Associations of traditional healthy lifestyle and sleep quality with metabolic dysfunction-associated fatty liver disease: two population-based studies.

Aims: To examine whether an extended lifestyle metrics incorporating sleep quality improves risk stratification for metabolic dysfunction-associated fatty liver disease (MAFLD), at-risk metabolic dysfunction-associated steatohepatitis (MASH) and significant fibrosis.

Methods: A total of 5011 participants with abdominal ultrasound from Imaging sub-cohort of South China Cohort (ISSCC) and 3672 participants underwent vibration controlled transient elastography from US National Health and Nutrition Examination Survey (US NHANES) were included. Liver Essential 5 was constructed by incorporating sleep quality into traditional healthy lifestyles (HLS).

Results: A total of 4.66-17.72% of the association between traditional HLS and MAFLD was mediated by sleep quality regardless of the detection techniques, and their joint associations on MAFLD were significant in both cohorts. ORs for individuals with poor sleep and unfavorable HLS were 1.72 (1.29-2.30) in ISSCC and 2.25 (1.55-3.26) in US NHANES, respectively. Around half of the participants previously considered as following a favorable HLS were re-classified by Liver Essential 5 with significantly higher prevalences of MAFLD in both cohorts (P < 0.001). Similar results were also found on at-risk MASH and significant fibrosis in US NHANES. ORs of participants with per one increment increase in Liver Essential 5 were 0.82 (0.77-0.89) and 0.79 (0.70-0.88) for MAFLD in ISSCC and US NHANES, 0.62 (0.48-0.78) for at-risk MASH and 0.78 (0.65-0.93) for significant fibrosis.

Conclusions: Liver Essential 5, which incorporates sleep quality and traditional lifestyle factors, provides additional risk stratification for MAFLD-related outcomes.