Prevalence of MAFLD in the U.S. based on NHANES 2009–2018: differences in demographic characteristics, physical indices and lifestyle conditions

Abstract

Background

The incidence of metabolic dysfunction-associated fatty liver disease (MAFLD) is high among U.S. adults, but studies on its occurrence in different ethnic and age groups are limited. The aim of the present study was to assess MAFLD occurrence among the U.S. adults by considering demographic characteristics, physical indices, and lifestyle conditions.

Methods

This study utilized the National Health and Nutrition Examination Survey (NHANES) data 2009–2018 from 23,546 participants aged ≥ 20 years. Variables such as age, sex, race, body mass index (BMI), waist circumference (WC), blood pressure, sedentary behavior, sleep, and depression were analyzed.

Results

Among 9933 participants, 3562 had MAFLD (34.1%), with notably higher percentages of Mexican-Americans (54.1%) and lower percentages of blacks (20.5%). The incidence of MAFLD was significantly greater (P < 0.001) in males (39%) than in females (29.2%), which was particularly evident within the 36–40 years age group. The MAFLD incidence exhibited an age-dependent pattern, initially increasing and subsequently declining (except for whites). Compared to white MAFLD patients, black MAFLD patients exhibited greater BMI, WC, systolic blood pressure (SBP), and diastolic blood pressure (DBP) values, whereas values for these measures were lower among Mexican–American patients. Logistic regression analysis adjusting for age and sex revealed that depression was more common among MAFLD patients (P < 0.001), except for severe depression (P > 0.05). Notably, the MAFLD incidence was not significantly associated with sedentary behavior or sleep duration.

Conclusions

The MAFLD incidence varies across different racial, age, and sex groups, and targeted interventions are essential for reducing the burden of MAFLD. However, further research is necessary to explore the correlations among MAFLD incidence, sleep patterns, and an inactive lifestyle.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-025-03956-2.

Background

The term MAFLD was introduced by a consortium of international experts in 2020 to replace the existing term nonalcoholic fatty liver disease (NAFLD) [1]. MAFLD was defined by the concurrent presence of hepatic steatosis (≥ 5%) and metabolic disorders. Since the inception of the terminology, MAFLD has demonstrated superior prognostic capabilities over traditional NAFLD terminology in several domains, such as the prediction of liver and non-liver-related mortality and the identification of hepatic fibrosis [2]. Furthermore, MAFLD is more effective than the recently proposed diagnostic criteria of metabolic dysfunction-associated steatotic liver disease (MASLD) in identifying high metabolic risk, progressive liver fibrosis and predicting cardiovascular event-related mortality [3–5]. However, despite the increasing incidence of MAFLD across global populations, there is a scarcity of information on its differential disease burden across various demographic variables, such as ethnicity and age. The literature demonstrates significant health disparities across demographic variables for individuals with various conditions, but their role in the context of MAFLD has not been sufficiently evaluated. In light of the above, the present study employed the term MAFLD to identify patients with fatty liver disease associated with metabolic dysfunction in a more accurate manner, as well as to ascertain those with a poor prognosis. Moreover, an effort was made to ascertain the underlying biological and sociological factors contributing to these observed differences through an investigation of the distribution of MAFLD cases across diverse populations.

MAFLD has emerged as the primary contributor to long-term liver disease, affecting at least 36.7% of adults in U.S. [6]. Patients, medical systems, and the social economy are anticipated to endure persistent burdens associated with MAFLD. Most studies on MAFLD have focused on its association with factors such as chronic diseases, environmental pollutants and poor dietary habits [6–8]. In contrast, there are few epidemiological studies on MAFLD. Although previous epidemiological studies have shown that MAFLD is significantly associated with male sex, higher BMI, greater WC, hypertension and type 2 diabetes mellitus (T2DM), comprehensive studies examining the variations in these indicators across different races, age groups, sexes, and other relevant factors are rare [9]. In addition, studies have recently demonstrated that sleep-related indicators and depressive states may be associated with MAFLD, but this association has not yet been evaluated at the population level [10–13].

