The impact of dietary interventions on liver health biomarkers in individuals with metabolic dysfunction-associated steatotic liver disease (MASLD): a systematic literature review and meta-analysis of randomized controlled trials

TL;DR

This study reviews how different diets affect liver health in people with MASLD, finding that fasting and Mediterranean diets improve key biomarkers.

Contribution

The study provides a meta-analysis comparing dietary interventions for MASLD, highlighting fasting and Mediterranean diets as effective.

Findings

Fasting reduced ALT and liver stiffness in MASLD patients.

Mediterranean diet improved ALT, liver stiffness, and MRI-PDFF in MASLD patients.

LCHF/ketogenic diets and Omega-3 supplementation did not significantly affect ALT.

Abstract

Metabolic dysfunction-associated steatotic liver disease (MASLD) and its subtype, metabolic dysfunction-associated alcohol-related liver disease (MetALD), represent the most prevalent chronic liver diseases worldwide, closely linked to unhealthy dietary patterns. Lifestyle modification is considered first-line treatment, yet the comparative effectiveness of different dietary approaches remains unclear. This systematic review and meta-analysis aimed to evaluate the impact of dietary interventions on liver health biomarkers in individuals with MASLD and MetALD.

A systematic database search was conducted for randomised controlled trials (RCTs, 2018–2024). Eligible trials assessed dietary interventions in MASLD or MetALD and reported changes in alanine aminotransferase (ALT), liver stiffness, MRI-proton density fat fraction (MRI-PDFF), and controlled attenuation parameter. Data were synthesized using weighted mean differences with fixed or random effects models.

Sixty-eight full-text articles were included in the systematic review, of which 24 met the criteria for the meta-analysis. Since no eligible studies were identified in individuals with MetALD, the findings apply solely to people with MASLD. In studies on fasting interventions ALT (MD = − 12.47 IU/L; 95% CI − 22.03,− 2.92; p = 0.01; n = 6) and liver stiffness (MD = − 0.24 kPa; 95% CI − 0.46, − 0.03; p = 0.03; n = 4) were reduced compared to controls. The Mediterranean diet (MedDiet) resulted in significant differences in ALT (MD = − 2.93 IU/L; 95% CI − 5.68, − 0.19; p = 0.04; n = 9), liver stiffness (MD = − 0.35 kPa; 95% CI − 0.54, − 0.16; p = 0.00; n = 4), and MRI-PDFF (MD = − 1.37%; 95% CI − 2.33, − 0.40; p = 0.01; n = 5). LCHF/ketogenic diets (n = 6) and Omega-3 fatty acids supplementation (n = 4) did not significantly alter ALT.

Fasting and MedDiet showed positive effects on surrogate biomarkers in MASLD. Larger, long-term isocaloric RCTs with standardized outcome reporting are warranted to confirm these findings.

The online version contains supplementary material available at 10.1007/s00394-025-03870-z.

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