Management of NAFLD in Primary Care Settings

Vincent W.S. Wong; Shira Zelber-Sagi; Kenneth Cusi; Patrizia Carrieri; Eugene Wright; Javier Crespo; Jeffrey V. Lazarus


Liver International. 2022;42(11):2377-2389. 

In This Article

Abstract and Introduction


Non-alcoholic fatty liver disease (NAFLD) affects at least 25% of the general population and is an increasingly important cause of cirrhosis and hepatocellular carcinoma. Although it is the research focus of the hepatology field, it is clear that primary care physicians are seeing the majority of NAFLD patients and are in a pivotal position to provide quality care. In this article, we review the role of primary care in the management of NAFLD. NAFLD is common in patients with diabetes, obesity and other metabolic risk factors. Abdominal ultrasonography is the most commonly used method to diagnose fatty liver. Simple fibrosis scores have high negative predictive values in excluding advanced liver fibrosis and future liver-related events and can be used in primary care as initial evaluation. An abnormal result should be followed by subsequent workup or specialist referral. Primary care is the ideal setting to institute multidisciplinary care, especially the involvement of dietitians and physical activity trainers in lifestyle intervention, as well as initiating the discussion of bariatric surgery in patients with severe obesity. Although specific drug treatment for steatohepatitis would require a more precise diagnosis, metabolic drugs that improve both steatohepatitis and cardiovascular outcomes (e.g. glucagon-like peptide-1 receptor agonists) may be considered in patients with NAFLD.


Non-alcoholic fatty liver disease (NAFLD) is defined as fat accumulation in the liver.[1] The histological range of NAFLD includes non-alcoholic fatty liver (NAFL or simple steatosis), and non-alcoholic steatohepatitis (NASH), defined as hepatic steatosis and inflammation with hepatocyte injury, potentially progressing to cirrhosis and hepatocellular carcinoma.

Since 2010, a "multiple-hit" model of causation suggests that different risk factors or effect modifiers act simultaneously on both intrahepatic and extrahepatic pathways to generate steatosis, inflammation and fibrosis.[2]

NAFLD affects at least 25% of the global adult population with huge associated costs.[3] Pharmaceutical interventions will be cost-effective in the NAFLD fibrosis population only if major clinical outcomes come at a modest annual price.

Globally, the NAFLD pandemic mainly impacts socially marginalised communities as they are greatly exposed to unhealthy ultra-processed food, sedentary behaviour, and social stress and stigma, which reduce their opportunity for NAFLD prevention, early diagnosis and care.[4] These effects are amplified by the lack of targeted screening/care policies against the marketing of ultra-processed food and efforts to reduce social inequities, which are ultimately the true main structural drivers of obesity/NAFLD pandemics.[5]

Primary care physicians may be an important entry point for prevention, screening and care of NAFLD, because they regularly receive adult and paediatric patients at risk of NAFLD (Figure 1). Moreover, early detection and management of comorbidities have the potential to reduce the burden of cardiovascular and liver-related mortality.[6–8] Finally, a trustful patient–primary care physician relationship can improve patient awareness about their disease stage, which was associated with adherence to lifestyle interventions.[9]

Figure 1.

Risk factors and the natural history of NAFLD. Primary care is in a pivotal position to identify patients with fatty liver disease and significant liver fibrosis, institute behavioural interventions, and provide multidisciplinary care for the liver and the concomitant metabolic and cardiovascular conditions. NAFL, non-alcoholic fatty liver; NASH, non-alcoholic steatohepatitis.

Nevertheless, involving primary care in NAFLD management faces several challenges, which include: how to go about transforming primary care physicians into prevention stakeholders and incentivising them for their novel role; figuring out which diagnostic tools and training to support lifestyle changes; and how to build clinical care pathways, especially for the most severely affected patients.[10]

There is currently a lack of focus on primary care in NAFLD management guidelines and recommendations, though other specialties such as endocrinology and cardiology are starting to recognise the significance of NAFLD.[11] We conducted this review to shed light on previous challenges around this and to provide recommendations for building the most effective primary care-based models and clinical pathways for patients with NAFLD (Box 1).