The aim of the present study was to assess MAFLD occurrence in the U.S. by considering demographic characteristics, physical indices, and lifestyle conditions, including age (continuous and classified), sex, ethnicity, BMI, WC, SBP, DBP, sedentary behavior, hours of sleep and depression status. Furthermore, our research aimed to investigate the prevalence of MAFLD across diverse age groups and ethnicities.

Methods

Study population

The present study analyzed data retrieved from the NHANES, a major program approved by the National Center for Health Statistics that spanned 5 cycles from 2009 to 2018. The NHANES survey utilizes a sophisticated, multiphase sampling strategy to gather data on demographics, socioeconomic status, dietary habits, and health-related details. Each year, a sample of approximately 5,000 individual individuals from the general population (≥ 2 months of age) was collected and analyzed. A more detailed description of the NHANES has been provided in previous studies [14, 15]. All participants provided informed written consent. This survey received ethical approval from the National Center for Health Statistics Research Ethics Review Board (protocol number: 2018–01).

Diagnostic criteria and covariates

Liver steatosis was diagnosed using the U.S.-Fatty Liver Index (U.S.-FLI) score, with a threshold of 30 points or above, which has been previously demonstrated to be a dependable metric for identifying liver steatosis in the U.S [16].

Participants were classified as having T2DM if any of the following conditions were met [17]: 1) physician-diagnosed diabetes, 2) fasting blood glucose (FBG) level ≥ 126 mg/dL, 3) 2-h oral glucose tolerance test (OGTT) level ≥ 200 mg/dL, or 4) hemoglobin A1c (HbA1c) level ≥ 6.5%.

BMI was calculated as follows: 

$$\mathrm{BMI}(\mathrm{kg}/{\mathrm{m}}^2)=\mathrm{weight}(\mathrm{kg})/{\mathrm{height}}^2({\mathrm{m}}^2)$$

The diagnosis of MAFLD was established by the presence of hepatic steatosis along with a minimum of one of the following criteria [1]: 1) overweight or obese (BMI ≥ 25 kg/m²); 2) T2DM; or 3) two or more risk factors for metabolic disorders, including a) WC ≥ 88 cm for females and ≥ 102 cm for males; b) high blood pressure (≥ 130/85 mmHg); or c) elevated plasma triglyceride levels (≥ 150 mg/dL) or prescription medicine; d) low plasma high-density lipoprotein levels (< 40 mg/dL for males and < 50 mg/dL for females) or prescription medicine; e) prediabetes status (FBG 100 mg/dL-125 mg/dL or HbA1c: 5.7% −6.4%); f) homeostasis model assessment of insulin resistance (HOMA-IR) score ≥ 2.5; or g) plasma hypersensitive C-reactive protein level > 2 mg/L.

Depression status was categorized based on the Patient Health Questionnaire (PHQ-9) score, which was administered to assess how often individuals experienced symptoms of depression within the preceding two weeks. Depression severity, ranging from mild to moderate, moderately severe, or severe, was associated with PHQ-9 scores of 5, 10, 15, and 20, respectively [18].

Covariates, including age, sex, ethnicity, sleep duration, and sedentary behavior, were considered in the analysis. Individuals were asked by trained interviewers, utilizing a computer assisted personal interview system, to report the information. Sleep duration and sedentary behavior were considered continuous variables in this study. Ethnicity was classified as White, Black or Mexican–American.

