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At a routine clinic visit, a person living with type 2 diabetes typically expects to review their blood glucose levels. However, routine tests may instead reveal concerns about liver health. Many people are unaware of metabolic dysfunction-associated steatotic liver disease (MASLD) and may not realise that diabetes can also affect the liver. As a result, this diagnosis often comes as a surprise. This scenario is more common than thought.
MASLD and type 2 diabetes affect up to 70% of people with diabetes, with both conditions rising the fastest in low- and middle-income countries, they represent a growing global health challenge. MASLD, previously known as non-alcoholic fatty liver disease, is defined as the accumulation of fat in the liver due to underlying metabolic dysfunction, particularly insulin resistance. It is not the result of significant alcohol intake. Although MASLD often progresses without symptoms, it can lead to serious complications over time.Early screening, lifestyle changes, and integrated care can reduce complications and improve long-term health outcomes.
Recent evidence suggests MASLD may affect around 30% of the global population. Rates are markedly higher among people with type 2 diabetes, with estimates that range from 60-70%, but only 10-20% present with advanced liver fibrosis.. As a result, this dual burden often goes undetected. Despite this, awareness is low, with many people being diagnosed only when the condition is advanced.
Recent evidence suggests MASLD may affect around 30% of the global population. Rates are markedly higher among people with type 2 diabetes
The interaction between these two conditions is cyclic. First, fat builds up in the liver. Over time, this causes inflammation and liver damage. At the same time, MASLD can worsen insulin resistance. This creates a feedback loop that makes type 2 diabetes harder to manage. Because the two conditions interact, treating them together can lead to better outcomes.
MASLD and type 2 diabetes together threaten multiple organs, not just the liver. Research shows that MASLD sharply increases the risk of cardiovascular disease and chronic kidney disease, two of the most common diabetes-related complications.
Additionally, type 2 diabetes accelerates liver scarring (fibrosis). In fibrosis, healthy liver tissue is replaced by scar tissue. Over time, this can turn into cirrhosis or liver failure.
When MASLD develops, it is often asymptomatic, making early detection challenging. Many living with type 2 diabetes are unaware of liver complications. In low-resource settings, the risk is even greater: several additional barriers severely limit the ability to diagnose. Access to imaging tools, such as ultrasound, is often restricted, and healthcare providers’ awareness may be limited.
The financial burden of healthcare also makes it hard to get tests. At the same time, health systems often prioritise infectious diseases. As a result, MASLD and type 2 diabetes are usually treated separately, which can delay optimal care.
As mentioned MASLD and type 2 diabetes are both rising worldwide. However, LMICS are facing the most rapid escalation. This challenge is driven by several interconnected factors: urbanisation, unhealthy nutrition and reduced physical activity. Meanwhile, healthcare systems are under mounting pressure from competing demands. As a result, people with chronic conditions such as MASLD often go undetected.
The Middle East and North Africa Region has seen the highest increase in MASLD with an estimated 141 million people in the region affected, and about 25 million people living with MASLD and type 2 diabetes. Furthermore, underreporting in these countries limits the accuracy of prevalence estimates and differences in diagnostic methods make comparisons difficult. Long-term data are also limited in several regions, particularly in Africa. These regions already bear the brunt of the global diabetes burden – around 75% of all cases – intensifying the risk of liver disease.
The Middle East and North Africa Region has seen the highest increase in MASLD with an estimated 141 million people in the region affected, and about 25 million people living with MASLD and type 2 diabetes
We know that the timely detection of MASLD and type 2 diabetes complications requires practical, scalable approaches. Practical solutions include stepwise screening models that begin with simple risk scores derived from routine clinical data. When used promptly, they can identify individuals at higher risk of liver fibrosis.
Following this, an ultrasound can detect fat accumulation in the liver. Where available, elastography can assess the severity of fibrosis. This structured approach reduces reliance on expensive or invasive procedures. Furthermore, studies from countries such as India and China show that screening within diabetes clinics is effective. Therefore, integrating liver assessment into routine diabetes care offers a realistic solution.
Currently, no single medication targets MASLD. However, some diabetes treatments improve liver health. GLP-1 receptor agonists can reduce liver fat, improve glucose management and also help with weight management.
SGLT2 inhibitors also improve insulin resistance and reduce liver fat. Pioglitazone is a less expensive option but may cause weight gain, which can limit its use. New treatments, such as FXR agonists, show promise for treating liver fibrosis. Nonetheless, the cost limits their accessibility in low-resource countries.
No single medication targets MASLD. However, some diabetes treatments improve liver health
Prevention remains a key part of managing MASLD and type 2 diabetes. Lifestyle improvements, such as dietary changes, increased physical activity, and better blood glucose control, can reduce liver fat and slow progression. Importantly, these strategies must be deployed without delay and tailored to every cultural and economic context. They remain a lifeline, even where healthcare resources are strained. While new therapies continue to emerge, they remain out of reach for many who need them most, underscring the need for policies to tackel these sharp inequalities to prevent needless suffering and deaths worldwide.
MASLD and type 2 diabetes should be addressed through a more integrated approach to care, with liver health becoming part of routine diabetes management. At the same time, healthcare providers require training to recognise and manage MASLD effectively. Expanding access to affordable screening tools will support earlier diagnosis.
Policies that improve access to care are of the solution, while immediate investment in prevention and treatment can help reduce long-term complications. Addressing MASLD and type 2 diabetes together is an opportunity to improve outcomes and tackle health inequalities worldwide.
