Sex-specific associations between pubertal development and MASLD in children: evidence from the PROC study.

BACKGROUND: Metabolic dysfunction-associated steatotic liver disease (MASLD) is prevalent in children. This study aimed to determine the sex-specific association between pubertal development and risk of MASLD in children. METHODS: This longitudinal study included 1544 children aged 10-13 years from two follow-ups of a Chinese pediatric cohort (the PROC study) in Beijing. Pubertal development was assessed using Tanner staging. We employed Bayesian logistic regression to examine the cross-sectional association between pubertal development and MASLD, and employed Bayesian mixed-effects models to verify its longitudinal association. External validation was performed using National Health and Nutrition Examination Survey (NHANES) data, where puberty was defined by total testosterone in boys and estradiol in girls. RESULTS: The overall prevalence of MASLD declined with advancing pubertal stages. In boys, compared with early puberty, mid-puberty (aOR = 0.34, 95% highest density interval (HDI): 0.11-0.68) and late puberty (aOR = 0.22, 95% HDI: 0.03-0.59) showed significantly lower MASLD risk. No significant association was observed among girls. NHANES validation confirmed this protective association in boys at late puberty (aOR = 0.25, 95% HDI: 0.01-0.95), but not in girls. CONCLUSIONS: Mid-to-late puberty may significantly decrease the risk of MASLD in boys, whereas no clear association was observed in girls. IMPACT: This study reveals a sex-specific protective effect of puberty on MASLD risk in children, with advancing puberty associated with significantly lower odds of MASLD in boys, but not in girls. It adds longitudinal evidence on the puberty-MASLD association by assessing puberty via Tanner staging and conducting sex-specific analyses. The impact is to support tailoring prevention resources and health messages for MASLD by sex during puberty.