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Send us Fan Mail The original roundtable has three segments. Surfing the MASH Tsunami is preempting the third segment, which will be posted next week, to share our co-hosts' reactions to the positivity and energy they felt from a group of empowered SLD advocates.  Immediately after the roundtable, Louise suggested to Roger that they record a separate conversation sharing their reactions to what they had just witnessed. They turned the recording equipment on and resumed their conversation. Roger starts by noting that this is the first SurfingMASH episode comprised entirely of patient advocates at a moment when advocates felt empowered and optimistic. (Also, the Fellows were the first advocates to appear on SurfingMASH who are not part of the Advocate KOL community.) For Louise, her overpowering reaction is to the passion, because passion breeds energy and empowerment. She notes that the SLD advocates came from an array of liver-related backgrounds and from HIV, the original sources of truly empowered patients some 30 years ago.  Roger shares two thoughts. As he listened to the roundtable, he recalled earlier episodes, some four to five years ago, when it seemed that the physician KOL community was not in sync with the patient advocates' goals and needs. Continuing along this train of thought, he discusses the shift in identity from “MASH patient” to “person living with MASH.” To Roger, the term "MASH patient" suggests a person defined by the disease, whereas the term "patient living with MASH" empowers individual patients to manage the disease and its place in their lives in whatever way they choose. The advocates, he says, choose to learn and speak out confidently.  During the roundtable, Elena mentioned Úna Keightly, a Harrison Fellow from Ireland, who spoke from the floor at Paris MASH to request that patients learn about the outcomes of the trials in which they participate, whether the outcome is deemed a success or a failure. For the "MASH patient," a failed trial feels like a personal failure, but for a "person living the MASH," even the failed trial becomes an opportunity to learn about the disease and contribute to a long-term solution.  Louise mentions a comment from Harrison Fellow Pam Miller about her cardiologist giving her a potentially hepatotoxic medication without considering Pam's liver status. This reminded both Louise and Roger of a comment former Global Liver Institute President Donna Cryer made years ago to the effect of "it doesn't matter what kills me. If I'm dead, I'm dead."  From here, the conversation shifts to other changes in disease description Louise and Roger foresee: Describing the disease itself in more accessible terms, such as "liver stiffness" vs. "fibrosis level."Increasing the groups of attendees at events to include not only patients, but also the APPs who will provide much of the actual patient-level care.Educating those who still mischaracterize MASLD as “a bit of fat” that requires no action. Focusing more attention on post-menopausal women, who Louise notes are most likely to exhibit advanced SLD and cirrhosis. Being more sensitive to issues that drive changes in patients' quality of life, which might be the impact of hepatic encephalopathy, but might also relate to lean mass wasting with incretin agonists. Both foresee a growing “army” of advocates that can drive earlier detection, smarter trial design, and better everyday care. They cite some specific examples from the Fellows in the roundtable and others from their own life experiences. Ultimately, Louise and Roger share their belief that this program is an excellent tribute to Stephen Harrison, who strongly believed in the importance of patient advocates and the messages they convey. 

Send us Fan Mail In June, the Fatty Liver Foundation officially launched the Stephen A. Harrison Patient Advocacy program and announced its first class of 20 Fellows. In today's conversation, the program's organizers, Fatty Liver Foundation President Wayne Eskridge and Program Co-ordinator Elena Samsonova, share the program's goals and objectives with Louise Campbell and Roger Green.  The bulk of this conversation focuses on the program's goals and scope for its first year. First, though, Harrison Fellow Julie Peyout from Canada describes what it means to her to be part of the program. (Julie's connection was interrupted while her colleagues were answering this question earlier in the roundtable.) Wayne points out that, while the FLF originally focused on NAFLD and NASH, the new nomenclature has led them to broaden their focus to all forms of SLD. (He plans to rebrand as the Steatotic Liver Foundation.) Elena describes the program's four "pillars":  Mentorship - Having an experienced advocate guide each Fellow as they pursue the next steps in their advocacy.Education - Learning more about SLD.Networking - Connecting with other advocates and industry decision-makers at conferences.Fellowship - Supporting each other as they grow new skills and have new experiences. Wayne elaborates on some of the "robust flow of information" the Fellows will receive. He focuses on three areas: what he calls "the nuts and bolts of the regulatory process", clinical trials from the researcher and trialist perspectives and more general information about how different functions inside a pharmaceutical company work.  As the conversation winds down, Roger cites this podcast's mission to "make a big fat dent in MASH" and asks the Fellows about the dent they anticipate making. Elena responds with a story from the previous week's meetings, during which another Fellow stated that when she has participated in trials, she has never received information on what the trial results and learnings actually showed. Elena describes watching clinicians and trialists respond by discussing ways participants could receive such information in the future. 

