Playing the Long Game: SingHealth’s Lifelong Approach to Liver Care

When Elizabeth (not patient’s real name) was 16, she did not think she had a liver problem.

She had gone to a SingHealth Polyclinics complaining of abdominal cramps and irregular periods — the sort of routine appointment many teenagers make. Instead, she was referred to KK Women's and Children's Hospital (KKH) for further evaluation. A scan showed a “bright liver”, an imaging finding that suggests fat accumulation, and blood tests revealed her alanine aminotransferase (ALT) levels were three times above normal. She was told she had excess weight, was prediabetic — and confused.

“I don’t drink. I didn’t feel sick,” she remembered thinking.

Elizabeth was diagnosed with metabolic associated steatotic liver disease (MASLD), a chronic condition in which excess fat builds up in the liver due to metabolic factors such as obesity, insulin resistance, and abnormal blood sugar or cholesterol levels — not alcohol use. In its early stages, MASLD rarely causes symptoms, but over time, it can lead to liver inflammation, scarring and, in severe cases, liver failure if left unmanaged.

Elizabeth’s story is becoming increasingly common in Singapore.

A silent condition, detected early

Rising childhood obesity rates have driven a sharp increase in MASLD among children. According to a study by KKH, about 25 in every 1,000 children seen at the hospital are now affected — a 14‑fold increase since 2003.

What makes MASLD concerning is how subtly it develops. Most children show no symptoms, and the condition is often discovered incidentally, as it was for Elizabeth. By the time liver enzymes rise or imaging changes appear, significant metabolic changes may already be underway.

At KKH, Elizabeth was seen by the paediatric hepatology team. “In children, MASLD is not just a liver problem and a significant proportion of patients present also with other manifestations of the metabolic syndrome such as dyslipidaemia, diabetes, and hypertension even in childhood,” explains Dr Chiou Fang Kuan, Head and Senior Consultant, Department of Gastroenterology, Hepatology and Nutrition Service at KKH. “It sits within a broader metabolic and behavioural context, and that often involves the entire family. A family‑centred approach addresses the lifestyle factors that contribute to the condition and provides opportunities for prevention and long‑term management.”

For most young patients, care is delivered through a coordinated, multidisciplinary approach. For Elizabeth, her care plan was anchored in a structured weight management programme involving paediatricians, hepatologists and endocrinologists. At home, her family adjusted her diet with guidance from a dietitian, and she began regular sessions with an exercise physiologist.

By the end of the first year, her liver health had improved.

Preparing early for adulthood

Even while Elizabeth was still in her mid‑teens, conversations about her future care had already begun. Unlike acute illnesses that resolve, MASLD is a condition that unfolds over decades. Improvements can be sustained, but relapses are possible if metabolic risks return.

To ensure continuity, KKH prepares adolescents early for transition to adult care at Singapore General Hospital (SGH). This is enabled by the Paediatric Onset Liver Disease (POLD) transition programme, which ensures that care does not reset at adulthood. From around age 15, patients are guided to take ownership of their condition – learning their diagnosis, managing appointments, and speaking independently during consultations.

At 18, Elizabeth was introduced to her future adult hepatologist together with her KKH paediatric team. Her medical history, care plan, and progress were already familiar to the adult team, supported by shared electronic medical records across SingHealth.

“This matters,” says Dr Victoria Ekstrom, Clinical Assistant Professor, Department of Gastroenterology & Hepatology at SGH. “Families meet the new doctor while still within the institution that has cared for them for years. The unfamiliar adult clinician is introduced by the familiar paediatrician.” Patients and families are also reassured when they see the close working relationship between the paediatric and adult hepatologists in the clinic.

It is not a one-off handover, but a sustained, coordinated effort. By the time Elizabeth’s care came under SGH at 21 years old, the move felt less like a handover — and more like a continuation.

For Elizabeth, adulthood brought new challenges. She started working night shifts — and soon missed appointments. Instead of discharging her from care, the team reached out to understand why. Once they learned about her work schedule, appointments were shifted to earlier time slots to accommodate Elizabeth’s routine.

Mental health and social context are addressed alongside medical management, recognising that emotional stress, work patterns, and life transitions can directly affect long‑term outcomes.

Staying the course

Today, Elizabeth is 25. Her liver condition is stable. She remains under follow‑up, but now reaches out early when issues arise. MASLD has not disappeared from her life, but it does not define her.

Her journey illustrates what managing MASLD requires: not a single intervention, but a system designed to evolve with the patient.

MASLD is a disease that develops quietly and progresses slowly. The care that manages it must do the same — staying consistent, adaptive, and connected over decades.

For patients like Elizabeth and the SingHealth team, that is what it means to truly play the long game.