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  • Original Article
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Mapping Metabolic Dysfunction-associated Steatotic Liver Disease Models of Care across 17 Middle East and North Africa Countries: Insights into Guidelines, Infrastructure, and Referral Systems

  • Mohamed El-Kassas1,2,3,* ,
  • Khalid M. AlNaamani2,3,4,
  • Rofida Khalifa5,
  • Yusuf Yilmaz2,3,6,
  • Asma Labidi2,7,
  • Maen Almattooq2,8,
  • Faisal M. Sanai2,9,
  • Maisam W.I. Akroush Nabil Debzi2,11,
  • Mohammed A. Medhat2,12,
  • Imam Waked2,13,
  • Ali Tumi2,14,
  • Mohamed Elbadry1,2,
  • Mohammed Omer Mohammed15,
  • Ala I. Sharara2,16,
  • Ali El Houni17,
  • Mohamed Alsenbesy18,19,
  • Hisham El-Khayat20,
  • Mina Tharwat21,
  • Abdel-Naser Elzouki2,3,22,
  • Khalid A. Alswat2,3,23,
  • Zobair M. Younossi3,24 and
  • on behalf of the Steatotic Liver Disease Study Foundation in Middle East and North Africa (SLMENA) Collaborators∧
 Author information 

Abstract

Background and Aims

Metabolic dysfunction-associated steatotic liver disease (MASLD) represents an escalating healthcare burden across the Middle East and North Africa (MENA) region; however, system-level preparedness remains largely undefined. This study aimed to assess existing models of care, clinical infrastructure, policy frameworks, and provider perspectives across 17 MENA countries.

Methods

A cross-sectional, mixed-methods survey was distributed to clinicians from MASLD-related specialties across the region. A total of 130 experts (87.2% response rate) from academic, public, and private sectors in 17 countries participated. The questionnaire addressed national policies, diagnostic and therapeutic practices, referral pathways, multidisciplinary team (MDT) integration, and patient/public engagement. Quantitative responses were analyzed descriptively, while qualitative inputs underwent thematic analysis.

Results

Only 35.4% of respondents confirmed the presence of national clinical guidelines for MASLD, and 73.1% reported the absence of a national strategy. Structured referral pathways were reported by 39.2% of participants, and only 31.5% believed the current model adequately addresses MASLD. While 60% supported MDT approaches, implementation remained inconsistent. Limited access to transient elastography was reported by 26.2% of providers. Public education efforts were minimal: 22.3% reported no available tools, and 87.7% indicated the absence of patient-reported outcomes data. Nearly half (47.7%) cited poor patient adherence, attributed to low awareness, financial barriers, and lack of follow-up.

Conclusions

Significant policy, structural, and educational gaps persist in MASLD care across the MENA region. To address this rising burden, countries must adopt integrated national strategies, expand access to non-invasive diagnostic tests, institutionalize MDT care, and invest in both public and provider education as essential pillars of system-wide preparedness.

Graphical Abstract

Keywords

Metabolic dysfunction-associated steatotic liver disease, MASLD, Middle East and North Africa region, MENA, Models of care, MoCs, Multidisciplinary care

Introduction

Metabolic dysfunction-associated steatotic liver disease (MASLD), previously termed non-alcoholic fatty liver disease (NAFLD), is currently the most prevalent cause of chronic liver disease worldwide.1 Approximately 20% of individuals with MASLD progress to metabolic dysfunction-associated steatohepatitis, a major contributor to advanced liver fibrosis, cirrhosis, and hepatocellular carcinoma, leading to substantial economic burdens, increased healthcare costs, and reduced patient quality of life.2,3

Globally, MASLD prevalence has increased markedly in recent decades, rising from 25.3% during 1990–2006 to 38.2% between 2016–2019, representing a 50.4% increase over 30 years.4 The Middle East and North Africa (MENA) region, including Arab countries in North Africa, the Levant, the Gulf, and Turkey, exhibits one of the highest global prevalence rates of MASLD, second only to Latin America, at approximately 36.5%.5,6 Notably, prevalence within this region varies considerably, reaching as high as 56% in Egypt (reference). This increased prevalence is largely attributable to the high burden of MASLD-associated risk factors in the region, such as obesity, which is reported to affect 55% of females and 30% of males in Kuwait, significantly surpassing global averages of 19% and 14%, respectively.3,6,7 The prevalence of type 2 diabetes in the MENA region is also exceptionally high, ranking first globally at 12%, compared to the global average of 8%.7 Additionally, sedentary lifestyles are more common in the MENA region (33%) than globally (28%).8 The region is also experiencing a rapid increase in MASLD-related complications, with annual rates per 100,000 individuals of 3.45 for liver-related complications, 1.76 for mortality, and 1.71 for disability-adjusted life years, all significantly exceeding global averages.9

Given the complexity of MASLD, effective management requires integrated, patient-centered models of care (MoCs) across all levels of healthcare. These frameworks enable timely diagnosis, coordinated multidisciplinary treatment, and ongoing follow-up involving primary care, hepatology, endocrinology, cardiology, nutrition, obesity medicine, bariatric surgery, and mental health services.10 Despite this obvious need, previous studies have highlighted significant deficiencies within national and subnational strategic frameworks for MASLD management in many regions, including MENA.11 Public health responses remain fragmented and insufficiently developed to address the escalating disease burden adequately.10,11 Importantly, there is a lack of region-wide assessments evaluating the presence of national strategies, referral systems, and integrated MoCs tailored to MASLD in the MENA region. Most existing studies have focused on epidemiological trends or isolated national experiences, leaving a substantial gap in understanding the systemic and structural readiness of MENA health systems. The region remains at the epicenter of the global MASLD epidemic, yet responses are hindered by the absence of region-specific guidelines, fragmented care models, and limited data. A recently proposed regional research and action agenda underscored the urgency of multisectoral coordination to strengthen surveillance systems, integrate MASLD into non-communicable disease policies, and prioritize workforce training and capacity building.12 This study was therefore designed to fill that critical gap by capturing frontline expert insights from 17 countries to identify strengths, systemic deficiencies, and actionable priorities. The findings aim to inform evidence-based strategies and support regionally tailored improvements in MASLD care delivery.

Methods

Study design

This study employed a cross-sectional, mixed-methods design to assess the current landscape of MASLD care across the MENA region. The approach integrated both quantitative and qualitative components to capture a broad range of clinical practices, system-level preparedness, and provider perspectives.

Setting and sampling frame

The study was conducted under the auspices of the Steatotic Liver Disease Study Foundation in Middle East and North Africa (hereinafter referred to as SLMENA), a regional scientific consortium established to advance research, awareness, and clinical collaboration on MASLD (www.slmena.org ). Survey participants were selected using purposive and convenience sampling methods. Leveraging SLMENA’s professional network, a curated list of experts actively involved in MASLD diagnosis and management from 17 MENA countries was compiled. The survey invitation was initially distributed to 149 eligible professionals via direct email and affiliated professional societies.

Survey instrument and data collection

Data were collected through an online survey developed collaboratively by a panel of regional experts. The survey was pilot-tested among five senior experts from different MENA countries to ensure clarity, relevance, and contextual appropriateness. Based on their feedback, minor adjustments were made to enhance comprehensibility and content validity.

The survey was administered over two months (February–March 2025). It consisted of both closed-ended questions (multiple-choice and Likert-scale formats) to capture quantitative data, and open-ended questions to elicit qualitative insights into barriers, facilitators, and actionable strategies for improving MASLD care. Survey domains included:

  • National policies and public health strategies related to MASLD;

  • Availability and accessibility of clinical guidelines;

  • Diagnostic and therapeutic modalities currently in use;

  • Structure and efficiency of referral pathways;

  • Degree of multidisciplinary collaboration in MASLD care;

  • Provider perceptions of system gaps, public awareness, and opportunities for improvement.

