In Model 2 (adjusted for age, gender, race, smoking status, physical activity, hypertension, diabetes, AST, ALT, HbA1c, HDL-C, LDL-C, statin use, and insulin use), the Q3 and Q4 groups showed significant association with higher incidence of high-risk MASH (Q3: OR = 6.99, 95 % CI: 1.23–39.78; Q4: OR = 24.46, 95 % CI: 2.94–203.31). Here, INS is linked to metabolic dysfunction-associated steatohepatitis.