Statistical analysis

The analyses were performed using RStudio (version 2023.09.0) and R (version 4.2.2). To generate estimates for the entire study period (10 years), a representative weighted sample was constructed by allocating an equal portion of the two-year weight to each individual surveyed between 2009 and 2018. All analyses utilized weighted samples and accounted for the NHANES design to derive relevant estimates for the U.S. population. Continuous variables are presented as weighted means with corresponding 95% confidence intervals (95% CI), and comparisons were conducted using the weighted linear regression analysis method. Categorical variables are described as weighted percentages with 95% CIs, and their differences were assessed using the chi-square test. Multivariate logistic regression models adjusted for covariates such as age, sex, and race were used to explore associations between demographic factors, physical characteristics, life-stage characteristics and MAFLD occurrence. P < 0.05 was considered to indicate statistical significance (two-tailed).

Results

Of the 49,693 individuals who were enrolled in the NHANES between 2009 and 2018, 28,520 (pregnant women and individuals aged < 20 years). Of the remaining population, 3,751 were excluded because of missing data on BMI, WC, SBP or DBP; 1946 were excluded due to lack of information on sedentary behavior, sleep hours or the PHQ-9 score. Alternatively, 13,045 persons with missing records for important covariates (fasting insulin, fasting triglycerides, and γ-glutamyl transpeptidase) were also excluded. Finally, 9,933 participants with complete data were included in the analysis (Fig. 1).

Fig. 1.

Flow diagram showing participants included in the study

To determine whether the burden of MAFLD varies according to demographic characteristics, we first aimed to determine the MAFLD incidence in a subset of the data extracted from the NHANES stratified by age, sex, ethnicity and other relevant covariates. The initial sample in this study included 9,933 participants from the NHANES with complete data, representing 29.5 million unstructured U.S. individuals. A total of 3562 patients were diagnosed with MAFLD, resulting in a weighted prevalence rate of 34.1% (95% CI 32.5%−35.7%). Among the excluded population (n = 39,760), 33.1% self-identified as white, 23.2% as black, 18.2% as Mexican-Americans, and 25.5% belonged to other ethnic groups; 49.3% were male, and 50.7% were female.

Notably, the MAFLD incidence was 35.1% during 2009–2010, reached its nadir in the 2013–2014 cycle (30.7%), and peaked in 2017–2018 (36.3%) (Appendix Table 1). No statistically significant difference was observed in the overall incidence of MAFLD compared to that in 2009–2010 (P > 0.05) (Fig. 2).

Fig. 2.

Trends in MAFLD incidence across age groups from 2009 to 2018

Incidence of MAFLD varies by age, sex, and race

The incidence of MAFLD was observed to vary according to age, sex, and ethnicity. The lowest incidence of MAFLD was observed in individuals aged > 20–25 years (18.2%, 95% CI 14.6%−21.9%) (Appendix Table 2), while the highest was observed in those aged 61–65 years (45.8%, 95% CI 41.4%−50.3%), but not in those aged > 75 years (35.9%, 95% CI 32.0%−39.7%). White individuals showed an age-related increase in MAFLD incidence, whereas in black and Mexican–American individuals, the incidence increased with age but decreased after the age of 70 years (except for Mexican–American females) (Fig. 3, Appendix Table 3). Regarding sex, 39.0% (95% CI 36.8%−41.2%) of the males and 29.2% (95% CI 27.1%−31.3%) of the females were found to have MAFLD. This condition was more common in males, particularly in the 36–40 years age group, for which the male-to-female ratio was 1.7. However, this disparity between sexes narrowed over time, from a ratio of 1.54 in 2009 to 1.31 in 2017–2019. For ethnicity, black individuals had the lowest incidence at 20.5% (95% CI 18.5%−22.4%), white individuals had an incidence of 34.4% (95% CI 32.6%−36.3%), and Mexican–American individuals had the highest incidence at 54.1% (95% CI 50.6%−57.5%). These trends were consistent across age groups and were statistically significant (P < 0.001) (Fig. 4).

Fig. 3.

Prevalence of MAFLD in three ethnic populations across age groups

Fig. 4.

