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Medscape
42 minutes ago
- Medscape
ADA Issues New MASLD Guidelines
A new consensus report from the American Diabetes Association (ADA) provides a practice-oriented framework for screening and managing metabolic dysfunction–associated steatotic liver disease (MASLD) in people with diabetes and prediabetes. Published online on May 28, 2025, in Diabetes Care, the report is a comprehensive update to the recommendations the ADA released in 2023. It is intended for clinicians treating patients with diabetes — primarily type 2 diabetes (T2D) — but also type 1 diabetes with obesity and prediabetes. Topics covered include the rationale for the recent change in terminology, epidemiology, fibrosis risk stratification, monitoring, treatment, and referral guidance, with interprofessional team management emphasized throughout. 'This will provide primary care doctors and anyone taking care of people with diabetes the tools to diagnose [MASLD] early and guide therapy…to prevent cirrhosis, and refer to the hepatologist as needed for additional therapy and monitoring,' lead author Kenneth Cusi, MD, professor of medicine at the Division of Endocrinology, Diabetes & Metabolism in the Department of Medicine at the University of Florida, Gainesville, Florida, told Medscape Medical News . The guidelines recommend that clinicians routinely screen people with T2D or prediabetes for MASLD. 'We explain that the liver should be incorporated into our management in the same way we do for chronic kidney disease, eye disease, and nerve disease as an end-organ damage that is particularly affected by diabetes,' Cusi said. In the United States, at least 70% of people with T2D have MASLD, about half of whom have the more progressive form termed metabolic dysfunction–associated steatohepatitis (MASH). About 1 in 5 with T2D have advanced liver fibrosis. The presence of MASH increases the risks for complications including cirrhosis, hepatocellular carcinoma, and overall mortality, according to the new consensus report. Liver disease has not been a focus of diabetes management until recently, Cusi noted. 'We didn't think about it. The epidemic of obesity, and with that, of diabetes, is driving this liver disease. The obesity epidemic has had a big worsening since the 1990s, so this damage in the past 20 or 30 years is just now becoming evident in the liver.' Terminology Change: Highlighting Insulin Resistance, Reducing Stigma The document reviews the current nomenclature for SLD, which was officially changed in 2023 to remove the words 'fatty' and 'alcoholic.' Now, MASLD is defined as the presence of SLD with at least one metabolic risk factor such as obesity, hypertension, prediabetes, high triglycerides, low high-density lipoprotein cholesterol, or T2D, with minimal or no alcohol consumption (< 20 g/d for women; < 30 g/d for men). The term 'MetALD' is used for those with MASLD who also have increased alcohol consumption (20-50 g/d for women; 30-60 g/day for men). Steatosis in the setting of alcohol consumption above those levels is termed 'alcohol-associated liver disease (ALD).' The term MASH is defined as steatohepatitis with at least one metabolic risk factor and minimal alcohol consumption. 'At-risk MASH' refers to steatohepatitis with clinically significant fibrosis (stage F2 or higher). Diagnosis: Staged Screening for Fibrosis The document recommends routine screening of people with T2D, prediabetes, and/or obesity with cardiovascular risk factors, with the goal of identifying those with high-risk MASH. Intervention is then aimed at preventing fibrosis progression and cirrhosis. A graphic diagnostic algorithm advises initial use of the noninvasive Fibrosis-4 (FIB-4) tool, which risk stratifies based on age, liver enzymes, and platelet count. 'The FIB-4 is composed of very simple things that are already in the electronic medical record of all patients. We also discuss the role of electronic medical records to improve implementation,' Cusi said. Those with a FIB-4 < 1.3 have a low risk for future cirrhosis and can be managed in primary or team care with optimized lifestyle and repeated FIB-4 every 1-2 years. If the FIB-4 is > 2.67, direct referral to a liver specialist is advised. If FIB-4 is between 1.3 and 2.67, a second risk-stratification test is recommended. Ideally, this would be a liver stiffness measurement (LSM), most commonly with transient elastography. If that is unavailable, an alternative is the noninvasive enhanced liver fibrosis (ELF) test. If the LSM is < 8.0 kPa or ELF is < 7.7, the fibrosis risk is low and routine management can continue with repeat testing in 1-2 years. But if higher, hepatology referral is recommended. Treatment: