Body weight categories and fat distribution in relation to all-cause mortality among adults with metabolic dysfunction-associated steatotic liver disease: a population-based analysis of NHANES, 2007–2018

Martin Tze Wah Kueh; Made Ayu Utami Intaran; Rachel Goh; Gwyneth Kong; Hui Lian Koh; Yip Han Chin; Mark Y Chan; Carel W Le Roux; Anurag Mehta; Muhammad Shahzeb Khan; Mark D Muthiah; Nicholas WS Chew

doi:10.1136/bmjopen-2025-113719

Body weight categories and fat distribution in relation to all-cause mortality among adults with metabolic dysfunction-associated steatotic liver disease: a population-based analysis of NHANES, 2007–2018

Martin Tze Wah Kueh
, Made Ayu Utami Intaran
, Rachel Goh
, Gwyneth Kong
, Hui Lian Koh
, Yip Han Chin
, Mark Y Chan
, Carel W Le Roux
, Anurag Mehta
, Muhammad Shahzeb Khan
, Mark D Muthiah
, Nicholas WS Chew

Research output: Contribution to journal › Article › peer-review

2 Citations (Scopus)

7 Downloads (Pure)

Abstract

OBJECTIVE: Although body mass index (BMI)-defined non-obesity metabolic dysfunction-associated steatotic liver disease (MASLD) predicts poor prognosis, the role of visceral adiposity and weight-based phenotypes is unclear. This study aimed to examine the clinical correlates of four unique MASLD phenotypes based on BMI and waist-to-height ratio (WHtR) and to assess the prognostic value of this classification with respect to mortality.

DESIGN: Population-based cross-sectional study with prospective mortality follow-up.

SETTING: Nationally representative US population derived from the National Health and Nutrition Examination Survey (NHANES), 2007-2018.

PARTICIPANTS: 6300 adults with MASLD, sampled from NHANES 2007 to 2018.

METHODS: Participants were allocated into four phenotypes based on obesity/lean and central adiposity status. Obesity was defined as BMI≥30 kg/m², while those without obesity were determined as lean. High central adiposity was defined as WHtR≥0.6.

PRIMARY OUTCOME MEASURE: The primary outcome was all-cause mortality. This was ascertained through National Death Index linkage with follow-up censored at 31 December 2019.

RESULTS: Among adults with MASLD, 72.1% had obesity with high central adiposity (mean follow-up: 6.9±3.5 years). The non-obesity, high central adiposity phenotype (9.6%) exhibited the highest rates of hypertension (60.2%), type 2 diabetes (31.8%) and chronic kidney disease (23.3%). This phenotype portended the poorest 6-year survival (p<0.001) and was independently associated with higher all-cause mortality (adjusted HR (aHR) 3.1, 95% CI 1.3 to 7.7). A J-shaped association was observed between BMI and mortality, with increasing WHtR linked to elevated risk.

CONCLUSION: Non-obesity MASLD with high central adiposity confers the poorest survival and cardiometabolic burden.

Original language	English
Article number	e113719
Pages (from-to)	1-10
Number of pages	10
Journal	BMJ Open
Volume	16
Issue number	6
Early online date	25 Jun 2026
DOIs	https://doi.org/10.1136/bmjopen-2025-113719
Publication status	Published (in print/issue) - 25 Jun 2026

Bibliographical note

Publisher Copyright:
© Author(s) (or their employer(s)) 2026. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.

Data Availability Statement

Data are available in a public, open access repository. The datasets analysed during the current study are publicly available from the National Health and Nutrition Examination Survey (NHANES) repository maintained by the Centers for Disease Control and Prevention (CDC), available at https://www.cdc.gov/nchs/nhanes.

Funding

This research is funded by the NUHS Seed Fund (NUHSRO/2022/RO5+6/ Seed- Mar/03) and the 427 National Medical Research Council Transition Award.

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

SDG 3 Good Health and Well-being

Keywords

Mortality
Cardiovascular Disease
Body Mass Index
Obesity, Abdominal
Body Weight
Prospective Studies
Cross-Sectional Studies
Nutrition Surveys
Humans
Middle Aged
Risk Factors
Obesity/epidemiology
Male
Non-alcoholic Fatty Liver Disease/mortality
Cause of Death
Waist-Height Ratio
United States/epidemiology
Adiposity
Female
Adult
Body Fat Distribution

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Kueh, M. T. W., Intaran, M. A. U., Goh, R., Kong, G., Koh, H. L., Chin, Y. H., Chan, M. Y., Le Roux, C. W., Mehta, A., Khan, M. S., Muthiah, M. D., & Chew, N. WS. (2026). Body weight categories and fat distribution in relation to all-cause mortality among adults with metabolic dysfunction-associated steatotic liver disease: a population-based analysis of NHANES, 2007–2018. BMJ Open, 16(6), 1-10. Article e113719. https://doi.org/10.1136/bmjopen-2025-113719

