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Gulati et al. Metab Target Organ Damage 2024;4:9 https://dx.doi.org/10.20517/mtod.2023.45 Page 5 of 17

published in 2022 investigated the electronic health records of 139,336 patients in the United States and
found that the rate of MASLD diagnosis was higher in non-Hispanic White patients with metabolic
syndrome compared to non-Hispanic Black patients with metabolic syndrome, particularly among females
[26]
and patients aged 18-39 years and 40-59 years . One study analyzing 134 subjects compared non-Hispanic
Black individuals to non-Hispanic White individuals and found that while Black individuals had a lower
intrahepatic triglyceride content, the prevalence of metabolic associated steatohepatitis (MASH) [formerly
called non-alcoholic steatohepatitis (NASH)] was even among the two groups in patients who had
[27]
MASLD . This study showed that once MASLD develops, MASH develops as frequently and as severely in
Black individuals as compared to White individuals with MASLD. The prevalence of MASLD has also been
increasingly investigated among Asian American populations. Utilizing data from NHANES from 2011-
2016, a study found Asian Americans to have a lower prevalence of MASLD than non-Hispanic White
individuals (18.3% vs. 28.4%) .
[28]
Limitations of determining racial and ethnic distribution of MASLD
Several limitations affect the currently available evidence on the prevalence of MASLD in different racial
and ethnic groups. Incomplete documentation is one factor. A meta-analysis published in 2020 investigated
the inclusion of racial and ethnic minority groups in 38 North American clinical trials for MASLD from
2005 to 2019 . This study found that documentation of racial and ethnic demographic data occurred in less
[10]
than half of the trials. More specifically, less than half of the trials (45%) included documentation regarding
the participation of Hispanic individuals. When documentation does occur, it is generally self-reported race
or ethnicity and often in less descriptive categories such as “Hispanic.” Underrepresentation is also a
significant problem in clinical trials. Of the total participants in all trials included in the study mentioned
previously, only 11.6 percent were reported to be Hispanic. While the study did show that enrollment of
Hispanic individuals increased over time (comparing trials from before and after 2015), enrollment lagged
behind the percentage of Hispanic individuals in the US population. Black patients are even more poorly
represented in clinical trials, as extensively documented in the literature from cardiology, oncology, and
other fields. Another study that points towards limitations of our current epidemiology data of MASLD is a
longitudinal observational study called TARGET-NASH published in 2021 . This study prospectively
[29]
followed a cohort of 3,474 pediatric and adult patients with MASLD in the United States for 5 years. The
study found that two-thirds of the patient population with MASLD did not have a liver biopsy, and those
without a biopsy were more likely to be non-White, older, or have a normal ALT. Since a large amount of
the existing literature on MASLD is derived from data from liver biopsies, this study brings up the concern
that the reported epidemiology of MASLD may not be fully accurate as non-White patients may be less
likely to have had a liver biopsy. Other limitations within studies determining the racial and ethnic
distribution of MASLD include confounding factors such as sex, BMI, and other demographic
characteristics. For example, in the study by Browning et al., the prevalence of MASLD in Hispanic and
White men was similar (45% vs. 42%), so the overall difference may be driven by Hispanic and White
women (45% vs. 24%) . Similarly, when matching subjects for BMI, a significant difference was not seen
[13]
within insulin resistance or the presence of MASLD between Hispanic and White individuals . Further
[30]
research is needed to determine racial and ethnic incidence patterns without the influence of confounding
factors.

Disparities in prognosis and detection of MASLD by racial and ethnic groups
Studies have demonstrated a poorer prognosis for Hispanic individuals with MASLD compared to others.
Hispanic individuals in the United States experience the greatest burden of MASLD-related hepatocellular
carcinoma (HCC) compared with other ethnicities [31,32] . Interestingly, United States-born Hispanic
individuals are at a higher risk for MASLD-related HCC compared with non-United States-born Hispanic
[33]
individuals . On the contrary, foreign-born Asians are at a higher risk for MASLD-related HCC compared