Lifestyle, Plus Old and New Drugs The report details lifestyle modification for MASLD, including nutrition plans; physical activity; behavioral health; and the role of diabetes self-management, education and support. The role of obesity treatment in people with MASLD, both metabolic surgery and pharmacotherapy, is also discussed at length. No current pharmacologic treatments have been approved for MASLD, but both semaglutide and tirzepatide have demonstrated benefit in treating MASH and are approved for treating T2D, obesity, and other related comorbidities. A thyroid hormone receptor beta agonist, resmetirom, was approved in early 2024 for the treatment of MASH with fibrosis stages F2 and F3, but is extremely expensive at about $50,000 a year, Cusi noted. An older, generic glucose-lowering drug, pioglitazone, has also shown benefit in reducing fibrosis and may be a lower-cost alternative. The document also includes a section on alcohol intake, which complicates the MASLD picture, Cusi noted. 'We think that this is going to help doctors to consider alcohol, which is often overlooked and under-reported. If patients have moderate fibrosis, they should completely quit alcohol.' Cusi has received research support (to his institution) from Boehringer Ingelheim, Echosens, Inventiva, Labcorp, and Perspectum, and has served as a consultant for Aligos Therapeutics, Arrowhead, AstraZeneca, 89bio, Bristol-Myers Squibb, Boehringer Ingelheim, Eli Lilly, GlaxoSmithKline, Novo Nordisk, ProSciento, Sagimet Biosciences, Siemens USA, Zealand Pharma, and Terns Pharmaceuticals.
Fast Company
43 minutes ago
- Fast Company
A winding new bridge connects Honolulu's downtown to the beach
Honolulu's coastal Ala Moana Boulevard is a critical road in the Hawaiian capital, but it's also a major hindrance. With six lanes of fast-moving traffic and few easily accessible crossing points, it's effectively a hurdle between the city and its main public space, Ala Moana Park, and the broad beach there. Now, a stunning new pedestrian bridge has opened to make it easier to cross that rushing road. Winding its way from the edge of downtown Honolulu over the highway to a boat harbor and the corner of Ala Moana Park, the pedestrian bridge is an elegant piece of urban infrastructure, accented by artwork and connected to a series of paths cutting through a lush tropical landscape. It's part of Victoria Ward Park, a two-phase publicly accessible open space connected to Ward Village, the 60-acre mixed use development that aims to redefine the urban realm in this part of the city. Developed by Howard Hughes, Ward Village is a blank slate development on former warehouse land that will add, over the course of decades, more than 5,000 units of housing, nearly 1 million square feet of retail, and more than three acres of public greenspace. Several condo buildings are fully occupied and many future condos are already pre-sold, representing more than $6 billion in revenue, according to Howard Hughes' 2024 annual report. Beyond its Honolulu project, the company made more than $1.75 billion in revenue in 2024, according to Pitchbook. Building a bridge to downtown Greenspace, primarily in the form of Victoria Ward Park, is a key part of the company's strategy for luring residents and businesses, and turning Ward Village into a new model for urban development in Honolulu. 'A goal for Ward Village is to make the overall neighborhood significantly more walkable, comfortable, and safe,' says Doug Johnstone, president of the Hawaii region for Howard Hughes. Born and raised in Honolulu, Johnstone says that while the city is full of world-class amenities, its urban realm can sometimes be lacking. 'It's inherently a little disjointed and difficult to get around,' Johnstone says. That's why the Ward Village development—estimated to cost several billion dollars over a planned implementation period that runs through the 2030s—set aside the space for the park, and spent a considerable amount of time coordinating with state and local officials to get the pedestrian bridge built. Costing a total of $17.8 million, the bridge is technically a project of the state's Department of Transportation. It was mostly funded by a federal grant, and Howard Hughes helped pay for the 20% portion of the budget required from local sources, donating land, funding the bridge design and providing environmental documentation. 'There's a lot of folks wearing different hats that are trying to see it through, and making sure also it's done well aesthetically and experience-wise,' Johnstone says. 