As the NASH pandemic grows in the number and diversity of patient cases, one patient group receiving increased notice includes patients with “lean NASH,” those with “normal” BMI levels (BMI<23 for Asians; BMI<25 for other racial groups). Last month, Gastroenterology published Best Practice recommendations for diagnosing and treating lean NASH. In this conversation, co-authors, Drs. Michelle Long and Mazen Noureddin join Louise Campbell and Roger Green to discuss the development of the one-page algorithm that lies at the heart of this publication. This conversation starts with Mazen Noureddin pointing out specific elements of the algorithm "that we're proud of." He notes that they start by identifying two specific patient groups they chose to focus on based in part on cost-effectiveness analysis: patients with Type 2 Diabetes and patients over age 40. They rely on the dominant diagnostic paths, which they recommend following with FibroScan. They recommend confirming the diagnosis with MRI or biopsy if there is any doubt. Most important, they pull all this information into a one-page algorithm that incorporates recommendations for primary care or endocrinology (pre-diagnosis) with hepatologists (post-diagnosis for patients with NASH and Fibrosis Level 2 or higher). They also discuss other tests of more recent development: MAST, FAST, MEFIB, cT1 and other multi-parametric measures. Louise compliments the publication for its simplicity and clarity. She also notes approvingly that it recommends repeat testing every 6 months to two years, depending on the level of fibrosis. This is a more frequent schedule than the 3-5 years most commonly recommended by other algorithms. She likes not only the increased frequency but also the stratification of test frequency based on the level of risk. Michelle agrees strongly. She notes that with a 3-5 year follow-up recommendation, many patients will be lost to follow-up. Mazen goes on to note that with T2D patients, physicians check annually for eye, kidney or neurological complications. He asks why FIB-4 should not be added to that list. Louise identifies another benefit: patients are more likely to realize when they have not had their annual tests, whereas they are less likely to recall after a three-year gap. The rest of the conversation centers around reasons that a 6-12 month recommendation makes more sense while requiring little additional time or spending. When Roger suggests that a rationale for 3-5 year testing might be so that payers are not concerned about the likely downstream costs, Mazen notes that based on his research and assessment, annual will be cost effective.