Send us Fan Mail In June, the Fatty Liver Foundation officially launched the Stephen A. Harrison Patient Advocacy program and announced its first class of 20 Fellows. In today's conversation, Louise Campbell and Roger Green interview the founders to learn what motivated them to launch this program, and we meet five of the initial Fellows.  Program Co-ordinator Elena Samsonova opens the conversation by celebrating last week's onboarding of 20 inaugural Fellows and the chemistry between them. She goes on to introduce five of them: Steven Rodrigues (ALD, UK citizen) shares his recent experience giving a 15-minute national interview on BBC Radio 5 discussing ALD clinical insights. Silvana Lesidrenska (Hepatitis B, Bulgaria) shares her desire to learn more about SLD as part of her advocacy leading a liver patients association in Bulgaria. Julie Peyout (MASH, Canada) is a great-grandmother who was recently found free after therapy for Non-Hodgkin's Lymphoma. Pam Miller (MASH cirrhosis, US) learned 24 years ago that she had MASH cirrhosis when her surgeon aborted a bariatric procedure. Since then, she has lived with cirrhosis and experienced hepatic encephalopathy (HE). She has participated in clinical trials, lobbied legislators, and collaborated with professional societies. Melanie Smith  (MASH cirrhosis, US) has lived with stage-4 MASH cirrhosis since age 36 (sixteen years ago) and experiences hepatic encephalopathy (HE). She has led support groups for over a decade. Next, Fatty Liver Foundation President Wayne Eskridge recounts the program's foundational story. He describes Stephen as a man with a genuine commitment to patients and his passing as a "tremendous loss." This led Wayne to discuss this idea with Rebecca Taub of Madrigal, "another one of my heroes." (Madrigal supports this program.)  Elena describes how she joined the FLF to lead this program. Roger asks the Fellows where and how they intend to make a difference. Their goals vary, from working in a Biopharma company advocating for patients to "going to the top," perhaps even lobbying the HHS Secretary, to expanding their own education and knowledge about the various forms of SLD.  

