Perspectives of gastroenterologists on the evolving epidemiology and management of non-alcoholic fatty liver disease in Pakistan: a qualitative study.

OBJECTIVES: To explore gastroenterologists' perspectives on the changing epidemiology of non-alcoholic fatty liver disease (NAFLD) in Pakistan and identify barriers to its diagnosis and management. DESIGN: Qualitative exploratory study using face-to-face semi-structured in-depth interviews. SETTINGS: Public and private healthcare settings in Islamabad, Rawalpindi and surrounding regions of Pakistan. PARTICIPANTS: 22 consultant gastroenterologists and postgraduate trainees in gastroenterology registered with the Pakistan Medical and Dental Council, with over 2 years of clinical experience managing patients with NAFLD. Participants were recruited through purposive sampling. PRIMARY AND SECONDARY OUTCOMES: Primary outcomes included physicians' perceptions of epidemiological changes, risk factors, clinical presentation patterns and barriers to NAFLD care. Secondary outcomes included proposed strategies for prevention and management. RESULTS: Five major themes emerged from thematic analysis: (1) changing epidemiology-alarming rises in prevalence, demographic shift toward younger adults (20-30 years), and increasing presentation with advanced disease; (2) multifactorial risk factors-poor diet, sedentary lifestyle, metabolic comorbidities including diabetes and obesity, hypertension and genetic-hormonal influences; (3) clinical presentation-asymptomatic early disease with incidental detection, non-specific symptoms, and distinct gender-occupational patterns (housewives, post-menopausal women, sedentary professionals); (4) significant barriers to care-profound patient unawareness, poor compliance with lifestyle modifications, diagnostic limitations (FibroScan unavailability) and financial constraints restricting access to advanced diagnostics and pharmacotherapy (pharmacotherapy including newer agents such as Resmetirom for metabolic dysfunction-associated steatohepatitis); (5) proposed strategies-public awareness campaigns, targeted screening programmes, lifestyle modification and multidisciplinary collaborative care models. CONCLUSION: NAFLD in Pakistan represents a silent epidemic with alarming epidemiological shifts towards younger populations and advanced disease. Urgent implementation of multifaceted strategies including public awareness campaigns, targeted screening of at-risk populations and multidisciplinary collaborative care models is imperative.