Competing Cardiometabolic Pathways of Obesity and Metabolic Dysfunction–Associated Steatotic Liver Disease

Background and Aims: Metabolic dysfunction-associated steatotic liver disease (MASLD) progression is influenced by other metabolic disorders. However, quantitative evidence regarding disease pathway competition remains limited. In the current study, we utilized competing risk survival analysis to determine whether obesity-related MASLD development competes with hypertension and type 2 diabetes pathways. Methods: We conducted a 13-year (2007-2020) prospective cohort study involving 16,770 participants without MASLD, hypertension, or type 2 diabetes at baseline. Competing risk regression modeled the first occurrence of each disease during follow-up. Subdistribution hazard ratios (HRs) were estimated adjusting for age, sex, and baseline cardiometabolic parameters, with sensitivity analyses across body mass index (BMI) cutoffs and demographic subgroups. Conclusion: Individuals with a high BMI who developed MASLD exhibited a lower incidence of subsequent hypertension, suggesting apparent inverse associations that may reflect competing metabolic pathways. These findings suggest that obesity-related metabolic dysfunction may progress along distinct pathways-hepatic vs vascular-thereby supporting phenotype-specific risk stratification.