Lifestyle changes—specifically the Mediterranean diet and aerobic exercise—can meaningfully improve liver health in patients with metabolic dysfunction–associated steatotic liver disease (MASLD) and metabolic dysfunction–associated steatohepatitis (MASH), according to one study.1 The findings highlight reductions in body weight, waist circumference, and liver enzymes supporting these interventions as frontline strategies for managing liver-related morbidity.
This meta-analysis is published in BioMed Central.
Researchers believe that these findings collectively support the role of both the Mediterranean diet and structured exercise in improving anthropometric and liver-related outcomes among patients with MASLD/MASH. | Image credit: Rodica Ciorba – stock.adobe.com
“Our findings provide insight into the potential benefits of lifestyle interventions, specifically the MD [Mediterranean diet] and aerobic exercise for the management of MASLD,” wrote the researchers of the study. “Given the rising global prevalence of MASLD, these lifestyle strategies represent accessible and effective nonpharmacological options for disease management.”
Diet is known to play an important role in MASLD and its progressive form, MASH.2 Although excess calorie intake can worsen hepatic fat accumulation and systemic inflammation, insufficient intake may contribute to sarcopenia and gut microbiome imbalance—both factors that can accelerate disease progression.
In this study, the researchers conducted a comprehensive systematic review and meta-analysis, searching Embase, MEDLINE via Ovid, Cochrane Central, and Web of Science Core Collection from database inception through April 1, 2025.1 Randomized controlled trials were eligible if they enrolled adults with MASLD or MASH and evaluated the effects of the Mediterranean diet, exercise (aerobic, resistance, or combined), or both.
Primary outcomes included anthropometric measures, liver enzymes, and indices or grades of liver steatosis and fibrosis.
From 4806 search results, 37 unique randomized controlled trials met inclusion criteria, with 11 assessing the Mediterranean diet, 27 evaluating exercise interventions, and 2 examining the combination of diet and exercise.
The analysis showed that the Mediterranean diet significantly reduced body weight (–2.38 kg; 95% CI, –4.11 to –0.66), body mass index (–0.70 kg/m²; 95% CI, –1.03 to –0.36), waist circumference (–1.56 cm; 95% CI, –3.02 to –0.09), and alanine aminotransferase (ALT) levels (–3.96 IU/L; 95% CI, –6.54 to –1.38) compared with controls.
Aerobic exercise also led to significant reductions in body weight (–1.56 kg; 95% CI, –2.31 to –0.82) and waist circumference (–2.14 cm; 95% CI, –2.87 to –1.41), while combined aerobic-resistance training decreased weight by –1.90 kg (95% CI, –3.59 to –0.22). Resistance exercise also produced improvements in ALT, lowering levels by –15.40 IU/L (95% CI, –28.60 to –2.20).
However, the researchers acknowledged several study limitations. Studies varied widely in how the Mediterranean diet and exercise were defined, implemented, and compared, making results harder to interpret. Additionally, the lack of blinding, small sample sizes, and short study durations further limited certainty, and many outcomes were supported by low-quality evidence. Therefore, the researchers noted that larger, standardized trials with longer follow-up are needed to confirm these findings.
Despite these limitations, the researchers believe that these findings collectively support the role of both the Mediterranean diet and structured exercise in improving anthropometric and liver-related outcomes among patients with MASLD/MASH.
“Lifestyle interventions remain a pillar treatment in patients with MASLD/MASH,” wrote the researchers. “Standardized procedures to measure and report outcomes in patients with MASLD/MASH are needed to provide accumulated robust evidence on the effects of lifestyle on clinical profiles.”
References
1. Arita VA, Cabezas MC, Hernández Vargas JA, et al. Effects of Mediterranean diet, exercise, and their combination on body composition and liver outcomes in metabolic dysfunction-associated steatotic liver disease: a systematic review and meta-analysis of randomized controlled trials. BMC Med. 2025;23(1):502. doi:10.1186/s12916-025-04320-7
2. Klein H. Calorie consumption tied to mortality risk in men with MASLD. AJMC®. June 2, 2025. Accessed August 29, 2025. https://www.ajmc.com/view/calorie-consumption-tied-to-mortality-risk-in-men-with-masld