Important issues that primary care physicians, hepatologists, and other specialists face in the management of NAFLD include siloed practices (in which specialists mainly focus on their organ system) and a lack of screening, even in high-risk populations—and this is, perhaps, even more important. The ownership of screening has been somewhat unsettled. For example, it has been noted that endocrinologists treat many patients with diabetes and obesity who are at a heightened risk for NAFLD, but screening for liver disease may or may not occur in that setting. The entire range of obesity is associated with NAFLD. More than 95% of patients with severe obesity who are undergoing bariatric surgery will have NAFLD. Likewise, some studies have suggested that approximately 33% to 66% of patients with diabetes have NAFLD. So, when you consider both diabetes and obesity, the risk is high.

Anecdotally, I rarely receive referrals from endocrinologists for NAFLD evaluations, which suggests that patients are not being screened in that setting. Possible barriers to screening could include uncertainty regarding the setting in which screening should take place, in addition to practical time constraints. There is a set amount of time in the clinic to focus on the established areas of responsibility, whether it is primary care, endocrinology, or cardiology. Ultimately, the totality of the patient is often not considered, and issues such as NAFLD may be overlooked.

Specialists can make a big difference in the assessment and management of NAFLD by collaborating with other specialties and primary care physicians to determine the best way to care for these patients. This includes not only at the clinic level but also at educational forums. Liver meetings, such as those from the American Association for the Study of Liver Diseases, can take the lead in terms of joining forces with other professional societies, such as the American College of Physicians, the American Diabetes Association, or the American College of Cardiology, and setting up some sessions in which there could be joint discussions and joint presentations. I believe that this approach would increase NAFLD awareness.

In collaborating with primary care physicians, I think that we need to start with small steps, in recognition of what they are already asked to do in the routine overall care of their patients. For instance, it might be useful to develop an alert for primary care patients who have risk factors such as obesity and diabetes that directs clinicians to check their Fibrosis-4 (FIB-4) index. It should be as seamless as possible. If the FIB-4 can be integrated into the electronic medical record, along with an algorithm or referral pathway, then this would be helpful for both screening and referrals for NAFLD.