Metabolic dysfunction-associated steatotic liver disease (MASLD), formerly known as non-alcoholic fatty liver disease (NAFLD), has emerged as the most common chronic liver disease worldwide and represents the hepatic manifestation of metabolic dysfunction [1]. The recent change in nomenclature emphasizes the close association between hepatic steatosis and metabolic risk factors such as obesity, insulin resistance, dyslipidemia, hypertension, and type 2 diabetes mellitus (T2DM). MASLD encompasses a broad spectrum of liver pathology ranging from simple steatosis to steatohepatitis, fibrosis, cirrhosis, and hepatocellular carcinoma [2]. Owing to its asymptomatic nature during the early stages, the disease often remains undiagnosed until advanced liver damage has occurred, making it a significant public health concern [3].

Type 2 diabetes mellitus is one of the strongest risk factors for the development and progression of MASLD [4]. Chronic insulin resistance, hyperglycemia, and altered lipid metabolism contribute to excessive hepatic fat accumulation and promote inflammation and fibrosis [5]. Individuals with T2DM not only have a higher prevalence of MASLD than the general population but are also at an increased risk of developing advanced fibrosis, liver-related complications, and cardiovascular disease [6]. Conversely, the coexistence of MASLD further worsens glycemic control and increases the risk of diabetic microvascular and macrovascular complications, highlighting the bidirectional relationship between these two disorders [7].

The global prevalence of MASLD among individuals with T2DM has been estimated to exceed 50%, with even higher rates reported in Asian populations [8]. India is witnessing a rapid rise in both diabetes and obesity, leading to an increasing burden of MASLD [9]. Despite this growing epidemic, routine screening for MASLD is not universally practiced in patients with T2DM because many individuals remain asymptomatic and the condition is often overlooked during routine diabetes care [10]. Early identification of affected patients is essential to facilitate timely lifestyle interventions, optimize metabolic control, and reduce the risk of progression to advanced liver disease [11].

Considering the increasing burden of MASLD among individuals with type 2 diabetes mellitus and its potential impact on clinical outcomes, the present study aimed to determine the prevalence and severity of MASLD in patients with T2DM and to evaluate its association with demographic characteristics, clinical features, metabolic risk factors, and biochemical parameters.

This hospital-based cross-sectional observational study was conducted in the Department of General Medicine over a period of one year, from May 2023 to May 2024, after obtaining approval from the Institutional Ethics Committee. A total of 100 consecutive adult patients diagnosed with type 2 diabetes mellitus (T2DM) and attending the outpatient department or admitted to the inpatient wards during the study period were enrolled after obtaining written informed consent. Patients aged ≥18 years with established T2DM were included in the study. Patients with significant alcohol intake, chronic viral hepatitis (hepatitis B or C), autoimmune liver disease, drug-induced liver disease, pregnancy, known chronic liver disorders of other etiologies, or incomplete clinical records were excluded. Detailed demographic and clinical information, including age, sex, residence, duration of diabetes, smoking status, alcohol consumption, and comorbidities such as hypertension and dyslipidemia, was recorded using a structured case record form. Anthropometric measurements, including height, weight, body mass index (BMI), and waist circumference, were obtained using standardized techniques. Blood pressure was measured after an adequate period of rest. Laboratory investigations included fasting blood glucose, glycated hemoglobin (HbA1c), liver function tests (AST and ALT), and fasting lipid profile comprising total cholesterol, triglycerides, high-density lipoprotein (HDL), and low-density lipoprotein (LDL). Metabolic syndrome was identified according to standard diagnostic criteria. All participants underwent abdominal ultrasonography performed by an experienced radiologist to assess the presence and severity of metabolic dysfunction-associated steatotic liver disease (MASLD). Hepatic steatosis was graded as mild, moderate, or severe based on standard ultrasonographic features, including hepatic echogenicity, visualization of intrahepatic vessels, and posterior beam attenuation. Participants were subsequently categorized into MASLD and non-MASLD groups for comparative analysis. The collected data were entered into Microsoft Excel and analyzed using IBM SPSS Statistics for Windows, Version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation (SD), while categorical variables were presented as frequencies and percentages. Associations between categorical variables were assessed using the Chi-square test or Fisher's exact test, as appropriate. Differences in continuous variables between groups were analyzed using the independent Student's t-test. Variables demonstrating statistical significance in univariate analysis were entered into a multivariate logistic regression model to identify independent predictors of MASLD, and adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were calculated. A p value of <0.05 was considered statistically significant.

