MASLD/MASH in Spain

A liver health policy brief

This country profile offers an overview of the current policy landscape of metabolic dysfunction-associated steatotic liver disease (MASLD) and metabolic dysfunction-associated steatohepatitis (MASH) in Spain.

MASLD comprises a spectrum of chronic liver disease ranging from simple fat deposits in the liver (hepatic steatosis) to inflammation and liver fibrosis, potentially progressing to cirrhosis, hepatocellular carcinoma (HCC), and end-stage liver disease.1

Over the past four decades, the prevalence of MASLD has increased markedly alongside the obesity epidemic and the increase in metabolic syndrome, positioning it as the most common chronic liver disease worldwide. A recent systematic review estimated its global prevalence at 32.4% in the general population.2 Approximately one in five individuals with MASLD will progress to MASH, a more severe inflammatory form that can lead to cirrhosis and HCC.3,4 Importantly, the clinical impact of MASLD extends beyond liver-specific complications. It plays an important role in systemic morbidity and mortality, contributing to cardiovascular, metabolic, and extrahepatic neoplastic diseases.5 This is partly due to its complex and bidirectional relationship with components of metabolic syndrome. For instance, while type 2 diabetes (T2D) is a major risk factor for hepatic progression, MASLD itself worsens glycemic control and increases the risk of both microvascular and macrovascular complications.6

Beyond its health implications, MASLD is also associated with a considerable decline in health-related quality of life and imposes a substantial burden on healthcare systems.7 Despite its growing significance, MASLD and MASH remain under-recognised in health policy agendas.8 This profile provides policy information on MASLD/MASH in Spain and recommends new policy actions.

  1. In 2021, there were an estimated 8 (7.3–8.7) million people, 18.3% (16.7-8) of all ages, living with MASLD in Spain9, with an estimated 21% increase to 12.7 million people (27.6% of the population) by 2030.10
  2. In 2016, MASH cases were estimated at 1.8 million (3.9% of the population), with a 49% increase to 2.7 million expected people (5.9% of the population) by 2030.10
  3. The prevalence rate of MASLD in children is likely to be between 5% and 10% in the general population.11
  4. MASH was the direct cause of death for 3,260 people in 2016 and is expected to be the cause of death for 7,590 people in 2030, i.e., a 133% increase in MASH mortality.10
  5. Data from a population-based Spanish cohort between 2015 and 2020 showed that people living with MASH and fibrosis (stages F2-F3) constituted 1.33% (95% CI 0.29-5.98) of the general population, while approximately 0.70% (95% CI 0.10-4.95) had cirrhosis.12
  6. In 2021, the estimated number of liver cancer cases due to MASH was 419 (281-610).9
  7. Direct healthcare costs associated with MASH are expected to more than double from $1.48 billion in 2021 to $3.5 billion in 2040, indicating a 136% increase​.13

  1. In 2023, diabetes (all types, diagnosed) prevalence of 7.6% was registered in the general population,14 with some previous estimates as high as 14% (diagnosed and undiagnosed).15
  2. In 2022, the age-adjusted mortality rate due to diabetes (all types) was 19.6 per 100,000 inhabitants.14
  3. In 2024, the age-standardised prevalence of diabetes (all types) in people aged 20-79, including those undiagnosed, was 9.7%.16
  4. In 2024, the proportion of diabetes-related deaths (all types) in people aged 20-79 was 13.7%, with 22,125 deaths due to diabetes.16
  5. The estimated prevalence of pre-diabetes is 23.4% (95% CI 20.2 – 26.6%) and of T2D is 6.5%.17
  6. For children with MASLD who did not have T2D at baseline, the incidence rate of T2D was 3000 cases per 100,000 person-years, for an annual incident rate of 3% in children enrolled in the NASH CRN.18

  1. According to the Spanish National Statistics Institute (INE), in 2022, 34.3% of the adult population was classified as having overweight and 14.1% as having obesity.19
  2. In 2025, the estimated impact of overweight and obesity on GDP is -2.3%.20
  3. An estimated 37.0% of adults may have obesity in 2035.20
  4. The ENE-COVID study, conducted in 2020 with a representative sample of the Spanish population aged 2 to 17 years, revealed that 30% of children and adolescents had excess weight, with 10.7% meeting criteria for obesity.21
  5. The ALADINO 2023 study reported that among children aged 6 to 9 years, 23.3% had overweight and 17.3% had obese.22
  6. This panorama situates Spain as the ninth country in Europe with one of the highest prevalences of excess weight.23

