All Children With NAFLD Meet the Criteria for MAFLD and MASLD : Evidence From a Chinese Longitudinal Cohort

We read with interest the recent article by Song et al. demonstrating relatively small differences in prevalence estimates and mortality outcomes across non-alcoholic fatty liver disease (NAFLD), metabolic dysfunction-associated fatty liver disease (MAFLD) and metabolic dysfunction-associated steatotic liver disease (MASLD) in adults [1]. This study is a valuable addition to the existing literature involving adult populations from China [2] and Brazil [3]. However, evidence from paediatric populations is lacking. We used data from Huantai Childhood Cardiovascular Health Cohort study to compare the detection rates of paediatric NAFLD, MAFLD and MALSD. Briefly, the study is an ongoing cohort that initially enrolled 1515 children aged 6–11 years from Zibo City, China, in 2017 (wave 1) [4]. Follow-up surveys were conducted biennially in 2019 (wave 2), 2021 (wave 3) and 2023 (wave 4). Abdominal ultrasounds were performed in all children to assess hepatic steatosis. After ruling out alcohol consumption and other causes of chronic liver disease (e.g., viral infections), all children with hepatic steatosis were classified as having NAFLD in our cohort. MAFLD was defined as the presence of overweight (including obesity) or central obesity, prediabetes (or type 2 diabetes), or two or more additional metabolic risk factors (i.e., elevated triglycerides, high blood pressure, low high density lipoprotein-cholesterol [HDL-C] and increased triglycerides-to-HDL-C ratio) in combination with hepatic steatosis [5]. MASLD was identified by the presence of at least one of five metabolic risk factors along with hepatic steatosis [6]. After excluding children with missing data used for MAFLD or MASLD diagnosis, a total of 1417, 1232, 1329 and 1154 children, respectively, were included in waves 1 through 4 of this cohort (Figure 1). The detection rates of NAFLD increased progressively from 1.3% in 2017 to 2.2% in 2019, 3.9% in 2021 and 7.9% in 2023. Notably, 100% of children with NAFLD met the diagnostic criteria for both MAFLD and MASLD across all four waves. For example, in 2023 (wave 4), 91 children were diagnosed with NAFLD, and all of them (100%) were also classified as having MAFLD or MASLD. Across four waves, among the five metabolic risk factors associated with MASLD, overweight (including obesity) or central obesity was the most prevalent (100%), followed by high blood pressure (27.8%–57.7%), while prediabetes (7.7%–29.6%) and low HDL-C (6.6%–22.2%) were less common. Similarly, for MAFLD, overweight (including obesity) or central obesity was the most prevalent risk factor, while prediabetes was the least prevalent in three waves. Our study showed for the first time that there was no difference in the detection rate of steatotic liver disease in a Chinese paediatric sample, regardless of the criteria used (NAFLD, MAFLD or MASLD). These findings confirm that historical data on NAFLD in paediatric population remain valid under the updated MAFLD or MASLD definition. Furthermore, in our sample, all children diagnosed with NAFLD, MAFLD or MASLD were found to be overweight or obese, underscoring the importance of targeted steatotic liver disease screening in paediatric populations with overweight or obesity. B.X. and L.Y. designed the study. L.Y. wrote the original draft and conducted data analysis. Y.Q. and M.Z. collected and curated the data. All authors critically revised the manuscript, have read and agreed to submit the manuscript. We acknowledge all of the participants in our study and the staff responsible for conducting the Huantai Childhood Cardiovascular Health Cohort study. Ethical approval was obtained from the Ethics Committees of Shandong University (Ethical Approval Number: 20160308). Written informed consent was obtained from participating children and their parents or guardians. The authors declare no conflicts of interest. The datasets described in the current study will be made available upon request pending application and approval.