A total of 100 patients with type 2 diabetes mellitus were included in the study. The majority of participants were aged 50–59 years (36.0%), followed by ≥60 years (29.0%). Males constituted 58.0% of the study population, while 61.0% were from urban areas. The largest proportion of patients had diabetes for 5–10 years (39.0%), whereas 19.0% were smokers and 14.0% reported alcohol consumption (Table 1).

Table 1. Baseline Characteristics of the Study Participants (N = 100)

Most participants were obese (62.0%) and had an increased waist circumference (68.0%). Hypertension and dyslipidemia were present in 59.0% and 64.0% of patients, respectively, while metabolic syndrome was identified in 71.0%. Nearly one-third (30.0%) had poor glycemic control with HbA1c ≥9%, whereas 46.0% had HbA1c between 7% and 8.9% (Table 2).

Table 2. Clinical Characteristics and Metabolic Profile (N = 100)

The mean age of the study participants was 54.8 ± 9.7 years, with a mean diabetes duration of 8.2 ± 5.1 years. The average BMI was 28.1 ± 4.5 kg/m² and mean waist circumference was 97.4 ± 10.8 cm. The mean HbA1c was 8.3 ± 1.5%, while the mean ALT and AST levels were 43.9 ± 19.6 U/L and 37.4 ± 15.2 U/L, respectively (Table 3).

Table 3. Laboratory Parameters (N = 100)

MASLD was detected in 63.0% of the study participants, whereas 37.0% had no evidence of hepatic steatosis. Among patients with MASLD, moderate steatosis was the most common grade (42.9%), followed by mild (38.1%) and severe steatosis (19.0%) (Table 4).

Table 4. Prevalence and Severity of MASLD (N = 100)

A significantly higher proportion of patients aged ≥50 years and those with diabetes duration exceeding 10 years had MASLD compared to their counterparts (p<0.05). Although MASLD was more common among males and urban residents, these associations were not statistically significant (p>0.05) (Table 5).

Table 5. Association Between Demographic Variables and MASLD

MASLD showed significant associations with obesity, increased waist circumference, dyslipidemia, metabolic syndrome, and HbA1c ≥9% (all p<0.05). Although hypertension was more frequent among patients with MASLD, the association did not reach statistical significance (p=0.058) (Table 6).

Table 6. Association Between Clinical Characteristics and MASLD

Patients with MASLD had significantly higher mean BMI, waist circumference, HbA1c, triglyceride levels, ALT, and AST compared with those without MASLD. Conversely, HDL cholesterol levels were significantly lower among patients with MASLD (all p<0.05) (Table 7).

Table 7. Comparison of Laboratory Parameters Between Patients With and Without MASLD

Multivariate logistic regression demonstrated that obesity (AOR=3.84), increased waist circumference (AOR=3.12), dyslipidemia (AOR=2.68), HbA1c ≥9% (AOR=2.47), and diabetes duration greater than 10 years (AOR=2.21) were independent predictors of MASLD after adjustment for potential confounding factors (all p<0.05) (Table 8).