Data analysis

Quantitative data were analyzed using descriptive statistics, including frequencies, percentages, means, and standard deviations. Comparative analyses explored differences in practices and capacities across countries and care settings. Qualitative data from open-ended responses were analyzed using thematic content analysis.

Ethical considerations

The study was approved by the Research Ethics Committee of the Faculty of Medicine, Helwan University, Cairo, Egypt (Serial 152-2024). Before beginning the survey, participants were informed of the study’s purpose, their eligibility, and the voluntary nature of participation. Informed consent was obtained electronically prior to survey access. Although participants were asked to provide their names for verification and coordination purposes, all identifying information was stored separately from the survey responses and was not linked to the analytical dataset. Anonymity of responses was maintained during data analysis, and all information was handled in accordance with data protection and confidentiality standards.

Results

A total of 130 healthcare professionals involved in the diagnosis and management of MASLD who met the inclusion criteria completed the survey, yielding a high response rate of 87.2%. All participants were actively engaged in diagnosing, treating, or managing MASLD across diverse healthcare settings, including hospitals, specialized clinics, and primary care facilities, representing 17 countries within the MENA region. The sample included 81 male and 48 female respondents, with one participant preferring not to disclose their gender. The majority were senior clinicians, with 66.1% aged 46 years or older, most commonly in the 46–55-year range (36.9%). Professional backgrounds reflected the study’s clinical focus: 58.5% identified as hepatologists and 38.5% as gastroenterologists. Geographically, the strongest representation came from Turkey (22.3%), Egypt (17.7%), Saudi Arabia (17.7%), and Tunisia (15.4%). Academic and public sector institutions were the most common practice settings, with 48.5% working in university hospitals and 38.5% in government or public healthcare systems. Most participants (93.1%) were practicing clinicians. Regarding scholarly activity, 74.6% had authored between one and five publications related to MASLD, while 19.2% had published six to twenty-five papers. Notably, 67.7% had more than a decade of professional experience, and 49.3% had over 10 years of direct experience managing MASLD cases. Table 1 presents demographic, professional, and MASLD-related characteristics of study participants.

Table 1

Demographic, professional, and MASLD-related profiles of study participants from the MENA region

Variablesn = 130%
Gender
  Woman4836.9
  Man8162.3
  Prefer not to say10.8
Age (years)
  25 – 351511.5
  36 – 453829.2
  46 – 554836.9
  56 – 652216.9
  > 6575.4
Primary specialty
  Hepatology7658.5
  Gastroenterology5038.5
  Endocrinology10.8
  Nutrition10.8
  Other121.5
Country of work
  Turkey2922.3
  Egypt2317.7
  Saudi Arabia2317.7
  Tunisia2015.4
  Oman107.7
  Libya64.6
  Kuwait53.8
  Jordan32.3
  Algeria21.5
  Iraq21.5
  Other275.4
Primary sector of work
  Academia (university hospital)6348.5
  Public5038.5
  Private1511.5
  Civil society10.8
  Other310.8
Primary field or area of work
  Clinician/medical doctor12193.1
  Healthcare administration32.3
  Clinical research64.6
Number of authored publications focused on MASLD
  1 – 59774.6
  6 – 252519.2
  26 – 5043.1
  51 – 10010.8
  > 10032.3
Years of experience in the field
  Less than 5 years1310.0
  5–10 years2922.3
  11–20 years4937.7
  More than 20 years3930.0
Years of experience managing patients with MASLD
  Less than 5 years1813.8
  5–10 years4836.9
  11–20 years4736.2
  More than 20 years1713.1

1One hepatobiliary and liver transplant surgeon and one acute medicine specialist. 2Bahrain, Lebanon, Morocco, Palestine, Qatar, United Arab Emirates, and Yemen (one representative each). 3Armed forces. MASLD, metabolic dysfunction-associated steatotic liver disease; MENA, Middle East and North Africa. MASLD, metabolic dysfunction-associated steatotic liver disease; MENA, Middle East and North Africa.

The following sections provide a detailed analysis of each survey domain to explore patterns, gaps, and contextual insights related to MASLD care across the region.

National policy or strategy for MASLD

MASLD remains underrepresented in national healthcare strategies, with 73.1% of respondents reporting that their country lacks a dedicated national policy or strategy. Among the 26.9% whose countries do have a policy, only 6.1% rated it as comprehensive, addressing nearly all key aspects of MASLD management. Furthermore, only 10.8% believed MASLD is recognized as a public health concern to a great or very great extent, underscoring the need for stronger policy prioritization.

Gaps in national clinical guidelines

National clinical guidelines are also lacking, with only 35.4% of respondents reporting the presence of nationally recognized MASLD guidelines, while 64.6% indicated their absence. Turkey (Turkish Association for the Study of the Liver; 15.4%) and Saudi Arabia (The Saudi Society for the Study of Liver Disease and Transplantation; 10.8%) were the primary contributors, though other MENA countries had limited representation. Only 29.2% of respondents could locate and share their national guidelines’ URLs. While 30.7% found their national guidelines easy or very easy to access, only 20% reported them as widely available. Implementation in clinical practice remains limited, with just 9.2% stating that guidelines are applied to a great or very great extent, suggesting barriers to adoption.

Reliance on international guidelines

In the absence of national guidelines, 58.5% of respondents reported relying on international guidelines, primarily from the European Association for the Study of the Liver (EASL) (37.7%) and the American Association for the Study of Liver Diseases (20%). Additionally, 23.1% reported using both national and international guidelines (Table 2).

Table 2

National policies, strategies, and clinical guidelines for MASLD in the MENA region

Variablesn = 130%
Does your country have a national policy or strategy specifically addressing MASLD?
  Yes3526.9
  No9573.1
If a national MASLD policy or strategy exists, how would you rate its comprehensiveness in addressing all aspects of MASLD management? (n = 35)
  Lacks key elements32.3
  Addresses some key aspects118.5
  Addresses most key aspects1310.0
  Addresses nearly all key aspects53.8
  Addresses all key aspects comprehensively32.3
To what extent does your country’s national healthcare strategy address MASLD as a significant public health concern? (n = 35)
  To a small extent53.8
  To some extent1612.3
  To a great extent107.7
  To a very great extent43.1
Does your country have nationally recognized clinical guidelines for the diagnosis and management of MASLD?
  Yes4635.4
  No8464.6
If yes, which organization(s) developed these national guidelines? (n = 46)
  SASLT1410.8
  TASL2015.4
  ESHGID21.5
  MAIDEN10.8
  UCHID10.8
  Don’t know86.2
If this guideline is publicly available on the internet, please share its URL (n = 46)
  Know and share the URL3829.2
  Don’t know86.2
If yes, how widely are these national MASLD guidelines available to healthcare professionals across the country? (n = 46)
  Difficult to access10.8
  Moderately easy to access53.8
  Easy to access1813.8
  Very easy to access2216.9
To what extent are these national MASLD guidelines available in clinical practice across the country? (n = 46)
  To a small extent86.2
  To some extent129.2
  To a great extent1813.8
  To a very great extent86.2
To what extent are these national MASLD guidelines implemented in clinical practice across the country? (n = 46)
  To a small extent107.7
  To some extent2418.5
  To a great extent75.4
  To a very great extent53.8
If national guidelines are not available, are international guidelines (e.g., EASL, AASLD, etc.) utilized in your country for MASLD management?
  Yes7658.5
  No86.2
  Both national and international guidelines are utilized3023.1
  Only national guidelines are utilized1612.3
If national guidelines are not available, which international guidelines are primarily used in your country?
  EASL guidelines4937.7
  AASLD guidelines2620.0
  APASL guidelines10.8
  EASL guidelines and national guidelines2317.7
  AASLD guidelines and national guidelines64.6
  APASL guidelines and national guidelines10.8
  Only national guidelines1612.3
  No international guidelines are followed86.2

SASLT, The Saudi Society for the Study of Liver Diseases and Transplantation; TASL, Turkish Association for the Study of the Liver; ESHGID, Egyptian Society of Hepatology, Gastroenterology and Infectious Diseases; MAIDEN, Metabolic Fatty Liver Disease Consortium; UCHID, United Conference of Hepatogastroenterology & Infectious Diseases; EASL, European Association for the Study of the Liver; AASLD, American Association for the Study of Liver Diseases; APASL, Asian Pacific Association for the Study of the Liver. MASLD, metabolic dysfunction-associated steatotic liver disease; MENA, Middle East and North Africa; SASLT, The Saudi Society for the Study of Liver Diseases and Transplantation; TASL, Turkish Association for the Study of the Liver; ESHGID, Egyptian Society of Hepatology, Gastroenterology and Infectious Diseases; MAIDEN, Metabolic Fatty Liver Disease Consortium; UCHID, United Conference of Hepatogastroenterology & Infectious Diseases; EASL, European Association for the Study of the Liver; AASLD, American Association for the Study of Liver Diseases; APASL, Asian Pacific Association for the Study of the Liver.

