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religious or cultural norms. Hence, what was the need to come up with another term?

FINDING A BETTER TERM?
The term “NAFLD” is imprecisely defined; there is uncertainty regarding its pathogenesis and there is a
perceived need for a new nomenclature. However, renaming was not attempted because of certain
[3]
fundamental concerns regarding the identity of the entity . Limiting people’s choices in a survey to select a
suitable term restricts their options to the provided list. In the recent survey, which leads to the suggestion
[1]
of “MASLD” , only a constrained set of terms was presented simply based on an a priori decision that
NAFLD needs to be renamed rather than for conceptually advancing the field. The proposed set of terms
potentially influenced participants’ responses, prompting and steering them toward predetermined
outcomes. If there were more options, there is a good chance that the outcomes of the survey would have
been different. Metabolic dysfunction-associated fatty liver disease is a good term. A patient might ask,
“What is metabolic dysfunction?” There are clear and simple criteria for this, which can be easily
understood by patients. This simplicity and clarity can be invaluable in fostering patient understanding,
empowerment, and education.

IS IT WISE TO COMPARTMENTALIZE ALCOHOL RELATED FATTY LIVER DISEASE AND
NAFLD?
It is difficult to isolate practically or mechanistically alcohol-associated liver disease and NAFLD because
many people (and perhaps a majority in many countries) consume alcohol. Some studies suggest that
hepatic steatosis is more highly correlated with obesity than heavy drinking . This implies that overweight
[4]
individuals may be at a greater risk for developing this condition compared to those who primarily consume
large amounts of alcohol. However, the amount of alcohol consumed and its cut-offs are arbitrary and “less
meaningful”, considering the complexity and heterogeneity of alcohol metabolism, the genetics of the
body’s anti-oxidant systems, immunity and inflammation, as well as endogenous gut microbial alcohol
production . Furthermore, many common signaling pathways and genes result in similar responses that
[5]
decide the prognosis in both conditions. This makes it very difficult to separate the two entities. Again,
MAFLD defines, in affirmative terms, the criteria which patients must meet to be diagnosed with the
condition, and which will adversely impact their liver health. The amount of alcohol they drink, or for that
matter, whether they have viral hepatitis, has no bearing on whether the patient has metabolic dysfunction-
associated fatty liver disease or not. Thus, MAFLD deftly disentangles itself from the mix of positive and
negative criteria (arbitrarily defined levels of reported alcohol consumption) required for a MASLD
diagnosis.

FATTY LIVER AS A DISEASE
Polar bears, codfish, and sharks, to name a few, have livers full of fat. It is their natural depot for fat storage
after adipose tissue . Even in humans, some amount of liver fat storage is physiological and varies across
[6]
the lifespan, but not when it is in excess for a person’s stage in their lifespan. A few studies suggest that fatty
[7]
liver is present in up to 80% of octogenarians at postmortem . Interestingly, murine studies suggest that
liver fat in older age is associated with longevity . In humans, however, excess liver fat typically signals an
[8]
underlying metabolic disease. It also serves as an excellent, cost-effective surrogate maker for predicting
liver, cardiovascular, and pancreatic morbidities, as well as cancer .
[3,6]
IS MASLD ABOUT BEING POLITICALLY CORRECT?
The SI unit of force is Newton, named after Sir Isaac Newton. Sir Newton invested heavily in a company
[9]
called The South Sea Company . The major business of this company was shipping of enslaved Africans