Metabolic liver disease cases are set to soar, driven by obesity and rising blood sugar, as clinicians face a growing pool of patients at risk of cirrhosis and cancer.
Metabolic liver disease is rapidly emerging as one of the defining clinical challenges of the next three decades, with new global modelling suggesting nearly one in five people worldwide could be affected by 2050.
The latest Global Burden of Diseases Study 2023 analysis, published in The Lancet Gastroenterology & Hepatology, estimates that 1.3 billion people – around 16.1% of the global population – were living with metabolic dysfunction-associated steatotic liver disease (MASLD) in 2023.
This represented a 142.7% increase in case numbers since 1990. The prevalence is forecast to rise to approximately 1.8 billion cases by mid-century, a 42% increase driven predominantly by population growth, with smaller but significant contributions from worsening metabolic risk profiles.
“The rising prevalence could be offset by improved care to prevent these complications, but it might also mean that there is an accumulating pool of at-risk individuals who have not had sufficient time to develop complications and will do so in the coming years,” the researchers wrote.
“Thus, the increasing prevalence remains concerning. Despite this trend, MASLD is not currently included in major global health strategies or action plans.
“Our findings provide an evidence base for policy makers to set specific targets and to align MASLD prevention, screening, and treatment efforts with broader metabolic and liver disease initiatives.”
Australia has not been immune from the rising case numbers. In 1990 the prevalence rate of MASLD was 7226 per 100,000 people. In 2023 that number rose by almost 30% to 9335 per 100,000 people. The global percentage rise during that period was 29%.
For clinicians, the most striking finding was the divergence between rising prevalence and relatively stable age-standardised disease burden, the researchers said.
While total disability-adjusted life years (DALYs) attributable to MASLD have more than doubled in absolute terms since 1990, the age-standardised DALY rate has remained largely unchanged over the same period.
This suggested that improvements in the management of cirrhosis and hepatocellular carcinoma were offsetting some of the downstream impact, even as the number of patients entering the disease pathway continued to expand.
The consequence was an accumulating pool of patients with pre-cirrhotic disease, many of whom were asymptomatic but remained at risk of progression.
MASLD encompasses a spectrum from simple steatosis through to metabolic dysfunction-associated steatohepatitis (MASH), cirrhosis and liver cancer, with progression influenced by metabolic comorbidities and ongoing inflammatory activity.
The study’s findings indicated that the current surge was occurring largely in earlier disease stages, raising concerns about a delayed wave of advanced liver complications in the coming decades.
Geographical variation remained pronounced. North Africa and the Middle East recorded the highest age-standardised prevalence rates globally, more than three times higher than those observed in high-income Asia Pacific regions.
These differences were not fully explained by sociodemographic status, suggesting region-specific drivers including diet, urbanisation and genetic susceptibility.
Countries with lower Healthcare Access and Quality indices experienced disproportionately higher DALY rates, underscoring the role of health system capacity in mitigating disease progression and complications.
Age and sex patterns provided further clinical insight. Although prevalence rates peaked in older age groups, the absolute number of cases was highest among younger adults, with a peak at 35–39 years in men and 55–59 years in women.
This reflected both population structure and the earlier onset of metabolic risk factors, and signalled a longer lifetime exposure to disease with implications for cumulative morbidity, the researchers noted.
Risk factor analysis reinforced MASLD’s position within the broader metabolic disease landscape. High fasting plasma glucose was the leading contributor to disease burden, followed by elevated body mass index and smoking.
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The strong association with glycaemic dysregulation highlighted the overlap with type 2 diabetes and supported integrated management approaches targeting insulin resistance and metabolic syndrome.
Notably, the modelling suggested that population growth, particularly in sub-Saharan Africa and parts of the Middle East, would be the dominant driver of future case increases, rather than ageing alone.
However, gradual increases in age-standardised prevalence rates indicated that underlying epidemiological shifts, including rising obesity and sedentary lifestyles, would continue to contribute.
For health professionals, the findings carried several implications, the researchers said.
MASLD should be considered a core component of non-communicable disease management rather than a niche hepatology issue, given its close links to cardiovascular disease, chronic kidney disease and diabetes.
In addition, the growing burden in younger populations and low- and middle-income countries highlighted the need for earlier identification and intervention, including risk stratification in primary care settings.
Despite its scale, MASLD remained largely absent from major global NCD strategies, contributing to low awareness, underdiagnosis and inconsistent management pathways. The authors argued that incorporating MASLD into national and international policy frameworks, alongside targeted prevention strategies addressing obesity and hyperglycaemia, would be critical to altering the current trajectory.
Without such action, clinicians were likely to face an expanding cohort of patients progressing from asymptomatic steatosis to advanced liver disease, with significant implications for liver transplantation demand, oncology services and long-term healthcare costs.
“Although the DALY rate over the same period was relatively stable, the growing pool of people with MASLD – many of whom are asymptomatic – carry a major risk of future complications,” the researchers concluded.
“MASLD is no longer predominantly a condition associated with westernised diets and lifestyles, yet the condition is not clearly included as a target within global strategies and action plans, such as SDGs.
“Thus, we hope that these findings will guide the worldwide community in setting a specific target for this condition, assessing regional and temporal trends, and allocating resources to prevent, diagnose, and manage MASLD, with interventions and policies to mitigate risk factors associated with the disease.”
