MASLD prevalence reverses after 50 in hospitalized adults

In a cross-sectional analysis of 136,816 adults hospitalized at a tertiary medical center in China, metabolic dysfunction-associated steatotic liver disease (MASLD) was more prevalent among younger men but more common among women after age 50. Overall, 39,431 participants, or 28.8% of the study population, met the researchers’ criteria for MASLD. The age-related reversal was pronounced: after adjustment for calendar year, women aged 18–50 had about half the odds of MASLD compared with men of the same age group, while women aged 51–80 had 69% higher odds than men.

These findings describe associations within a hospitalized population and do not establish that aging or sex causes the disease. The study, conducted by Zhaozhimin Liu and Suosu Wei at the People’s Hospital of Guangxi Zhuang Autonomous Region, used electronic medical records from January 1, 2014, through September 7, 2023. Eligible patients were adults aged 18–80 who underwent liver ultrasonography during hospitalization.

Investigators initially identified 255,187 people, then retained the first admission ultrasound for each unique patient and excluded 118,371 records, or 46.4%, because information needed to classify metabolic dysfunction was missing. The final cohort included 71,690 women and 65,126 men. Comparisons were stratified into ages 18–50 and 51–80, with logistic regression used to estimate odds ratios and test whether the association between sex and MASLD changed with age.

MASLD was identified when ultrasonography showed hepatic steatosis and at least one metabolic criterion was present: body mass index of at least 23 kg/m² under Asian criteria, fasting plasma glucose of at least 5.6 mmol/L or a previous type 2 diabetes diagnosis, blood pressure of at least 130/85 mmHg, triglycerides of at least 1.7 mmol/L, or low high-density lipoprotein cholesterol, with sex-specific thresholds of below 1.0 mmol/L for men and 1.3 mmol/L for women. Patients with hepatitis B or C were excluded from the MASLD group. Because the records did not contain waist circumference, glycated hemoglobin, medication use or quantitative alcohol intake, the researchers could not apply every element of current consensus criteria or distinguish MASLD from metabolic dysfunction-associated steatotic liver disease with alcohol use.

The age-stratified pattern was visible in the raw prevalence figures. At age 18, MASLD affected 6.1% of women and 11.7% of men, while at age 48 the respective rates were 25.4% and 30.8%. The direction changed by age 51, when prevalence was 31.1% in women and 29.3% in men.

By age 60, 41.1% of women met the criteria compared with 28.2% of men, and female prevalence reached its highest reported age-specific value, 45.2%, at age 63. A formal interaction test confirmed that the sex difference varied by age (P < 0.001). In models adjusted for calendar year, the adjusted odds ratio for women versus men was 0.50 (95% confidence interval, 0.48–0.52) at ages 18–50 and 1.69 (1.64–1.74) at ages 51–80.

Metabolic adjustment changed the interpretation of the younger group’s association. When the researchers additionally adjusted for age, BMI, glucose, triglycerides, high-density lipoprotein cholesterol, type 2 diabetes, cardiovascular disease and calendar year, the lower MASLD odds among women aged 18–50 were no longer statistically significant: the adjusted odds ratio was 0.974 (95% confidence interval, 0.925–1.025; P = 0.311). In contrast, the association between female sex and MASLD remained significant among women aged 51–80 after full adjustment, with an adjusted odds ratio of 2.342 (95% confidence interval, 2.262–2.426; P < 0.001).

This pattern suggests that measured metabolic risk factors account for much of the sex difference in younger adults, whereas factors not captured by the model remain relevant in older women. The study did not measure menopausal status or reproductive hormones, so the possibility that endocrine changes contribute to the older-women pattern could not be tested directly. The metabolic burden was greater among older participants overall.

