We read with great interest the article by Santos et al., recently published in your journal.1 The study’s aim was to evaluate the differences in diets between healthy children and adolescents and those with metabolic dysfunction-associated steatotic liver disease (MASLD). The findings reported indicate that the participants with MASLD consumed less protein, vitamin E, zinc, and iron, and an association between the waist-to-height ratio and MASLD was also found. The authors highlighted the importance of combatting abdominal obesity from an early age and improving dietary quality in children and adolescents. Even though the study provides relevant data in an area with limited evidence, we wish to comment on certain aspects to enrich the discussion and contribute to future studies.

According to the study design, it is not clear whether there were differences in diet before disease onset or if, once diagnosed, the patients modified their eating habits with a diet prescribed by a healthcare professional. This information is essential for determining whether the differences observed in nutrient intake between patients with MASLD and healthy children and adolescents was due to strict medical control or to another factor that has not yet been studied.

Likewise, we suggest that the present and future authors consider analyzing the level of awareness the participants or their caregivers have regarding MASLD and the influence of diet on the disease. It has been shown that risk perception and nutritional education may condition dietary choices, and consequently, the metabolic profiles in patients.2 In the specific context of pediatric fatty liver disease, Arenaza et al. demonstrated that a 22-week family-based educational program significantly reduced added sugar intake and was associated with improvements in fatty liver in children with overweight/obesity.3 Those authors also found that sugar-sweetened beverage intake was positively associated with fatty liver.4 Said findings underscore the need to evaluate nutritional literacy in both participants and their caregivers in future MASLD studies.

Another aspect we consider important to analyze is the socioeconomic status or family income level of the patients and their caregivers, given the direct influence on the availability, access, and quality of foods consumed. A study conducted in Argentina reported that adults belonging to middle or high socioeconomic levels were less likely to present with a low healthy eating index, compared with individuals from low socioeconomic levels.5 The inclusion of these variables would enable a more comprehensive and contextualized analysis of dietary intake to be conducted on children with MASLD.

In conclusion, the article by Santos et al. contributes to the growing field of MASLD research in the pediatric population, highlighting that the quantity and quality of food intake may be related to this disease. We believe that including the variables of level of awareness of MASLD and socioeconomic status/family income in future studies, as well as information on dietary prescriptions provided by healthcare professionals to children with MASLD, are crucial for understanding the relation between disease diagnosis and dietary intake.