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Page 12 of 17 Gulati et al. Metab Target Organ Damage 2024;4:9 https://dx.doi.org/10.20517/mtod.2023.45

Giammarino et al. specifically investigated the relationship between socioeconomic deprivation and
MASLD. After retrospectively reviewing the electronic medical records of 1,430 patients in a large tertiary
healthcare network in New York, their analysis found a significant association between four or more
[82]
socioeconomic parameters in predicting MASH . The areas with socioeconomic factors found to predict
MASH and associated with greater severity of MASH included areas with public healthcare versus private,
higher percentage of foreign-born individuals, higher percentage without a car, and crowded housing units.
This study found that areas with higher social deprivation index (SDI), i.e., more impoverished areas, had
more Black and Hispanic populations. Poverty also increases one’s risk of harmful exposures, including
metals such as cadmium and arsenic that are associated with the development of MASLD as discussed
previously. The study from 2023 analyzing 423 soil samples within the southern United States found that for
every 10 percentiles of increase in poverty rank, the concentration of cadmium in the soil increased
significantly by 4.7 percent . Individuals’ socioeconomics can increase their risk of harmful exposures and
[62]
also distance them from healthy resources. A significant percentage of Hispanic individuals (15% vs. 11% of
non-Hispanic White individuals) in the United States live in lower-income communities where the nearest
grocery market can be up to 10 miles away. This may contribute to poor diet quality and the development of
metabolic syndrome features and MASLD.

Significant disparities by race and ethnicity are seen in access to healthcare. The United States Census
Bureau from 2022 revealed that Hispanic people in the United States have the highest uninsured rate in the
nation at 17.7%, whereas non-Hispanic White people have an uninsured rate of 5.7%. A lack of health
insurance can play a role in increasing one’s risk for obesity and thus MASLD in a variety of ways, including
lower utilization of preventative healthcare to reduce metabolic risk factors such as hypertension, diabetes
mellitus, hyperlipidemia, lower utilization of bariatric surgery, and also lower use of weight-reducing
medications . In addition, studies in the past have shown that lack of health insurance may lead to
[83]
increased weight gain as a side effect from older, less expensive medications due to not being able to use the
newer, more expensive options . Not only can lack of insurance affect one’s risk of developing MASLD,
[84]
but also one’s prognosis with MASLD. Adejumo et al. investigated hospitalizations with ICD codes for
MASLD from 2007-2014 in the United States and found that uninsured patients hospitalized with MASLD
had higher mortality, longer length of stay, and poorer discharge disposition than the privately insured, thus
implying that one’s insurance status does impact their disease course .
[18]

CONCLUSION
Although it was previously known that racial and ethnic disparities exist within the distribution of MASLD,
this narrative review shares recent literature that summarizes and elucidates these disparities. Recent studies
show that within the United States, Hispanic populations have the highest incidence of MASLD and among
Hispanic populations, those of Mexican origin have the greatest burden of MASLD. An increasing amount
of research has also been conducted to determine why these disparities exist. What is clear is that there is
not a single factor driving MASLD disparities but a variety of factors that contribute to increasing Hispanic
individuals’ risk for MASLD. These include genetics, environmental exposures, health behaviors, and
socioeconomic disparities.

There are a variety of future steps to be taken to better understand and reduce these disparities. A major
limitation of interpreting racial and ethnic disparities of MASLD reflects the lack of inclusion of diverse
populations in observational, epidemiologic, and interventional trials in MASLD and the lack of appropriate
race and ethnicity documentation. In addition, there are limitations to some of the standard diagnostic
markers used for MASLD when it comes to certain races and ethnicities, thus inhibiting us from detecting
MASLD accurately in individuals of all backgrounds. It is imperative that going forward, efforts be made to