Prevalence of MAFLD by sex and age. a Prevalence of MAFLD in male. b Prevalence of MAFLD in female

In summary, MAFLD incidence was influenced by age, sex, and ethnicity, with the highest incidences observed in older individuals, males, and Mexican-Americans. MAFLD incidence increased with age but slightly decreased in individuals older than 70 years, particularly within certain ethnic groups. The study also showed a narrowing of the sex disparity over the studied years (Fig. 5, Appendix Table 4).

Fig. 5.

Distribution of U.S.-FLI values across racial groups

MAFLD is associated with increased BMI, WC, SBP, and DBP values

The study population was divided into MAFLD and non-MAFLD groups (Table 1). Comparisons between all the groups were adjusted for age and sex. The MAFLD group exhibited significantly greater BMI, WC, SBP, and DBP than did the non-MAFLD group (P < 0.001). The impact of MAFLD on BMI and WC was the most significant for black individuals (9.8 kg/m², 24.5 cm), followed by white individuals (8.9 kg/m², 22.1 cm), and finally Mexican-Americans (7.4 kg/m², 17.6 cm). Notably, the influence of MAFLD on SBP was most pronounced in white individuals (6.0 mmHg), while its effect on DBP was particularly prominent in Mexican-Americans (4.0 mmHg).

Table 1.

The differences in BMI, WC, SBP, and DBP between MAFLD and non-MAFLD group

Variables	MAFLD	Non-MAFLD	Mean Difference	P
BMI, kg/m2
Black	38.6(37.8–39.4)	28.8(28.4–29.1)	9.8(9.0–10.6)	< 0.001
White	34.6(34.2–35.1)	26.1(25.9–26.4)	8.9(8.4–9.3)	< 0.001
Mexican American	33.7(33.3–34.1)	26.7(26.3–27.1)	7.4(6.9–7.9)	< 0.001
Waist, cm
Black	120.9(119.5–122.4)	95.6(94.7–96.5)	24.5(22.8–26.3)	< 0.001
White	115.6(114.7–116.5)	92.7(92.1–93.3)	22.1(21.0–23.3)	< 0.001
Mexican American	109.3(108.2–110.3)	91.3(90.4–92.2)	17.6(16.3–19.0)	< 0.001
SBP, mmHg
Black	131.4(129.3–133.4)	125.5(124.4–126.6)	3.7(1.5–6.0)	= 0.002
White	127.1(126.2–128)	118.5(117.9–119.2)	6.0(5.1–6.9)	< 0.001
Mexican American	124.1(122.9–125.3)	115.3(113.9–116.6)	5.6(4.3–6.9)	< 0.001
DBP, mmHg
Black	74.3(72.7–76)	70.7(69.8–71.5)	3.5(2.0–4.2)	< 0.001
White	71.9(71–72.8)	68.6(68–69.3)	3.4(2.5–4.2)	< 0.001
Mexican American	71.6(70.7–72.5)	66.8(65.9–67.7)	4.0(2.7–5.4)	< 0.001

In the subsequent analysis, we categorized patients with MAFLD into six groups based on sex and ethnicity using a cutoff age of 60 years (Appendix Table 5). Compared to white MAFLD patients, black MAFLD patients had significantly greater BMIs (38.6 kg/m² vs. 34.6 kg/m²), WCs (120.9 cm vs. 115.6 cm), SBPs (131.4 mmHg vs. 127.1 mmHg), and DBPs (74.3 mmHg vs. 71.9 mmHg) (P < 0.01). Conversely, Mexican–American MAFLD patients had lower BMI, WC, SBP, and DBP values. A more detailed presentation of the values related to the four major body measurements of MAFLD patients by ethnicity and age group is provided in Appendix Table 6. An ethnic analysis of four anthropometric indices of patients with MAFLD revealed a consistently elevated BMI and the highest incidence of obesity (BMI ≥ 30 kg/m²). The WC of patients with MAFLD ranged between 100 and 120 cm. Individuals in the black population exhibited elevated SBP and DBP values (Fig. 6, Appendix Table 7).

Fig. 6.