Current snapshot of MASLD/MASH guidelines, policy and integration in Spain

  • Yes
  • No

Guidelines

  • Guidelines on clinical assessment and management of MASLD/MASH24

  • Active case finding and surveillance covered by MASLD/MASH guideline24

  • Diagnosis covered by MASLD/MASH guideline24

  • Treatment and management covered by MASLD/MASH guideline24

Policy and integration

  • MASLD/MASH specific policies/acts are in place25

  • MASLD/MASH included across NCD policy26,27

  • Evidence of integration with other NCDs at strategic level (federal, state, city)26,27

  • Mention of MASLD/MASH included across other NCD strategies: mentioned within diabetes,28,29 CVD,30 and obesity31 strategies

Key policy recommendations for MASLD/MASH in Spain

  1. Launch a Ministry of Health-led whole-of-government strategy
  2. Create a national MASLD registry, cohort, or observatory
  3. Add MASLD/MASH as an indicator to the list of Key Health System Indicators
  4. Increase awareness and education of MASLD/MASH among at-risk groups and healthcare professionals
  5. Leverage electronic health records (EHR) through integrated automated diagnostic tools
  6. Strengthen the capacity of community health services to prevent and treat MASLD through social prescribing

Launch a Ministry of Health-led whole-of-government strategy

Create a national MASLD registry, cohort, or observatory

Add MASLD/MASH as an indicator to the list of Key Health System Indicators

Increase awareness and education of MASLD/MASH among at-risk groups and healthcare professionals

Leverage electronic health records (EHR) through integrated automated diagnostic tools

Strengthen the capacity of community health services to prevent and treat MASLD through social prescribing

  • Biomedical Research Network for Diabetes and Associated Metabolic Diseases (CIBERDEM)
  • Biomedical Research Network for Liver and Digestive Diseases (CIBEREHD)
  • Biomedical Research Network for Obesity and Nutrition (CIBEROBN)
  • General Council of Official Nursing Colleges of Spain
  • Diabetes Study Group in Primary Health Care (GEDAPS)
  • Spanish Association for the Study of the liver (AEEH)
  • Spanish Public Health Society (SESPAS)
  • Spanish Society for the Study of Obesity (SEEDO)
  • Spanish Society of Diabetes (SED)
  • Spanish Society of Digestive Pathology (SEPD)
  • Spanish Society of Endocrinology and Nutrition (SEEN)
  • Spanish Society of Family and Community Medicine (semFYC)
  • Spanish Society of General and Family Physicians (SEMG)
  • Spanish Society of Preventive Medicine, Public Health and Healthcare Management (SEMPSPGS)
  • Spanish Society of Primary Care Physicians (SEMERGEN)

This policy brief was initiated by Jeffrey V. Lazarus (director of the Global Think-tank on Steatotic Liver Disease and professor, CUNY SPH and ISGlobal). Trenton M. White (post-doctoral research at ISGlobal) led the writing with input from Paula Iruzubieta Coz (Gastroenterology and Hepatology Department, Marqués de Valdecilla University Hospital, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL)), Javier Crespo Garcia (professor of Medicine, Universidad de Cantabria y Instituto de Investigación Valdecilla), Dídac Mauricio (Global Think-tank on Steatotic Liver Disease local chair and director of the Department of Endocrinology & Nutrition, CIBERDEM, IR Sant Pau, Hospital de la Santa Creu i Sant Pau and professor in the Faculty of Medicine, University of Vic – Central University of Catalonia), Juan M. Pericàs (Liver Unit, Vall d’Hebron University Hospital; VHIR; Universitat Autònoma de Barcelona; Centros de Investigación Biomédica en Red, Enfermedades Hepáticas y Digestivas (CIBERehd)), Juan Manuel Mendive (family physician, La Mina Primary Health Care Academic Centre, University of Barcelona), Manuel Romero Gomez (Global Think-tank on Steatotic Liver Disease scientific committee member, UCM Digestive Diseases, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla (HUVR/CSIC/US), Department of Medicine, University of Seville; Centro De Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)), Miguel A. Rubio (Department of Endocrinology & Nutrition. Hospital Clínico San Carlos (IDISSC)), Núria Alonso (Department of Endocrinology and Nutrition. Hospital Universitari Germans Trias i Pujol, Badalona; Institut d’Investigació en Ciències de la Salut Germans Trias i Pujol; Autonomous University of Barcelona), Jordi Gracia-Sancho (Liver Vascular Biology Lab, IDIBAPS Research Institute – Hospital Clínic de Barcelona – CIBEREHD), Jose M. Martin-Moreno (Professor of Preventive Medicine and Public Health, University of Valencia & Innovative Health Management, Foundation for Health and Economics), Elisa Pose (Liver Unit, Hospital Clinic de Barcelona), and Gema Fruhbeck Martínez (Obesity Area of Clínica University of Navarra, CCUN, CIBEROBN, IdiSNA, Pamplona).