Background <p>Metabolic Dysfunction-Associated Fatty Liver disease (MAFLD) among lean individuals is increasingly recognized. We aimed to compare the prevalence, metabolic characteristics, and outcomes of lean vs overweight/obese-MAFLD patients.</p> Methods <p>Databases of Embase, Medline, and Web of Science were searched from inception till October 2023. Only cohorts adhering to the lean-MAFLD criteria as defined by the international consensus statement were included.</p> Results <p>In the pooled analysis of 10,013,382 individuals, the prevalence of lean-MAFLD in the general population was 1.94% (95% CI 1.10–3.39%, <i>I</i>² = 98.7%). Lean and overweight/obese-MAFLD patients had similar metabolic characteristics for blood pressure, LDL, TG, blood glucose, and HbA1c. There was an increased incidence rate and likelihood for liver-related mortality for lean-MAFLD vs overweight/obese-MAFLD [1.33 per 1000 patient-years (95% CI 1.28–1.39) vs 0.76 (95% CI 0.25–2.28), (OR 3.56 (95% CI 3.45–3.67), <i>p</i> &lt; 0.01). There were similar incidence rates and odds ratios between lean vs overweight/obese-MAFLD for: (1) all-cause mortality [10.08 per 1000 patient-years (95% CI 9.93–10.23) vs 8.94 per 1000 patient-years (95% CI 4.08–19.57), (OR 1.92 (95% CI 0.01–220.57), <i>p</i> = 0.33)]; (2) cardiovascular-related mortality [2.53 per 1000 patient-years (95% CI 0.65–9.96) vs 2.07 per 1000 patient-years (95% CI 0.80–5.39), (OR 1.91 (95% CI 0.02–142.76), <i>p</i> = 0.58)]; and (3) cancer-related mortality [3.42 per 1000 patient-years (95% CI 3.33–3.51) vs 3.15 per 1000 patient-years (95% CI 1.21–8.19), (OR 1.99 (95% CI 0.29–13.52), <i>p</i> = 0.13).</p> Conclusion <p>Lean-MAFLD patients have an equivalent metabolic burden compared to overweight/obese-MAFLD patients and thus a similar incidence rate of major extrahepatic complications. However, they have an increased risk of liver-related mortality.</p> Graphical abstract <p></p>