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Cultural Considerations in MASH
An Expert Focus on Cultural Considerations for Managing MASH

Released: February 19, 2024

Mazen Noureddin
Mazen Noureddin, MD, MHSc
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Key Takeaways
  • Lifestyle modifications such as diet and exercise remain a cornerstone in the treatment of MASH.
  • Healthcare professionals should consider patient needs and cultures when “prescribing” changes in diet to promote weight loss.
  • MASH clinical trials need to include patients from marginalized and underrepresented communities, who also need to benefit from novel therapies.

In improving patient outcomes in metabolic dysfunction‒associated steatohepatitis (MASH), one of the largest problems healthcare professionals (HCPs) face today is that many patients are undiagnosed. Thankfully, we now have clear guidelines that request the screening of all persons with type 2 diabetes (T2D) or 2 or more metabolic risk factors, via simple non-invasive tests such as the Fibrosis-4 Index (FIB-4), followed by transient elastography, or Enhanced Liver Fibrosis (ELF) if needed. It is critical that HCPs actively screen eligible patients to quicken initiation of treatment that is tailored to their specific needs to stave off disease progression.

Prescribing Culturally Informed Diet Modifications
When considering treatment options for patients with MASH, lifestyle modifications continue to be the major player—yet quality care for this patient population always should consider cultural differences or needs. For example, making substantial changes to one’s diet could become a barrier. Recently, Harrison and colleagues showed that the thyroid hormone receptor β–selective agonist resmetirom was superior compared with placebo for resolution of MASH and improvement in liver fibrosis by at least 1 stage, so HCPs soon may have an FDA-approved therapy. However, we will still need to encourage weight loss and exercise among our patients with MASH. Diet is the main treatment option to induce long-term weight loss, in addition to some other agents. HCPs should tailor their diet and exercise “prescriptions” to the individual; there is no pill or modification that fits the needs of all patients.

Rather, there are cultural differences and varying types of diets to consider. In general, the Mediterranean diet has the most beneficial impact. Nevertheless, we also are seeing great benefits with a low-carb diet. Unfortunately, this is one of the hardest diets to abide by, especially considering that carbohydrates are food staples for many cultures (eg, rice in Asia, Latin America, and Africa and wheat in the Middle East). Taking these specific foods away from individuals can be incredibly demanding of them; thus, prescribed changes to diet must be tailored to the individual. If patients cannot adopt a low-carb diet, ask if they can reduce their daily calorie intake. Furthermore, increasing the intake of certain foods or drinks, such as fiber or coffee, is helpful, but HCPs should ensure that there are no contraindications with their current prescriptions. Finally, reducing one’s intake of red meat (and processed red meat, especially) is incredibly beneficial. In this case, HCPs can request that patients switch their choice of protein to fish or chicken.

Promoting and Maintaining Weight Loss
Although agents such as glucagon-like peptide-1 receptor antagonists (GLP-1 RAs) can be helpful for some patients with obesity, I have found that at the initial stage, many patients must overcome their hunger and eating habits. Some must overcome these needs when at social events, because a lot of socialization in our society is set around food or drink. Once patients start seeing their weight decrease and experiencing the benefits of this, however, they will be further motivated and may find that losing weight has become an easier endeavor. It is the initial stage that can be the most difficult to “power through.”

Once patients start losing weight, their weight will plateau. Then the challenge becomes Maintaining the weight loss without regain is a challenge and patients need to be aware of different obstacles along the way such as unsustainable behavioral changes and/or loss of motivation. If patients need help, HCPs can assist in providing information on exercise programs, accessing a personal trainer (if they are interested and can afford it), gym memberships, and available medication options.

Furthering Science via Clinical Trials
In treating MASH, I explore clinical trial opportunities and enrollment criteria with each patient. My organization is lucky to have a research center where we can be part of the advancement of science. With the evolving research landscape of MASH, there are now different mechanisms that we use and tailor to patients’ needs. For instance, if a patient has GI problems (nausea, vomiting, or other GI issues) already, we try not to give them a GLP-1 RA as a first line therapy and try something else. Currently, GLP-1 RAs are still investigational for treatment of MASH in the absence of T2D and/or obesity.

At this particular time, it is critical to continue offering clinical trial opportunities to patients and encouraging them to enroll, especially those from marginalized or underrepresented populations. We need them to be included and to contribute to research because they also need to benefit from these novel therapies. If patients are not interested in clinical trials, I will then emphasize the need for weight loss and exercise while waiting for approved therapies with an indication for MASH.

Outside of clinical trials, there are no approved combination therapies yet for treating MASH. For example, vitamin E and pioglitazone are not a recommended combination. There are some initial data suggesting a benefit with using them in patients with MASH, but these data need further validation through research and analysis. Patients can use weight loss medications, such as GLP-1 RAs, but there are no FDA-approved combination therapies just yet.

Your Thoughts?
How often do you prescribe GLP-1 RAs for T2D or obesity in patients who also have MASH? You can get involved in the discussion by answering the polling question or posting a comment below.

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