We are grateful for Dr. Park and Dr. Yu’s insightful comments on our recent publication, “Current burden of steatotic liver disease and fibrosis among adults in the United States, 2017-2023” [1,2]. Their editorial highlights the critical need to tackle the rising prevalence of steatotic liver disease (SLD), especially within the challenging backdrop of the coronavirus disease 2019 (COVID-19) pandemic. The pandemic has posed unique challenges to public health and worsened existing health conditions, including chronic liver diseases [3].

As global obesity rates climb, the prevalence of SLD also increases, leading to significant complications such as liver cirrhosis and hepatocellular carcinoma (HCC) and an increase in mortality [4,5]. Within SLD, several subcategories exist, notably metabolic dysfunction-associated steatotic liver disease (MASLD), metabolic dysfunction and alcohol-related SLD (MetALD), and alcohol-related liver disease (ALD) [6]. The current prevalence of SLD varies among diverse racial groups in the United States, with SLD affecting a significant portion of the adult population. The weighted age-adjusted prevalence of SLD is approximately 35%, and nearly one-third of US adults are reported to have MASLD [1]. Such prevalences are concerning as MASLD is projected to become a leading contributor to chronic liver disease burden, potentially surpassing other chronic liver diseases in terms of adverse outcomes [7].

The editorial highlights the importance of recognizing variations in disease prevalence across different racial and ethnic groups [1,2]. Notably, Hispanics and non-Hispanic Asians exhibited a higher prevalence of MASLD. This discrepancy is associated with genetic factors such as variations in the PNPLA3 gene, which contribute to hepatic fat accumulation and individual susceptibility to MASLD [1,2]. In contrast, non-Hispanic Whites and Hispanics showed elevated prevalences of MetALD and ALD. Non-Hispanic Blacks had a consistently lower prevalence.

The COVID-19 pandemic has drastically impacted the global public health systems, leading to a decline in routine health screenings and management for chronic diseases, including SLD. The COVID-19 era and COVID-19 infection emerged as independent predictors of in-hospital mortality among hospitalizations with cirrhosis and decompensated cirrhosis in the United States [8]. Additionally, all-cause and HCC-related mortality from ALD and MASLD increased rapidly during the COVID-19 pandemic compared to the pre-pandemic era in the United States [9,10]. Pandemic-induced lifestyle changes, such as increased time spent indoors, reduced physical activity [11], and higher alcohol consumption [12], contributed to worsening liver health among individuals predisposed to SLD. During this period, individuals at high risk did not receive necessary monitoring or intervention, resulting in a rise in fibrosis progression related to SLD [1]. The editorial emphasizes that the pandemic significantly disrupted public health efforts, intensifying existing challenges. As healthcare systems focused heavily on combating the pandemic, the management of chronic liver diseases like SLD became a lower priority, underscoring a critical need for establishing robust healthcare strategies to address such conditions in the event of future public health emergencies.

Despite advancements in medications like Resmetirom, which has shown promise in treating metabolic dysfunction-associated steatohepatitis (MASH) with fibrosis, lifestyle modifications remain the cornerstone of managing SLD. Essential lifestyle modifications include dietary interventions, increased physical activity, and strategies to reduce alcohol consumption. In an era where obesity is often considered an issue of individual responsibility, the editorial advocates for a broader, more supportive approach involving community and healthcare system participation. It emphasizes the need for policies and programs that promote healthier lifestyles, particularly in underserved populations disproportionately affected by SLD. To effectively address the growing burden of SLD, we advocate for a multidisciplinary approach involving healthcare providers, public health officials, researchers, and community organizations. This coordinated effort aims to establish comprehensive care strategies, including regular monitoring, early interventions, and public awareness campaigns. Furthermore, healthcare systems should learn from the COVID-19 pandemic to proactively prepare for future challenges. Formulating policies that ensure high-risk populations remain prioritized during health crises is essential to prevent the deterioration of conditions like SLD and chronic liver disease. With nearly one-third of US adults affected by MASLD, it is crucial for healthcare providers and policymakers to act decisively. Improving liver health outcomes and enhancing the quality of life for affected individuals should be a top priority.

The editorial sheds light on the critical issue of health disparities in the prevalence of SLD across different racial and ethnic groups. It highlights the need for targeted research identifying specific risks and barriers to care faced by underserved populations. Addressing these disparities effectively requires healthcare systems to adapt strategies and ensure equitable access to SLD management. By understanding the complexity of health disparities, the impact of lifestyle modifications, and the importance of community support, the healthcare system can develop more effective strategies for managing SLD.