Distribution of physical measurements in MAFLD patients across racial groups. a Distribution of BMI in MAFLD patients across racial groups. b Distribution of waist in MAFLD patients across racial groups. c Distribution of SBP in MAFLD patients across racial groups. d Distribution of DBP in MAFLD patients across racial groups. Abbreviation: MAFLD, metabolic dysfunction-associated fatty liver disease; BMI, body mass index; SBP, systolic blood pressure; DBP, diastolic blood pressure

In summary, the study’s findings indicate that MAFLD is associated with higher BMI, WC, SBP, and DBP values, with variations observed across ethnic groups. Black individuals with MAFLD exhibited the most significant increases in BMI and WC, while white individuals and Mexican–American individuals showed the greatest increases in SBP and DBP values, respectively.

MAFLD is associated with mild to moderate depression

Overall, compared with those in the non-MAFLD group, the proportion of MAFLD patients reporting no depression (32.0%), mild depression (40.3%) or moderate to severe depression (47.3%) gradually increased, while the proportion of MAFLD patients reporting severe depression (32.5%) decreased (Appendix Table 8). By utilizing logistic regression analysis while controlling for age and sex, MAFLD patients exhibited significant differences in the prevalence of mild depression, moderate depression, and moderate to severe depression compared to those without depression (P < 0.001), but there was no difference in the severe depression group (P > 0.05). The distributions of black and white MAFLD patients in the moderate to severe depression group and below-depression group differed from those in the group reporting no depression, while there was no discernible distinction observed between the group with severe depression and the group without depression. Notably, 78.3% of Mexican–American patients with MAFLD were diagnosed with moderate to severe depression.

The differences in sleep and sedentary behavior between the MAFLD group and the non-MAFLD group are shown in Table 2. Among those in the white population, individuals in the non-MAFLD group had a slightly greater average sleep duration (7.3 h) than did those in the MAFLD group (7.2 h), which was statistically significant (P = 0.039). No notable differences in sleep or sedentary behaviors were found among the other groups.

Table 2.

The differences in sleep and sedentary behavior between MAFLD and non-MAFLD group

Group	MAFLD	Non-MAFLD	P
Sleep duration
Total	7.2(7.1–7.2)	7.2(7.2–7.3)	> 0.05
Black	6.7(6.5–7)	6.8(6.7–6.9)	> 0.05
White	7.2(7.1–7.3)	7.3(7.2–7.4)	0.039
Mexican American	7.2(7.1–7.4)	7.3(7.1–7.4)	> 0.05
Sedentary time
Total	399.0(388.3–409.8)	380.0(369.1–391.0)	> 0.05
Black	414.7(365.5–463.8)	414.9(372.7–457.2)	> 0.05
White	413.9(402–425.7)	385.5(373.1–397.8)	0.043
Mexican American	317.9(291–344.9)	319.7(271.5–367.9)	> 0.05

In summary, MAFLD patients are more likely to report mild to moderate depression than non-MAFLD patients are, but this trend does not extend to individuals with severe depression. Ethnic differences exist in the incidence of depression among MAFLD patients, with a particularly high incidence of moderate to severe depression in Mexican American patients. The sleep duration was marginally shorter in white MAFLD patients than in their non-MAFLD counterparts.

Discussion

Demographic characteristics, physical indices, and lifestyle conditions were considered in this study to assess the occurrence of MAFLD in the U.S.

In this study, we found that the MAFLD incidence in the U.S. population peaked in males aged 66–70 years and in females aged 71–75 years. This finding contrasts with a Chinese study in which the peak age for MAFLD was younger, at 51 years for men and 66 years for women [19]. There was a noticeable delay in the peak age of MAFLD among Americans compared to that among Chinese individuals, suggesting that the peak age for MAFLD may vary by geographical location. Additionally, the MAFLD incidence does not consistently increase with age, although older adults generally present with more metabolic disorders and receive physical health examinations more frequently. This may be attributed to the survivor effect, where healthy older adults are more likely to survive to be included in the study [20, 21].