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title = "Body weight categories and fat distribution in relation to all-cause mortality among adults with metabolic dysfunction-associated steatotic liver disease: a population-based analysis of NHANES, 2007–2018",

abstract = "OBJECTIVE: Although body mass index (BMI)-defined non-obesity metabolic dysfunction-associated steatotic liver disease (MASLD) predicts poor prognosis, the role of visceral adiposity and weight-based phenotypes is unclear. This study aimed to examine the clinical correlates of four unique MASLD phenotypes based on BMI and waist-to-height ratio (WHtR) and to assess the prognostic value of this classification with respect to mortality.DESIGN: Population-based cross-sectional study with prospective mortality follow-up.SETTING: Nationally representative US population derived from the National Health and Nutrition Examination Survey (NHANES), 2007-2018.PARTICIPANTS: 6300 adults with MASLD, sampled from NHANES 2007 to 2018.METHODS: Participants were allocated into four phenotypes based on obesity/lean and central adiposity status. Obesity was defined as BMI≥30 kg/m², while those without obesity were determined as lean. High central adiposity was defined as WHtR≥0.6.PRIMARY OUTCOME MEASURE: The primary outcome was all-cause mortality. This was ascertained through National Death Index linkage with follow-up censored at 31 December 2019.RESULTS: Among adults with MASLD, 72.1\% had obesity with high central adiposity (mean follow-up: 6.9±3.5 years). The non-obesity, high central adiposity phenotype (9.6\%) exhibited the highest rates of hypertension (60.2\%), type 2 diabetes (31.8\%) and chronic kidney disease (23.3\%). This phenotype portended the poorest 6-year survival (p<0.001) and was independently associated with higher all-cause mortality (adjusted HR (aHR) 3.1, 95\% CI 1.3 to 7.7). A J-shaped association was observed between BMI and mortality, with increasing WHtR linked to elevated risk.CONCLUSION: Non-obesity MASLD with high central adiposity confers the poorest survival and cardiometabolic burden.",

keywords = "Mortality, Cardiovascular Disease, Body Mass Index, Obesity, Abdominal, Body Weight, Prospective Studies, Cross-Sectional Studies, Nutrition Surveys, Humans, Middle Aged, Risk Factors, Obesity/epidemiology, Male, Non-alcoholic Fatty Liver Disease/mortality, Cause of Death, Waist-Height Ratio, United States/epidemiology, Adiposity, Female, Adult, Body Fat Distribution",

author = "Kueh, \{Martin Tze Wah\} and Intaran, \{Made Ayu Utami\} and Rachel Goh and Gwyneth Kong and Koh, \{Hui Lian\} and Chin, \{Yip Han\} and Chan, \{Mark Y\} and \{Le Roux\}, \{Carel W\} and Anurag Mehta and Khan, \{Muhammad Shahzeb\} and Muthiah, \{Mark D\} and Chew, \{Nicholas WS\}",

note = "Publisher Copyright: {\textcopyright} Author(s) (or their employer(s)) 2026. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.",

year = "2026",

month = jun,

day = "25",

doi = "10.1136/bmjopen-2025-113719",

language = "English",

volume = "16",

pages = "1--10",

journal = "BMJ Open",

issn = "2044-6055",

publisher = "BMJ Publishing Group",

number = "6",

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Kueh, MTW, Intaran, MAU, Goh, R, Kong, G, Koh, HL, Chin, YH, Chan, MY, Le Roux, CW, Mehta, A, Khan, MS, Muthiah, MD & Chew, NWS 2026, 'Body weight categories and fat distribution in relation to all-cause mortality among adults with metabolic dysfunction-associated steatotic liver disease: a population-based analysis of NHANES, 2007–2018', BMJ Open, vol. 16, no. 6, e113719, pp. 1-10. https://doi.org/10.1136/bmjopen-2025-113719

Body weight categories and fat distribution in relation to all-cause mortality among adults with metabolic dysfunction-associated steatotic liver disease: a population-based analysis of NHANES, 2007–2018. / Kueh, Martin Tze Wah; Intaran, Made Ayu Utami; Goh, Rachel et al.
In: BMJ Open, Vol. 16, No. 6, e113719, 25.06.2026, p. 1-10.

Research output: Contribution to journal › Article › peer-review

TY - JOUR

T1 - Body weight categories and fat distribution in relation to all-cause mortality among adults with metabolic dysfunction-associated steatotic liver disease: a population-based analysis of NHANES, 2007–2018

AU - Kueh, Martin Tze Wah

AU - Intaran, Made Ayu Utami

AU - Goh, Rachel

AU - Kong, Gwyneth

AU - Koh, Hui Lian

AU - Chin, Yip Han

AU - Chan, Mark Y

AU - Le Roux, Carel W

AU - Mehta, Anurag

AU - Khan, Muhammad Shahzeb

AU - Muthiah, Mark D

AU - Chew, Nicholas WS

N1 - Publisher Copyright: © Author(s) (or their employer(s)) 2026. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.

