What lifestyle interventions are recommended for patients with metabolic associated steatotic liver disease (MASLD) who are overweight or obese?

Lifestyle Interventions for MASLD in Overweight/Obese Patients

For overweight or obese patients with MASLD, implement a structured weight loss program targeting ≥7-10% body weight reduction through a Mediterranean dietary pattern combined with ≥150 minutes/week of moderate-intensity exercise, as this approach improves liver inflammation and fibrosis while reducing cardiovascular mortality. 1

Weight Loss Targets: Dose-Dependent Histological Benefits

The magnitude of weight loss directly correlates with specific histological improvements 1:

• ≥5% weight loss: Reduces hepatic steatosis/liver fat content
• 7-10% weight loss: Improves liver inflammation and achieves MASH resolution
• >10% weight loss: Improves fibrosis and achieves fibrosis regression

These thresholds represent strong evidence from interventional trials with histological endpoints, demonstrating a clear dose-response relationship between weight reduction and liver injury improvement 1.

Dietary Approach: Mediterranean Pattern as First-Line

Adopt a Mediterranean dietary pattern as the primary nutritional strategy, characterized by 1, 2:

• High intake of vegetables, fruits, low-fat dairy, nuts, olive oil, legumes, unprocessed fish and poultry
• Strict minimization of processed meats, ultra-processed foods, and sugar-sweetened beverages
• Avoidance of foods high in added fructose

Caloric Restriction Strategy

Implement a hypocaloric diet with 500-1000 kcal/day deficit to achieve the target weight loss 1. The macronutrient composition matters less than total energy deficit for achieving weight loss, though the Mediterranean pattern offers additional insulin sensitivity benefits 1.

Important caveat: High-protein diets (both animal and plant-based) may provide superior liver fat reduction (36-48% decrease) compared to low-protein/high-carbohydrate diets in patients with type 2 diabetes, though this should not override the Mediterranean pattern recommendation 1.

Exercise Prescription: Structured and Specific

Prescribe ≥150 minutes/week of moderate-intensity OR 75 minutes/week of vigorous-intensity physical activity 1, 2. Both aerobic exercise and resistance training effectively reduce liver fat 1.

Exercise Implementation Strategy

• Aerobic exercise: 150-240 minutes/week of moderate-vigorous intensity as the foundation 3
• Resistance training: Add to aerobic exercise, particularly for patients losing weight through diet or pharmacotherapy to prevent sarcopenia and bone/lean mass loss 3
• Tailor the specific exercise modality to patient preference to maximize long-term adherence 1

Critical point: Exercise provides liver benefits even without significant weight loss, reducing hepatic steatosis and transaminases independently 1, 4.

Alcohol and Smoking: Strict Avoidance

• Alcohol: Discourage consumption; mandate complete avoidance in patients with advanced fibrosis or cirrhosis 1
• Smoking: Complete avoidance recommended 1

Multidisciplinary Care Model: Essential for Success

A multidisciplinary team approach is mandatory given the complex interplay between MASLD and cardiometabolic comorbidities 1, 2. This team should include:

• Hepatology/gastroenterology
• Endocrinology
• Cardiology
• Nutrition/dietetics
• Behavioral therapy specialists

This coordinated approach ensures comprehensive management of both liver disease and extrahepatic metabolic conditions (type 2 diabetes, hypertension, dyslipidemia) that contribute to overall morbidity and mortality 1, 2.

Behavioral Therapy Components

Integrate behavioral interventions including 1:

• Self-monitoring techniques
• Clinician-provided motivation and self-efficacy building
• Setting realistic, negotiable goals
• Identifying and overcoming barriers to adherence

Special Considerations for Cirrhosis

For patients with compensated cirrhosis and obesity: Implement moderate weight reduction (3-5%) combined with high-protein intake and physical activity to prevent sarcopenia 1.

For decompensated cirrhosis or sarcopenia: Shift to a high-protein diet with late-evening snacks rather than aggressive weight loss 1.

Common Pitfalls to Avoid

• Insufficient weight loss: Many patients achieve <5% weight loss, which only improves steatosis but not inflammation or fibrosis 1
• Unsustainable dietary approaches: Extreme macronutrient restriction (very low-carb, very low-fat) may produce short-term results but fail long-term 1
• Exercise without dietary modification: While beneficial, exercise alone has limited ability to improve liver histology beyond steatosis 1
• Neglecting cardiometabolic comorbidities: MASLD patients die primarily from cardiovascular disease, not liver disease, making comprehensive metabolic management essential 1

Long-Term Goals Beyond Liver Outcomes

Prioritize 1, 2:

• Quality of life and overall survival
• Cardiometabolic benefits
• Prevention of cirrhosis, hepatocellular carcinoma, type 2 diabetes, and cardiovascular disease

These outcomes supersede surrogate liver markers and should guide treatment intensity and duration.