Diagnostic and therapeutic modalities in current use

Transient elastography (FibroScan®) (85.4%) was the most commonly used diagnostic tool, followed by imaging (72.3%) and blood-based tests (70.8%). Although non-invasive approaches are preferred, liver biopsy (31.5%) continues to be used in selected cases. Among non-invasive tests (NITs), FIB-4 (70%) was widely used, whereas APRI (33.8%) was less common. FibroScan was used frequently or routinely by 58.4% of respondents, but 12.3% reported very infrequent use, suggesting variability in accessibility. Serological NITs followed a similar pattern: 52.3% reported frequent or routine use, while 19.2% reported rare or no use. Notably, 26.2% of respondents found FibroScan difficult to access, despite 73.8% considering it at least moderately available. Insurance coverage for NITs was limited, with only 37.7% reporting full coverage and 33.1% reporting partial coverage.

Treatment strategies and availability of MASLD medications

Lifestyle modification (96.9%) was the most widely adopted intervention. Pharmacologic treatments not approved by the U.S. Food and Drug Administration (FDA) (e.g., vitamin E, pioglitazone) were commonly used (62.3%) and were available or widely available in 71.5% of cases. In contrast, FDA-approved medications (8.5%) were rarely used, mainly due to their unavailability (82.3%), highlighting a major gap in access to approved pharmacotherapies. Bariatric surgery (63.8%) was recognized as a treatment option, particularly for MASLD associated with obesity, and was moderately to widely available in 80.8% of cases, though accessibility challenges persisted in some regions. Insurance coverage varied: lifestyle interventions (43.1%) and non-FDA-approved drugs (47.7%) had the highest coverage, but substantial gaps remained. FDA-approved treatments faced major financial barriers, with only 5.4% reporting coverage and 90.8% reporting no coverage. Bariatric surgery was partially or fully covered in 63.8% of cases, yet 36.2% reported no coverage, reflecting disparities in access.

Guideline adherence and provider involvement

A total of 35.4% of respondents reported that treatment decisions were based on guidelines to a great or very great extent, while 46.9% followed guidelines to some extent, indicating inconsistencies in evidence-based practice. Hepatologists (84.6%) and gastroenterologists (81.5%) were the primary providers managing MASLD, while endocrinologists (54.6%), primary care physicians (47.7%), and nutritionists (42.3%) also played significant roles. Other specialties, including internal medicine, cardiology, and surgery (7.7%), were involved to a lesser extent (Table 3).

Table 3

MASLD risk stratification, diagnostic tools, treatment strategies, and accessibility in the MENA region

Variablesn = 130%
Which diagnostic tools are routinely used for MASLD risk stratification in your country?*
  Liver biopsy4131.5
  FibroScan (with or without CAP)11185.4
  Blood tests (ALT, AST, GGT, etc.)9270.8
  Imaging (ultrasound, MRI, CT)9472.3
  FIB-49170.0
  APRI4433.8
  NFS2720.8
  Other (please specify)121.5
How often are radiological non-invasive tests (e.g., FibroScan/CAP) used in your country for initial MASLD diagnosis?
  Never used10.8
  Used very infrequently1612.3
  Used occasionally3728.5
  Used frequently4534.6
  Used routinely3123.8
How often are serological non-invasive tests (e.g., FIB-4, APRI, NFS) used in your country for initial MASLD diagnosis?
  Never used21.5
  Used very infrequently2317.7
  Used occasionally3728.5
  Used frequently4333.1
  Used routinely2519.2
How would you rate the availability of FibroScan across your country?
  Difficult to access3426.2
  Moderately accessible5340.8
  Easily accessible3023.1
  Very easily accessible1310.0
Are all these non-invasive tests covered by national health insurance (or similar organizations) or by relevant health insurance reimbursement policy?
  Yes4937.7
  No3829.2
  Partially covered4333.1
Which treatment strategies are typically used for MASLD patients in your country?*
  Lifestyle modifications (diet, exercise)12696.9
  Non-FDA-approved pharmacologic interventions (e.g., vitamin E, pioglitazone)8162.3
  FDA-approved pharmacologic interventions (e.g., resmetirom)118.5
  Bariatric surgery (when indicated according to guidelines)8363.8
  Other (please specify)275.4
Please rate the availability of each of the following treatment options across your country using the scale below
  Non-FDA-approved pharmacologic interventions (e.g., vitamin E, pioglitazone)
    Unavailable43.1
    Limited1713.1
    Moderate1612.3
    Available6247.7
    Widely available3123.8
  FDA-approved pharmacologic interventions (e.g., resmetirom)
    Unavailable10782.3
    Limited1813.8
    Moderate32.3
    Available10.8
    Missing10.8
  Bariatric surgery (when indicated according to guidelines)
    Limited2519.2
    Moderate3325.4
    Available4836.9
  Widely available2418.5
Are any of these treatment options covered by national health insurance (or similar organizations)?
  Lifestyle modifications (diet, exercise)
    Yes5643.1
    No5542.3
    Partially covered1914.6
  Non-FDA-approved pharmacologic interventions (e.g., vitamin E, pioglitazone)
    Yes6247.7
    No4131.5
    Partially covered2720.8
  FDA-approved pharmacologic interventions (e.g., resmetirom)
    Yes75.4
    No11890.8
    Partially covered53.8
  Bariatric surgery (when indicated according to guidelines)
    Yes4635.4
    No4736.2
    Partially covered3728.4
To what extent are MASLD treatment decisions in your country based on evidence-based guidelines?
  Not at all32.3
  To a small extent2015.4
  To some extent6146.9
  To a great extent4333.1
  To a very great extent32.3
What are the specialties that primarily manage MASLD patients in your country*
  Hepatologists11084.6
  Gastroenterologists10681.5
  Endocrinologists7154.6
  Primary care physicians (PCPs)6247.7
  Nutritionist5542.3
  Other (please specify)3107.7

*Questions with multiple responses. 1LiverFASt test and occasionally liver biopsy. 2GLP-1 agonists (n = 3), GLP-1 RA for non-surgical weight loss, Liraglutide, endoscopic procedures (e.g., sleeve, balloon), and SGLT2 inhibitors. 3Internal Medicine (n = 7), cardiologists, pediatricians, and surgeons. MASLD, metabolic dysfunction-associated steatotic liver disease; FibroScan, vibration-controlled transient elastography device; CAP, controlled attenuation parameter; FIB-4, fibrosis-4 index; APRI, aspartate aminotransferase–to–platelet ratio index; NFS, NAFLD fibrosis score; ALT, alanine aminotransferase; AST, aspartate aminotransferase; GGT, gamma-glutamyl transferase; MRI, magnetic resonance imaging; CT, computed tomography; NIT(s), non-invasive test(s); FDA, U.S. Food and Drug Administration.