Send us Fan Mail 00:00:00 - Surf's Up: Season 6 Episode 14 Louise Campbell and Roger Green interview key players in the inaugural Dr. Stephen A. Harrison Patient Advocacy Fellowship program, including Wayne Eskridge of the Fatty Liver Foundation (FLF), which initiated the program, Program Coordinator Elena Samsonova, and five Harrison Fellows. 00:05:08 - Part I: How the Harrison Fellowship Came To Be Elena opens by celebrating last week's onboarding of 20 inaugural Fellows and the chemistry between them. She goes on to introduce five of them: Steven Rodrigues (ALD, UK citizen) shares his recent experience giving a 15-minute national interview on BBC Radio 5 discussing ALD clinical insights. Silvana Lesidrenska (Hepatitis B, Bulgaria) shares her desire to learn more about SLD as part of her advocacy leading a liver patients association in Bulgaria. Julie Peyout (MASH, Canada) is a great-grandmother who was recently found free after therapy for Non-Hodgkin's Lymphoma. Pam Miller (MASH cirrhosis, US) learned 24 years ago that she had MASH cirrhosis when her surgeon aborted a bariatric procedure. Since then, she has lived with cirrhosis and experienced hepatic encephalopathy (HE). She has participated in clinical trials, lobbied legislators, and collaborated with professional societies. Melanie Smith  (MASH cirrhosis, US) has lived with stage-4 MASH cirrhosis since age 36 (sixteen years ago) and experiences hepatic encephalopathy (HE). She has led support groups for over a decade. Next, Wayne recounts the program's foundational story. He describes Stephen as a man with a genuine commitment to patients and his passing as a "tremendous loss." This led Wayne to discuss this idea with Rebecca Taub of Madrigal, "another one of my heroes." (Madrigal supports this program.)  Elena describes how she joined the FLF to lead this program. Roger asks the Fellows where and how they intend to make a difference. Their goals vary, from working in a Biopharma company advocating for patients to "going to the top," perhaps even lobbying the HHS Secretary, to expanding their own education and knowledge about the various forms of SLD.   00:34:46 - Part II: Goals of the Harrison Fellowship Program This conversation focuses on the program's goals and scope for its first year. Wayne points out that, while the FLF originally focused on NAFLD and NASH, the new nomenclature has led them to broaden their focus to all forms of SLD. (He plans to rebrand as the Steatotic Liver Foundation.) Elena, it describes the program's four "pillars":  Mentorship - Having an experienced advocate guide each Fellow as they pursue the next steps as Advocates.Education - Learning more about SLD.Networking - Connecting with other advocates and industry decision-makers at conferences.Fellowship - Supporting each other as they grow new skills and have new experiences. 00:55:09 - Experts: Louise and Roger Discuss This Roundtable Roger and Louise share their enthusiasm for the unprecedented sense of empowerment they felt among patient advocates while leading this discussion. Both comment on the identity shift from “MASH patient” to “person living with MASH.” Louise mentions that doctors or APPs still minimize disease by characterizing MASLD as “a bit of fat” that requires no action. Roger suggests that focusing on the total patient will include not only the efficacy of medicines but also potential side effects or safety concerns. Louise comments that advanced disease and cirrhosis occur most often in post-menopausal women with cirrhosis, and discusses implications. Both foresee a growing “army” of advocates that can drive earlier detection, smarter trial design, and better everyday care. 01:11:11 - Business Report and Wrap-up

Send us Fan Mail This discussion on ways to improve MASH patient management comes from the early July roundtable on "Major Issues of the First Six Months of 2025." As a reminder, that roundtable included the three co-hosts (Louise, Jörn Schattenberg and Roger Green)  Roger drives this conversation, focusing on two very different, yet very important issues: the first is the increasing dynamism of the in-office scanning market, with leader Echosens developing new products and services, while companies like e-Scopics, Sonic Incytes, and Mindray (Hepatus) are introducing new devices with competing profiles. Roger discusses the idea that some scanners keep all data resident in the machine, while others send it immediately to the cloud. Louise suggests that while we should welcome any reliable scanning device to the market, Echosens has a significant advantage in terms of data richness and depth when compared to all competitors. (NOTE: This benefit became clearer when Echosens submitted a Letter of Intent to the FDA to qualify liver stiffness measurement (LSM) using VCTE, as found in FibroScan, as a reasonably likely surrogate endpoint in clinical trials for MASH. Separately, he lists some concerns about how the Trump Administration's focus on cutting services to the poor, coupled with Robert F. Kennedy Jr.'s distrust of pharmaceuticals and mainstream health research, might limit the number of Americans with access to healthcare and the kinds of care they can access.  At the end of this conversation, Roger asks Jörn and Louise what they consider major issues for the next six months.

Send us Fan Mail Last month, The Lancet posted online an article from Stine Johansen, Fredrik Åberg, Emmanuel Tsochatzis and Aleksander Krag, titled "Screening for Advanced Liver Disease." The article aims to update the Wilson and Jungner criteria, initially developed in 1960, to address modern needs and issues. In this conversation, Professor Krag and Dr. Johansen join Roger Green to discuss their article.  There are many nuances and high points to cover in this thoughtful, fairly lengthy conversation, but one key point is that screening a mass population for HCC or cirrhosis has an entirely different set of issues and criteria compared to the screening usually discussed on this podcast, which involves identifying a population at increased risk for MASLD or MASH and screening them. Also, healthcare is far more expensive than it was in 1960 with a plethora of high-cost ways to diagnose, treat and manage patients. As a result, the authors started with the 10 Wilson and Jungner criteria and added eight more. During this conversation, Stine emphasizes the need for a comprehensive clinical trial on this issue, and all panelists agree that LiverAIM is likely to serve as the study.

