Source: CMSA Today
BY JANET COULTER, MSN, MS, RN, CCM, FCM
Did you know that metabolic dysfunction–associated steatotic liver disease (MASLD) now affects 1 in 4 United States adults? MASLD is emerging as one of the most pressing public health challenges of the 21st century. Once considered a condition of middle-aged individuals with obesity and metabolic syndrome, serious liver disease is affecting young adults in their mid-twenties and early thirties. This is largely due to obesity, insulin resistance, dyslipidemia, and sedentary lifestyles.
MASLD is the most common chronic liver disease worldwide. In the United States, it is estimated that about one in four adults has MASLD. That is about 80 to 100 million people, and there are rising rates among adolescents and young adults. Of these, about 20% to 25% develop Metabolic Dysfunction Associated Steatohepatitis (MASH), which can progress to scarring, cirrhosis, liver failure, and even hepatocellular carcinoma (Younossi et al., 2023). MASH is a critical public health concern. For professional case managers, this trend underscores the importance of early identification, coordinated interventions, and comprehensive support to improve outcomes and quality of life.
Young adults represent a growing number of those affected by liver disease. Recent studies estimate that between 18% and 25% of adults under 35 already have MASLD, and that 10% to 17% of U.S. adolescents meet diagnostic criteria. Among adolescents with obesity, the prevalence exceeds 35% (Ciardullo et al., 2023). These data illustrate that MASLD is no longer a disease of older age but is increasingly a condition with roots in early adulthood and even adolescence.
The clinical consequences of this increase are significant. The number of patients with clinically significant liver fibrosis is expected to nearly double by 2050, while new annual cases of hepatocellular carcinoma and liver transplantations are projected to nearly double and quadruple, respectively. The economic impact of metabolic dysfunction–associated steatotic liver disease (MASLD) in the United States is substantial and continues to grow. Current estimates suggest that MASLD accounts for approximately $103 billion annually, or about $1,600 per affected individual. On a per-patient basis, the average direct cost of MASH is expected to increase from $1,316 to nearly $2,900 annually (Le et al., 2025). The financial burden is most pronounced in patients with advanced disease. MASLD is now the second leading cause of liver transplantation in the U.S. and is projected to become the leading cause within the next decade. This highlights the urgent need for early detection and coordinated case management to lessen not only the clinical consequences but also the immense financial strain associated with MASLD and MASH.
Several factors contribute to the growing prevalence of MASLD among young adults. Obesity and sedentary lifestyle remain the strongest risk factors for the disease. Recent studies show that more than half of overweight or obese adults develop MASLD. This risk is increased by diets high in processed foods, sugar, and fat combined with inadequate physical activity. These lifestyle patterns contribute significantly to metabolic dysfunction and the early onset of liver disease in young adults.
Type 2 diabetes and insulin resistance are intricately linked to the progression of MASLD into its more severe form, MASH. A nationwide cohort study reported that individuals with persistent MASLD had up to a fivefold increased risk of developing type 2 diabetes, particularly among adults under the age of 40 (Mantovani et al., 2022). This highlights the intertwined relationship between metabolic disease and liver injury and reinforces the need for early identification and intervention.
Genetics and ethnicity also play a significant role in liver disease development and progression. Advances in genomics, including the use of polygenic risk scores, now make it possible to identify individuals at higher genetic risk for MASLD and advanced fibrosis. Hispanic populations, in particular, continue to be disproportionately affected due in part to genetic susceptibility.
Social determinants of health further compound disease burden. Socioeconomic status, food insecurity, and access to healthcare are strongly associated with MASLD prevalence and severity in United States adults, independent of race or ethnicity. These findings emphasize the need to address environmental and community-level barriers when planning case management interventions.
Although MASLD is not caused by alcohol use, even moderate alcohol consumption can accelerate disease progression. Recent clinical guidelines from the European Association for the Study of the Liver (EASL) recommend that patients with MASLD reduce or eliminate alcohol intake to minimize risk of progression to MASH and advanced liver disease (EASL–EASD–EASO, 2024).
