Reply to correspondence on “Differences in liver and mortality outcomes of non-alcoholic fatty liver disease by race and ethnicity: A longitudinal real-world study”

Synergistic effects and systemic issues

As they correctly pointed out, the interplay between genetic predispositions, environmental exposures, and socioeconomic conditions creates a complex landscape influencing MASLD outcomes. The historical and ongoing impact of systemic issues, such as redlining, employment discrimination, and disparities in access to healthcare, has undoubtedly played a crucial role in determining the health outcomes of marginalized communities. These challenges have led to environments where disadvantaged groups are more likely to experience adverse health outcomes, including those related to MASLD. Addressing these issues requires a multifaceted approach involving policy changes, community engagement, and efforts to improve the social determinants of health.

Genetic and environmental interactions

The synergistic effects of genetic, environmental, and socioeconomic factors are central to understanding MASLD disparities. Research has consistently shown that these factors do not operate in isolation but interact in ways that can exacerbate health outcomes. For instance, genetic predispositions can be modified by environmental factors such as diet and physical activity, which are themselves shaped by socioeconomic conditions [3]. Understanding these interactions is crucial for developing effective interventions.

Clinical outcomes in Black and Hispanic populations

Their findings on the paradoxical situation faced by Black population—lower MASLD prevalence but worse clinical outcomes—highlight critical areas for intervention. Delayed diagnosis and suboptimal treatment, often resulting from systemic barriers and implicit biases in clinical settings, require urgent attention. The higher burden of metabolic comorbidities in this group further complicates their prognosis. Additionally, the specific risks encountered by Hispanic population, including higher liver-related mortality, underscore the necessity of considering genetic polymorphisms and the broader socio-cultural context in which these individuals live.

The observed differences within Hispanic subgroups, such as individuals of Mexican heritage exhibiting higher MAFLD prevalence than those from other backgrounds, emphasize the importance of disaggregated data. Recognizing these nuances allows for more tailored and effective public health interventions and healthcare policies.

Implications for Asian American subgroups

The recognition that Asian American individuals exhibit the lowest cumulative incidence of adverse outcomes in their study, yet potentially experience variable risks among subgroups, aligns with the broader theme of heterogeneity within racial categories. In line with the themes of their study, our previous research also underscores the significance of socioeconomic and lifestyle factors in liver disease outcomes [4]. This study highlights how dietary quality can modify the relationship between advanced liver fibrosis and mortality, suggesting that even in populations with high genetic predispositions to liver disease, environmental factors like diet play an important role in disease progression and outcomes. Future research and policy efforts must prioritize the collection and analysis of disaggregated race and ethnicity data. Such efforts will enable more precise identification of at-risk populations and the development of targeted interventions.

Additional insights from lean MASLD

Another critical issue within the Asian population is the prevalence of lean MASLD. Despite having a normal body mass index (BMI), these individuals often exhibit significant metabolic dysfunction, with a prognosis similar to that of individuals who are overweight or obese. Studies have shown that the prevalence of lean MASLD varies widely, ranging from 5% to 26% in normal-weight individuals [5]. Interestingly, even with lower BMI thresholds for overweight and obesity in Asians, the prevalence of MASLD is not lower. This highlights the importance of focusing on metabolic health rather than just body weight. The metabolic flexibility and adaptation in these individuals play crucial roles in disease progression. Those initially metabolically flexible may eventually lose this capacity, leading to disease progression similar to observed in obese individuals [5]. Given the lack of specific guidelines for managing normal-weight individuals with MASLD, there is an urgent need for research and tailored treatment strategies for this population.

The role of awareness, education, and community engagement

The alarmingly low awareness of MASLD among the U.S. population represents a significant missed opportunity for early diagnosis and intervention [6]. This gap in awareness, despite frequent healthcare interactions, emphasizes the need for enhanced community outreach and education initiatives. Healthcare providers must be better equipped to screen for MASLD, especially in individuals with known risk factors.

Improving awareness and education is paramount, not only among patients but also within the medical community. Continued professional development and training for healthcare providers can ensure they are up to date with the latest guidelines and interventions for MASLD, enabling them to offer optimal care to all individuals, regardless of racial or ethnic background.

Addressing structural barriers and policy change

Addressing the structural barriers that contribute to health disparities is crucial. Efforts to dismantle systemic racism and improve access to quality healthcare, education, nutritious food, and safe living environments are fundamental to reducing these disparities. Policy changes at the community and systemic levels are necessary to ensure that new pharmacotherapies and other medical advancements in MASLD treatment are accessible to all individuals equitably.

In conclusion, their research contributes significantly to our understanding of these complex issues and provides a foundation for future efforts to address MASLD disparities. By focusing on these key areas, we can work towards a more equitable healthcare system that meets the needs of individuals from diverese racial or ethnic backgrounds.