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. 2024 Oct 29;4(1):219.
doi: 10.1038/s43856-024-00649-x.

Disparities in steatosis prevalence in the United States by Race or Ethnicity according to the 2023 criteria

Luis Antonio Díaz  1   2   3   4 , Jeffrey V Lazarus  4   5   6 , Eduardo Fuentes-López  7 , Francisco Idalsoaga  2   8 , Gustavo Ayares  2 , Hailemichael Desaleng  8 , Pojsakorn Danpanichkul  9 , Thomas G Cotter  10 , Winston Dunn  11 , Francisco Barrera  2 , Karn Wijarnpreecha  12   13   14 , Mazen Noureddin  15 , Naim Alkhouri  16 , Ashwani K Singal  17 , Robert J Wong  18 , Zobair M Younossi  4   19   20   21 , Mary E Rinella  22 , Patrick S Kamath  23 , Ramon Bataller  24 , Rohit Loomba  1 , Marco Arrese  2   3   4 , Juan Pablo Arab  25   26   27   28
Affiliations

Disparities in steatosis prevalence in the United States by Race or Ethnicity according to the 2023 criteria

Luis Antonio Díaz et al. Commun Med (Lond). .

Abstract

Introduction: The 2023 nomenclature defined criteria for steatotic liver disease (SLD), including metabolic dysfunction-associated SLD (MASLD), alcohol-associated liver disease (ALD), and the overlapping MASLD/ALD (MetALD). We aimed to assess racial and ethnic disparities in the SLD prevalence among United States (US) adults based on this new nomenclature.

Methods: We undertook a cross-sectional study employing the 2017-2018 National Health and Nutrition Examination Survey (NHANES) database. We identified SLD according to a controlled attenuation parameter ≥288 dB/m, liver stiffness ≥7.2 kPa, or elevated aminotransferase levels. Alcohol use thresholds were established according to the updated SLD definition. We estimated prevalences using the complex design of the NHANES survey. Multivariable logistic regressions with complex design weights were employed.

Results: A total of 5532 individuals are included. The mean age is 45.4 years, and 50.9% are women. The adjusted estimated prevalence of MASLD is 42.4% (95% CI: 41.1-43.8%), MetALD 1.7% (95% CI: 1.3-2.0%), and ALD 0.6% (95% CI: 0.3-0.8%). Hispanics exhibit a higher prevalence of SLD, but there are no significant differences in advanced fibrosis prevalence due to SLD among racial/ethnic groups. In MASLD, men, individuals aged 40-64 and ≥65 years, Hispanics, those with health insurance, higher BMI, diabetes, hypertension, hypertriglyceridemia, and low high-density lipoprotein (HDL) cholesterol or use of lipid-lowering agents are independently associated with a higher risk, while Blacks have the lowest risk. In MetALD, men and higher BMI are independently associated with a higher risk of MetALD in adjusted multivariable analysis. In ALD, the adjusted multivariable analysis shows that only health insurance is independently associated with a lower ALD risk.

Conclusions: MASLD prevalence is high in the US, especially in men, older individuals, and Hispanics. MetALD and ALD prevalence was substantial but could be underestimated.

Plain language summary

This study aims to estimate the prevalence of different types of fatty liver disease, in which excess fat occurs in the liver. A particular type of fatty liver disease that is not caused by excess alcohol consumption affects 42.4% of adults in the USA, with men, older adults, and Hispanics being more likely to have this form of liver disease. People with health insurance are less likely to have liver disease caused by excess alcohol consumption. These results highlight the importance of targeted prevention efforts in people with a higher risk of developing liver disease. Future public health strategies should focus on reducing risk factors and providing equitable healthcare access.

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Conflict of interest statement

Rohit Loomba serves as a consultant to Aardvark Therapeutics, Altimmune, Arrowhead Pharmaceuticals, AstraZeneca, Cascade Pharmaceuticals, Eli Lilly, Gilead, Glympse Bio, Inipharma, Intercept, Inventiva, Ionis, Janssen Inc., Lipidio, Madrigal, Neurobo, Novo Nordisk, Merck, Pfizer, Sagimet, 89 bio, Takeda, Terns Pharmaceuticals and Viking Therapeutics. Rohit Loomba has stock options in Sagimet biosciences. In addition, his institution received research grants from Arrowhead Pharmaceuticals, Astrazeneca, Boehringer-Ingelheim, Bristol-Myers Squibb, Eli Lilly, Galectin Therapeutics, Gilead, Intercept, Hanmi, Intercept, Inventiva, Ionis, Janssen, Madrigal Pharmaceuticals, Merck, Novo Nordisk, Pfizer, Sonic Incytes and Terns Pharmaceuticals. Rohit Loomba is a co-founder of LipoNexus Inc. Other authors declare that they have no conflicts of interest.

Figures

Fig. 1
Fig. 1. Unadjusted prevalence of fibrosis stage in individuals with metabolic dysfunction-associated steatotic liver disease (MASLD), alcohol-associated liver disease (ALD), and overlapping MASLD and ALD (MetALD).
Estimations include a the prevalence according to the pre-specified criteria, and b the prevalence obtained in the sensitivity analysis. Thresholds for fibrosis staging were based on liver stiffness measurements, including significant fibrosis (F2) ≥ 8.2 kPa, advanced fibrosis (F3) ≥ 9.7 kPa, and cirrhosis (F4) ≥ 13.6 kPa. Sensitivity analysis identified steatotic liver disease based on CAP ≥ 288 dB/m or LSM ≥ 7.2 kPa exclusively. The numerical data used to plot this figure is available in Supplementary Data 2.
Fig. 2
Fig. 2. Prevalence of steatotic liver disease (SLD) and liver fibrosis by age and race/ethnicity.
a Adjusted prevalence of SLD and b prevalence of advanced fibrosis according to age and race/ethnicity in individuals aged 15 years or older in the United States (2017–2018). Models were adjusted by age and sex, and error bars represent 95% confidence intervals.
Fig. 3
Fig. 3. Unadjusted prevalence of steatotic liver disease (SLD) and advanced fibrosis according to the presence of excess weight and abnormal glucose metabolism in the United States (2017–2018).
a SLD prevalence according to the presence of excess weight; b SLD prevalence according to abnormal glucose metabolism and type 2 diabetes mellitus (T2DM); c advanced fibrosis prevalence according to the presence of excess weight; and d advanced fibrosis prevalence according to abnormal glucose metabolism and T2DM. We defined abnormal glucose metabolism as fasting glucose ≥100 mg/dL, or 2-hour post-load glucose levels ≥140 mg/dL, glycated hemoglobin ≥5.7%, T2DM, or treatment for T2DM, while increased adiposity and excess weight were described as a BMI ≥ 25 kg/m² (≥23 kg/m² in Asian populations) or elevated waist circumference (>94 cm for men and >80 cm for women). Error bars represent the 95% confidence interval from estimations using the complex design of the survey. The numerical data used to plot this figure is available in Supplementary Data 2.
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