Cumulative metabolic, behavioral, and early-life factors for MASLD in Chinese children with validation in U.S. adolescents

Aim: This study aimed to explore the cumulative effects of metabolic, behavioral, and early-life risk factors on metabolic dysfunction-associated steatotic liver disease (MASLD). Methods: Data were obtained from a school-based longitudinal survey conducted in Beijing in 2023. Logistic regression models were used to examine independent associations, construct a risk score, and assess the cumulative effects of risk factors on pediatric MASLD. The risk score was further validated using data from the National Health and Nutrition Examination Survey (NHANES) 2017-2020 cycles. Results: The prevalence of MASLD among Chinese children was 4.4% at baseline and 7.6% at follow-up. Baseline MASLD was significantly associated with exposure to second-hand smoke (OR = 2.36) and sedentary behavior (SB, OR = 3.21). Each one-unit increase in the risk score was associated with a 73% higher risk of MASLD at baseline, with similar cumulative effects observed in the NHANES cohort. At follow-up, each unit increase in the score corresponded to a 263% higher risk of MASLD. Furthermore, the risk of incident MASLD and persistent MASLD increased by 150% and 111%, respectively, for each unit increase in the score. Conclusion: Within a conceptual framework addressing multiple levels of risk, we found that metabolic, behavioral, and early-life factors exert cumulative effects on pediatric MASLD. These effects were evident despite the substantial differences between the Chinese and U.S. populations. Targeted intervention strategies informed by this framework - such as improving the early-life environment, promoting healthier lifestyle behaviors, and maintaining favorable metabolic profiles - are essential for the management of pediatric MASLD.