Non-alcoholic fatty liver disease (NAFLD) is a potentially serious liver disease that affects approximately one-quarter of the global adult population, causing a substantial burden of ill health with wide-ranging social and economic implications. It is a multisystem disease and is considered the hepatic component of metabolic syndrome. Unlike other highly prevalent conditions, NAFLD has received little attention from the global public health community. Health system and public health responses to NAFLD have been weak and fragmented, and, despite its pervasiveness, NAFLD is largely unknown outside hepatology and gastroenterology. There is only a nascent global public health movement addressing NAFLD, and the disease is absent from nearly all national and international strategies and policies for non-communicable diseases, including obesity. In this global Delphi study, a multidisciplinary group of experts developed consensus statements and recommendations, which a larger group of collaborators reviewed over three rounds until consensus was achieved. The resulting consensus statements and recommendations address a broad range of topics — from epidemiology, awareness, care and treatment to public health policies and leadership — that have general relevance for policy-makers, health-care practitioners, civil society groups, research institutions and affected populations. These recommendations should provide a strong foundation for a comprehensive public health response to NAFLD.
Bibliographical noteFunding Information:
The European Association for the Study of the Liver (EASL) International Liver Foundation (EILF) acknowledges funding from Intercept Pharmaceutics, as well as Bristol-Myers Squibb and Merck Sharp & Dohme. The authors thank in particular T. White (ISGlobal) and A. Hobbs (CUNY) for providing technical support during implementation of the Delphi methodology, and to N. Lee and the Wilton Park team for facilitating the online convening of the core group on 16 February 2021. Three observers attended the session: M. Sicuro (EILF), Y. Nedelcheva (EASL) and K. Ray (Nature Reviews Gastroenterology & Hepatology). The translations in Supplementary Tables 2–7 were provided by Springer Healthcare, and checked and revised by the authors, and are reproduced in Supplementary information as supplied.
meetings from Gilead. V.W.-S.W. declares grants or contracts from Gilead (to institution); consulting fees and participation on boards (personal) from 3V-BIO, AbbVie, Allergan, Boehringer Ingelheim, Center for Outcomes Research in Liver Diseases, Echosens, Gilead Sciences, Hanmi Pharmaceutical, Intercept, Inventiva, Merck, Novartis, Novo Nordisk, Perspectum Diagnostics, Pfizer, ProSciento, Sagimet Biosciences, TARGET PharmaSolutions and Terns; honoraria (personal) from Abbott, AbbVie, Bristol-Myers Squibb, Echosens, Gilead Sciences; and support for attending meetings or travel (institution) from Abbvie and Gilead. Y.Y. declares research grants from Biocordex and Gilead; honoraria from Gilead, Bilim, Pharmactive, Sanovel and Echosens; and participated on advisory boards for Novo Nordisk and Abbvie. J.P.A., K.C., M.A.D., J.G., T.T.-K.H, M.H.I., P.N.N., P.O., D.R., S.K.S., S.Z.-S. and Z.M.Y. declare no competing interests.
A.K. declares grants/contracts from Intercept and Novartis and conference support from Intercept. E.A.T. has received personal fees from Intercept, Gilead, Pfizer and Promethera, and honoraria from Intercept, Gilead and Pfizer. E.A.T. is a member of the Governing Board of the European Association for the Study of the Liver. H.C.-P. has received honoraria from Intercept and Novo Nordisk. H.H. has received grants or contracts from Intercept, AstraZeneca, MSD, Pfizer, EchoSens, Stockholm City Council, Swedish Cancer Foundation, Radiumhemmets Forskningsfonder, Julins Fond, Stockholm Innovation Foundation, Skandia Research Foundation, Åke Wiberg Foundation, Bengt Ihre Foundation and Tore Nilson Foundation, participated on an advisory board for BMS and Gilead, and has stock or stock options in Novo Nordisk. H.E.M. has received grants to EASL International Liver Foundation to support NAFLD activities from Intercept, Genfit, BMS and MSD. J.C. reports consultant and/or speaker and/or participated in clinical trials sponsored by and/or received grants and research support from Gilead Sciences, AbbVie, MSD, Shionogi, Intercept Pharmaceuticals, Janssen Pharmaceuticals, Celgene and Alexion (all outside the submitted work). J.M.S. declares a research grant from Gilead; consulting fees from Boehringer Ingelheim, BMS, Genfit and Gilead, Intercept Pharmaceuticals, Madrigal, Novartis, Novo Nordisk, Nordic Bioscience, Pfizer, Roche, Sanofi, Siemens Healthcare