Table 8. Multivariate Logistic Regression Analysis for Predictors of MASLD

The present study demonstrated a high prevalence of MASLD (63.0%) among patients with type 2 diabetes mellitus, emphasizing the close association between diabetes and hepatic steatosis. This prevalence is consistent with the systematic review and meta-analysis by Younossi et al., who reported a pooled global prevalence of NAFLD of 55.5% among patients with T2DM, with even higher prevalence in hospital-based studies [12]. Similarly, Targher et al. highlighted that more than half of patients with T2DM have NAFLD and are at substantially greater risk of progression to steatohepatitis, advanced fibrosis, and liver-related complications because of persistent insulin resistance and metabolic dysfunction [13]. The prevalence observed in the present study therefore supports the growing evidence that fatty liver disease is a major yet often under-recognized comorbidity in individuals with T2DM. The present study found significant associations between MASLD and obesity, increased waist circumference, dyslipidemia, metabolic syndrome, poor glycemic control, and longer duration of diabetes. These findings are in agreement with the observations of Targher et al., who described obesity, visceral adiposity, insulin resistance, and dyslipidemia as the principal drivers of hepatic steatosis in patients with T2DM [13]. Likewise, Younossi et al. demonstrated that obesity and metabolic syndrome markedly increase the likelihood of developing NAFLD and advanced fibrosis among diabetic individuals [12]. These findings reinforce the concept that MASLD is a multisystem metabolic disorder rather than an isolated liver disease, and its development reflects the cumulative burden of metabolic risk factors. Patients with MASLD in the present study also had significantly higher BMI, waist circumference, HbA1c, triglycerides, AST, and ALT levels, along with lower HDL cholesterol concentrations than patients without MASLD. Similar findings have been reported by Mantovani et al., who concluded that poor glycemic control, elevated liver enzymes, obesity, and dyslipidemia are strongly associated with the severity and progression of NAFLD in patients with diabetes [14]. Furthermore, Younossi reviewed the global burden of NAFLD and emphasized that the increasing prevalence of obesity and T2DM has contributed substantially to the worldwide rise in fatty liver disease and its hepatic and extrahepatic complications [15]. These similarities suggest that routine metabolic evaluation can facilitate early identification of patients at increased risk of MASLD. Multivariate logistic regression in the present study identified obesity, increased waist circumference, dyslipidemia, HbA1c ≥9%, and longer duration of diabetes as independent predictors of MASLD. These findings indicate that simple clinical and biochemical parameters can effectively identify diabetic patients at high risk for fatty liver disease in routine clinical practice. Since MASLD often remains asymptomatic until advanced stages, early screening using abdominal ultrasonography together with optimization of glycemic control, weight reduction, and management of associated metabolic abnormalities may reduce disease progression and improve long-term hepatic and cardiovascular outcomes. The findings of the present study further support current recommendations advocating active screening for fatty liver disease in patients with type 2 diabetes, particularly those with obesity and poor metabolic control.

A total of 100 patients with type 2 diabetes mellitus were included in the study. The majority of participants were aged 50–59 years (36.0%), followed by ≥60 years (29.0%). Males constituted 58.0% of the study population, while 61.0% were from urban areas. The largest proportion of patients had diabetes for 5–10 years (39.0%), whereas 19.0% were smokers and 14.0% reported alcohol consumption (Table 1).

Table 1. Baseline Characteristics of the Study Participants (N = 100)

Most participants were obese (62.0%) and had an increased waist circumference (68.0%). Hypertension and dyslipidemia were present in 59.0% and 64.0% of patients, respectively, while metabolic syndrome was identified in 71.0%. Nearly one-third (30.0%) had poor glycemic control with HbA1c ≥9%, whereas 46.0% had HbA1c between 7% and 8.9% (Table 2).

Table 2. Clinical Characteristics and Metabolic Profile (N = 100)

The mean age of the study participants was 54.8 ± 9.7 years, with a mean diabetes duration of 8.2 ± 5.1 years. The average BMI was 28.1 ± 4.5 kg/m² and mean waist circumference was 97.4 ± 10.8 cm. The mean HbA1c was 8.3 ± 1.5%, while the mean ALT and AST levels were 43.9 ± 19.6 U/L and 37.4 ± 15.2 U/L, respectively (Table 3).

Table 3. Laboratory Parameters (N = 100)

MASLD was detected in 63.0% of the study participants, whereas 37.0% had no evidence of hepatic steatosis. Among patients with MASLD, moderate steatosis was the most common grade (42.9%), followed by mild (38.1%) and severe steatosis (19.0%) (Table 4).

Table 4. Prevalence and Severity of MASLD (N = 100)

A significantly higher proportion of patients aged ≥50 years and those with diabetes duration exceeding 10 years had MASLD compared to their counterparts (p<0.05). Although MASLD was more common among males and urban residents, these associations were not statistically significant (p>0.05) (Table 5).

Table 5. Association Between Demographic Variables and MASLD

MASLD showed significant associations with obesity, increased waist circumference, dyslipidemia, metabolic syndrome, and HbA1c ≥9% (all p<0.05). Although hypertension was more frequent among patients with MASLD, the association did not reach statistical significance (p=0.058) (Table 6).

