Future burden of MASLD in the United States: A state-level forecasting study, 2022-2050

Abstract

Background and Aim: The rising prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) poses a significant public health challenge, yet the future burden at a subnational level is poorly quantified. State-specific projections are crucial for guiding policy, resource allocation, and targeted public health interventions. We project the future burden of MASLD by state to 2050. Materials and Methods: We developed a state-level forecasting model using data from the Global Burden of Disease (GBD) 2021 study and state-level population projections from the Weldon Cooper Center. For each state, historical age-and sex-specific MASLD DALY rates (1990-2021) were projected to 2050 using automatic ARIMA/ETS time-series forecasting. Projected rates were then applied to annual state population projections to estimate the absolute DALY burden. Associated direct healthcare costs were calculated using a derived national-average cost per MASLD DALY, discounted at 3% annually. A probabilistic sensitivity analysis (PSA) with 1,000 iterations was performed to quantify uncertainty in baseline DALY rates and costs. Results: Over the projection period (2022-2050), the total discounted MASLD burden in the U.S. is projected to be 5.5 million DALYs, with associated healthcare costs exceeding $2.3 trillion. The absolute burden is concentrated in the most populous states, with California (Mean DALYs: 444,363; 95% UI: 395,767-494,159), Texas (386,956; 95% UI: 337,640-435,164), and Florida (311,884; 95% UI: 275,974-347,758) projected to have the highest lifetime burdens. However, DALY rates per 100,000 population are projected to be highest in states within the South and Appalachia. Conclusion: The future burden of MASLD in the United States is projected to be substantial, growing, and geographically unequal, with distinct hotspots of high per-capita burden and divergent future trends. These state-level projections underscore the urgent need for tailored, regional public health strategies and provide essential data to inform state-level policy and resource allocation to address the escalating MASLD epidemic.