Visceral Adiposity as the Primary Determinant of MASLD Risk: Reconsidering the Role of Skeletal Muscle Indices

Liang et al. claim skeletal muscle indices (ASM/weight or ASM/BMI) protect against MAS Denny LD, but this likely reflects adiposity confounding. Table 1 shows identical absolute muscle mass yet +35% visceral adipose tissue (VAT) in MASLD cases. Table S13 identifies VAT as the strongest predictor (RR 1.68 per SD), yet it was systematically excluded from all models. The apparent muscle effects vanish with proper VAT adjustment. We propose the ASM/VAT ratio (-26% in MASLD) as the true sarcopenic obesity metric. Studies must include VAT as covariate/mediator to reveal genuine muscle–liver crosstalk.