Low awareness of MASLD among U.S. adults: Trends from NHANES 2017–2023
Year: 2025
Type: article
Abstract: INTRODUCTION Metabolically dysfunction–associated steatotic liver disease (MASLD) is a silent but growing epidemic worldwide, particularly in the United States. While most individuals remain asymptomatic during early stages, progression to metabolic dysfunction–associated steatohepatitis (MASH) and fibrosis carries substantial morbidity and limits opportunities for timely intervention.1 The COVID-19 pandemic likely accelerated this burden by exacerbating metabolic risk factors through increased sedentary behavior, unhealthy diet, and obesity.2 The approval of resmetirom, the first FDA-approved therapy for MASH with significant to advanced fibrosis (F2–F3), marks a major step toward disease modification. Yet, effective management still largely depends on patients’ disease awareness, given its asymptomatic nature. Without awareness, patients are unlikely to seek evaluation, undergo testing for risk stratification, adopt lifestyle changes, or be considered for pharmacologic therapy. An analysis of the National Health and Nutrition Examination Survey (NHANES) 2001–2016 revealed that >95% of individuals with suspected MASLD were unaware of their condition.3 In this study, we aimed to assess the prevalence of MASLD, the degree of fibrosis and resmetirom eligibility, the impact of the COVID-19 pandemic, self-reported disease awareness, and its associated factors. METHODS This study utilized the NHANES data cycle 2017–2020 and 2021–2023, a nationally representative survey of the noninstitutionalized U.S. population conducted by the National Center for Health Statistics (NCHS), which included vibration-controlled transient elastography (VCTE) data. The NHANES study protocol was approved by the NCHS Research Ethics Review Board; the 2017–2020 cycle was designated “pre-pandemic” as field operations were suspended in March 2020 due to COVID-19, and 2021–2023 cycle as “late-pandemic,” reflecting resumed operations during a period of largely normalized healthcare access and behavior. Adults aged ≥18 with valid VCTE and body mass index (BMI) were included. MASLD was defined as presence of hepatic steatosis (controlled attenuation parameter >274 dB/m)4 with ≥1 cardiometabolic risk factor: BMI >25 (non-Asians) or >23 (Asians) kg/m2; prediabetes/diabetes or antidiabetics use; hypertension (BP >130/85 mmHg) or antihypertensives use; triglycerides >150 mg/dL or antihyperlipidemics use; or HDL <40 (men) or <50 (women) mg/dL or antihyperlipidemics use.5 Participants with viral hepatitis and significant alcohol intake (≥20 g/day women, ≥30 g/day men) were excluded. Compensated advanced chronic liver disease (cACLD) was defined as liver stiffness (LS) ≥15 kPa. Clinically significant portal hypertension (CSPH) was defined as LS ≥25 kPa, LS 21–25 with platelets <150×109/L, or LS 15–20 with platelets <110×109/L.6 Individuals with MASLD and LS 8–15 kPa were considered resmetirom-eligible in this study.7 The proportion of participants with MASLD with and without resmetirom eligibility and cACLD was calculated. Liver disease awareness was assessed using self-reported responses to the questionnaire. Factors associated with awareness among individuals with MASLD were evaluated using logistic regression. Details of the survey design and sampling methods are available on the NHANES website.8,9 All statistical analyses were performed using SAS 9.4 (SAS Institute Inc.). RESULTS A total of 13,190 U.S. adults with valid VCTE and BMI were included, representing ~219 million (M) individuals after applying survey weights (133.2M