Background <p>Hepatic involvement in Type 1 Diabetes Mellitus (T1DM) is increasingly recognized, with hepatopathy emerging as an important but underexplored comorbidity. Data on its prevalence and associated factors, particularly in Indian children and adolescents, remain limited.</p> Objective <p>To estimate the prevalence of ultrasound-diagnosed hepatopathy and identify its associated risk factors among Indian children and adolescents with T1DM.</p> Methods <p>This cross-sectional study included 510 children and adolescents with T1DM from a tertiary care center in western India. Clinical, anthropometric, biochemical, dietary, physical activity, and resting metabolic rate (RMR) data were collected. Hepatopathy was assessed using ultrasonography. Logistic regression analysis was performed to identify independent associated factors.</p> Results <p>The prevalence of hepatopathy was 10.4%. Children with hepatopathy had significantly higher waist circumference, blood pressure, insulin requirements, and lower moderate-to-vigorous physical activity (<i>p</i> &lt; 0.05). They also exhibited poorer glycemic control, dyslipidemia, elevated liver enzymes, and reduced insulin sensitivity. RMR adjusted for insulin was significantly lower in those with hepatopathy. Multivariable analysis identified that higher waist circumference, higher insulin dose, elevated triglycerides, poor glycemic control, lower physical activity, and lower RMR were associated with hepatopathy (<i>p</i> &lt; 0.05).</p> Conclusion <p>Hepatopathy is a clinically relevant comorbidity among Indian children and adolescents with T1DM, associated with metabolic dysfunction, lifestyle factors, and altered energy metabolism. Early identification through ultrasound-based screening and targeted interventions focusing on glycemic control, adiposity, and physical activity may be critical in preventing long-term hepatic and cardiometabolic complications.</p>