We need you to become a liver health champion. You need to measure the FIB-4 in all your patients. You can include it in your electronic medical records, or you can get it from any calculator on the web. But you really cannot leave your patients without knowing if they’re at risk of cirrhosis. I’m Kenneth Cusi. I’m a professor of medicine at the University of Florida in Gainesville, North Florida, United States. My training and career has focused on the role of type 2 diabetes, obesity and insulin resistance in driving metabolic disease and complications. And in the last 20 years, we work with our research team in understanding the mechanisms and treatments for this disease and its early diagnosis. Traditionally, guidelines have focused on complications of diabetes from the cardiovascular perspective or microvascular disease like eyes, kidneys and nerves. But in the past 10 or so years, we have begun realising that there is an epidemic of liver disease affecting our people with prediabetes and diabetes. We were unaware of that, but now we are clearly understanding the value of early diagnosis. The liver has become important because recent studies have highlighted that about 7 out of 10 people with type 2 diabetes have steatosis, fat accumulation in the liver, to a degree that can lead to cirrhosis in the future. Actually, 1 in 5 people with type 2 diabetes just screened in primary care clinics have a degree of fibrosis, or liver scarring, that puts them on a path to cirrhosis, the same as proteinuria for chronic kidney disease. Now, having steatosis and steatohepatitis, what we call MASH, makes the management of diabetes more difficult. Typically, people will have more insulin resistance, and the abnormalities that we see in the liver have an impact on the cardiovascular management of our patients. Moreover, we know that we have interventions that, if placed in an early stage of the disease, can prevent disease progression, and even the consequences of this, which are cirrhosis, liver transplantation, and even hepatocellular carcinoma. Given the problem, the American Diabetes Association has since 2023 put a number of recommendations that we update annually. But this year [2025], we have the first consensus report made by a broad spectrum of professionals involved in liver health, including endocrinologists or diabetologists, of course, hepatologists, and gastroenterologists, obesity management, nurses, nurse practitioners, the entire diabetes team. But now focused on early detection. The ADA wants that this detection be centred on the FIB-4. A FIB-4 equal or greater than 1.3 puts you at a risk of future cirrhosis and calls for additional testing. What is even more important is that we know that the FIB-4 correlates with future liver events in terms of not only cirrhosis, but decompensation, and increased cardiovascular risk. That’s why the FIB-4 has become the cornerstone of what the American Diabetes Association wants all people with diabetes to have tested in their visits with their doctors. Once you identify people that have a FIB-4 equal or greater than 1.3, we try to do a second test that’s based on imaging, which is transient elastography, and if above a certain value, 8.0 kPa, this triggers the consult with the liver specialist. If it’s lower, the patient will remain in primary care and has his cardiometabolic risk managed. But the important thing is that we have medicines now that can improve the care of our patients. The management of people with MASLD involves lifestyle changes, reduction of cardiovascular risk, sending the patient to bariatric surgery as needed, but particularly management of their obesity or their overweight if they have that with medications centred on GLP-1 receptor agonists, dual agonists, pioglitazone or their combination. The American Diabetes Association wants you to consider MASLD as one of the risk factors to decide the pharmacological management in the same way we do for heart failure or chronic kidney disease with SGLT2 inhibitors, and choose these agents, GLP-1/dual agonists, pioglitazone or their combination to prevent disease progression. In 2024, the FDA approved resmetirom for the management of patients with MASLD. And recently, semaglutide was reported in a phase 3 study to be effective to reverse steatohepatitis and fibrosis and is undergoing review for approval in late 2025. So, we have tools today to diagnose MASLD at an early stage, and we have tools today to prevent disease progression, and improve the quality of life of our patients. What we really need is not just being aware of the risk of MASLD. We need you to become a liver health champion. We want you at your local place to consider three important aspects: Number one, your patients with type 2 diabetes are being affected by MASLD, and you can do something about it. What to do is your second bullet. You need to measure the FIB-4 in all your patients. You can include it in your electronic medical records or you can get it from any calculator on the web. But you really cannot leave your patients without knowing if they’re at risk of cirrhosis. And to prevent cirrhosis, the third point, lifestyle changes and overall holistic management of the patient: Use medications that can help weight management and diabetes control, including GLP-1 receptor agonists, dual agonists and pioglitazone. They have all shown in phase 2 and, particularly semaglutide, in phase 3 studies to beneficial. And when that is not enough, remember that to work with your gastroenterologist to consider medicines that are specific, such as resmetirom and more recently semaglutide.