MASLD/MASH is moving up Europe’s liver health agenda as its clinical burden rises alongside obesity, type 2 diabetes and broader cardiometabolic risk. A recent analysis published in The Lancet Regional Health – Europe assesses how ready the 27 European Union countries and the United Kingdom are to address metabolic dysfunction-associated steatotic liver disease (MASLD) and its advanced form, metabolic dysfunction-associated steatohepatitis (MASH). MASLD is the most common chronic liver disease in the region, with an estimated adult prevalence of 30.4% across the EU and UK. Despite this burden, MASLD/MASH has limited visibility in national strategies, non-communicable disease priorities and clinical guidance, creating gaps in prevention, early detection, surveillance, monitoring and coordinated care.
Policy Architecture Remains Thin
No EU country or the UK has a government-issued national MASLD/MASH strategy or action plan. Spain and the UK have national action plans from non-state actors, while Romania and Sweden have subnational strategies or action plans issued by governmental bodies. Thirteen countries mention MASLD/MASH in other national or subnational strategies or action plans, most often those addressing obesity, liver disease and diabetes. These references usually sit within broader documents rather than functioning as operational MASLD/MASH policy. No country includes MASLD/MASH in its priority list of non-communicable diseases. This leaves prevention, timely detection and integrated care without a coherent policy architecture across the region.
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Clinical guidance shows a wider but still uneven policy footprint. Fifteen countries have national MASLD/MASH clinical practice guidelines, while 25 mention MASLD/MASH in other national guidelines. Obesity guidelines include MASLD/MASH most often, followed by diabetes, cirrhosis, liver transplantation, liver cancer and primary care guidance. At European level, MASLD/MASH appears in type 2 diabetes, obesity and HIV guidance, but population-level prevention and management recommendations remain limited. Many guidelines for related conditions treat MASLD/MASH mainly as a complication rather than a condition requiring co-management across specialties. The commonly used European liver, diabetes and obesity guidance offers a regional reference point, but national implementation remains incomplete.
Disease Burden Outpaces System Response
MASLD/MASH carries a substantial clinical and economic burden in Europe. MASLD is closely connected with obesity, type 2 diabetes and cardiovascular disease, and MASH is the second leading cause of end-stage liver disease and liver transplantation. Direct annual medical costs for MASH are expected to rise between 2021 and 2040 in Germany, France, Italy, Spain and the UK. The burden includes liver fibrosis, cirrhosis, hepatocellular carcinoma and wider cardiometabolic complications. Compared with obesity, diabetes, cardiovascular disease and cancer, MASLD/MASH receives far less policy attention despite its overlap with these conditions.
Diagnostic pathways already exist, but implementation varies. Current European MASLD guidance recommends stepwise risk stratification, using simple, low-cost serum-based non-invasive tests such as the Fibrosis-4 Index as first-line tools in primary care, followed by more advanced biomarkers or imaging for individuals at higher risk. Guidance also recommends screening for liver fibrosis with non-invasive tests in people with cardiometabolic risk factors, especially those with abnormal liver enzymes, imaging evidence of steatosis, obesity, type 2 diabetes or additional metabolic risk factors. At the same time, resmetirom and semaglutide gained European Medicines Agency approval in 2025 as specific therapies for people living with non-cirrhotic MASH. These approvals increase the need for diagnostic capacity, treatment monitoring, referral pathways and equitable access across the full MASLD continuum.
Integrated Care and Prevention Offer Policy Levers
MASLD/MASH prevention aligns with existing public health priorities on nutrition, physical activity, alcohol consumption and cancer prevention, but European dietary and non-communicable disease frameworks rarely place it alongside those agendas. European food-based dietary guidance focuses on cancer, cardiovascular disease, respiratory disease and type 2 diabetes without specifically addressing MASLD/MASH. Recent MASLD guidance recommends non-pharmacological interventions, including dietary patterns such as the Mediterranean diet, unprocessed or minimally processed foods, reduced ultra-processed food intake, lower sugar-sweetened beverage consumption, physical activity, weight management and reduced or no alcohol use. European physical activity policy also remains weak, with stronger action still needed on built environment, transport and healthcare settings.
Health system organisation also limits readiness. Liver diseases have traditionally sat within hepatology or gastroenterology, while diabetes and obesity have sat within endocrinology or internal medicine. This structural divide creates parallel pathways, inconsistent referral routes and a fragmented care experience. Primary care physicians may lack familiarity with new steatotic liver disease terminology, clear referral guidance or access to non-invasive testing. Stronger collaboration between cardiology, endocrinology, hepatology and primary care could support coordinated care models. Existing non-communicable disease structures, digital health tools, integrated data systems, automated algorithms and primary care-based detection approaches create opportunities for surveillance, risk stratification and care coordination. Italy’s National Prevention Plan for 2020–2025 shows how a single prevention framework can address several major diseases.
Europe has the clinical rationale, diagnostic tools and emerging treatment options to manage MASLD/MASH more coherently, but policy readiness remains low. Current gaps span national strategies, non-communicable disease frameworks, population prevention, clinical guidance, surveillance and multidisciplinary care pathways. Without stronger political and health system attention, late diagnosis, fragmented care, rising costs and unequal access are likely to persist. Integrating MASLD/MASH into existing policy and healthcare structures would support prevention, detection, long-term management and more consistent care for people affected by liver and cardiometabolic disease.
Source: The Lancet Regional Health – Europe
Image Credit: iStock