Send us Fan Mail This discussion on ways to improve MASH patient management comes from the early July roundtable on "Major Issues of the First Six Months of 2025." As a reminder, that roundtable included the three co-hosts (Louise, Jörn Schattenberg and Roger Green)  Louise drives this conversation based on two related issues she sees emerging: (i) increasing opportunities for motivated patients to manage their own health and (ii) managing the total patient in an environment where people may be taking incretin agonists as if they are consumer drugs. With increased access to scanning, providers can monitor patients (and patients can self-monitor) more closely. However, some of the issues a provider might find are tricky: patients who undertake what Louise describes as "the sneaky areas patients think are normal, but are probably contributing to disease" due to miseducation or no education on healthy eating and lifestyle, or patients purchasing and using incretin agonists through consumer channels, but possibly at subtherapeutic doses. Vigilance and probing are key here, but health systems will need to train more people on the types of probing that uncover underlying issues and behaviors that patients mistakenly believe to be healthy.  The discussion also extends to the role of NITs in diagnosis and patient management, and how providers need to shift the paradigm away from describing a patient by fibrosis stage and instead focus on the amount of fat in the liver and its overall suppleness.

Send us Fan Mail 00:00:00 - Surf's Up: Season 6 Episode 13  Louise Campbell, Jörn Schattenberg and Roger Green continue their discussion of some major issues from earlier this year, while co-authors Aleksander Krag and Stine Johanset join Roger to discuss their recent publication in The Lancet, titled "Screening for Advanced Liver Disease."  00:04:45 - Major Issues of the First Six Months: Integrated Patient Management Louise drives this conversation based on two related issues she sees emerging: (i) increasing opportunities for motivated patients to manage their own health and (ii) managing the total patient in an environment where people may be taking incretin agonists as if they are consumer drugs. With increased access to scanning, providers can monitor patients (and patients can self-monitor) more closely. However, some of the issues a provider might find are tricky: patients who undertake what Louise describes as "the sneaky areas patients think are normal, but are probably contributing to disease" due to miseducation or no education on healthy eating and lifestyle, or patients purchasing and using incretin agonists through consumer channels, but possibly at subtherapeutic doses. Vigilance and probing are key here, but health systems will need to train more people on the types of probing that uncover underlying issues and behaviors that patients mistakenly believe to be healthy.  00:21:02 - Newsmakers: Aleksander Krag and Stine Johansen discuss Screening for Advanced Liver Disease Last month, The Lancet posted online an article from Stine Johansen, Fredrik Åberg, Emmanuel Tsochatzis and Aleksander Krag, titled "Screening for Advanced Liver Disease." The article aims to update the Wilson and Jungner criteria, originally developed in 1960, to address modern needs and issues. In this conversation, Professor Krag and Dr. Johansen join Roger Green to discuss their article.  There are many nuances and high points to cover in this thoughtful, fairly lengthy conversation, but the key point is that screening a mass population for HCC or cirrhosis has an entirely different set of issues and criteria compared to the screening usually discussed on this podcast, which involves identifying a population at increased risk for MASLD or MASH and screening them.  00:54:42 - Major Issues of the First Six Months: Changes in US Health Policy and Potential for Dynamism in the In-Office Scanning Market  Roger drives this conversation, focusing on two very different, yet very important issues: the first is the increasing dynamism of the in-office scanning market, with leader Echosens developing new products and services, while companies like e-Scopics, Sonic Incytes, and Mindray (Hepatus) are introducing new devices with competing profiles. Roger discusses the idea that some scanners keep all data resident in the machine, while others send it immediately to the cloud. Louise suggests that we should welcome any reliable scanning device to the market.  Separately, he lists some concerns about how the Trump Administration's focus on cutting services to the poor, coupled with Robert F. Kennedy Jr.'s distrust of pharmaceuticals and mainstream health research, might limit the number of Americans with access to healthcare and the kinds of care they can access.  At the end of this conversation, Roger asks Jörn and Louise what they consider major issues for the next six months. 01:11:40 - Business Report and Wrap-Up