Referral pathways for MASLD patients

A formal referral pathway from primary to secondary and tertiary care exists in only 39.2% of cases, while the majority (60.8%) reported the absence of such pathways, highlighting a major gap in structured patient transitions. Even when referral pathways exist, adherence remains suboptimal, with only 26.9% of respondents confirming consistent adherence and frequent adherence reported in just 17.7% of cases. The clarity of referral pathways is also a concern, as 23.1% reported moderate ambiguity and 7.7% found them unclear or difficult to follow. Referral delays present another issue, with 10% of respondents experiencing significant delays, while only 7.3% described the process as timely or extremely timely, suggesting poor access to specialized care. Overall, only 13.1% rated the referral process as effective, while 20% believed it was moderately effective, pointing to gaps in coordination. Unnecessary referrals remain a concern, occurring occasionally or frequently in 31.5% of cases, which may indicate inefficiencies in patient assessment at the primary care level. The most commonly cited reasons for unnecessary referrals include uncertainty regarding referral criteria (23.1%), lack of awareness among primary care physicians regarding MASLD management (22.3%), limited access to diagnostic tools in primary care (15.4%), inadequate communication between primary and secondary care (14.6%), and overestimation of disease severity (13.1%).

Multidisciplinary team (MDT) approach and access to MASLD specialists

The use of an MDT approach in MASLD care is limited, with 54.6% of respondents indicating it is rarely or never implemented, and only 8.5% reporting frequent or extensive use, highlighting a need for more integrated care. Despite this, MDT care is perceived as highly or extremely effective by 60% of respondents, suggesting strong potential benefits if implemented more widely. Access to MASLD specialists also varies across the MENA region. While 31.6% of respondents reported easy or very easy access to specialists, 47.7% described moderate ease of access, and 20.7% reported access as difficult or very difficult.

MASLD care, services, and follow-up

MASLD patients most frequently seek initial care at internal medicine (27.7%) and primary care clinics (27.7%), followed by hepatology (22.3%) and gastroenterology clinics (19.2%). Notably, specialized MASLD clinics are almost nonexistent (0.8%), suggesting a lack of dedicated care facilities for this growing public health concern. The most commonly performed services include abdominal ultrasound (90%), basic laboratory investigations (89.2%), management of comorbidities (71.5%), and fibrosis risk assessment (53.8%). Referral to higher-level care is initiated in only 27.7% of cases, suggesting that most MASLD cases are initially managed at the primary care level. Structured follow-up systems are also lacking, with only 17.7% of respondents reporting their existence, meaning the vast majority (82.3%) lack formal mechanisms for tracking patient progress. The most frequently cited reasons for lack of follow-up include lack of disease awareness (57.7%), fragmented healthcare systems (46.9%), high case volume (32.3%), lack of reporting systems (37.7%), and multiple physicians managing the same patient (20.8%), which may lead to disorganized care (Table 4).

Table 4

MASLD referral pathway, multidisciplinary team approach, services provided, and follow-up in the MENA region

Variablesn = 130%
Does a referral care pathway exist for MASLD patients from primary to secondary/tertiary care in your country?
  Yes5139.2
  No7960.8
Are the referral pathways for MASLD patients from primary to secondary/tertiary care adhered to in your country? (n = 51)
  Yes3526.9
  No1612.3
How frequently are the referral pathways for MASLD patients from primary to secondary/tertiary care adhered to in your country? (n = 51)
  Frequently2317.7
  Sometimes2519.2
  Rarely32.3
How clear and well-defined are the referral pathways for MASLD patients from primary to secondary/tertiary care in your country? (n = 51)
  Unclear and difficult to follow107.7
  Moderately clear; some ambiguity3023.1
  Clear and easy to follow118.5
How would you rate the timeliness of the referral process for MASLD patients in ensuring timely access to specialized care? (n = 51)
  Very slow; significant delays53.8
  Slow; noticeable delays86.2
  Moderately timely; some delays2519.2
  Timely; minimal delays115.8
  Extremely timely; no delays21.5
How effective is the referral process in your country at ensuring that MASLD patients receive appropriate and timely specialized care? (n = 51)
  Ineffective86.2
  Moderately effective2620.0
  Effective1713.1
How frequently do unnecessary referrals occur for MASLD patients in your country? (n = 51)
  Very frequently53.8
  Frequently107.7
  Occasionally2620.0
  Infrequently107.7
What are the most common reasons for unnecessary referrals*
  Uncertainty regarding referral criteria3023.1
  Lack of awareness among PCPs regarding MASLD management2922.3
  Lack of access to diagnostic tools in primary care2015.4
  Inadequate communication between primary and secondary care providers1914.6
  Overestimation of disease severity by referring physicians1713.1
To what extent is a multidisciplinary team (MDT) approach used for managing MASLD patients across your country?
  Not at all used1813.8
  Used rarely5340.8
  Used sometimes4836.9
  Used frequently107.7
  Used very extensively10.8
Considering your own experiences in your practice, how effective would you say the MDT approach is in improving patient care coordination and outcomes for MASLD patients?
  Not at all effective43.1
  Minimally effective1310.0
  Moderately effective3526.9
  Highly effective5240.0
  Extremely effective2620.0
How easy is it to access specialists with expertise in MASLD management across your country?
  Very difficult to access21.5
  Difficult to access2519.2
  Moderately easy to access6247.7
  Easy to access3426.2
  Very easy to access75.4
Where do patients typically first access care for MASLD in your country?
  Internal Medicine Clinic3627.7
  Gastroenterology Clinic2519.2
  Hepatology Clinic2922.3
  MASLD Specialized Clinic10.8
  Endocrinology Clinic32.3
  Primary Care Clinic3627.7
When a patient is first diagnosed with MASLD, what services are typically provided at the initial point of contact?*
  Requesting basic laboratory investigations, including liver enzymes11689.2
  Fibrosis risk assessment7053.8
  Abdominal ultrasound examination11790.0
  Evaluation of obesity-related comorbidities7356.2
  Management of co-morbidities (DM, hypertension, and dyslipidemia)9371.5
  Referral to secondary or tertiary care3627.7
  All of the above10.8
Is there a system to ensure strict follow-up of MASLD patients after initial diagnosis and/or the start of treatment in your country?
  Yes2317.7
  No10782.3
In your opinion, what are the reasons for the lack of follow-up to diagnosed MASLD patients*
  High case volume4232.3
  Fragmented healthcare system6146.9
  Lack of disease awareness7557.7
  Lack of a reporting system4937.7
  Multiple physicians per patient2720.8

*Questions with multiple responses. MASLD, metabolic dysfunction-associated steatotic liver disease.

Countries such as Saudi Arabia and Turkey reported the highest adoption of MDT care models, while others, including Algeria and Lebanon, demonstrated more limited implementation. Similarly, structured referral pathways were more frequently reported in Gulf countries than in North African settings.

Healthcare professionals’ perceptions of effectiveness, challenges, and resources in MASLD MoCs and public awareness in the MENA region

Close to half of healthcare professionals (48.5%) believe that patients do not comply well with MASLD MoCs. The main reasons include lack of patient awareness (75.4%), disease underestimation by treating physicians (53.8%), and the high cost of investigations (30%). A notable 87.7% of respondents believe that there are insufficient studies on patient-reported outcomes (PROs) related to MASLD in their countries. When assessing the effectiveness of current MoCs, only 31.5% of respondents felt they adequately addressed MASLD, while 37.6% disagreed. Public awareness is also a major concern, with 56.9% of respondents rating it as low, 11.5% as very low, and only 1.5% considering it high. This underscores the need for nationwide awareness campaigns to improve early detection and patient engagement. In terms of patient education resources, websites are the most widely available (60%), while other tools such as brochures (32.3%), educational campaigns (30%), and support groups (10.8%) are less prevalent. Alarmingly, 22.3% of respondents reported no available resources at all.

Opinions on whether healthcare systems are well-equipped to manage MASLD are mixed, with only 37.7% believing their system is prepared. Major barriers to MASLD management include lack of awareness (48.5%), lack of national guidelines (45.4%), inadequate treatment options (40.8%), limited diagnostic access (39.2%), and insufficient funding (38.5%). Encouragingly, 48.5% of respondents believe that risk stratification is feasible in primary care; however, 27.6% disagreed, indicating ongoing challenges.

