CT-Assessed Abdominal Visceral Adiposity and MASLD: A Sex-Stratified Cross-Sectional Analysis

Why It Matters

Visceral adiposity, not overall weight, drives MASLD risk, highlighting the need for body‑composition metrics in screening and prevention strategies, especially for women who face steeper risk gradients.

Key Takeaways

• Visceral fat predicts MASLD better than BMI
• Risk rises sharply after sex-specific VFA thresholds
• Women show steeper VFA-MASLD risk gradient than men
• Subcutaneous fat and muscle mass have weak associations
• CT waist circumference improves MASLD discrimination beyond BMI

Pulse Analysis

Metabolic dysfunction‑associated steatotic liver disease has become a leading cause of chronic liver injury worldwide, yet traditional obesity metrics such as BMI often miss high‑risk individuals. In Asian populations, metabolic complications can arise at lower BMI levels, prompting researchers to turn to imaging‑based assessments that differentiate visceral from subcutaneous fat. Computed tomography offers precise quantification of abdominal compartments, enabling clinicians to capture the metabolically active visceral depot that directly drains into the portal circulation and fuels hepatic insulin resistance.

The Chinese cohort analyzed by Xu et al. demonstrates that visceral fat, measured at the L3 vertebral level, eclipses BMI as a MASLD predictor for both sexes. Logistic models revealed an 11.5‑fold increase in men and a striking 32.5‑fold rise in women at the highest VFA quartiles, with restricted cubic spline curves pinpointing inflection points near 12,500 mm² for men and 7,860 mm² for women. These non‑linear, sex‑specific thresholds suggest that modest visceral accumulation may be tolerable, but once a critical volume is surpassed, hepatic steatosis risk accelerates dramatically. Subcutaneous fat and skeletal‑muscle indices contributed minimally after adjusting for visceral adiposity, underscoring the primacy of central fat distribution.

Clinically, the findings argue for integrating CT‑derived waist circumference or VFA into MASLD risk algorithms, particularly for patients with normal BMI but elevated central obesity. Enhanced discrimination (AUC gains of 0.05‑0.06) could refine referral pathways for liver imaging, lifestyle counseling, and pharmacologic trials. Future longitudinal work should test whether targeted reduction of visceral fat—through diet, exercise, or bariatric interventions—translates into lower MASLD incidence or slower disease progression. Policymakers might also consider insurance coverage for opportunistic CT‑based body‑composition analysis in high‑risk groups, leveraging existing diagnostic scans to improve public‑health surveillance without additional radiation exposure.