OBJECTIVE: We aimed to evaluate the differences in clinical features and lifestyle between Han and ethnic minority populations in Guangdong Province, China and their impacts on the ever-growing burden of metabolic dysfunction-associated steatotic liver disease (MASLD). METHODS: In this cross-sectional investigation in Guangdong Province, China, one of the most densely populated areas with imbalanced development, multistage stratified random sampling was used. Demographic, socioeconomic, and lifestyle data of participants were collected. Assessment of hepatic steatosis and liver stiffness measurement were performed. RESULTS: A total of 7287 individuals were recruited, including 7076 Han and 211 ethnic minority individuals, with similar MASLD prevalence between the two groups (35.8% vs 34.6%, p = 0.771). More ethnic minority individuals presented advanced fibrosis (≥ F3) overall and in subgroups of overweight/obesity, lean/normal weight, and males, but less advanced fibrosis in females and age of 30-34 years (all p <
0.05) than the Han Chinese. Proper physical activity was associated with a reduced risk of MASLD (Han: odds ratio [OR] 0.64, p = 0.021
ethnic minority: OR 0.06, p = 0.017). Sufficient sleep, drinking tea, and dietary fiber intake were protective factors for MASLD, while long sedentary duration, midnight snacks, dining out, and excessive intake of salt, red meat, and sugar were associated with a higher risk of MASLD in Han Chinese only. CONCLUSIONS: There was a strikingly high burden of MASLD in the ethnic minority in Guangdong Province, China, and their lifestyle differences compared with Han Chinese may contribute to the epidemic surge of MASLD.