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The Cardiovascular Risk Paradox in Normal-Weight Steatotic Liver Disease Beyond Body Mass Index-Based Detection.
Masashi Hirooka1, Teruki Miyake2, Ryo Yano2
1Total Medical Support Center, Ehime University Hospital, Toon, Ehime, Japan.
Gastro Hep Advances
|June 8, 2026
Summary
Normal-weight individuals with fatty liver disease have a significantly higher risk of cardiovascular disease (CVD). This highlights the need for metabolic screening beyond BMI to identify at-risk populations.
Area of Science:
- Cardiology
- Metabolic Health
- Hepatology
Background:
- Current cardiovascular screening often overlooks normal-weight individuals with metabolic dysfunction.
- Steatotic liver disease (SLD) is a common metabolic dysfunction that may be missed in normal-weight individuals.
- This oversight can lead to the underdetection of a high-risk population for cardiovascular disease (CVD).
Purpose of the Study:
- To assess the prevalence of cardiovascular disease (CVD) across four distinct metabolic phenotypes.
- Phenotypes were defined by body mass index (BMI) and hepatic steatosis status.
- To investigate the cardiovascular risk associated with normal-weight individuals with steatotic liver disease (NWSLD).
Main Methods:
- Analysis of 34,848 Japanese adults from a community health screening program (2007-2010).
- Classification into four metabolic phenotypes based on BMI and hepatic steatosis using the fatty liver index.
- Comparison of cardiovascular risk across phenotypes using logistic regression and machine learning models.
Main Results:
- Normal-weight individuals with SLD (NWSLD) exhibited the highest CVD prevalence (3.63%) compared to healthy controls (0.72%) and obese individuals with SLD (1.76%).
- NWSLD remained strongly associated with CVD after multivariable adjustment (OR: 3.63; 95% CI: 2.11-5.88; P < .001).
- Inclusion of NWSLD improved CVD prediction models compared to BMI-only assessments, demonstrating enhanced clinical efficiency.
Conclusions:
- Normal-weight individuals with steatotic liver disease (NWSLD) represent a significant, yet unrecognized, cardiovascular risk phenotype.
- This finding challenges the sole reliance on BMI for cardiovascular risk assessment.
- Supports the implementation of metabolic-based precision screening strategies for improved cardiovascular risk identification.
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