GmbH; speakers bureau from Falk Foundation, and MSD Sharp & Dohme. J.V.L. reports grants, personal fees and other support from AbbVie, personal fees from CEPHEID, personal fees from Genfit, grants, personal fees and other support from Gilead Sciences, personal fees from GSK, personal fees from Intercept, personal fees from Janssen, and grants and personal fees from MSD, outside the submitted work. L.C. declares: grants from Gilead; speaker’s bureau for Abbvie, Echosens, Gilead, Intercept, Novo Nordisk; has been a member of an advisory board for Allergan, Alexion, Echosens, Gilead, Intercept, MSD, Novo Nordisk, Pfizer and Servier. L.V. declares grants or contracts from Gilead; honoraria from MSD, Gilead, AlfaSigma and Abbvie; support for attending conferences from Gilead; participation on advisory or safety boards for Intercept, Pfizer and Gilead. M.N. has received unrestricted research grants from Gilead, Abbie and Merck, and was President of the World Hepatitis Alliance 2018–2020. M.R. has received honoraria from Alnylam, Amgen, AMRA, BMS, Boehringer Ingelheim, Centara, Coheres, Enanta, Galecto, Intercept, Madrigal, NGM Biopharmaceuticals, Novo Nordisk, Pfizer, Fractyl, Gelesis, Siemens, Thetis, Terns, Rivus, 3vBio (Sagimet), 89bio, Novartis, Immuron, Merck and Taiwan J Pharmaceuticals. M.R.-G. reports grants from Intercept, grants from Gilead Sciences, personal fees from Shionogi, personal fees from Alfa Wassermann, personal fees from ProSciento, personal fees from Kaleido, personal fees from Novo Nordisk, personal fees from MSD, personal fees from BMS, personal fees from Allergan, personal fees from Boehringer Ingelheim, personal fees from Zydus, personal fees from Intercept Pharma and personal fees from Gilead Science, outside the submitted work. Q.M.A. declares grant funding from multiple EFPIA partners via the EU IMI2-funded consortium Litmus (Abbvie, Antaros Medical, Allergan/Tobira, AstraZeneca, BMS, Boehringer Ingelheim International, Echosens, Ellegaard Gottingen Minipigs, Eli Lilly & Company, Exalenz Bioscience Ltd., Genfit, Glympse Bio, GlaxoSmithKline, HistoIndex, Intercept Pharma Europe Ltd., iXscient Ltd., Nordic Bioscience, Novartis Pharma AG, Novo Nordisk A/S, One Way Liver Genomics SL, Perspectum Diagnostics, Pfizer Ltd., Resoundant, Sanofi-Aventis Deutschland GmbH, SomaLogic Inc., Takeda Pharmaceuticals International SA.); grants from Glympse Bio; royalties/licences from Elsevier; consulting fees from Allergan, AstraZeneca, Blade Therapeutics, BMS, Cirius Therapeutics, CymaBay, Eli Lilly, Galmed, Genfit, Gilead, HistoIndex, Intercept, Inventiva, Madrigel, Metacrine, NGMBio, Novartis, Novo Nordisk, Pfizer, Poxel Pharma and The Medicines Company; honoraria from MedScape and Fishawack; and participation on safety or advisory boards for North Sea Therapeutics and Medpace. R.L.B. declares grants or contracts from Novo Nordisk and GLWL Research; consulting fees (personal) from Novo Nordisk, Viiv, Boehringer Ingelheim and International Medical Press; has participated on safety or advisory boards for Novo Nordisk and Pfizer; has been an unpaid trustee of the Association for the Study of Obesity, BOMMS Council Member and Trustee of Obesity Empowerment Network UK. R.L. declares grants or contracts from Allergan, AstraZeneca, Boehringer-Ingelheim, Bristol-Myers Squibb, Eli Lilly, Galectin Therapeutics, Galmed Pharmaceuticals, Genfit, Gilead, Intercept, Inventiva, Janssen, Madrigal Pharmaceuticals, Merck, NGM Biopharmaceuticals, Pfizer and Sonic Incytes; consulting fees from Aardvark Therapeutics, Altimmune, Anylam/Regeneron, Amgen, Arrowhead Pharmaceuticals, AstraZeneca, Bristol-Myers Squibb, CohBar, Eli Lilly, Galmed, Gilead, Glympse bio, Hightide, Inipharm, Intercept, Inventiva, Ionis, Janssen Inc., Madrigal, Metacrine, Inc., NGM Biopharmaceuticals, Novartis, Novo Nordisk, Merck, Pfizer, Sagimet, Theratechnologies, 89bio and Viking Therapeutics; and is co-founder of Liponexus. S.F. declares grants or contracts from Gilead, Roche, Bristol-Myers Squibb and Genfit; consulting fees from Roche, Gilead, Allergan, Abbvie, Bayer, Bristol-Myers Squibb, Boehringer Ingelheim, Merck Sharp & Dohme, Janssen, Actelion, Astellas, Genfit, Inventiva, Intercept, Echosense, Genentech, Novo Nordisk, Novartis, AstraZeneca, Galmed, Promethera, Coherus, Madrigal, Julius Clinical, NGM Bio; and honoraria from Gilead, Genfit, Bayer, Abbvie, Intercept, Allergan. V.M. declares unrestricted contributions to the Liver Forum. V.R. declares grants or contracts from Gilead; consulting fees from Novo Nordisk, Galmed, Madrigal, AstraZeneca, Intercept, Terns, Theratechnologies, NGM, Bristol-Myers Squibb; and support for attending
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