Send us Fan Mail Key Opinion Leaders Manal Abdelmalek, Naim Alkhouri, Scott Isaacs and Zobair Younossi join Roger Green to discuss the FDA's approval of semaglutide for patients with non-cirrhotic MASH. This conversation centers on the roles that new technologies and an expanded APP population will play in MASLD and MASH management in the US, and concludes by exploring how care might look different 12 months from now, and then in subsequent years.  As panelists identify some of the changes they foresee if we are to manage the tsunami of undiagnosed MASLD patients, many comments touch on themes discussed earlier in this episode. A couple are unique. Zobair and Scott discuss the increased role that artificial intelligence and big data analytics will play in identifying high-risk patients and improving clinical pathways. Additionally, Zobair notes that we must remember that the vast majority of MASLD patients will never develop MASH. Manal foresees a more sophisticated approach to selecting pharmacotherapies as prescribers have a broader set of options, each with its own benefits and drawbacks. Scott anticipates a "paradigm shift" in which endocrinologists view MASH similarly to how they view retinopathy, neuropathy and retinopathy. Naim suggests that one year will not look tremendously different from today, but that five years from now will be an entirely different picture, which he describes in some detail. 

Send us Fan Mail Key Opinion Leaders Manal Abdelmalek, Naim Alkhouri, Scott Isaacs and Zobair Younossi join Roger Green to discuss the FDA's approval of semaglutide for patients with non-cirrhotic MASH. This conversation focuses on how the US healthcare system must adapt to handle the growing number of MASH and MASLD patients who might seek treatment, given likely increases in publicity and education. The conversation starts with a focus on the implications of semaglutide approval for hepatologists. Naim states that many hepatologists are currently uncomfortable managing patients on GLP-1 agonists. This will need to change. Manal points out that providers must check for cirrhosis when testing for MASH and understand how to respond accordingly. An increase in the number of providers having access to in-office scanning devices will facilitate this process. Zobair shifts to a larger point:  even if all related specialists integrate MASH into their practices, the actual patient care demand will require alternative pathways in which the responsibility for patient care will rest with specialist APPs. The number of APPs necessary to handle this load and trained to do so does not currently exist in the US. Increased APP training must, and will, become an area for increased investment and focus. After Naim Alkhouri describes some of the differences between resmetirom and semaglutide in terms of practical treatment decisions, the discussion focuses on why MASLD and MASH will create unique challenges for hepatology practices. Manal views the issue as a matter of time; practices cannot absorb large numbers of new, non-urgent patients. Naim suggests that the real issue is the business question: specialists today do not profit simply from treating patients. Zobair agrees with Naim and notes that the challenge is not unique to hepatology. He expresses the hope that AI and efficient database management will make it easier to target, screen, diagnose and treat patients...given sufficient providers (mostly APPs) to treat them. 

Send us Fan Mail Key Opinion Leaders Manal Abdelmalek, Naim Alkhouri, Scott Isaacs and Zobair Younossi join Roger Green to discuss  FDA's approval of semaglutide for patients with non-cirrhotic MASH. This conversation focuses on benefits for patients and ways that having two drugs with different modes of action will change pharmacotherapy choices. This conversation starts with the group describing the sense of "enthusiasm" and "fulfillment" hepatology drug developers feel to see two drugs approved in the US and many other major changes to come (more drug approvals, FDA acceptance of a path to approval that is not based on liver biopsy). One interesting takeaway is that while the approval of semaglutide will likely change the number of patients treated with MASH pharmacotherapy, the greater impact of this approval will be on public awareness of MASH and the accompanying demand for treatment. In terms of actual drug use, the first major change will come among patients living with obesity but not Type 2 diabetes. Most of these patients previously saw their semaglutide prescriptions rejected for payment by health insurers. However, many of these patients will be living with MASH, and they are likely to see their prescriptions approved.  Instead, the largest impact may involve increased education and awareness. Scott pointed out that endocrinologists, who frequently prescribe incretin agonists, will have reason to learn how to diagnose and manage MASH in patients they already treat. Zobair noted that an array of companies, starting with pharmaceutical manufacturers and scanning companies, will dramatically increase investments in prescriber and patient education.  Another important benefit may come in terms of coverage. Scott points out that most patients living with obesity but not diabetes are unlikely to have their semaglutide prescriptions covered by commercial insurers. Those living with non-cirrhotic MASH are likely to have semaglutide covered. A separate but related point: Naim reports that ~30% of the MASH patients he sees are taking an incretin agonist at the time of initial visit.