pre-pandemic and 85.8M late-pandemic). The weighted prevalence of hepatic steatosis was 42.2% (95% CI: 40.5%–43.9%) pre-pandemic and 39.7% (95% CI: 37.5%–42.0%) late-pandemic (p=0.08). Among those with steatosis, 91.4% (95% CI: 89.8%–93.0%) pre-pandemic and 90.5% (95% CI: 88.7%–92.3%) late-pandemic met MASLD criteria, corresponding to 50.5M and 30.4M U.S. adults, respectively. Age, sex, BMI, and race/ethnicity did not differ significantly between periods. Most individuals with MASLD had LS <8 kPa: 83.0% (95% CI: 80.0%–86.1%) pre-pandemic and 79.1% (95% CI: 76.9%–81.3%) late-pandemic (p=0.04). The prevalence of MASLD-related cACLD increased from 3.7% (95% CI: 2.6%–4.7%) pre-pandemic to 5.4% (95% CI: 4.1%–6.7%) late-pandemic (p=0.03). CSPH was present in 1.5% (95% CI: 0.9%–2.2%) pre-pandemic and 1.9% (95% CI: 0.9%–3.0%) late-pandemic (p=0.51). Resmetirom eligibility among adults with MASLD was 13.3% (95% CI: 10.8%–15.9%) pre-pandemic and 15.7% (95% CI: 14.0%–17.3%) late-pandemic (p=0.14), reflecting 6.7M and 4.8M U.S. adults, respectively (Table 1). TABLE 1 - Characteristics of eligible U.S. adults with MASLD in pre-pandemic and late-pandemic eras Characteristic Pre-pandemic (2017–March 2020) Late-pandemic (Aug 2021–Aug 2023) p Number of U.S. residents with MASLD [in millions (SE)] 50.5 (1.7) 30.4 (1.2) — Age [y (SE)]a 50.7 (0.6) 50.5 (0.5) 0.87 Male [% (95% CI)] 55.0 (52.0, 58.0) 53.7 (51.8, 55.7) 0.47 Race/ethnicity [% (95% CI)] Mexican American 12.1 (8.7, 15.5) 9.6 (3.7, 15.4) 0.63 Other Hispanic 7.6 (5.8, 9.3) 10.5 (7.1, 13.8) Non-Hispanic White 61.7 (56.2, 67.2) 59.1 (54.7, 63.4) Non-Hispanic Black 8.6 (6.2, 11.0) 9.3 (5.6, 12.9) Non-Hispanic Asian 5.6 (3.8, 7.5) 6.1 (3.0, 9.1) Other Races 4.4 (3.3, 5.4) 5.6 (4.1, 7.1) BMI categories [% (95% CI)] <18.5 0.02 (0.0, 0.06) 0.03 (0.0, 0.08) 0.98 18.5–25 5.5 (3.7, 7.2) 5.2 (3.4, 7.1) 25–30 26.9 (23.8, 29.9) 27.6 (24.5, 30.7) ≥30 67.6 (63.6, 71.6) 67.1 (63.1, 71.2) Proportion of U.S. residents with MASLD eligible for resmetirom [% (95% CI)] 13.3 (10.8, 15.9) 15.7 (14.0, 17.3) 0.14 Proportion of U.S. residents with MASLD eligible for resmetirom [in millions (SE)] 6.7 (0.7) 4.8 (0.3) 0.14 Proportion of U.S. residents with MASLD-related cACLD (% [95% CI]) 3.7 (2.6, 4.7) 5.4 (4.1, 6.7) 0.03 Proportion of U.S. residents with MASLD-related cACLD (in millions (SE)) 1.8 (0.3) 1.7 (0.2) 0.03 Proportion of U.S. residents with MASLD-related cACLD with CSPH (% [95% CI]) 1.5 (0.9, 2.2) 1.9 (0.9, 3.0) 0.51 Proportion of U.S. residents with MASLD-related cACLD with CSPH (in millions (SE)) 0.8 (0.2) 0.6 (0.2) 0.51 Proportion of participants aware of their liver disease in each subgroup (% [95% CI]) Participants with MASLD 5.8 (4.5, 7.2) 6.7 (5.4, 8.1) 0.36 Participants with MASLD are eligible for resmetirom 12.1 (5.4, 18.8) 10.3 (6.4, 14.2) 0.63 Participants with MASLD-related cACLD 8.5 (2.8, 14.2) 20.4 (13.8, 27.0) 0.02 Participants with MASLD-related cACLD with CSPH 10.5 (0.3, 20.6) 31.2 (16.3, 46.1) 0.02 aWeighted mean with SE.Abbreviations: BMI, body mass index; cACLD, compensated advanced chronic liver disease; CSPH, clinically significant portal hypertension; MASLD, metabolic dysfunction–associated steatotic liver disease. Awareness of liver disease among individuals with MASLD remained low, with 5.8% (95% CI: 4.5%–7.2%) pre-pandemic and 6.7% (95% CI: 5.4%–8.1%) late-pandemic reporting awareness (p=0.36). Among those eligible for resmetirom, awareness was 12.1% (95% CI: 5.4%–18.8%) pre-pandemic and 10.3% (95% CI: 6.4%–14.2%) late-pandemic (p=0.63). Awareness among individuals with MASLD-related cACLD increased significantly from 8.5% (95% CI: 2.8%–14.2%) to 20.4% (95% CI: 