Table 6. Association Between Clinical Characteristics and MASLD

Patients with MASLD had significantly higher mean BMI, waist circumference, HbA1c, triglyceride levels, ALT, and AST compared with those without MASLD. Conversely, HDL cholesterol levels were significantly lower among patients with MASLD (all p<0.05) (Table 7).

Table 7. Comparison of Laboratory Parameters Between Patients With and Without MASLD

Multivariate logistic regression demonstrated that obesity (AOR=3.84), increased waist circumference (AOR=3.12), dyslipidemia (AOR=2.68), HbA1c ≥9% (AOR=2.47), and diabetes duration greater than 10 years (AOR=2.21) were independent predictors of MASLD after adjustment for potential confounding factors (all p<0.05) (Table 8).

Table 8. Multivariate Logistic Regression Analysis for Predictors of MASLD

The present study demonstrated a high prevalence of MASLD (63.0%) among patients with type 2 diabetes mellitus, emphasizing the close association between diabetes and hepatic steatosis. This prevalence is consistent with the systematic review and meta-analysis by Younossi et al., who reported a pooled global prevalence of NAFLD of 55.5% among patients with T2DM, with even higher prevalence in hospital-based studies [12]. Similarly, Targher et al. highlighted that more than half of patients with T2DM have NAFLD and are at substantially greater risk of progression to steatohepatitis, advanced fibrosis, and liver-related complications because of persistent insulin resistance and metabolic dysfunction [13]. The prevalence observed in the present study therefore supports the growing evidence that fatty liver disease is a major yet often under-recognized comorbidity in individuals with T2DM. The present study found significant associations between MASLD and obesity, increased waist circumference, dyslipidemia, metabolic syndrome, poor glycemic control, and longer duration of diabetes. These findings are in agreement with the observations of Targher et al., who described obesity, visceral adiposity, insulin resistance, and dyslipidemia as the principal drivers of hepatic steatosis in patients with T2DM [13]. Likewise, Younossi et al. demonstrated that obesity and metabolic syndrome markedly increase the likelihood of developing NAFLD and advanced fibrosis among diabetic individuals [12]. These findings reinforce the concept that MASLD is a multisystem metabolic disorder rather than an isolated liver disease, and its development reflects the cumulative burden of metabolic risk factors. Patients with MASLD in the present study also had significantly higher BMI, waist circumference, HbA1c, triglycerides, AST, and ALT levels, along with lower HDL cholesterol concentrations than patients without MASLD. Similar findings have been reported by Mantovani et al., who concluded that poor glycemic control, elevated liver enzymes, obesity, and dyslipidemia are strongly associated with the severity and progression of NAFLD in patients with diabetes [14]. Furthermore, Younossi reviewed the global burden of NAFLD and emphasized that the increasing prevalence of obesity and T2DM has contributed substantially to the worldwide rise in fatty liver disease and its hepatic and extrahepatic complications [15]. These similarities suggest that routine metabolic evaluation can facilitate early identification of patients at increased risk of MASLD. Multivariate logistic regression in the present study identified obesity, increased waist circumference, dyslipidemia, HbA1c ≥9%, and longer duration of diabetes as independent predictors of MASLD. These findings indicate that simple clinical and biochemical parameters can effectively identify diabetic patients at high risk for fatty liver disease in routine clinical practice. Since MASLD often remains asymptomatic until advanced stages, early screening using abdominal ultrasonography together with optimization of glycemic control, weight reduction, and management of associated metabolic abnormalities may reduce disease progression and improve long-term hepatic and cardiovascular outcomes. The findings of the present study further support current recommendations advocating active screening for fatty liver disease in patients with type 2 diabetes, particularly those with obesity and poor metabolic control.

The present study demonstrated a high prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) among patients with type 2 diabetes mellitus, with obesity, central adiposity, dyslipidemia, poor glycemic control, and longer duration of diabetes emerging as significant predictors. These findings highlight the strong interplay between metabolic dysfunction and hepatic steatosis, emphasizing the need for routine screening for MASLD in individuals with T2DM, particularly those with multiple metabolic risk factors. Early identification through non-invasive imaging, coupled with optimization of glycemic control, weight management, and correction of associated metabolic abnormalities, may facilitate timely intervention, prevent progression to advanced liver disease, and improve long-term hepatic and cardiovascular outcomes.

Acknowledgement: None

Funding: None

Conflict of Interest: None

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