Fasting glucose-to-HDL cholesterol ratio and risk of MASLD in nonobese Chinese adults: A retrospective cohort study

Metabolic dysfunction-associated steatotic liver disease (MASLD) is increasingly recognized in nonobese individuals; however, reliable markers for early risk identification remain limited. The fasting glucose-to-high-density lipoprotein cholesterol (FHR) ratio, which reflects integrated glucolipid metabolism, has emerged as a potential indicator. This study aimed to evaluate the association between FHR and the incidence of MASLD in nonobese adults. This retrospective cohort study included 16,173 nonobese Chinese adults (body mass index < 25 kg/m2) from the Wenzhou Health Examination Cohort. Participants without MASLD at baseline were categorized into quartiles according to their FHR levels. Incident MASLD was diagnosed using abdominal ultrasonography during follow-up. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) after adjusting for demographic, clinical, and metabolic factors. Dose-response relationships were assessed using restricted cubic spline models, and receiver operating characteristic (ROC) analysis was performed to evaluate predictive performance. During follow-up, 2322 participants developed MASLD. Higher FHR levels were significantly associated with an increased risk of MASLD. In the fully adjusted model, each 1-unit increase in FHR was associated with a 22% higher risk of MASLD (HR, 1.22; 95% CI: 1.17-1.27, P < .001). Compared to the lowest quartile, the highest quartile showed a significantly elevated risk (HR: 2.10, 95% CI: 1.78-2.48; P for trend < 0.001). A positive dose-response relationship was also observed. ROC analysis showed that FHR had a moderate predictive ability (AUC, 0.701; 95% CI, 0.690 to 0.713), with an optimal cutoff value of 3.87. Elevated FHR was independently associated with an increased risk of MASLD in nonobese Chinese adults. Thus, FHR may serve as a simple and cost-effective biomarker for early risk stratification in this population.