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research and therapeutic innovation in steatotic liver diseases.

The integration of MASLD and MetALD into international coding systems, such as the International
Classification of Diseases (ICD), is crucial for ensuring consistency in epidemiological data collection,
facilitating the comparison of clinical studies, and advancing long-term research efforts. A recent global
expert consensus statement recommends that the currently available ICD codes for NAFLD and NASH can
[57]
be used to define MASLD and MASH, respectively . However, the precise definition of MetALD remains a
topic of ongoing debate, particularly concerning the alcohol consumption thresholds that will be used to
[58]
distinguish MASLD and MetALD . This issue is especially significant in light of recent studies indicating
that even small amounts of alcohol can negatively impact liver disease progression . Establishing clear and
[32]
standardized alcohol consumption thresholds is essential for accurately classifying patients with MetALD.
The differentiation between MASLD, MetALD, and ALD is not only critical for optimizing treatment and
prevention strategies but also for ensuring that historical data can be effectively leveraged in future research.
Such precision in classification will enhance the utility of these coding systems and promote consistency
across clinical and research settings.

THE SOCIAL IMPACT OF MASLD TERMINOLOGY
The transition from the term NAFLD to more inclusive nomenclatures like MASLD not only represents an
effort to more accurately characterize the disease but also seeks to reduce the associated stigma and better
reflect the spectrum of individuals affected, regardless of their body weight or alcohol consumption
[59]
habits . Individuals with NAFLD, particularly those with obesity, may face stigmatization not only due to
their weight but also because of associated comorbidities, including the liver disease itself [60-63] . Historically,
[63]
terms like “fatty” and “non-alcoholic” have been identified as potentially stigmatizing , and this perception
may significantly impact health-related quality of life (HRQL) [62,64] .

Therefore, removing the term “fatty” from the MASLD nomenclature could reduce associated stigma,
particularly for patients who experience feelings of guilt or negative self-perception related to their obesity
or liver disease. While the term “fatty” has traditionally been associated with negative connotations, recent
surveys indicate that many patients do not perceive it as highly stigmatizing [65,66] . Nevertheless, patients who
do perceive stigma due to their diagnosis or body weight tend to experience a greater psychological burden,
[62]
negatively affecting their self-perception and overall well-being . The shift to MASLD nomenclature could
alleviate part of this stigma by removing the term “non-alcoholic”, which may reduce feelings of guilt and
improve patients’ emotional well-being. However, it is important to note that the stigma associated with
[67]
obesity is likely to persist, as it remains a central factor in the pathogenesis of this disease .

Additionally, the terminology used to describe liver diseases may vary in its cultural interpretation,
influencing how these conditions are perceived and managed in different regions . Adopting a more
[68]
inclusive term like MASLD could help reduce these disparities, promoting greater acceptance of the disease
and facilitating its management in diverse cultural and socioeconomic contexts. However, it is crucial to
ensure that diagnostic criteria are applied uniformly and do not present significant variations across
populations.

Another key aspect that the new MASLD nomenclature must address is the integration of social
determinants of health into its classification and management. Factors such as socioeconomic disparities,
inequalities in access to healthy foods, and variability in lifestyle options play a crucial role in the
progression of MASLD [69,70] . Incorporating these determinants into clinical guidelines is essential to ensure
that management strategies are accessible and applicable in all settings, particularly for vulnerable