Body composition assessment for risk stratification of hepatic steatosis in patients with type 2 diabetes and MASLD undergoing osteoporosis screening

Background and aims – Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common cause of chronic liver disease worldwide. Type 2 diabetes (T2D) and obesity are major risk factors for its development and progression. Body mass index (BMI), although widely used in clinical practice, fails to adequately reflect individual differences in body composition and fat distribution. This study evaluated the association of adiposity and reduced muscle mass – measured by dual-energy X-ray absorptiometry (DXA) – with hepatic steatosis severity in patients with MASLD and T2D. Methods – Consecutive patients with MASLD and T2D were recruited at a tertiary hepatology centre. Body composition was assessed by DXA. Adiposity was defined using fat mass percentage, with values >25% in men and >35% in women indicating obesity. Muscle mass was assessed using the appendicular lean mass/height2(ALM/height²) index, with pathological values defined as <7.0 kg/m2in men and <5.5 kg/m2in women. Hepatic steatosis and fibrosis were evaluated by controlled attenuation parameter (CAP) and liver stiffness measurement (LSM), respectively. Statistical analyses included Spearman's rank correlation, Chi Square test, logistic regression, and receiver operating characteristic (ROC) curve analyses. Results – Ninety-seven patients (median age 61 years) were enrolled. DXA identified a pathological fat mass percentage in 97.9% of patients, whereas 46.4% met the BMI-based criteria for obesity. At multivariate analysis, fat mass percentage and pathological ALM/height2were independently related with severe hepatic steatosis (CAP ≥280 dB/m; OR 1.100, p = 0.011; OR 0.292, p = 0.013, respectively). ROC curve analysis identified specific cut-offs for fat mass percentage (38.65%, area under the curve [AUC] of 0.636) and ALM/height2index (6.7 kg/m2, AUC of 0.611) for detecting severe liver steatosis. A model combining both cut-offs yielded an AUC of 0.715 (95% C.I. 0.610 – 0.820, p = 0.001). Conclusions – In patients with MASLD and T2D, DXA-derived body composition measures may complement conventional anthropometric assessment and help identify individuals with severe hepatic steatosis.