Socioeconomic, Environmental Disadvantage Linked to Pediatric MASLD Risk

New research is shedding light on a significant association between social determinants of health (SDH) and metabolic dysfunction–associated steatotic liver disease (MASLD) in children with overweight or obesity.1

Study findings show children with MASLD were more likely to live in neighborhoods with greater socioeconomic and environmental disadvantage than their peers with overweight or obesity but without MASLD. Specifically, children with MASLD were more likely to reside in neighborhoods with lower socioeconomic advantage, reduced access to education and economic resources, poorer housing conditions, and greater environmental risks, including higher air pollution exposure.1

MASLD is the leading cause of liver disease among children, affecting up to 38% of children with obesity in the US. However, known risk factors like genetic predisposition, diet, and physical activity levels do not fully explain the variability in disease development.1,2

“Emerging evidence highlights the role of SDH in shaping disparities in pediatric liver disease,” Jeffrey Schwimmer, MD, a professor of pediatrics at UC San Diego School of Medicine and the director of the Fatty Liver Clinic at Rady Children’s Hospital San Diego, and colleagues wrote.1 “Identifying specific SDH linked to MASLD in children could inform strategies for early intervention and risk mitigation.”

To assess the association between neighborhood-level SDH and MASLD in children with overweight or obesity, investigators conducted a cross-sectional study of children evaluated in pediatric gastroenterology clinics, stratified by the presence of MASLD. For inclusion, patients were required to be < 18 years of age at their first visit, reside in California, and have a clear determination of the presence or absence of MASLD based on clinical evaluation.1

Cases were defined as children who were clinically suspected of having MASLD and subsequently underwent liver biopsy, which confirmed macrovesicular steatosis in ≥5% of hepatocytes, with exclusion of other liver diseases through comprehensive clinical assessment, including medical history, laboratory testing, and histopathological review. Controls were defined as children with overweight or obesity who were evaluated for MASLD but determined not to have the disease, based on normal alanine aminotransferase (ALT) levels and absence of hepatic steatosis on imaging, confirmed through either magnetic resonance imaging–proton density fat fraction (MRI-PDFF) or ultrasound, depending on availability. Children initially referred for suspected MASLD or obesity but found to have no SLD on liver imaging and normal liver enzymes were included as controls.1

In addition to clinical measures, neighborhood-level SDH were assessed using the California Healthy Places Index (HPI) 3.0.1

Of 1206 children initially screened for eligibility, a potential study cohort of 988 children whose presence or absence of SLD was evaluated were assessed. Among these, 310 had liver imaging without any steatosis; however, 15 were excluded for an invalid address for geocoding, leaving 295 children with overweight or obesity without SLD as the control group. The remaining 678 children had a liver biopsy performed, confirming hepatic steatosis. After excluding ineligible patients, 593 children with overweight or obesity were diagnosed with MASLD.1

Investigators did not observe any significant differences in age between children with and without MASLD (12.7 years vs 12.9 years; P = .32) but noted a greater proportion of children with MASLD were male compared with those without MASLD (65.9% vs 56.9%; P = .009). Race and ethnicity distributions also varied, with children in the MASLD group being more likely to identify as Hispanic (80.8% vs 65.8%; P <.001) and less likely to identify as White (20.7% vs 44.1%; P <.001). However, BMI did not differ significantly between groups, with a mean BMI of 30.9 kg/m2 in children with MASLD and 29.9 kg/m2 in those without MASLD (P = .05).1

Children in the study cohort, regardless of MASLD status, had lower HPI scores than the general population of San Diego County, with scores of −0.16±0.46 compared with 0.10±0.47 (P <.001). Further analysis revealed study participants without MASLD had a mean HPI of −0.03±0.48, approximating the 49th percentile, while those with MASLD had a mean HPI of −0.22±0.43, corresponding to roughly the 41st percentile (P = .01).1

Investigators also pointed out children with MASLD were more likely to live in neighborhoods with lower socioeconomic advantage across multiple HPI subdomains compared with those without MASLD, including the economic (P = .01), housing (P = .02), neighborhood (P = .004), social (P = .006), and healthcare access (P = .02) domains.1

Further analysis of HPI subdomains showed that greater economic (P = .04) and social (P = .04) scores were associated with lower AST levels, while increased education (P = .045) and healthcare access (P = .04) scores were associated with lower ALT levels. However, none of the HPI subdomains were significantly associated with histologic disease severity.1

This study provides further evidence that socioeconomic and environmental factors contribute to MASLD risk in children,” investigators concluded.1 “Future longitudinal studies should investigate whether specific SDH factors influence long-term MASLD outcomes, potentially guiding targeted public health interventions to improve the health trajectories of children at risk for MASLD.”

References

1. Venkatesh A, Thai N, Ugalde-Nicalo P, et al. Neighborhood disparities and metabolic dysfunction-associated steatotic liver disease in children with overweight or obesity. Hepatol Commun. doi:10.1097/HC9.0000000000000857

2. Mayo Clinic. Pediatric metabolic dysfunction-associated steatotic liver disease (MASLD), formerly known as nonalcoholic fatty liver disease (NAFLD). October 4, 2023. Accessed November 24, 2025. https://www.mayoclinic.org/medical-professionals/pediatrics/news/pediatric-metabolic-dysfunction-associated-steatotic-liver-disease-masld-formerly-known-as-nonalcoholic-fatty-liver-disease-nafld/mac-20555493