13.8%–27.0%) (p=0.02), and among those with CSPH from 10.5% (95% CI: 0.3%–20.6%) to 31.2% (95% CI: 16.3%–46.1%) (p=0.02). Central obesity (OR 3.4; 95% CI: 1.1–11.5), hypertension (OR 1.7; 95% CI: 1.1–2.6), and diabetes (OR 1.7; 95% CI: 1.2–2.6) were independently associated with greater awareness. DISCUSSION Early identification of MASLD, particularly among those with MASH or significant fibrosis, remains challenging given its asymptomatic nature. Resmetirom, when combined with lifestyle interventions, has the potential to alter long-term outcomes.7 In this analysis, an estimated 6.7M U.S. adults pre-pandemic and 4.8M late-pandemic met criteria for resmetirom eligibility, closely aligning with prior estimates by Le et al.10 for the pre-pandemic estimates. However, the impact of resmetirom and other emerging therapies depends on timely diagnosis. This is the first study to examine national trends in liver disease awareness among U.S. adults with MASLD before and after the COVID-19 pandemic using NHANES. While prior analyses emphasized MASLD burden,11 our findings highlight persistently low awareness, particularly among individuals with early stages and resmetirom eligibility. These results complement the findings from Lazarus et al.,12 who reported poor awareness of MASLD among the general population, individuals with diabetes, and primary care providers. A significant increase in MASLD-related cACLD and a trend toward higher CSPH prevalence underscore missed opportunities for intervention amid worsening metabolic health and pandemic-related care disruptions. Although awareness has modestly increased among individuals with more advanced fibrosis, overall awareness remains poor (Supplemental Figure S1, https://links.lww.com/HC9/C164). This study has limitations. First, the cross-sectional design and reliance on self-reported awareness precluded assessment from the providers’ perspective. Second, laboratory data were limited in the late-pandemic cycle, preventing consistent evaluation of viral hepatitis; however, given its low prevalence and consistent sensitivity analyses, this is unlikely to have affected results. Third, other chronic liver diseases (eg, autoimmune hepatitis) could not be excluded due to a lack of serologic data, though their low prevalence suggests minimal impact. Fourth, the lack of lipid profiles data in the late-pandemic cycle may have led to an underestimation of MASLD prevalence. Lastly, reliance on VCTE data without histologic confirmation may have overestimated the numbers of individuals eligible for resmetirom; however, this approach aligns with current guidance and the FDA-approved indication, which does not require biopsy, and thus better reflects real-world practice.7 Future studies directly comparing population-based estimates with real-world prescribing patterns will help clarify potential differences between these estimates. In conclusion, this study highlights the substantial burden of MASLD and persistently low patient awareness, underscoring the need for targeted education of both the general population and primary care providers. INSTITUTIONAL REVIEW BOARD STATEMENT NHANES adheres to the ethical principles outlined in the Declaration of Helsinki, with all participants providing informed consent prior to data collection. The NCHS Research Ethics Review Board approved the NHANES study protocol.
Source: Hepatology Communications
Authors: Jameel Alp, Pimsiri Sripongpun, Giovanni A. Roldan, Jesse A. Fletcher, Timothy Davie, Prowpanga Udompap
Language: English
Subfield: Epidemiology
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $2,700
OpenAlex ID: W4415166067