Opinion: The liver — a metabolic health blindspot on the global NCD agenda

At a time when the burden of noncommunicable diseases, or NCDs, is climbing relentlessly, overlooking a condition that strikes more than 1 in 3 adults — despite available solutions — is indefensible.

Chronic liver disease, or CLD, is a public health threat at the very core of the NCD crisis — especially due to metabolic dysfunction-associated steatotic liver disease, or MASLD (formerly called nonalcoholic fatty liver disease, or NAFLD), and its more advanced form, MASH. These severe metabolic liver diseases can cause liver scarring, known as fibrosis, cirrhosis, which is severe liver damage, or even liver cancer. Yet liver health remains a blind spot in the global response to addressing the metabolic health crisis.

This omission is no small oversight

Globally, CLD is the 11th leading cause of mortality, responsible for over 2 million lives lost per year. To put this in perspective, this figure surpasses global deaths from HIV, tuberculosis, and malaria combined. Importantly, a substantial portion of these deaths is due to liver cancer — now the third leading cause of cancer death — with late-stage MASLD/MASH driving this rise. Beyond the human toll, the economic burden is equally staggering. Previous evaluations show MASLD/MASH led to a combined cost of over $130 billion per year in the U.S. and Europe.

These are not abstract statistics; rather, they represent millions of lives and livelihoods, many in low- and middle-income countries, or LMICs, where health systems and economies are least equipped to respond. Consequently, this is an issue that global health leaders and policymakers can no longer afford to ignore.

A shared root: Metabolic dysfunction

Our call to recognize CLD as a priority, along with other major NCDs, is not a matter of single-issue advocacy. It stems from a broader effort to confront the escalating metabolic disease crisis in its entirety.

MASLD/MASH share risk factors with — and heighten the risk of — cardiovascular disease, Type 2 diabetes, and certain cancers. For example, more than 60% of people with Type 2 diabetes have MASLD, and individuals with MASLD face a two- to fivefold increased risk of developing diabetes compared to those without the condition. Fat buildup in the liver is one of the earliest, measurable hallmark signs of metabolic dysfunction, often appearing before diabetes or heart disease develops.

Despite the overlapping challenges presented by these conditions, there is the possibility of coordinated solutions. We have the knowledge and tools to act — what is lacking is the policy and leadership to make it happen.

The policy gap that fuels the metabolic health crisis

In the past 15 years, NCD policy frameworks have lagged in scientific understanding. Despite the scale, liver disease remains absent from key policy frameworks such as the World Health Organization’s “5x5” NCD agenda, while MASLD/MASH are absent from WHO’s Global Action Plan for NCDs and its “best buys” interventions. MASLD may be implicitly covered in Sustainable Development Goal, or SDG target 3.4 — which seeks to reduce premature mortality from NCDs — but it remains unnamed, unmeasured, and underaddressed in implementation strategies. This blind spot highlights a broader failure to confront the metabolic health crisis.

The result? A rising burden, low disease awareness, missed diagnoses, and fragmented care. In many countries, fewer than 10% of people living with MASLD may even know they have it.

Promising signs are emerging, though. Editorials in JAMA Network Open, Nature Reviews Gastroenterology & Hepatology, and The Lancet have called for MASLD to be included as a major, highly prevalent NCD on par with other NCDs addressed by WHO. What is needed most is formal recognition and integration within global policy to provide momentum and set a path forward to address the human and economic consequences of this disease.

Integration is not expansion — it’s completion

Integrating MASLD/MASH is not about stretching limited resources thinner; it’s about completing the picture. We cannot fully address metabolic disease without addressing the liver. A more integrated approach would strengthen prevention and care efforts and health system responses, centering these on how most people experience NCDs — rarely in isolation.

It’s time to move liver health from the margins to the mainstream of NCD policy. Concrete steps can be taken now across global and national platforms:

1. Pass a World Health Assembly resolution on liver health and metabolic dysfunction in 2027
A WHA resolution would formalize recognition and mandate WHO to address the issue, unlocking the guidance and investment needed to close the gap.

2. Integrate liver disease indicators into global NCD strategies and monitoring frameworks
Make MASLD/MASH part of how we define, track, and address NCDs — both within WHO and at the country and municipal levels.

3. Allocate dedicated resources for liver health within national NCD strategies
In addition to funding interventions that address MASLD/MASH risk factors — including unhealthy diets, alcohol use, and physical inactivity — countries should expand budgets to generate robust epidemiological data on MASLD/MASH, evaluate its full economic and societal burden, and advance legislative or policy initiatives that raise its profile within national health agendas.

4. Double diagnostic rates for MASLD by 2027 using simple tools in primary care
Noninvasive tools already exist. What is needed is provider training, public health messaging, access to technology, and system-wide automation and implementation.

5. Support campaigns that reflect the science — and the people
Stigma and confusion around liver disease hinder care. Messaging must be updated to reflect its metabolic roots. Initiatives such as the People-First Liver Charter are leading the way in restoring person-centredness to liver care — advocating for inclusive, respectful, and rights-based approaches.

6. Ensure that, from 2026, liver health is included in upcoming multilateral declarations and commitments
Future SDG review forums, global health strategy revisions, and health-related United Nations General Assembly high-level meetings, such as the focus on universal health coverage in 2027, must explicitly acknowledge liver disease to help drive real-world visibility, commitment, and progress.

We cannot fix a crisis we refuse to see. Liver disease is part of the NCD core. This is not an issue of “if.” It is a matter of when — and how many more lives will be lost before we act. With leadership to follow the science, we can usher in healthier lives, more resilient systems, and stronger communities.

To learn more about the Global Metabolic Health Roundtable Series, visit isglobal.org/en/-/global-metabolic-health-roundtable-series