Regarding disparities in access to care, 42.3% of respondents observed moderate disparities, while 20% reported significant disparities. The biggest challenges to effective MASLD care include lack of patient awareness (76.9%), patient adherence issues (66.2%), insufficient physician knowledge of the disease (50%), resource limitations (48.5%), and lack of trained personnel (48.5%) (Table 5).

Table 5

Healthcare professionals’ perceptions on effectiveness, challenges, and resources of MASLD models of care and public awareness in the MENA region.

Do you think that patients in your country have good compliance with the existing MASLD model of care (MoC)?
  Strongly disagree86.2
  Disagree5542.3
  Neither agree nor disagree5441.5
  Agree1310.0
If not, what are the main reasons for poor patient compliance?*
  Lack of patient awareness9875.4
  Disease underestimation by the treating physician7053.8
  High cost of investigations3930.0
  Inconvenient access to care3627.7
  Cultural barriers3023.1
  Other (please specify)132.3
In your opinion, are there sufficient studies in your country measuring patient-reported outcomes (PROs) related to MASLD MoC application?
  Yes1612.3
  No11487.7
Do you think the currently available MoC adequately addresses the full spectrum of MASLD, including its various manifestations and complications?
  Strongly disagree53.8
  Disagree4433.8
  Neither agree nor disagree3930.0
  Agree4131.5
  Strongly agree10.8
How would you rate the level of public awareness regarding MASLD in your country?
  Very low1511.5
  Low7456.9
  Average3930.0
  High21.5
What resources are available for patient education on MASLD in your country?*
  Websites7860.0
  Brochures4232.3
  Educational campaigns3930.0
  Support groups1410.8
  No available resources at all2922.3
  Other (please specify)296.9
Do you think the healthcare system in your country is well-equipped to effectively manage MASLD?
  Strongly disagree75.4
  Disagree3023.1
  Neither agree nor disagree4433.8
  Agree4131.5
  Strongly agree86.2
If not well-equipped, select all that apply as causes for this:*
  Lack of awareness6348.5
  Lack of national guidelines5945.4
  Inadequate treatment options5340.8
  Limited access to diagnostic tools and technologies5139.2
  Insufficient funding5038.5
  Lack of trained personnel4836.9
  Lack of basic disease epidemiological data4736.2
  Inefficient referral systems4635.4
  Poor healthcare infrastructure2620.0
Considering available resources, it is easy to implement risk stratification for liver disease in primary care centers in your country:
  Strongly disagree53.8
  Disagree3123.8
  Neither agree nor disagree2620.0
  Agree6348.5
  Strongly agree53.8
Do you observe any disparities in access to diagnosis or treatment for MASLD among different demographic groups in your country?
  No disparities2317.7
  Minor disparities2317.7
  Moderate disparities5542.3
  Significant disparities2620.0
  Extreme disparities32.3
What are the main challenges to providing effective MASLD care across your country?*
  Lack of patient awareness10076.9
  Patient adherence to treatment8666.2
  Lack of physicians’ disease knowledge6550.0
  Resource limitations6348.5
  Lack of trained personnel6348.5
  Limited access to advanced technologies5340.8
  Insufficient funding4836.9
  Cultural factors3829.2
  Systemic barriers3627.7

*Questions with multiple responses. 1Lack of effective treatment, the disease is asymptomatic, and poor judgment. 2Social media (n = 4), media, posters, physician-dependent education, if they visit a doctor for another reason, the doctor informs them about MASLD, and organizations run by national liver and major gastroenterological associations. MASLD, metabolic dysfunction-associated steatotic liver disease; MoC(s), model(s) of care; PRO(s), patient-reported outcome(s).

Thematic analysis of recommended strategies

Qualitative responses from 77 healthcare professionals (59.2%) revealed a clear consensus on the need for a comprehensive, multidisciplinary, and policy-driven approach to MASLD preparedness and management in the MENA region. Key themes included the urgent development and implementation of national guidelines, integration into primary healthcare protocols, and the establishment of national committees to guide policy and research. Enhancing public and provider awareness through campaigns, medical education, and school-based initiatives was strongly emphasized. Respondents also advocated for strengthening primary care through early detection programs, training on MASLD risk stratification, and establishing clear referral pathways. Multidisciplinary MoCs involving hepatologists, endocrinologists, nutritionists, and surgeons were encouraged, alongside improved access to diagnostics, pharmacologic therapies, and bariatric surgery. Lifestyle-focused interventions, such as dietary programs and regulation of unhealthy food environments, were considered essential. Participants additionally emphasized the need for robust epidemiological research, MASLD registries, and inclusion in global collaborations. Finally, increased government funding, insurance coverage, and investment in health system infrastructure were identified as critical enablers of effective MASLD care. The thematic analysis of strategies recommended by healthcare professionals for MASLD preparedness and management in the MENA region is detailed in Supplementary Table 1.

Discussion

Our study highlights a substantial misalignment between the rapidly increasing burden of MASLD in the MENA region and the current capacity of healthcare systems to respond effectively. Key systemic shortcomings include the absence of national strategies, limited implementation of multidisciplinary MoCs, and fragmented referral and follow-up pathways.

Notably, 73.1% of respondents reported the absence of a national MASLD strategy in their countries, underscoring a critical policy void. This lack of strategic direction likely contributes to delayed diagnosis, suboptimal management, and inconsistent quality of care across the region. This trend is not unique to MENA: an extensive 2022 global analysis covering 102 countries similarly found no national or subnational MASLD action plans,13 reflecting the persistent underrecognition of MASLD in global public health agendas and its limited integration into broader health strategies addressing other metabolic comorbidities.13 Likewise, a 29-country European review found that none had adopted a national strategy for MASLD, and regional efforts such as the European NAFLD Registry, backed by the EU and EASL, remain primarily academic and lack integration into formal policy frameworks.14

MASLD also remains largely absent from major global health frameworks. Neither the World Health Organization’s Universal Health Coverage Initiative nor the United Nations Sustainable Development Goals explicitly address MASLD or its progressive form, metabolic dysfunction-associated steatohepatitis.15,16 Similarly, the World Health Organization’s Package of Essential Noncommunicable Disease Interventions for primary healthcare in low-resource settings only indirectly addresses MASLD, primarily through diabetes management recommendations.17

At the country level, the lack of formal clinical guidelines further compounds the challenge. In our study, only 35.4% of respondents, primarily from Turkey and Saudi Arabia, reported the existence of MASLD-specific national guidelines. This finding is consistent with the global analysis by Lazarus et al., which showed that just one of the 14 MENA countries included in the study had incorporated MASLD into national guidance.13 Furthermore, MASLD was mentioned in alcohol-related or obesity-related guidelines in only three and six countries, respectively, and appeared in dyslipidemia and hypertension guidelines in just two and three countries. By contrast, Latin America and North America have integrated MASLD into national guidelines in approximately half of their countries.13 This disparity highlights varying levels of governmental recognition and may contribute to fragmented or incomplete care in underrepresented regions.

In the absence of national guidelines, many surveyed countries rely on international recommendations, most commonly those from EASL and the American Association for the Study of Liver Diseases. This trend mirrors findings by Lazarus et al., who reported that twelve nations globally substitute local strategies with international guidelines.13 However, our results also revealed substantial variability in adherence to international recommendations, suggesting that evidence-based practices are inconsistently applied across the region. Reliance on external guidance without contextual adaptation reflects a fragmented approach to MASLD care and may compromise effectiveness within local healthcare systems.

Despite 60% of our respondents considering MDTs highly effective for MASLD management, they reported that implementation remains limited. This gap between recognized best practices and actual service delivery may be driven by institutional barriers such as inadequate coordination, workforce shortages, and financial constraints.