We also discovered that the MAFLD incidence differed by sex, with a significant difference occurring in the 36–40 years age group, in which men had a greater incidence than women did. Relevant findings have been consistently reported in some studies [9, 22]. This finding aligns with prior research indicating that hormonal factors, such as the role of estrogen in metabolic processes, may contribute to this disparity [23]. The mechanism of action of this process is primarily related to the interaction between estrogen and estrogen receptors in liver cells, which restricts fatty acid synthesis while promoting the deposition of already formed fatty acids in subcutaneous adipose tissue, leading to decreases in the buildup of fat and the level of oxidative stress in the liver [24].

Our study revealed that the highest incidence of MAFLD was found among Mexican Americans. Genetic polymorphisms can partly explain this phenomenon. Among all ethnic groups in the U.S., PNPLA3 polymorphisms are most common among Mexican Americans [25, 26]. PNPLA3 is a transmembrane protein present in hepatocytes, hepatic stellate cells and adipose tissue that promotes the accumulation of triglycerides in the liver [27]. However, when the study population was stratified by BMI, a different pattern was observed, with black individuals having the highest incidence of MAFLD, whereas a similar incidence was observed between white individuals and Mexican American individuals [28].

BMI is widely considered to play an important role in the development of MAFLD and is considered a diagnostic indicator [1]. Clinical models using BMI, WC, and triglyceride levels are effective for screening and diagnosing MAFLD and other metabolic disorders [29]. However, our study revealed that the effect of BMI on MAFLD differed across ethnic groups. Specifically, black individuals with MAFLD had higher BMIs and WCs than did their counterparts. Despite the high MAFLD incidence, many Mexican American patients maintain a normal weight (BMI < 30 kg/m²). There is evidence suggesting that the risk of metabolic diseases is similar between normal-weight MAFLD patients and obese MAFLD patients [30]. Early metabolic disease screening should be considered for MAFLD patients with a normal weight. These observations of racial differences in the impact of BMI on MAFLD incidence should be further explored via prospective studies.

Additionally, our research showed that individuals with MAFLD had significantly elevated SBP and DBP values across all ethnic groups. The conditions of hypertension and MAFLD share common metabolic disruptions, such as insulin resistance, dyslipidemia, obesity, and inflammation due to fatty liver, which may contribute to their mutual reinforcement [31–33]. Epidemiological studies have demonstrated that hypertension is prevalent in up to 40% of patients with MAFLD [34]. Furthermore, MAFLD is linked to increased susceptibility to various other cardiovascular conditions [33, 35]. Therefore, potential pharmacotherapies for MAFLD include statins, lipid-lowering agents, hypoglycemic medications, antihypertensive compounds, and antioxidant intervention [36].

Lifestyle intervention has become a crucial therapeutic strategy for effectively managing MAFLD by ameliorating serum liver enzyme levels, reducing hepatic fat accumulation, and improving blood lipid profiles [37, 38]. In contrast, a sedentary lifestyle can increase susceptibility to obesity and T2DM, which has been identified as a contributing factor for MAFLD [39]. Our research indicated that there was a tendency for MAFLD patients to exhibit slightly longer sedentary periods than non-MAFLD individuals did, although the observed differences did not reach statistical significance (P > 0.05). Sleep duration did not differ notably between the MAFLD and non-MAFLD groups, suggesting that sleep patterns rather than sleep duration may be more relevant to MAFLD risk [11]. Furthermore, a large prospective cohort study supported the positive impacts of upholding a well-regulated sleep schedule on reducing the risk of MAFLD; this study included multiple evaluation indicators, such as sleep duration, type, insomnia, snoring and daytime sleep [10].

