A 22-year-old came to my office because he wanted to “get on track” with his health.

He was not in crisis. He did not feel sick. His labs were concerning, but not unusual for primary care: triglycerides in the 250s, a hemoglobin A1C near the diabetic range, elevated blood pressure and central obesity.

Then I reviewed his liver stiffness measurement. F3 fibrosis.

That result was hard to believe. Over time, it prompted me to reconsider how I evaluate metabolic risk in my practice.

We manage metabolic dysfunction every day. But are we consistently evaluating its organ-level consequences, especially in the liver where fibrosis may already be advancing silently?

A familiar pattern, with an incomplete picture

In my clinic, roughly half of adult patients present with some form of metabolic dysfunction. Obesity, prediabetes, diabetes, dyslipidemia and hypertension often cluster together in the same person. Globally, metabolic dysfunction-associated steatotic liver disease (MASLD) affects nearly one in three adults.

For years, my approach to liver assessment was typical. If alanine aminotransferase (ALT) or aspartate aminotransferase (AST) were elevated, I ordered additional labs, ruled out viral or autoimmune causes, sometimes obtained an ultrasound and counseled weight loss. If enzymes were normal, I felt reasonably reassured.

Liver enzymes do not stage fibrosis, and meaningful scarring can exist despite normal transaminases. Ultrasound confirms steatosis but does not measure fibrosis severity. That leaves uncertainty. We recognize metabolic risk, but we may not fully understand its impact on the liver.

American Association for the Study of Liver Diseases (AASLD) guidance underscores the importance of structured risk stratification in patients with suspected MASLD, including noninvasive assessment of fibrosis risk to determine who can be managed in primary care and who warrants specialty referral. Because fibrosis stage carries prognostic weight, relying only on liver enzymes or ultrasound can miss meaningful disease.

Why this matters now

Metabolic disease is appearing earlier in life. I routinely see insulin resistance, elevated triglycerides, and hypertension in patients in their late teens and twenties. Many feel entirely well. Most report no symptoms. Still, the underlying physiology progresses quietly.

The 22-year-old with F3 fibrosis was not ill in the traditional sense. He was metabolically dysregulated, and his liver reflected that reality.

At the same time, glucagon-like peptide-1 (GLP-1) receptor agonists and other agents are reshaping how we manage weight and glycemic risk. As we treat metabolic disease more proactively, we should also be clear about how it is affecting the liver. If the liver is among the first organs affected by insulin resistance, fibrosis assessment may deserve a more consistent place in the evaluation of high-risk metabolic patients.

MASLD as cardiometabolic disease

MASLD shares the same risk factors we manage every day in primary care. The lifestyle changes and medications we use for cardiometabolic disease influence liver health as well.

Seen this way, liver health is not separate from primary care. It is a direct reflection of cardiometabolic risk. Ignoring fibrosis risk means missing a key indicator of disease progression already within our scope to manage.

In my practice, adding structured fibrosis risk assessment has refined how I manage that picture. I have identified advanced fibrosis in patients whose laboratory values did not fully reflect their risk. Referral decisions have become more intentional, with high-risk patients co-managed earlier and lower-risk patients followed with defined intervals.

Conversations have also shifted. When fibrosis risk is quantified, discussions move from abstract lab abnormalities to clearer next steps.

Noninvasive tools such as vibration-controlled transient elastography can support that assessment at the point of care. The process is straightforward and adds objective information to clinical decision-making. Instead of suggesting repeat labs in six months, I can explain a patient’s fibrosis risk and outline a more precise plan.

Right patient, right level of care

Hepatology resources remain limited, and workforce projections suggest continued strain in the years ahead. Structured risk stratification supports more thoughtful collaboration between primary care and specialty care. Patients with low fibrosis risk can often be managed effectively within primary care through focused metabolic intervention. Those with advanced fibrosis can be referred with greater urgency and clarity.

This approach does not shift responsibility. It aligns it. Specialty care remains essential, particularly for advanced disease. Primary care, meanwhile, continues to serve as the foundation for prevention and longitudinal management.

An evolving standard

We routinely use hemoglobin A1C to guide diabetes care. We stage chronic kidney disease with estimated glomerular filtration rate (eGFR). We estimate cardiovascular risk to inform treatment decisions.

As our understanding of MASLD advances, it becomes increasingly difficult to ignore fibrosis risk in patients with clear metabolic dysfunction. Our diagnostic approaches should evolve alongside our therapeutic tools.

The aim is not indiscriminate testing. It is thoughtful alignment. When we describe our work as preventive medicine, our assessments should reflect the complications we hope to prevent.

The 22-year-old who prompted this reflection is now several months into a coordinated care plan. He has lost significant weight and reports feeling better. His liver findings led to earlier specialty involvement and more targeted intervention than I might otherwise have pursued.

His case does not suggest that every patient requires fibrosis assessment. It does suggest that metabolic disease extends beyond laboratory values. Organ-level insight can meaningfully shape care.

Primary care has always adapted as evidence evolves. As metabolic disease becomes more prevalent and appears earlier in life, integrating structured fibrosis risk assessment into metabolic care may represent a natural and responsible progression.

Radhika Vayani is an internal medicine physician.