In most cases, MASLD care in our study begins in general internal medicine or primary care clinics but is subsequently confined to hepatology or gastroenterology services, with very few dedicated MASLD clinics reported. Even where expertise exists, access remains uneven: while 31.6% of respondents reported easy access to MASLD experts, 20.7% still found such access difficult. This disparity reflects the unequal distribution of specialists and varying levels of system readiness, contributing to delayed diagnosis and fragmented management.

Additional barriers cited by respondents include high patient volumes, fragmented care pathways, and limited awareness among both healthcare providers and patients. Together, these factors underscore the absence of integrated follow-up systems for MASLD, increasing the likelihood of uncoordinated care and poorer long-term outcomes.

Several international centers have demonstrated the effectiveness of integrated MDT models for managing MASLD. These models show how MDTs and risk-based referral systems can improve diagnostic precision, reduce unnecessary referrals, and enhance patient outcomes.18–20 While implementation varies, these examples offer scalable frameworks adaptable to MENA healthcare systems. Such multidisciplinary clinics provide integrated access to hepatology, endocrinology, cardiology, nutrition, and primary care services at a single site, enabling comprehensive, streamlined management. Virtual co-location through multidisciplinary teleconsultations and remote lifestyle interventions presents a scalable solution for expanding MASLD care in MENA, particularly in urban settings where physical integration may be challenging.21

The European Pathway Association defines a clinical care pathway as a structured, multidisciplinary intervention designed to coordinate care for a specific patient population over a defined period.22 A persistent barrier identified in our study is the lack of robust referral pathways, which are critical for effective MASLD care. Appropriate management depends on accurate risk stratification: patients with early-stage disease can often be managed in primary care, whereas those with advanced fibrosis or cirrhosis require specialist input at secondary or tertiary levels, potentially including transplant services.23,24

Primary care plays a pivotal role in identifying and managing non-advanced MASLD cases18,20; however, limited awareness among healthcare providers remains a major barrier.25 Despite the centrality of structured pathways and effective triage systems, our data highlight significant shortcomings: only 39.2% of respondents reported the presence of formal referral systems linking primary to secondary or tertiary care. Even when such systems exist, they are often inconsistently applied or poorly defined, leading to delays in specialist access and treatment initiation. These findings mirror results from a European study reporting widespread deficits in referral algorithms and structured lifestyle programs, underscoring systemic gaps in MASLD care across diverse health systems.14

Structured, risk-based referral pathways that use clear thresholds to guide triage demonstrate tangible benefits in improving efficiency, disease stratification, and equitable, timely access to specialist care.18,20,26 Nonetheless, implementation challenges persist, including inadequate GP training, limited financial resources, weak digital infrastructure, and poor integration of lifestyle services.

While liver biopsy remains the diagnostic gold standard, NITs such as FibroScan and FIB-4 are increasingly used for risk stratification owing to their practicality and strong negative predictive value.27–29 Our findings reflect this global shift toward non-invasive diagnostics. Most respondents reported using tools such as FibroScan and FIB-4, in line with EASL and AGA recommendations for a two-tiered NIT-based stratification strategy.30,31 However, access remains uneven: 26.2% of participants reported difficulty accessing FibroScan, highlighting the need to expand diagnostic capabilities, especially in resource-limited settings.

Equity in MASLD care also emerged as an implicit theme in our findings. Participants reported notable variations in access to diagnostic tools, multidisciplinary services, and referral pathways between urban and rural settings, as well as between public and private healthcare sectors. These disparities likely reflect broader systemic inequities in healthcare infrastructure, workforce distribution, and funding allocation across the MENA region. Addressing these gaps will require targeted strategies to ensure that advancements in MASLD care reach under-resourced settings, particularly by strengthening primary care capabilities and expanding access to non-invasive diagnostics beyond major urban centers. Socioeconomic, gender, and ethnic disparities further compound the challenges of MASLD care across the MENA region. While our study did not directly collect disaggregated data on these dimensions, prior research indicates that lower socioeconomic status is associated with increased MASLD prevalence and reduced access to non-invasive diagnostics and specialty care, particularly in rural and underserved areas.13 Women in certain MENA countries may face additional barriers due to gender-based healthcare access norms, underdiagnosis, and limited representation in clinical research.32 Moreover, ethnic minorities and migrant populations often lack access to comprehensive insurance coverage and culturally adapted health education, which may contribute to diagnostic delays and suboptimal adherence.33 These disparities highlight the need for more inclusive health system policies and the integration of equity indicators into future MASLD MoCs and regional surveillance efforts.

Lifestyle modification remains the cornerstone of MASLD treatment, and in our study, it was the most commonly utilized intervention. Non-FDA-approved pharmacotherapies, such as vitamin E and pioglitazone, were also frequently employed, while access to recently approved agents like resmetirom remained unavailable. However, the region’s limited participation in global clinical trials presents a major barrier to adopting evidence-based therapies tailored to local needs. This underrepresentation constrains the applicability of international treatment recommendations in MENA, where metabolic, genetic, and lifestyle factors may differ significantly.34 To bridge this gap, concerted efforts are needed to strengthen regional research networks, streamline regulatory pathways, and increase clinician and patient engagement in research. These actions would not only improve access to emerging therapies but also ensure that future treatment strategies are informed by, and responsive to, regional realities.

Our findings reveal substantial deficiencies in current MASLD MoCs. Nearly half of surveyed healthcare professionals reported poor patient adherence, frequently attributing this to low disease awareness, underrecognition by non-specialists, and the high cost of diagnostic evaluation. These observations align with existing studies showing widespread underdiagnosis of MASLD by non-hepatology providers and limited public awareness of the disease.35,36

Additionally, 87.7% of respondents noted the lack of PRO research, and only 31.5% believed that current MoCs adequately address MASLD. While validated PRO tools, such as the CLDQ-NAFLD and NASH-CHECK, are available to assess symptoms and health-related quality of life,37,38 their limited integration into routine practice reflects missed opportunities for patient-centered care.

Public education efforts also appear insufficient. Websites are the most commonly reported educational resource; however, brochures, awareness campaigns, and outreach materials remain scarce, with over 22% of respondents indicating no patient education tools at all. These findings call for stronger public health strategies, enhanced provider training, and improved communication pathways. Echoing this, a study by Lazarus et al. reported that only 24% of countries had funded liver disease awareness campaigns, and few had active advocacy groups for MASLD, contributing to delayed diagnosis and suboptimal adherence.13

Beyond awareness, reducing stigma within clinical environments can promote shared decision-making and greater patient engagement.21 Digital innovations, such as the NAFLD Simulator, can aid in visualizing disease progression and guiding treatment choices. Integration of such tools into healthcare systems could improve health literacy, empower patients, and support evidence-based decision-making by clinicians.39

This study provides important insights into MASLD care across the MENA region, underpinned by strong participation and broad geographic representation spanning 17 countries. It reflects the perspectives of clinicians from MASLD-related specialties and sheds light on key diagnostic, policy, and treatment challenges confronting health systems in the region. While the number of participants varied by country, this heterogeneity does not compromise the value of the data. The study’s primary objective was to gather informed, context-specific insights into national MASLD care structures and barriers. In this regard, even a single knowledgeable respondent can yield meaningful information about policy frameworks, system capacity, and clinical pathways. Accordingly, the study prioritized broad geographic inclusion over equal numerical representation, enabling the identification of both inter-country differences and region-wide trends.

Nevertheless, some limitations should be acknowledged. The reliance on self-reported data introduces the possibility of perceptual bias, and the exclusive focus on clinical stakeholders omits the views of other key factors such as patients, policymakers, and allied health professionals. Furthermore, the cross-sectional design provides only a temporal snapshot, limiting the ability to assess longitudinal trends. Despite these constraints, the findings provide a robust and timely foundation for developing targeted, context-sensitive strategies to enhance MASLD care delivery and system preparedness across the region.

