What is the clinical evidence from this study?

Study design: Cross-Sectional. Population: Hepatic steatosis and liver fibrosis (n=3905). Intervention: Waist-to-height ratio (WHtR) vs. Body mass index (BMI). Primary outcome: Hepatic steatosis (PR 10.45, 95% CI 6.74-16.22).

What does this research mean for the field?

Waist-to-height ratio outperforms body mass index in identifying U.S. adults at high risk for hepatic steatosis and liver fibrosis. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

What question did this study set out to answer?

This research compares waist-based measures and BMI for identifying hepatic steatosis and liver fibrosis.

June 7, 2026

2600-P: Waist-to-Height Ratio Outperforms BMI in Identifying Hepatic Steatosis and Fibrosis in U.S. Adults

Key Result

Elevated waist-to-height ratio outperformed BMI in identifying hepatic steatosis (PR 10.45; 95% CI 6.74-16.22) and increased liver stiffness (PR 3.92; 95% CI 2.36-6.51) in U.S. adults.

Key Points

This research compares waist-based measures and BMI for identifying hepatic steatosis and liver fibrosis.
Cross-sectional analysis of adults aged ≥18 years from NHANES 2021-2023, excluding specific health conditions.
Assessment of hepatic steatosis and stiffness using transient elastography and defined thresholds.
Comparison of BMI, waist circumference, waist-to-hip ratio, and waist-to-height ratio for predictive effectiveness.
Hepatic steatosis (CAP >260 dB/m) observed in 46.5% of participants; liver stiffness (LSM ≥8 kPa) in 10.9%.
WAUC for WHtR and WC was higher than BMI for hepatic steatosis (0.82-0.83 vs 0.81) and liver stiffness (0.76 vs 0.74).
Elevated WHtR correlated with a significantly higher prevalence of hepatic steatosis (PR 10.45; 95% CI 6.74-16.22) and increased liver stiffness (PR 3.92; 95% CI 2.36-6.51).

Study Design

Type

Cross-Sectional (n=3,905)

Multicenter

Yes

Structured PICO

Does waist-to-height ratio outperform BMI in identifying hepatic steatosis and liver fibrosis in adults?

Population

3,905 U.S. adults aged ≥18 years from NHANES 2021-2023, excluding those with pregnancy, heavy alcohol use, or viral hepatitis, assessed for hepatic steatosis and liver stiffness.

Exposure

Waist-to-height ratio (WHtR) and other waist-based anthropometric measures (waist circumference, waist-to-hip ratio)

Comparator

Body mass index (BMI)

Outcome

Identification of moderate to severe hepatic steatosis (controlled attenuation parameter >260 dB/m) and advanced fibrosis (liver stiffness measurement ≥8 kPa) assessed by transient elastographysurrogate

Waist-to-height ratio is a simple measure of central adiposity that outperforms BMI in identifying adults at high risk for hepatic steatosis and liver fibrosis.

Main Result

Relative Risk: 10.45 (95% CI 6.74–16.22)

Abstract

Introduction and Objective: Hepatic steatosis is highly prevalent yet frequently undiagnosed, despite strong associations with cardiometabolic disease and liver fibrosis. Body mass index (BMI) is widely used but inadequately reflects ectopic and visceral adiposity, which are more closely linked to cardiometabolic disease. We compared BMI with waist-based anthropometric measures to identify hepatic steatosis and increased liver stiffness at clinically relevant thresholds. Methods: We conducted a cross-sectional analysis of adults aged ≥18 years from NHANES 2021-2023, excluding pregnancy, heavy alcohol use, and viral hepatitis. Measures included BMI, waist circumference (WC), waist-to-hip ratio (WHR), and waist-to-height ratio (WHtR). Hepatic steatosis and liver stiffness were assessed using transient elastography, defining moderate to severe hepatic steatosis as controlled attenuation parameter (CAP) 260 dB/m and advanced fibrosis as liver stiffness measurement (LSM) ≥8 kPa. NHANES-weighted receiver operating characteristic analyses estimated weighted area under the curve (WAUC), and high-risk categories were evaluated using weighted regression models. Results: Among 3,905 participants (mean age 47 years; 50% female), CAP 260 dB/m was present in 46.5% and LSM ≥8 kPa in 10.9%. WHtR and WC demonstrated greater discrimination than BMI for hepatic steatosis (WAUC 0.82-0.83 vs 0.81) and increased liver stiffness (WAUC 0.76 vs 0.74), while WHR performed less well. At high-risk thresholds, elevated WHtR was associated with markedly higher prevalence of hepatic steatosis (PR 10.45; 95% CI 6.74-16.22) and increased liver stiffness (PR 3.92; 95% CI 2.36-6.51). Conclusion: WHtR, a simple measure of central adiposity, outperforms BMI for identifying individuals at high risk for hepatic steatosis and liver fibrosis. Incorporating waist-based measures into routine assessment may improve detection of cardiometabolic disease and support pragmatic risk stratification in clinical and population settings. Disclosure S. Jang: None. D.K. Ernest: None. A. Herrera Chancay: None. L. Xie: None. J.M. Francis: None. M.S. Mathew: None. S.E. Messiah: None. J. Almandoz: Consultant; Current; AbbVie Inc., Amgen Inc., Boehringer Ingelheim International GmbH, Eli Lilly and Company, Kailera, Novo Nordisk, Metsera, Rhythm Pharmaceuticals, Inc., Rivus.

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