Send us Fan Mail 00:00:00 - Surf's Up, Season 6, Episode 12 This week's episode is a special three-part roundtable on the implications of the FDA's recent approval of semaglutide. Naim Alkhouri, Manal Abdelmalek, Scott Isaacs and Zobair Younossi join Roger Green in a discussion that focuses less on specifics of pharmacotherapy and more on how having two drugs available will change MASH management in the US. 00:08:45 - Part I: How Will The Semaglutide Approval Affect Patient Treatment and Pharmacotherapy? The group starts by describing the sense of "enthusiasm" and "fulfillment" hepatology drug developers feel to see two drugs approved in the US and many other major changes to come (more drug approvals, FDA acceptance of a path to approval that is not based on liver biopsy). One interesting takeaway is that while the approval of semaglutide will likely change the number of patients treated with MASH pharmacotherapy, the greater impact of this approval will be on public awareness of MASH and the accompanying demand for treatment. In terms of actual drug use, the first major change will come among patients living with obesity but not Type 2 diabetes. Most of these patients previously saw their semaglutide prescriptions rejected for payment by health insurers. However, many of these patients will be living with MASH, and they are likely to see their prescriptions approved. Instead, the largest impact may involve increased education and awareness. Scott  pointed out that endocrinologists, who frequently prescribe incretin agonists, will have reason to learn how to diagnose and manage MASH in patients they already treat. Zobair noted that an array of companies, starting with pharmaceutical manufacturers and scanning companies, will dramatically increase investments in prescriber and patient education. 00:25:30 - Part II: How the Structure of Medical Practice Is Likely To Change Naim states that many hepatologists are currently uncomfortable managing patients on GLP-1 agonists. This will need to change. Manal points out that providers must check for cirrhosis while testing for MASH and understand how to respond. An increase in the number of providers having access to in-office scanning devices will facilitate this process. Zobair states that even if all the related specialists integrate MASH into their practices, the actual patient care demand will require alternate  pathways in which the responsibility for patient care will rest with specialist APPs. After Naim Alkhouri describes some of the differences between resmetirom and semaglutide in terms of practical treatment decisions, the discussion focuses on why MASLD and MASH will create unique challenges for hepatology practices. Manal views the issue as a matter of time; practices cannot absorb large numbers of new, non-urgent patients. Naim suggests that the real issue is the business question: specialists today do not profit simply from treating patients. Zobair agrees with Naim and notes that the challenge is not unique to hepatology. He expresses the hope that AI and efficient database management will make it easier to target patients, screen, diagnose and treat them. 00:44:17 - Part III: What Happens Next? In this final section, panelists identify some of the changes they foresee if we are to manage the tsunami of undiagnosed MASLD patients. Many of the comments touch on themes discussed earlier in this episode, but a couple are unique. Zobair states we must remember that the vast majority of MASLD patients will never develop MASH. Manal foresees a more sophisticated approach to selecting pharmacotherapies as prescribers have a broader set of options, each with its own benefits and drawbacks. Scotts anticipates a "paradigm shift" in which endocrinologists view MASH similarly to how they view retinopathy, neuropathy and retinopathy. 01:02:03