Conclusions

This study reveals substantial gaps in MASLD care across the MENA region, including limited national strategies, weak guideline implementation, underutilized multidisciplinary collaboration, and fragmented referral systems. Despite these deficiencies, the insights gathered from regional experts highlight both systemic challenges and actionable opportunities for improvement. Advancing MASLD care in the region will require more than medical interventions; it demands a paradigm shift that strengthens health system capacity, fosters responsive policy development, and builds human resource capabilities. The collective voices of frontline clinicians reflect a strong readiness for system transformation. Their call to action underscores the urgency of integrated national strategies, patient-centered multidisciplinary care, expanded public education, and robust health system preparedness. A shift from reactive measures to proactive, structured approaches is essential to ensure timely diagnosis, long-term management, and equitable access to care for MASLD patients across MENA.

Supporting information

Supplementary Table 1

Thematic analysis of strategies recommended by healthcare professionals for MASLD preparedness and management in the MENA region.

(DOCX)

Click here for additional data file.

Declarations

Acknowledgement

The authors acknowledge the contributions of the SLMENA collaborators. The complete list of contributors and their institutional affiliations is provided below. Contributors list – Steatotic Liver Disease Study Foundation in Middle East and North Africa (SLMENA) Collaborators: Faisal Abaalkhail (Gastroenterology Department, King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Saudi Arabia), Nermeen Abdeen (Tropical Medicine Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt), Aliaa Abdel Wahed (Hepatology and Gastroenterology Department, National Liver Institute, Shebin Elkom, Egypt), Ehab Abdelatti (Internal Medicine Department, Faculty of Medicine, Menoufia University, Menoufia, Egypt), Sara Abdelhakam (Tropical Medicine Department, Ain Shams University, Cairo, Egypt), Walaa Abdelhamed (Tropical Medicine and Gastroenterology Department, Sohag University, Sohag, Egypt), Mohamed Abdel-Samiee (Hepatology and Gastroenterology Department, National Liver Institute, Shebin Elkom, Egypt), Nakhli Abdelwahab (Gastroenterology Department, Mongi Slim Hospital, Faculté de médecine de Tunis, Tunis, Tunisia), Mosaab Abdulkarim (Gastroenterology Department, BGC Clinic, Tripoli, Libya), Abdalraouf Abdulsalam (Gastroenterology Department, Central Hospital, Tripoli, Libya), Raed Abughosh (Outpatient Clinic, Raed Abughosh Clinic, Amman, Jordan), Imad Abumallouh (Medical Department, Medical City for Military and Security Services, Muscat, Oman), Gupse Adali (Gastroenterology and Hepatology Department, University of Health Sciences, Umraniye Training and Research Hospital, Istanbul, Türkiye), Meral Akdogan Kayhan (Gastroenterology Department, Bilkent City Hospital, Health Science University, Ankara, Türkiye), Murat Akyildiz (Gastroenterology and Hepatology Department, Koc University School of Medicine, Istanbul, Türkiye), Al Warith Al Hashmi (Hepatobiliary and Liver Transplant Department, Royal Hospital, Muscat, Oman), Maimouna Al Mandhari (Hepatobiliary and Liver Transplant Department, Royal Hospital, Muscat, Oman), Halima Al Shuaili (Medical Department, Medical City for Military and Security Services, Muscat, Oman), Siham Al Sinani (Pediatrics Department, University Medical City, Muscat, Oman), Abduljaleel Alalwan (Hepatobiliary and Liver Transplant Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia), Hamad Alashgar (Gastroenterology Department, King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Saudi Arabia), Saad Aldosari (Gastroenterology Department, King Abdulaziz Medical City, Jeddah, Saudi Arabia), Zaid Alezzi (Gastroenterology Department, Sana’a University, Sana’a, Yemen), Abdullah Alghamdi (Gastroenterology Unit, Medical Department, King Fahad Hospital, Jeddah, Saudi Arabia), Waleed Alghamdi (Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia), Mansour Alghanem (Gastroenterology Department, Jaber Hospital, Alzahra, Kuwait), Abeer Al-Gharabally (Thunayan Al Ghanim Gastroenterology Centre, Amiri Hospital, Kuwait City, Kuwait), Waleed Al-hamoudi (Medicine Department, King Saud University, Riyadh, Saudi Arabia), Mohammed Aljawad (Gastroenterology Department, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia), Bandar Aljudaibi (Gastroenterology Department, King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Saudi Arabia), Abdulrahman Aljumah (Gastroenterology Department, Dr. Sulaiman Al-Habib Medical Group - Al Rayan Hospital, Riyadh, Saudi Arabia), Abdullah Alkalbani (Medical Department, Medical City for Military and Security Services, Muscat, Oman), Majed Almaghrabi (Gastroenterology Section, Department of Medicine, National Guard Hospital, Jeddah, Saudi Arabia), Fahd Almalki (Medicine Department, Umm Al-Qura University, Makkah, Saudi Arabia), Faisal Alotaibi (Gastroenterology and Hepatology Department, King Fahad Medical City, Riyadh, Saudi Arabia), Ashraf Alsahafi (Pediatric Department, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia), Marwan Alsari (Gastroenterology Department, Central Hospital, Tripoli, Libya), Omar Alsiyabi (Hepatobiliary and Liver Transplant Department, Royal Hospital, Muscat, Oman), Ibrahim Altraif (Gastroenterology and Hepatology Department, Sulaiman Fakeeh Hospital, Riyadh, Saudi Arabia), Adnan Alzanbagi (Gastroenterology Department, King Abdullah Medical City, Makkah, Saudi Arabia), Derya Arı (Gastroenterology Department, Bilkent City Hospital, Health Science University, Ankara, Türkiye), Cigdem Arikan (Gastroenterology and Hepatology Department, Koc University School of Medicine, Istanbul, Türkiye), Fehmi Ateş (Gastroenterology Department, Mersin University, Mersin, Turkey), Myriam Ayari (Gastroenterology Department, Internal Security Forces Hospital, La Marsa, Tunis, Tunisia), Mohamed Babatin (Medicine Department, King Fahad Hospital, Jeddah, Saudi Arabia), Razan Bader (Liver Transplant Department, King Fahad Specialist Hospital, Dammam, Saudi Arabia), Gamal Badra (Hepatology and Gastroenterology Department, National Liver Institute, Shebin Elkom, Egypt), Yasemin Balaban (Gastroenterology Department, Hacettepe University, Ankara, Turkey), Metin Basaranoglu (Gastroenterology Department, Bezmialem Vakif University, Istanbul, Turkey), Nadia Ben Mustapha (Gastroenterology Department A, La Rabta Hospital, Tunis, Tunisia), Syrine Ben rhouma (Gastroenterology Department, Regional Hospital, Kef, Tunisia), Khalid Bzeizi (Gastroenterology Department, King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Saudi Arabia), Ali Çalışkan (Department of Gastroenterology, Adıyaman University, Adıyaman, Turkey), Arif Cosar (Gastroenterology Department, Karadeniz Technical University, Trabzon, Türkiye), Coskun Demirtas (Gastroenterology Department, Marmara University, Istanbul, Turkey), Dinc Dincer (Gastroenterology Department, Akdeniz University, Antalya, Turkey), Tamer Elbaz (Endemic Medicine Department, Cairo University, Cairo/Giza, Egypt), Yahya Elhamdi (Gastroenterology Department, Central Hospital, Tripoli, Libya), Eman Elkhateeb (Hepatology and Gastroenterology Department, National Liver Institute, Shebin Elkom, Egypt), Hamdy Elsobky (Hepatology and Gastroenterology Department, National Liver Institute, Shebin Elkom, Egypt), Aşkın Erdoğan (Department of Internal Medicine, Gastroenterology, Alanya Alaaddin Keykubat University, Alanya, Türkiye), Fatih Eren (Gastroenterology Department, Marmara University, Istanbul, Turkey), Hasan Eruzun (Gastroenterology Department, Samsun Training and Research Hospital, Samsun, Türkiye), Hanaa Fathelbab (Endemic Medicine Department, Minia University, Minia, Egypt), Magdy Fouad (Endemic Medicine Department, Minia University, Minia, Egypt), Hale Gökcan (Gastroenterology Department, Ankara University, Ankara, Turkey), Donia Gouiaa (Gastroenterology Department A, La Rabta Hospital, Tunis, Tunisia), Fulya Gunsar (Gastroenterology Department, Ege University, İzmir, Turkey), Wafa Haddad (Private Gastroenterology Practice, Tunis, Tunisia), Aya Hammami (Gastroenterology Department, University Hospital of Sahloul, Sousse, Tunisia), Lamine Hamzaoui (Gastroenterology Department, Mohamed Taher Maamouri Hospital, Nabeul, Tunisia), zekiye harput (Gastroenterology Department, Mersin University, Mersin, Turkey), Fuad Hasan (Department of Medicine, Kuwait University, Kuwait), Gdoura Hela (Gastroenterology Department, Université of Sfax, Sfax, Tunisia), Amal Helmy (Endemic Medicine Department, Cairo University, Cairo/Giza, Egypt), Boussourra Houda (Gastroenterology Department, Ghazela Medical Center, Ariana, Tunisia), Mona Ismail (Division of Gastroenterology, Department of Internal Medicine, Imam Abdulrahman bin Faisal University, Dammam, Saudi Arabia), Zülal İstemihan (Gastroenterology Department, Niğde Ömer Halisdemir University Training and Research Hospital, Niğde, Türkiye), Hanene Jeddi (Private Practice, Djerba, Tunisia), Mohamed Ali Jouini (Private Practice, Kélibia, Tunisia), Enas Kamal (Endemic Medicine Department, Minia University, Minia, Egypt), Bola Kamath (Medical Department, Medical City for Military and Security Services, Muscat, Oman), Banu Kara (Gastroenterology Clinic, Adana City Research and Education Hospital, Adana, Turkey), Caglayan Keklikkiran (Department of Gastroenterology, Recep Tayyip Erdogan University, Rize, Türkiye), Abdullah Khathlan (Gastroenterology and Hepatology Department, King Fahad Medical City, Riyadh, Saudi Arabia), Amal Khsiba (Gastroenterology Department, Mohamed Taher Maamouri Hospital, Nabeul, Tunisia), Murat Kiyici (Gastroenterology Department, Uludag University, Bursa, Türkiye), Hana Kodia (Private Practice, Ariana, Tunisia), Sarra Laabidi (Gastroenterology Department A, La Rabta Hospital, Tunis, Tunisia), Abdulnabi Masoud (Medicine Department, Sabha Central Hospital, Sabha, Libya), Khaled Matar (Gastroenterology Unit, European Gaza Hospital, Gaza, Palestine), Mohammad Mawardi (Gastroenterology Department, King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Saudi Arabia), Ashik Sainu (Gastroenterology Department, Aster Royal Hospital, Muscat, Oman), Asma Salah (Private Gastroenterology and Hepatology Practice, Kébili, Tunisia), İlker Şen (Gastroenterology Department, Şişli Hamidiye Etfal Education and Research Hospital, Istanbul, Türkiye), Meriem serghini (Gastroenterology Department A, La Rabta Hospital, Tunis, Tunisia), Hend Shousha (Endemic Medicine Department, Cairo University, Cairo/Giza, Egypt), Ben Hamida Sonia (Gastroenterology Department, Habib Bougatfa Hospital, Bizerte, Tunisia), Mina Tharwat (Tropical Medicine and Gastroenterology Department, Aswan University, Aswan, Egypt), Nurdan Tozun (Gastroenterology Department, Acibadem Mehmet Ali Aydınlar University, Istanbul, Türkiye), Ilker Turan (Gastroenterology Department, Ege University, İzmir, Turkey), Dilara Turan Gökçe (Department of Gastroenterology, Sincan Training and Research Hospital, Ankara, Türkiye), Haythem Yacoub (Gastroenterology Department A, La Rabta Hospital, Tunis, Tunisia), Mohamed Yacoub (Gastroenterology and Hepatology Department, Farwaneya Hospital, Farwaneya, Kuwait), Suna Yapali (Gastroenterology Department, Acibadem Mehmet Ali Aydınlar University, Istanbul, Türkiye), Hasan Yılmaz (Gastroenterology and Hepatology Institute, Kocaeli University, İzmit, Türkiye), Khalid Zaalook (Medicine Department, Sabha Central Hospital, Sabha, Libya), Doaa Zakaria (Tropical Medicine Department, Ain Shams University, Cairo, Egypt), Samy Zaky (Hepatogastroenterology and Infectious Diseases Department, Al-Azhar University, Cairo, Egypt), Essam Zayed (Hepatology and Gastroenterology Department, National Liver Institute, Shebin Elkom, Egypt), AbdElaali Zein El Imene (Private Practice, Tunis, Tunisia), Shahrazed Zemmouchi (Internal Medicine Department, Bainem’s Hospital, Algiers, Algeria), Mustapha Benazzouz (Hepatogastroenterology Department, Rabat International University, Rabat, Morocco)

