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

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.

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.

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.

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.