Send us Fan Mail This week's expert interview is with Dr. Emily Andaya, Medical Director of the Cardiovascular Program at Major Health Partners of Shelbyville, IN. She joins Louise Campbell and Roger Green to discuss the American Heart Assocation's CKM initiative, why she believe it should be titled "CKLM" for liver, and how including liver in the CKM scoring system would make it stronger and provide a more robust tool to help improve patients' health.  Emily begins by discussing her attendance at the American Society for Preventive Cardiology meeting in Boston the previous weekend, where Dr. Christos Montzoros presented a talk proposing that the liver's role in cardiovascular diseases is "equally critical" compared to the kidney and other multi-metabolic co-morbidities. Dr. Montzoros closed his talk by stating that the CKM syndrome description should be changed to CKLM to reflect the importance of the liver, and that the CKLM patient scoring and criteria should reflect this as well. Next, Emily describes the 0-to-4 scoring system that the CKM initiative has chosen to use and the recommendations that accompany the scoring system itself. The system does not neatly overlay the 4-point fibrosis scoring system or the NAS score, but Emily describes how these might be incorporated into the CKM score.  The conversation shifts to focus on patient management. Since the original CKM paper was published in 2023, resmetirom had not yet been approved and the paper itself focused more on screening than on treatment. To Emily, adding the "L" to CKM would entail adding resmetirom to treatment protocols as appropriate, and also considering drug combinations that addressed liver disease. Louise takes this issue from the other side, suggesting that every time a provider prescribes a drug to a CKM patient, the potential for negative liver effects should be part of the selection process. Emily and Louise agree that providers and patients should take a holistic approach to therapy for these patients. One benefit: even if a patient has multiple organs affected by multi-metabolic challenges, the provider can educate the patient that there is a single target disease to treat instead of multiple different diseases. As Roger notes, treating 4-5 discrete diseases simultaneously sounds overwhelming, while treating one overarching disease sounds far more manageable. The conversation ends with a focus on whether we are correctly identifying high-risk cardiovascular patients in the current environment, and how this more holistic focus might improve patient screening and identification.

Send us Fan Mail Multi-Metabolic Week focuses on the idea that MASLD and MASH are elements in a systemic set of Multi-Metabolic issues. This conversation is the second of two looking at the concept of the "Multi-Metabolic Clinic," a clinic that treats the entire spectrum of multi-metabolic diseases. This conversation starts by focusing on how the two clinics train other physicians and practices on multi-metabolic issues. The EDOM clinic in Spain is certified to provide nutritional training to other practices across the country, while the newer, smaller Trajectory Health Partners practice provides support on use of FibroScan and, more recently, Velacur from Sonic Incytes. Louise notes how important training is for optimal use of scanning devices, which includes both technical proficiency and knowledge of how to educate and motivate patients using the results of the scans.  From there, the conversations shifts to focus on differences between treating patients in a conventional practice vs. a multi-metabolic one. The key differences involve length of patient visit and use of allied providers to educate patients more fully. Next, Louise asks whether the clinics have data on reducing the number of patients needing to go to a hospital. EDOM has data while the younger Trajectory has a clear sense this happens but no large-scale practice data to support this sense.  Louise's last question is to ask how each physician would "sell" colleagues in their specialty on why to set up a multi-metabolic practice. The answers reflect the different specialties in which the physicians were trained originally (endocrinology in Spain, gastroenterology in the U.S.) but have significant common elements. 

Send us Fan Mail Multi-Metabolic Week focuses on the idea that MASLD and MASH are elements in a systemic set of Multi-Metabolic issues. This conversation is the first of two looking at the concept of the "Multi-Metabolic Clinic," a clinic that treats the entire spectrum of multi-metabolic diseases.  The core of this episode starts during the weekly groundbreaker exercise, during which our guests began to describe the path that brought them from single-disease specialization to the broader multi-metabolic practice.. Immediately after the groundbreakers, participants describe their clinics today, including patient population and principles underlying their approach to treatment.  For Karen, the path started in a conventional gastrointestinal practice. A decade ago, she gained certification in obesity medicine. While treating patients for obesity, she came to appreciate the interplay of obesity, diabetes and the other manifestations of multi-metabolic disease. Eventually, she divided her practice and time so that she spent half her time in the GI practice and the other half creating Trajectory Health Partners, a practice focused on overall metabolic health. For Dr. López, the initial goal was to "re-educate the hypothalamic problem," which he saw as the root cause of obesity and from which all other metabolic issues came. He describes this as "the auto-destruction button" of patients' lives, leading to two causes of death: (1) insulin resistance and related cardiovascular problems, and (2) short-telomere cancers.  The rest of this conversation focuses on the tests that the two clinics use to confirm MASLD or MASH and their approaches to treating multi-metabolic patients.