patients into the system through screening, which provides the rationale for GLI's theme for the day, "Act Now. Get Screened."
Roger states that this effort will drop a large number of patients "in the top of the funnel," and notes that earlier podcasts demonstrate limited adoption of clinical care pathways or other ways to manage an increased patient volume. He asks Jeff where the care pathway issue fits in the "Act Now. Get Screened" vision. Jeff states this is an issue for the entire field, not just patients, and that the field needs to collaborate on a turnkey way for PCPs to screen easily. 
Roger describes the concern raised Naim Alkhouri (Season 4, Episode 50.3) that the current clinical care pathway approach might create chaos in the system. Also, Roger asks whether US reimbursement policy is far enough along for the various actors to participate. Roger asks about the most effective action that patients and advocates can take. Jeff replies, "Get Screened."
Mike Betel suggests that while this may be an issue for the entire field, he believes the onus for keeping this issue in front of providers must come from patients assertively asking questions and seeking support. Jeff agrees, but describes the relationship between patient and provider in this case as "symbiotic."