Growing childhood fatty liver linked to increased future cardiovascular risk without approved treatments

A new review highlights the rising prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) in children, exposing them to potential lifelong cardiovascular risks and underscoring urgent gaps in diagnosis and treatment options.

A new review in the International Journal of Obesity argues that metabolic dysfunction-associated steatotic liver disease, or MASLD, is becoming a major childhood health threat with consequences that reach well beyond the liver. Led by Katherine McGoogan of Nemours Children’s Health in Jacksonville, Florida, with Vijay Hegde of Texas Tech University and senior author P. Babu Balagopal, the paper says the condition should be seen as part of a wider metabolic syndrome rather than as an isolated liver disorder. The authors also contend that it may raise cardiovascular risk even when the usual warning signs, such as high blood pressure, abnormal cholesterol or diabetes, are not yet present.

The concern is growing against the backdrop of rising childhood obesity, which researchers say has helped push MASLD from an adult problem into a common paediatric diagnosis. Children’s Hospital of Philadelphia says MASLD is now the most common chronic liver disease in children and affects at least 10% of children in the United States, while other reviews cited in the paper report far higher rates among children with obesity. The BMJ Paediatrics Open review also notes that prevalence is higher in some ethnic groups and in boys, underscoring how unevenly the disease is distributed.

The disease process is complex, shaped by insulin resistance, excess calorie intake, altered lipid handling and a mix of genetic and environmental influences. The review highlights the PNPLA3 gene, which appears to affect how severely liver scarring develops in some children, especially when paired with certain dietary patterns. That helps explain why two children with similar weight and diet histories can have very different outcomes. A separate review in BMJ Paediatrics Open similarly describes MASLD as a multifactorial condition in which excess fat accumulation and impaired fat removal drive liver injury.

What makes the findings especially troubling, the authors say, is the growing evidence that fatty liver in childhood may help set the stage for heart disease later in life. The review points to studies linking MASLD with cardiovascular disease independent of traditional risk factors, and to evidence of higher blood pressure in children with fatty liver disease over time. It also describes several biological pathways that could connect the liver and the heart, including inflammation, oxidative stress, mitochondrial dysfunction and changes in blood vessel function. In practical terms, the paper suggests that a liver problem diagnosed in childhood may be an early marker of a much broader cardiometabolic risk.

Diagnosis and treatment remain limited. The review says liver biopsy is still the most definitive test, but it is invasive and unsuitable for wide screening, while newer imaging and blood-based tests are promising but not yet universally available. On treatment, the message is sobering: there are no approved medicines specifically for paediatric MASLD. Children’s Hospital of Philadelphia says lifestyle change remains first-line treatment, and the expert statement from the Joint TASL-TSPGHAN committee likewise places diet, exercise and behavioural support at the centre of care, with medication and bariatric surgery reserved for selected cases. The review cites encouraging evidence from low-sugar diets, fructose restriction, omega-3-focused nutrition and docosahexaenoic acid supplementation, but says the field still lacks a proven drug therapy for children.