Ethical statement

The study was approved by the Research Ethics Committee of the Faculty of Medicine, Helwan University, Cairo, Egypt (Serial 152-2024). Before beginning the survey, participants were informed of the study’s purpose, their eligibility, and the voluntary nature of participation. Informed consent was obtained electronically prior to survey access.

Data sharing statement

Deidentified participant-level data, the questionnaire, the codebook, and analysis code are available from the corresponding author on reasonable request for non-commercial academic use, subject to SLMENA Data Access Committee review and a data use agreement. Aggregate results are provided in the article and Supplementary material.

Funding

None to declare.

Conflict of interest

MEK has been an Editorial Board Member of Journal of Clinical and Translational Hepatology since 2021. The other authors have no conflict of interests related to this publication.

Authors’ contributions

Study design (MEK, ME, ZMY, KMA); creating, piloting, and disseminating the survey (YY, AL, MAL, FMS, MWIA, ND, AT, IW, HEK, MOM, AIS, AEH, MAS, MT); writing the first draft of the manuscript (RK, MAM, KAA, ANE, MEK). All authors revised and approved the final version of the manuscript.

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El-Kassas M, AlNaamani KM, Khalifa R, Yilmaz Y, Labidi A, Almattooq M, et al. Mapping Metabolic Dysfunction-associated Steatotic Liver Disease Models of Care across 17 Middle East and North Africa Countries: Insights into Guidelines, Infrastructure, and Referral Systems. J Clin Transl Hepatol. Published online: Sep 1, 2025. doi: 10.14218/JCTH.2025.00286.
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Article History
Received Revised Accepted Published
June 14, 2025 August 2, 2025 August 9, 2025 September 1, 2025
DOI http://dx.doi.org/10.14218/JCTH.2025.00286
  • Journal of Clinical and Translational Hepatology
  • pISSN 2225-0719
  • eISSN 2310-8819
  • © 2025 Xia & He Publishing Inc.
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Mapping Metabolic Dysfunction-associated Steatotic Liver Disease Models of Care across 17 Middle East and North Africa Countries: Insights into Guidelines, Infrastructure, and Referral Systems

Mohamed El-Kassas, Khalid M. AlNaamani, Rofida Khalifa, Yusuf Yilmaz, Asma Labidi, Maen Almattooq, Faisal M. Sanai, Maisam W.I. Akroush Nabil Debzi, Mohammed A. Medhat, Imam Waked, Ali Tumi, Mohamed Elbadry, Mohammed Omer Mohammed, Ala I. Sharara, Ali El Houni, Mohamed Alsenbesy, Hisham El-Khayat, Mina Tharwat, Abdel-Naser Elzouki, Khalid A. Alswat, Zobair M. Younossi, on behalf of the Steatotic Liver Disease Study Foundation in Middle East and North Africa (SLMENA) Collaborators
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