PY - 2026/6/25

Y1 - 2026/6/25

N2 - OBJECTIVE: Although body mass index (BMI)-defined non-obesity metabolic dysfunction-associated steatotic liver disease (MASLD) predicts poor prognosis, the role of visceral adiposity and weight-based phenotypes is unclear. This study aimed to examine the clinical correlates of four unique MASLD phenotypes based on BMI and waist-to-height ratio (WHtR) and to assess the prognostic value of this classification with respect to mortality.DESIGN: Population-based cross-sectional study with prospective mortality follow-up.SETTING: Nationally representative US population derived from the National Health and Nutrition Examination Survey (NHANES), 2007-2018.PARTICIPANTS: 6300 adults with MASLD, sampled from NHANES 2007 to 2018.METHODS: Participants were allocated into four phenotypes based on obesity/lean and central adiposity status. Obesity was defined as BMI≥30 kg/m², while those without obesity were determined as lean. High central adiposity was defined as WHtR≥0.6.PRIMARY OUTCOME MEASURE: The primary outcome was all-cause mortality. This was ascertained through National Death Index linkage with follow-up censored at 31 December 2019.RESULTS: Among adults with MASLD, 72.1% had obesity with high central adiposity (mean follow-up: 6.9±3.5 years). The non-obesity, high central adiposity phenotype (9.6%) exhibited the highest rates of hypertension (60.2%), type 2 diabetes (31.8%) and chronic kidney disease (23.3%). This phenotype portended the poorest 6-year survival (p<0.001) and was independently associated with higher all-cause mortality (adjusted HR (aHR) 3.1, 95% CI 1.3 to 7.7). A J-shaped association was observed between BMI and mortality, with increasing WHtR linked to elevated risk.CONCLUSION: Non-obesity MASLD with high central adiposity confers the poorest survival and cardiometabolic burden.

AB - OBJECTIVE: Although body mass index (BMI)-defined non-obesity metabolic dysfunction-associated steatotic liver disease (MASLD) predicts poor prognosis, the role of visceral adiposity and weight-based phenotypes is unclear. This study aimed to examine the clinical correlates of four unique MASLD phenotypes based on BMI and waist-to-height ratio (WHtR) and to assess the prognostic value of this classification with respect to mortality.DESIGN: Population-based cross-sectional study with prospective mortality follow-up.SETTING: Nationally representative US population derived from the National Health and Nutrition Examination Survey (NHANES), 2007-2018.PARTICIPANTS: 6300 adults with MASLD, sampled from NHANES 2007 to 2018.METHODS: Participants were allocated into four phenotypes based on obesity/lean and central adiposity status. Obesity was defined as BMI≥30 kg/m², while those without obesity were determined as lean. High central adiposity was defined as WHtR≥0.6.PRIMARY OUTCOME MEASURE: The primary outcome was all-cause mortality. This was ascertained through National Death Index linkage with follow-up censored at 31 December 2019.RESULTS: Among adults with MASLD, 72.1% had obesity with high central adiposity (mean follow-up: 6.9±3.5 years). The non-obesity, high central adiposity phenotype (9.6%) exhibited the highest rates of hypertension (60.2%), type 2 diabetes (31.8%) and chronic kidney disease (23.3%). This phenotype portended the poorest 6-year survival (p<0.001) and was independently associated with higher all-cause mortality (adjusted HR (aHR) 3.1, 95% CI 1.3 to 7.7). A J-shaped association was observed between BMI and mortality, with increasing WHtR linked to elevated risk.CONCLUSION: Non-obesity MASLD with high central adiposity confers the poorest survival and cardiometabolic burden.

KW - Mortality

KW - Cardiovascular Disease

KW - Body Mass Index

KW - Obesity, Abdominal

KW - Body Weight

KW - Prospective Studies

KW - Cross-Sectional Studies

KW - Nutrition Surveys

KW - Humans

KW - Middle Aged

KW - Risk Factors

KW - Obesity/epidemiology

KW - Male

KW - Non-alcoholic Fatty Liver Disease/mortality

KW - Cause of Death

KW - Waist-Height Ratio

KW - United States/epidemiology

KW - Adiposity

KW - Female

KW - Adult

KW - Body Fat Distribution

UR - https://www.scopus.com/pages/publications/105043775107

U2 - 10.1136/bmjopen-2025-113719

DO - 10.1136/bmjopen-2025-113719

M3 - Article

C2 - 42350020

SN - 2044-6055

VL - 16

SP - 1

EP - 10

JO - BMJ Open

JF - BMJ Open

IS - 6

M1 - e113719

ER -

Body weight categories and fat distribution in relation to all-cause mortality among adults with metabolic dysfunction-associated steatotic liver disease: a population-based analysis of NHANES, 2007–2018

Abstract

Bibliographical note

Data Availability Statement

Funding

UN SDGs

Keywords

Access to Document

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Cite this