The results of this study underscore the significant regional disparities in the prevalence and severity of MASLD across various states and zones in India. Such disparities highlight the complex interplay of genetic, cultural, dietary, and socioeconomic factors in influencing the prevalence of MASLD and fibrosis.

This study revealed that the prevalence of MASLD varies significantly across regions in India. Previous studies have shown that the prevalence rates of MASLD and fibrosis in India are 55%–75% and 25%–38%, respectively [9]. Consistent with the existing literature, our study showed that the prevalence rates of MASLD, fibrosis, and cirrhosis in India were 68.2%, 33.7%, and 12.2%, respectively.

The north zone demonstrated the highest prevalence of MASLD (73.3%), and Uttarakhand demonstrated the highest prevalence among all states (80.0%). Similarly, the north zone demonstrated the highest prevalence of severe fibrosis (38.1%), and Punjab (47.6%) demonstrated the highest prevalence among all states. Conversely, the east and northeast zones demonstrated the lowest prevalence of MASLD and fibrosis, and Chhattisgarh (46.7%) demonstrated the lowest prevalence of MASLD among all the states studied. These findings are consistent with those of previous studies, which showed a high prevalence of MASLD and fibrosis in the northern states and a low prevalence in the eastern zone [10,11,12]. The prevalence of MASLD is strongly associated with metabolic syndrome [13, 14]. The high prevalence in the northern states may be due to dietary habits rich in saturated fats and a higher incidence of metabolic syndrome. These findings are consistent with those of previous studies, which showed that urbanization and lifestyle changes, such as increased consumption of high-calorie diets and reduced physical activity, are associated with MASLD [15, 16]. Despite showing a high prevalence of MASLD, the southern states such as Karnataka (MASLD, 70.9% and fibrosis, 36.5%) and Tamil Nadu (MASLD, 70.9% and fibrosis, 30.3%) demonstrate distinct regional patterns. Our results are consistent with those of previous studies, which showed a high prevalence of MASLD in Chennai (61.5%) [17], Kerala (49.8%), and Tamil Nadu (29.7%). In these regions, dietary practices characterized by higher consumption of rice and coconut oil and genetic predispositions may play a role in these patterns [4, 18,19,20]. Eastern and northeastern states, such as Bihar (MASLD, 58.5% and fibrosis, 30%), West Bengal (MASLD, 59.2% and fibrosis, 22.6%), and Assam (MASLD, 58.6% and fibrosis, 27.2%), demonstrated a lower prevalence than other regions. This discrepancy may be due to differences in dietary habits and lower urbanization rates [4, 21]. Consistent with our study results, a recent study showed that the prevalence is approximately 57% [9].

The western and central parts of India demonstrated a high prevalence of MASLD and severe liver fibrosis. Additionally, the prevalence of MASLD was 80.0%, 69.9%, 66.7%, and 60.2% in Uttarakhand, Uttar Pradesh, Gujarat, and Maharashtra, respectively. Very few studies have been conducted in this part of India. A previous study reported a prevalence of 43.6% in Bhopal [22], whereas another reported a prevalence of 16% in Mumbai. However, this study was conducted a decade ago [23]. A recent study conducted in Mumbai showed that the prevalence rates of steatosis and fibrosis in patients with diabetes were 75.1% and 28.0%, respectively. In our study, the prevalence rate was higher than that reported in these studies. Notably, this study reported data from certain states, such as Uttarakhand, Chhattisgarh, Jammu and Kashmir, Bihar, and Jharkhand, for which no studies have been conducted.

Most studies on the prevalence of MASLD in India are limited by their single-center, region-specific nature and the use of varying diagnostic methodologies, which hinder direct comparisons across studies [4,5,6, 10, 17, 24]. Multicentric studies that provide comprehensive nationwide data, particularly involving tertiary care centers, are needed. To the best of our knowledge, this is the first cross-sectional study to encompass the maximum number of states across all zones in India and use a standardized diagnostic technique to assess the prevalence of MASLD.

Community-based screening for liver disorders was not feasible earlier because liver biopsy was the gold standard for diagnosing MASLD. Ultrasound was widely used but could not differentiate among steatosis, fibrosis, and inflammation. MRI-based techniques have also been explored. However, liver biopsy is invasive and primarily used for research, whereas ultrasound and MRI have limitations in routine screening due to cost, accessibility, and feasibility for large-scale studies. VCTE is the globally used and validated elastography technique. Tissue elasticity can be measured using VCTE and is directly correlated with liver stiffness (LSM), which is correlated with the extent of fibrosis. In addition to measuring LSM, VCTE yields CAP, which measures liver fat and indicates the degree of MASLD [25]. The use of LSM and CAP in this study provided a more consistent, reliable, and thus comparable assessment of liver fibrosis and steatosis across regions.

The findings indicate that a significant proportion of the population exhibits varying degrees of fibrosis and steatosis, with notable regional differences. For example, the highest prevalence of cirrhosis (F4) was observed in states such as Uttar Pradesh (15.4%), Odisha (16.7%), Assam (13.6%), Punjab (19.4%), Kerala (20.0%), and Maharashtra (9.7%) in different zones of the country. Similarly, the highest prevalence of severe steatosis (S3) was observed in states such as Uttarakhand (40.0%), Bihar (29.4%), Assam (25.9%), Jammu and Kashmir (50.3%), Karnataka (36.1), and Gujarat (30.2%) in different zones of the country. These findings emphasize the need for standardized diagnostic criteria and methods for epidemiological studies on MASLD and liver fibrosis. The variability in diagnostic methods has been a major limitation in understanding the actual burden of MASLD and liver fibrosis in India and globally.

This study highlights the significant impact of socioeconomic factors and awareness on the prevalence of MASLD. A higher prevalence was observed in regions with higher socioeconomic status and better healthcare infrastructure, such as Uttar Pradesh, Gujarat, Maharashtra, Chandigarh, Delhi, Karnataka, and Tamil Nadu. This could be due to better diagnostic facilities and greater health awareness, leading to more frequent and accurate diagnoses. Increased health awareness may lead individuals to visit health camps organized in nearby regions with better infrastructure. Conversely, lower prevalence in less developed regions, such as Northeast India, Bihar, Jharkhand, and Chhattisgarh, may reflect underdiagnosis due to limited access to healthcare and lack of awareness of MASLD. Additionally, the lack of regular health checkups and screening programs in many parts of India contributes to the underestimation of the prevalence of MASLD. Public health initiatives aimed at increasing awareness and promoting regular screening, especially in rural and less developed areas, are crucial for the early detection and treatment of MASLD.

This study has some limitations. The selection of participants across various sites might have introduced bias and influenced the results, potentially affecting the generalizability of the results. However, the study covered most states to understand the nationwide distribution of the disease via a standardized approach. Furthermore, the cross-sectional study design offered only a snapshot of the prevalence of MASLD without assessing causality or temporal changes. Our study has used LSM and CAP obtained using FibroScan to assess the prevalence of MASLD. However, this approach is reported to be less accurate for patients with BMI > 30 kg/m2, especially while using M probe. We tried to overcome this limitation of the technique by using the XL probe to improve the reliability of the results [26]. Therefore, future studies with broader geographic coverage and detailed comorbidity data are needed to more comprehensively understand the prevalence of MASLD in India.