Finally, our study revealed that milder depression was associated with MAFLD, with the lowest impact observed in Mexican-Americans. Prior research has indicated that depression increases susceptibility to MAFLD [12, 40], and a recent study showed that depression scores are independently associated with MAFLD [13]. Chronic inflammation and oxidative stress are involved in the pathogenesis of depression and MAFLD [41]. Future research should further investigate this connection and explore interventions that simultaneously target mental health and metabolic improvements, offering a more holistic approach to managing MAFLD. This could include examining the effects of mental health interventions on MAFLD progression, as well as the impact of MAFLD management on psychological states.

This cross-sectional study has numerous limitations related to the use of NHANES data. First, our study focused primarily on the prevalence of MAFLD and did not investigate liver fibrosis or associated comorbidities. Patients presenting with both MAFLD and another liver disease, according to the diagnostic criteria, are considered to have dual or multiple etiologies of fatty liver disease. While our study did not delve into the specific interactions between these conditions, it is plausible that their coexistence could influence MAFLD progression. Second, owing to the limitations of available measurement tools, we employed the U.S.-FLI as a diagnostic criterion for liver steatosis instead of utilizing the gold standard method of liver biopsy. Finally, our study exclusively focused on three specific ethnic groups in the U.S. and did not investigate the prevalence of MAFLD among other ethnic populations, thus limiting its generalizability to the broader population. It is imperative to conduct extensive prospective cohort studies to validate the findings observed. Furthermore, it is essential to establish subgroup analysis for individuals who meet the diagnostic criteria for MAFLD and other liver diseases.

Conclusion

In conclusion, the incidence of MAFLD is increasing in the U.S. MAFLD is associated with sex, age, race, BMI, WC, blood pressure, and mental status (depression). However, further investigations are needed to explore the relationships between MAFLD and sedentary behavior as well as sleep patterns. When intervening in patients with MAFLD, it is crucial to consider demographic and physical indicators as well as patients'psychological status comprehensively while implementing personalized comprehensive interventions.

Abbreviations

MAFLD

Metabolic dysfunction-associated fatty liver disease

NAFLD

Non-alcoholic fatty liver disease

MASLD

Metabolic dysfunction-associated steatotic liver disease

NHANES

National Health and Nutrition Examination Survey

BMI

Body mass index

WC

Waist circumference

SBP

Systolic blood pressure

DBP

Diastolic blood pressure

T2DM

Type 2 diabetes mellitus

U.S.-FLI

U.S.-Fatty Liver Index

FBG

Fasting blood glucose

OGTT

Oral glucose tolerance test

HbA1c

Hemoglobin A1c

HOMA-IR

Homeostasis model assessment of insulin resistance

PHQ-9

Patient health questionnaire

95% CI

95% Confidence intervals

Authors’ contributions

All the authors made contributions to the conception and design of the study. The tasks of material preparation and data collection were performed by YD, SJH, MYM, and LQS. Statistical analyses were conducted by YD, MYM, SJH, and WJF. The manuscript’s initial draft was composed by YD and WJF. Subsequently, the manuscript underwent meticulous revisions by LYL, LQS, HXN, CJ and BZJ, who provided substantial enhancements to the document.

Funding

This research was funded by the Shanghai Leading Talent Program of Eastern Talent Plan Class A (002), Shanghai Municipal Health Commission Guidance Fund for Integrated Traditional Chinese and Western Medicine (ZXXT-202302), Shanghai Municipal Health Commission (JKKPYL-2022–15), Key Discipline Projects of Huadong Hospital (LCZX220), Shanghai Outstanding Young Medical Personnel Training Program (Excellence Project of Shanghai Municipal Health Commission, 20224Z0009) and Key Specialized Diseases Construction of Huadong Hospital (ZDZB2225).

Data availability

Data was provided within the manuscript or supplementary information files.

Declarations

Ethics approval and consent to participate

The data utilized in this study were sourced from NHANES, which was approved by the National Center for Health Statistics (NCHS) Ethics Review Board. Informed consent was obtained from all participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.