Allostatic load, unhealthy behaviors, and mortality risk among participants with and without metabolic dysfunction-associated steatotic liver disease.

BACKGROUND: Chronic stress and unhealthy behaviors are associated with metabolic dysfunction-associated steatotic liver disease (MASLD). However, whether and to what extent they are associated with mortality across different stages of MASLD remains unclear. This study aimed to examine the associations of allostatic load and unhealthy behaviors with mortality according to MASLD stage. METHODS: The study included 9761 participants from the National Health and Nutrition Examination Survey (2005-2018). MASLD was defined as hepatic steatosis with at least one cardiometabolic criterion. Allostatic load, an indicator of chronic stress, was assessed using 10 biomarkers. Health behaviors included diet, nicotine exposure, physical activity, and sleep duration. Cox proportional hazards models estimated the associations of allostatic load and health behavior score (HBS) with mortality. RESULTS: Among 9761 participants, 3158 (32.4%) were classified as having MASLD. During a median follow-up of 7.42 years, 922 participants died, including 268 cardiovascular deaths. Allostatic load and HBS were associated with all-cause and cardiovascular mortality among participants with and without MASLD. The combination of high allostatic load and poor HBS was associated with higher risks of all-cause and cardiovascular mortality, particularly among participants with MASLD [hazard ratio = 3.33, 95% confidence interval (CI) = 1.97-5.65 for all-cause mortality; hazard ratio = 3.66, 95% CI = 1.31-10.23 for cardiovascular mortality]. CONCLUSION: Higher allostatic load and poorer health behaviors were independently and jointly associated with higher risks of all-cause and cardiovascular mortality among participants with and without MASLD. These findings highlight the importance of chronic stress and poor health behaviors in MASLD management and prognosis.