Global trends, sex- and country-specific disparities in nonalcoholic fatty liver disease (NAFLD) mortality: A comprehensive analysis of the Global Burden of Disease data across 204 countries (1990–2023)

Nonalcoholic fatty liver disease (now termed metabolic dysfunction-associated steatotic liver disease [MASLD]) is a leading cause of liver-related mortality worldwide, linked to the rising prevalence of metabolic syndrome. Despite prior analyses using earlier Global Burden of Disease (GBD) iterations, comprehensive trends incorporating post-2020 data remain limited. This study provides the first analysis utilizing the latest GBD 2023 release, examining global, sex-, and country-specific disparities in MASLD age-standardized mortality rates (ASMR) from 1990 to 2023 across 204 countries, highlighting the impact of recent events like the COVID-19 pandemic on metabolic health. MASLD ASMR data were extracted from the GBD 2023 database, defined by International Classification of Diseases, 10th Revision codes. Estimated annual percentage changes (EAPC) in ASMR were calculated using logarithmic linear regression. Analyses were stratified by sex and country, with 95% confidence intervals derived from the standard error of β. Globally, the mean EAPC was 0.152% (range: -3.079% in the Republic of Korea to 4.143% in Kazakhstan) for both sexes, 0.020% for females (-3.630% in Bermuda to 4.612% in the Russian Federation), and 0.291% for males (-2.970% in the Republic of Korea to 4.277% in Turkmenistan). Increases predominated in 111 countries (54.4%), with significance in 94; declines in 93, significant in 78. Pronounced rises occurred in Eastern Europe/Central Asia (e.g., Kazakhstan, Russian Federation) and the Middle East (e.g., Oman), while declines were evident in East Asia (e.g., the Republic of Korea) and Southern Europe (e.g., Italy). Males showed higher EAPC in 119 countries, with a mean sex difference of 0.271%; notable disparities included Cuba (males 3.296% vs females -0.172%). Country-specific trends revealed vulnerabilities in low- and middle-income countries, with mixed patterns in Africa. This inaugural GBD 2023 analysis reveals a modest global rise in MASLD mortality, with regional surges in transitioning economies and male-predominant disparities. Urgent, tailored interventions targeting metabolic risks are essential to mitigate this escalating burden.