Background. Metabolic dysfunction-associated steatotic liver disease (MASLD) has become one of the leading causes of chronic liver disease, affecting up to 38% of the adult population and 60% of individuals with obesity of type 2 diabetes mellitus. Diagnosis of MASLD requires the presence of hepatic steatosis in >5% of hepatocytes, diagnosed by imaging or liver biopsy, and one of the following cardiometabolic risk factors: elevated body mass index (BMI), elevated waist circumference, pre-diabetes, type 2 diabetes, hypertension, or dyslipidemia. There is limited understanding of how social determinants of health (SDOH) such as education level and income affect MASLD prevalence.

Methods. We analyzed data from NHANES 2017-2018 and created two cohorts of patients with and without MASLD. Education and income were the main predictor variables, and MASLD prevalence was the outcome; both predictors were binarized based on observed patterns in the data. Covariates were selected based on literature linking MASLD to medical comorbidities and SDOH and included demographic, clinical, and socioeconomic factors, with collinearity assessed using variance inflation factors. Statistical analyses were conducted using R, with univariate and multivariable logistic regression models—including interaction terms—used to evaluate associations, and significance set at p < 0.05.

Results. We identified 2,130 participants with MASLD and 1,472 without MASLD. Participants with MASLD had higher rates of hypertension, diabetes, hypercholesterolemia, and obesity. MASLD was more prevalent among Mexican Americans and less prevalent among non-Hispanic Black individuals. Social determinants such as lower education, being married, and reduced physical activity were significantly associated with MASLD. In adjusted logistic regression models, college education or higher was independently associated with lower odds of MASLD, while income ≥$65,000 was not. Significant predictors of higher MASLD prevalence included older age, male gender, Mexican American and non-Hispanic Asian race/ethnicity, comorbidities, and marital status. Physical activity and non-Hispanic Black identity were protective. Interaction analysis showed no significant interaction between education and income, but a significant interaction was found between higher education and full food security, suggesting reduced MASLD prevalence in this subgroup. No significant interactions were found with income.

Conclusions. Higher education is a predictor for lower MASLD prevalence, whereas income level of $65,000 or more does not predict MASLD prevalence. Higher education may result in better access to food that could explain why patients present with better metabolic profiles that are protective against MASLD.