BACKGROUND AND AIMS: Lacking access to quality food may increase the risk of metabolic dysfunction-associated steatotic liver disease (MASLD). We investigated associations between food environment factors (food deserts and food swamps) and MASLD-related mortality across the United States. METHODS: MASLD-related deaths were obtained from the National Vital Statistics System (2016-2020) and food environment factors from Food Environment Atlas. Food deserts are areas where low-income residents have limited access to affordable and nutritious food due to a scarcity of nearby grocery stores. Food swamps are areas oversaturated with outlets offering limited healthy food options. RESULTS: Counties in the highest mortality quartile (fourth quartile) compared with the lowest mortality quartile (first quartile) were predominantly located in the South region (78.7% vs 23.5%) and rural areas (76.1% vs 26.6%). These counties also had higher rates of elderly residents (19.4% vs 16.5%), Hispanic residents (13.1% vs 10.5%), household crowding (2.83% vs 2.37%), no broadband Internet subscription (23.9% vs 12.7%), no high school diploma (16.1% vs 9.0%), poverty (30.2% vs 18.5%), unemployment (6.4% vs 4.7%), food deserts (8.7% vs 5.8%), and food swamp ratio (5.69 vs 4.28) (all P values <
.002). After adjusting for county sociodemographic and clinical factors and regions, mixed-effects linear regression models showed significant differences in mortality rates (per 100,000) between counties with the highest vs lowest quartiles of food deserts (25.65 vs 12.75, adjusted difference = 3.66 [95% confidence interval, 2.66-4.72]) and food swamps (27.13 vs 20.15 per 100,000, adjusted difference = 3.57 [95% confidence interval, 2.44-4.71]). CONCLUSIONS: In the United States, addressing sociodemographic and food environment disparities is paramount to reduce MASLD-related mortality.