28-29 GLP-1

The conversation about GLP-1 receptor agonists has been dominated by the number on the bathroom scale.

Weight loss is real, visible and easy to communicate, and it has carried these medicines into the public imagination faster than almost any drug class in living memory.

But it is a reductive way to think about what they do. Framing semaglutide and its peers as weight loss drugs sells short their most important promise – the treatment of metabolic dysfunction.

The scale measures weight in stones or kilograms. Being overweight is a sign of the metabolic dysfunction that underpins obesity. GLP-1 treats the metabolic disease of obesity. The weight loss is a marker of something deeper.

By improving insulin sensitivity, reducing visceral and ectopic fat, and lowering systemic inflammation, GLP-1 receptor agonists act on the biology that drives heart attacks, strokes and type 2 diabetes.

The landscape around GLP-1 is ever changing and almost daily there is discussion in the media about how it may help other health issues such as drug addiction, alcoholism and even reduce cancer risk.

Whilst most of these indications are in the early stages of research, one condition supported by high-quality evidence makes the case plainly for use of GLP-1s beyond obesity. Fatty liver disease, also known as metabolic dysfunction-associated steatotic liver disease or MASLD, is that condition.

MASLD is the most common chronic liver disease in the world. Recent global analysis puts adult prevalence at around 38%, and in the UK the British Liver Trust estimates that it affects roughly one in five people.

It is a population-level metabolic problem that happens to show up in the liver. MASLD is also quiet. It is typically asymptomatic until late, which means it is widely underdiagnosed and the true prevalence is almost certainly higher than the headline figures suggest.

Normal liver blood tests do not rule it out – up to a quarter of patients with clinically significant fibrosis have normal ALT and AST. Left unchecked, a proportion of patients progress through inflammation, known as steatohepatitis or MASH, to fibrosis, cirrhosis and, in the worst cases, liver failure or liver cancer.

MASLD is now one of the fastest-growing reasons for liver transplantation worldwide. Yet the liver is rarely where these patients meet their end.

The leading cause of death in MASLD is cardiovascular disease, not liver disease.

The condition travels with type 2 diabetes, hypertension, dyslipidaemia and chronic kidney disease, each compounding the others.

Around two-thirds of people with type 2 diabetes also have fatty liver. This is exactly why MASLD illustrates the broader argument so clearly – treat the metabolic dysfunction behind it.

The benefit is not confined to the liver; it also extends to the heart, the vasculature and the pancreas.

For a disease this common and this consequential, the care pathway has, until very recently, offered very little. For years the only options were lifestyle modification and watchful monitoring.

These matter, and meaningful weight loss can halt and even reverse early liver damage, but they ask a great deal of patients and deliver inconsistently at scale.

When disease is more advanced, guidance points towards specialist hepatology assessment. In practice that referral is hard to obtain.

NHS gastroenterology waits commonly run from 18 to 52 weeks, and a hepatologist appointment can take several months, during which the disease can progress silently.

What makes this moment different is that the therapeutic gap is closing. In August 2025 the US Food and Drug Administration granted accelerated approval to semaglutide 2.4mg (Wegovy) for MASH with moderate to advanced (F2 to F3) fibrosis, the first GLP-1 receptor agonist licensed for the indication.

The approval rested on the phase 3 ESSENCE trial, in which 62.9% of patients on semaglutide achieved resolution of steatohepatitis without worsening of fibrosis, against 34.3% on placebo, alongside fibrosis improvement and the cardiometabolic benefits the class is known for.

By the standards of a field defined by decades of failed trials, that is a genuinely effective treatment.

In the UK, the picture is more complicated. Wegovy is MHRA-licensed for weight management and cardiovascular risk reduction, but not yet for MASH.

Prescribing it for liver disease here is therefore off-label, which in practice confines it to a small number of hepatologists in the private sector.

NHS commissioning of MASH pharmacotherapy typically follows NICE guidance, and the relevant NICE update is not expected until 2027.

As a result, we have arrived at an odd and frustrating place – an effective, evidence-based treatment exists and clinicians know it works, but many of the patients who would benefit cannot access it.

This is where a different kind of provider can help. The diagnostic and treatment pathway for fatty liver is fragmented, split across blood tests, imaging, fibrosis staging and the management of multiple comorbidities that rarely sit in one place.

Bringing those elements together into a single, structured and comparatively accessible service would let far more patients be identified, risk-stratified using validated non-invasive tools, and managed appropriately, without an 18-month wait or an unaffordable bill.

I am passionate about building integrated metabolic care that treats fatty liver as the systemic condition, at a price point that opens the door to many more people than the current options allow.

There is another prize too. A service of this kind, delivered consistently and documented carefully, generates real-world evidence on how these treatments perform outside the trial setting, in the patients that clinicians actually see.

This means that a private consumer health service that goes beyond a well-known brand can offer a meaningful contribution to the literature and to the national conversation about how this disease should be managed.

The wider point is the one we started with. If we keep talking about GLP-1 medicines as a way to move a number on the scale, we will keep underusing them.

If we talk about them as treatments for metabolic dysfunction, fatty liver is one of the most compelling places to begin – one of the clearest opportunities to solve for an unmet patient need and broaden the public and clinician understanding of how GLP-1s are one of the sharpest tools we have to prevent cardiovascular and metabolic disease.

Common disease hiding in plain sight

Care pathway with a hole in the middle

Treatment has arrived, access has not

Closing the gap and learning while we do