Elevated BMI was present in 81.8% of older patients compared with 44.1% of younger patients; elevated blood pressure in 72.2% compared with 61.0%; and elevated triglycerides in 44.6% compared with 20.8%, with all comparisons yielding P < 0.001. People classified as having MASLD were also older than those without it, with median ages of 58 and 53 years, respectively. Their median BMI was 25.6 rather than 22.4 kg/m², median triglycerides were 1.6 rather than 1.1 mmol/L, and median high-density lipoprotein cholesterol was 1.1 rather than 1.2 mmol/L. Their median fasting glucose was 5.0 rather than 4.6 mmol/L, while median systolic blood pressure was 135 rather than 126 mmHg.

These are cross-sectional group differences rather than evidence that a metabolic abnormality developed after MASLD. Age patterns also differed between the sexes. Female MASLD prevalence increased across the observed age range, with a significant linear trend (P for trend < 0.001), while the corresponding trend for men was not significant (P for trend = 0.986).

Joinpoint analysis identified three change points in the male curve, at ages 25, 34 and 59. Prevalence rose steeply from age 18 to 25, with an annual percentage change of 12.97% (95% confidence interval, 7.25–30.00; P = 0.006), then plateaued through age 59 before declining from age 59 to 80 at an annual percentage change of −1.01% (95% confidence interval, −2.85 to −0.10; P = 0.048). The overall average annual percentage change for men was 1.41% (95% confidence interval, 1.05–1.89; P < 0.001).

The investigators said survival selection was one possible explanation for lower prevalence among the oldest men, but the cross-sectional data cannot test that possibility. Annual analyses from 2014 through 2023 showed that the age-dependent pattern persisted despite changes in hospital volume and overall prevalence. Among adults aged 18–50, women consistently had lower unadjusted odds than men; the female-to-male odds ratio was 0.58 (95% confidence interval, 0.48–0.69) in 2014 and 0.47 (0.36–0.61) in 2023.

Among those aged 51–80, women consistently had higher odds, with corresponding ratios of 1.71 (1.53–1.91) in 2014 and 1.36 (1.15–1.60) in 2023. Overall MASLD prevalence increased over the study period, but the annual sex-specific odds ratios were unadjusted and cannot be interpreted as independent effects of sex or time. The sample size also varied substantially by year, from 3,727 included patients in 2023 to 23,478 in 2022, which further limits simple interpretation of annual comparisons.

Fibrosis-risk estimates also rose with age among participants with MASLD. The proportion with a Fibrosis-4 index above 2.67, the study’s high-risk category, was 4.6% among women aged 51–80 versus 1.4% among younger women; among men, the corresponding proportions were 6.4% and 1.5%. FIB-4 is a calculated risk indicator rather than a direct diagnosis of advanced fibrosis.

The findings nevertheless indicate that the older female group with MASLD had both a higher prevalence of the condition and a larger share in the elevated FIB-4 category. The results require cautious interpretation because the study was conducted at one tertiary hospital, included only people who underwent ultrasonography during admission and depended on ultrasound rather than liver biopsy. Ultrasound can misclassify hepatic fat, and the large number of exclusions for missing metabolic data creates a risk of selection bias, although included and excluded patients were broadly similar across measured characteristics.

The results therefore support an age- and sex-specific pattern of MASLD burden in this clinical setting, but they cannot show that menopause causes the rise among older women, that any subgroup has greater disease progression, or that the pattern necessarily applies to the wider community population.

Subject of Research: Age-dependent sex differences in MASLD prevalence among hospitalized adults

Article Title: Sex differences in the prevalence of metabolic dysfunction-associated steatotic liver disease in hospitalized patients: a single-center cross-sectional study

Article References: Liu, Z., & Wei, S. (2026). Sex differences in the prevalence of metabolic dysfunction-associated steatotic liver disease in hospitalized patients: a single-center cross-sectional study. Frontiers in Endocrinology, 17, Article 1942008. https://doi.org/10.3389/fendo.2026.1942008

Image Credits: AI Generated

DOI: 10.3389/fendo.2026.1942008

Keywords: MASLD, sex differences, age interaction, liver steatosis, hospitalized adults, metabolic dysfunction, liver ultrasound, cross-sectional study, fibrosis risk, China, differences, prevalence