Michael’s Story
Michael is a 28-year-old graduate student who was diagnosed with MASLD after routine lab work revealed elevated liver enzymes. He was overweight, had a family history of diabetes, and reported minimal exercise due to his academic workload. Michael was referred to a case manager after an ultrasound confirmed fatty liver (steatosis). The case manager collaborated with his primary care provider and a hepatologist to build a comprehensive plan of care. A referral was made to a dietitian, and Michael was enrolled in a community-based exercise program. He also met with a behavioral health specialist to address stress and motivation. His case manager helped him apply for a campus wellness scholarship to cover the costs of fitness classes. The case manager also communicated regularly with providing emotional support and education. Over the next eight months, Michael lost 20 pounds, improved his diet, normalized his blood sugar, and reduced his liver enzyme levels. Regular follow-ups and supportive case management were critical to his success. Michael’s case illustrates the vital role of case managers in coordinating multidisciplinary care and addressing not only the medical condition but also the social and behavioral barriers that complicate care for young adults.
Current Treatment, Prognosis, and SDOH
Current treatment strategies focus on lifestyle modification including weight loss through diet and exercise. A weight loss of only 7% to 10% can significantly improve liver function. Controlling diabetes, hypertension, and dyslipidemia is essential. For now, lifestyle change supported by education and case management remains the most effective intervention. Clinical trials are investigating drugs that target metabolic pathways, inflammation, and fibrosis. The FDA recently approved resmetiron and Novo Nordisk’s Wegovy to specifically treat MASH along with diet and exercise. In advanced cases of MASH with cirrhosis, transplantation may be the only life-saving intervention.
Prognosis depends on the stage of the disease at diagnosis. Patients with uncomplicated MASLD have relatively good survival rates if lifestyle changes are implemented early. However, once the disease progresses to MASH and cirrhosis, survival declines significantly. Studies show that individuals with MASH have two- to- threefold higher risks of liver-related death compared to those with MASLD without inflammation (Younossi et al., 2019). Young adults face the additional challenge of living with chronic liver disease across their lifespan, which increases long-term morbidity.
Beyond physical health, MASLD and MASH carry significant psychosocial burdens for young adults. Many patients experience stigma and misconceptions, as MASLD is frequently misattributed to alcohol consumption, obesity, or poor lifestyle choices. This can discourage individuals from seeking care. Anxiety and depression are common in younger adults diagnosed with chronic disease at an early stage of life. Academic performance and career advancement may be disrupted by fatigue, medical appointments, or long-term lifestyle adjustments. Ongoing monitoring, specialty visits, and potential loss of work productivity can add financial strain. For case managers, recognizing these psychosocial impacts is critical for holistic care planning and patient support.
Case Management Interventions
– Screen Early: Young adults with obesity, diabetes, or metabolic syndrome should be screened for MASLD.
– Promote Lifestyle Change: Even modest weight loss can significantly improve outcomes.
– Coordinate Care: Link patients with dietitians, hepatologists, endocrinologists, and mental health providers.
– Address Psychosocial Needs: Provide support for stigma, anxiety, depression, and financial strain.
– Advocate for Resources: Help patients access wellness programs, nutrition assistance, and employer support.
– Monitor Long-Term: Regular labs and follow-up appointments are essential to prevent progression.
Metabolic dysfunction–associated steatotic liver disease (MASLD) is a chronic liver disease characterized by the buildup of excess fat in the liver in people who also have one or more features of metabolic dysfunction, such as obesity, insulin resistance, type 2 diabetes, or dyslipidemia. MASLD was formerly referred to as NAFLD (nonalcoholic fatty liver disease). Metabolic dysfunction–associated steatohepatitis (MASH) is the more severe form of MASLD. It is characterized by fat buildup in the liver and inflammation. MASH can progress to fibrosis, cirrhosis, liver failure, or hepatocellular carcinoma if left untreated. MASH was formerly referred to as NASH, nonalcoholic steatohepatitis. This terminology, updated in 2023. The shift from the older terms NAFLD and NASH was designed to better capture the metabolic roots of the disease and reduce stigma associated with the word “fatty” (Eslam et al., 2023).
