The burden of NAFLD (now referred to as MASLD)-related chronic liver disease and cirrhosis from 1990 to 2021 with projections to 2036: a comparative study of global China the United States and India.

Background: Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) poses a significant and growing global health challenge. This study leverages the Global Burden of Disease (GBD) 2021 database to analyze the epidemiology of NAFLD (Now Referred to as MASLD)-related chronic Liver disease and cirrhosis across China, the United States, India, and globally from 1990 to 2021.

Methods: Using publicly available GBD data, we applied advanced analytical techniques-including age-period-cohort modeling, decomposition analysis, health inequality assessment (Slope Index of Inequality), Joinpoint regression, and Bayesian modeling-to assess disease burden patterns across regions and disease stages.

Results: Significant national variations exist in NAFLD (Now Referred to as MASLD)-attributable Disability-Adjusted Life Years (DALYs) and mortality burden. India bears the highest global burden among the three nations studied, which collectively accounted for 33.2% of global NAFLD (Now Referred to as MASLD) DALYs and 34.7% of global NAFLD (Now Referred to as MASLD)-related deaths. China reported the highest number of prevalent cases and annual incident cases globally; together, these three nations represented 41.5% of global NAFLD (Now Referred to as MASLD) prevalence and 39.8% of new cases. Analysis of the Average Annual Percentage Change (AAPC) revealed an increasing burden trend in the US and India. In contrast, China exhibited a significant decreasing trend. Burden measures (DALYs, deaths) progressively escalated with age, peaking within the 55-59 and 65-69-year age groups, respectively, before declining. Pronounced sex disparities were observed: males consistently exhibited higher DALYs and deaths before peak ages, yet females surpassed males in burden after 60-64 years. Notably, the US exhibited an exceptional pattern where females demonstrated significantly higher DALYs and mortality across all age groups. Forecasting models suggest increasing Age-Standardized Rates (ASRs) related to burden in China for both sexes. Regarding sex-specific trajectory changes, projections indicate a slight increase in US female burden, while Indian males show a significant upward trend. Decomposition analysis identified population aging and growth as primary drivers of increasing cirrhosis burden, with aging predominantly influencing China's trajectory and epidemiologic dynamics exerting strong protective effects. Analysis of health inequalities indicated widening disparities across geographic locations between 1990 and 2021.

Conclusion: The global burden of NAFLD (Now Referred to as MASLD) -related disease is shaped by multifaceted factors-population aging, evolving epidemiologic dynamics, and socioeconomic disparities. While some regions exhibit declining DALYs and mortality, others (notably India and the US) face escalating burdens. Addressing these challenges necessitates tailored public health strategies that reflect distinct regional patterns. Implementing targeted interventions is imperative to mitigate health inequities and enhance global health outcomes.