As blogged previously, metabolic dysfunction-associated steatotic liver disease (MASLD) and steatohepatitis (MASH) (formerly called NASH or fatty liver disease) is extremely common, affecting 1 in 4 adults globally. Two thirds of people with type 2 diabetes have MASLD, and 37% have MASH. As such, Diabetes Canada has just published a brand new Clinical Practice Guideline chapter on MASLD and diabetes.

Why is it important to screen for and diagnose MASH/MASLD?

  • Fibrosis (scarring) of the liver can develop in MASH, which can lead to liver cirrhosis/liver failure, and liver cancer (hepatocellular carcinoma) – in fact, MASLD is a leading cause of both. People with cirrhosis should be screened every 6 months for liver cancer.
  • MASLD is closely tied to cardiovascular risk factors and disease, and CVD is the leading cause of death in people with MASH. If we diagnose MASLD/MASH, this can be a trigger to screen/adress CVD risk (though for people with diabetes, this should be done regardless).
  • MASLD is associated with a higher risk of other cancers of the gastrointestinal tract, pancreas, breast, lung, and gynecologic.
  • Treatments are available to improve MASH.

For all of the reasons above, the new Diabetes Canada guidelines recommend consideration of screening anyone with prediabetes or type 2 diabetes for MASLD-related liver fibrosis, especially if they have features of metabolic syndrome (and note that most people with T2D have metabolic syndrome).

How should people be screened?

The Diabetes Canada Guidelines recommend screening first with the FIB-4 score (a calculation based on a few blood tests – ALT, AST and platelets).

  • if FIB-4 score is <1.3, there is low probability of advanced liver fibrosis – repeat FIB-4 screen is recommended every 1-2 years.
  • if FIB-4 score is 1.3-2.67, they recommend additional testing such as transient elastrography or alternative lab test (eg ELF score) to further stratify risk, and consideration of referral to a liver specialist if these tests are not available.
  • If FIB-4 score is >2.67, referral to a liver specialist is recommended.

Note that there are other causes of fat and inflammation in the liver besides MASH/MASLD that need to be ruled out as well – check out this excellent Primary Care tool to guide evaluation.

How can MASH/MASLD be treated?

Weight management is central to treatment of MASH and MASLD, as they go hand in hand with obesity. Obesity is also central to the genesis of type 2 diabetes, with over 90% of people with type 2 diabetes having obesity (by BMI criteria). However, as BMI does not capture body composition (fat vs muscle), nor where fat is deposited, a person with ‘healthy’ range BMI can still have excess central fat, which is the driver of MASH/MASLD (and type 2 diabetes). Perhaps not surprisingly, 57% of people with type 2 diabetes and ‘healthy range’ BMI have MASLD, and may benefit from some (but not excessive) weight loss.

These Guidelines recommend 5-10% weight loss for people with T2D and MASLD-related liver fibrosis to decrease liver fat, and >10% weight loss to increase the chances of reversing fibrosis (scarring). [I would personally add to this that it is important to evaluate the person for excess adiposity (looking beyond only BMI, to waist, waist-to-height, and/or waist-to-hip measures as needed), and ensure that the weight loss being recommended is appropriate for the person’s overall holistic health – which in the vast majority of people with MASH/MASLD, it will be.]

Healthy lifestyle changes are emphasized in the Diabetes Canada guidelines as the main treatment modality for weight loss. Here I will point out that, as blogged previously, our 2025 Obesity Canada Pharmacotherapy Guidelines (disclosure: I am the lead author) recommend GLP1-based medications semaglutide (Wegovy), tirzepatide (Zepbound/Mounjaro), and liraglutide (Saxenda) for people with MASH, with the strongest evidence for semaglutide. (note: the key studies on semaglutide and tirzepatide were published after the Diabetes Canada MASLD guidelines were being finalized so were not included, though they do touch on semaglutide). The Diabetes Canada guidelines discuss diabetes medication pioglitazone’s benefit to liver health, but pioglitazone is rarely used these days for a number of reasons, one being that it causes weight gain. Bariatric surgery can also benefit MASLD/MASH and can markedly improve or induce remission of type 2 diabetes.

BOTTOM LINE: The new Diabetes Canada guidelines recommend consideration of screening anyone with prediabetes or type 2 diabetes for MASLD-related liver fibrosis, starting with a few simple blood tests to calculate a FIB-4 score.

Disclaimer: I am/have been an investigator in clinical trials of liraglutide, semaglutide, and tirzepatide. I receive honoraria as a continuing medical education speaker and consultant from the makers of semaglutide and liraglutide (Novo Nordisk), and tirzepatide (Eli Lilly).

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