Conclusion
MASLD in young adults is no longer a rare diagnosis but a rapidly growing epidemic with profound clinical, economic, and psychosocial consequences. By focusing on prevention, education, coordinated care, and psychosocial support, case managers can empower patients to make lasting lifestyle changes, access necessary resources, and improve survival outcomes. Michael’s journey is a reminder that with the right support, young adults can reverse the trajectory of this disease and reclaim their health—physically, emotionally, and socially. MASLD in young adults represents a growing challenge in healthcare, one that demands proactive involvement from case managers. Case managers can make a major difference through early screening, psychosocial support, education, care coordination and advocating for preventive health strategies.
| Feature | MASLD | MASH |
| Scope | Broad category (replaces NAFLD) | Subset of MASLD (replaces NASH) |
| Key Requirement | Fat in the liver + metabolic dysfunction | Fat in the liver + inflammation + hepatocyte injury ± fibrosis |
| Severity | Can be mild to moderate | More severe, progressive |
| Risk of Progression | Lower if managed early | Higher risk of cirrhosis, liver failure, cancer |
| Case Management Focus | Lifestyle change, monitoring metabolic conditions | Intensive monitoring, multidisciplinary care, long-term follow-up |
References
Ciardullo, S., Vergani, M., & Perseghin, G. (2023). Nonalcoholic fatty liver disease in patients with type 2 diabetes: Screening, diagnosis, and treatment. Journal of Clinical Medicine, 12(17), 5597. https://doi.org/10.3390/jcm12175597
EASL–EASD–EASO. (2024). Clinical practice guidelines on metabolic dysfunction–associated steatotic liver disease. Journal of Hepatology, 80(4), 1055–1083. https://www.journal-of-hepatology.eu/article/S0168-8278(24)00329-5/fulltext
Eslam, M., Newsome, P. N., Sarin, S. K., Anstee, Q. M., Targher, G., Romero-Gomez, M., … George, J. (2023). A new definition for metabolic dysfunction–associated fatty liver disease: An international expert consensus statement. Journal of Hepatology, 79(3), 610–622. https://pubmed.ncbi.nlm.nih.gov/32278004
Le, P., Zhang, X., Wong, R. J., Henry, L., & Younossi, Z. M. (2025). Estimated burden of metabolic dysfunction–associated steatotic liver disease in U.S. adults from 2020 to 2050. JAMA Network Open, 8(1), e2454707. https://doi.org/10.1001/jamanetworkopen.2024.54707
Mantovani, A., Dalbeni, A., Beatrice, G., Cappelli, D., & Gomez-Peralta, F. (2022). Non-alcoholic fatty liver disease and risk of macro- and microvascular complications in patients with type 2 diabetes. Journal of Clinical Medicine, 11(4), 968. https://doi.org/10.3390/jcm11040968
Younossi, Z. M., Golabi, P., de Avila, L., Paik, J. M., Srishord, M., Fukui, N., … Nader, F. (2019). Global epidemiology of nonalcoholic fatty liver disease and nonalcoholic steatohepatitis in patients with type 2 diabetes: A systematic review and meta-analysis. Journal of Hepatology, 71(4), 793–801. https://doi.org/10.1016/j.jhep.2019.06.021
Younossi, Z. M., Henry, L., Stepanova, M., et al. (2023). Global epidemiology and projections of metabolic dysfunction–associated steatotic liver disease. Hepatology, 77(4), 1335–1347. https://pubmed.ncbi.nlm.nih.gov/36626630/
Janet S. Coulter, MSN, MS, RN, CCM, FCM is president of CMSA. She is a board-certified transplant case manager with a wide variety of experiences including educator, administrator, team leader, and director of case management. Janet holds a Master of Science in Nursing from West Virginia University and a Master of Science in Adult Education from Marshall University. Janet has been a recipient of the CMSA National Award of Service Excellence and Southern Ohio Valley CMSA Case Management Leadership award. She was inducted as a Fellow of Case Management in 2022.
Image credit: ISTOCK.COM/JIAN FAN
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