'It's complementary to what we're doing in Ward Village, but also something Honolulu can be proud of.' Ocean-to-inland Making the bridge possible is the existence of Victoria Ward Park, which was designed by Vita Planning and Landscape Architecture. The first phase of the park covers 1.4 acres from the edge of Ala Moana Boulevard inland, and is now open. The second phase, covering roughly 2 acres higher inland and more nestled in the Ward Village development, will finish construction later this year. This ocean-to-inland connection became a guiding concept for the Honolulu park's design, according to Don Vita, founder of Vita Planning and Landscape Architecture. 'Going back and forth from the ocean up to the mountains is a very important cultural orientation in Hawaii and that's exactly what we did with the configuration and the location of the park,' he says. The section of the park closest to the ocean is more of a natural experience, inspired by the ecology of the region and the plants that were brought to Hawaii on canoes by its first settlers. Connecting to the pedestrian bridge, there are winding paths that slope up through this section of the park, passing by densely planted section and water features that reference the brackish ponds that would form on the shoreline. A large berm was created at the edge of the park as it approaches Ala Moana Boulevard, referencing the beach sand but also forming a buffer. 'It encloses the space so that you could have this very calming respite from the active urban activities that Honolulu offers,' Vita says. Higher up in the development and bisected by a road, the second section of the park will be more active, with space for vendors, events, and a playground. Having a street go through the space 'at first was kind of a challenge,' Vita says. 'We thought about it and it actually helped to tell the story of a passive and a more active space, and helped define those accordingly.' Creating publicly accessible space has become a strategy for Howard Hughes, which has included more than 270 parks and recreation spaces within its community development projects across the U.S., including in Summerlin, Nevada, and in the Houston area. In Honolulu, the new park space expands that ethos. But it's still in a bit of a gray zone as a privately-owned space that is publicly accessible. Vita says that unique condition influenced the design of the park and he creation of what he calls visual permeability. 'When people feel they're in a place that others are looking at them, they tend to behave a little better,' he says. 'Along with that visual permeability there's actual physical permeability. We made the spaces very free flowing so it doesn't feel you can't come here.' Making a new connection to the beach—and, conversely, reconnecting the beach to the city—is a way of giving downtown residents more access to the natural amenities of the area without expanding the city's developmental footprint or sprawling beyond its edges. 'What we've been doing over the years is trying to really advance smart growth in Honolulu,' Johnstone says. 'We want to really protect the environment and things that make it special and unique… The saying goes, if you want to keep the country country, you need to make the town town. And we're doing a bit of that here.'
Travel Weekly
an hour ago
- Travel Weekly
Hilton and Ford partner to transform Michigan Central Station into the NoMad Detroit
Hilton has unveiled plans to open a NoMad hotel inside Detroit's Michigan Central Station. The luxury hotel will be developed through a partnership with Ford Motor Company, which acquired Michigan Central Station in 2018. The hotel will be part of The Station at Michigan Central, a former passenger rail terminal that's being redeveloped into a district that will have retail, public parks, outdoor plazas and 1.2 million square feet of commercial space across multiple restored historic buildings. According to Hilton, the project will involve a "careful renovation" of the station. Detroit's passenger rail service ended in 1988. The largely vacant building fell into disrepair before being acquired by Ford. Hilton acquired NoMad last year and plans to rapidly grow the NoMad brand. In addition to the NoMad Detroit, Hilton said it has 15-plus deals in various stages of development globally. Those plans include the 173-room NoMad Singapore, which is expected to open in 2027. The new NoMad properties will join the flag's one hotel, the NoMad London, which opened in 2021. Hilton has accelerated the addition luxury and lifestyle hotels. The company expects to add three luxury and lifestyle hotels per week through 2025; more than 150 openings are planned worldwide this year. Hilton has approximately 1,000 luxury and lifestyle hotels globally across several brands, including Curio Collection, Tapestry Collection, Waldorf Astoria, LXR, Conrad, Graduate, Canopy, Signia, Motto and Tempo.
