A Healthy Diet is Associated with a Lower Risk of Hepatic Fibrosis

Evaluating the impact of the Dietary Approaches to Stop Hypertension diet versus a calorie-restricted diet on metabolic dysfunction-associated steatotic liver disease: A meta-analysis of randomized controlled trials

AIM

Metabolic dysfunction-associated steatotic liver disease (MASLD) can lead to increased morbidity and mortality. Diets high in refined carbohydrates and saturated fats elevate MASLD risk. The Dietary Approaches to Stop Hypertension (DASH) diet has shown metabolic benefits. This meta-analysis evaluates the impact of the DASH diet on MASLD progression.

METHODS

A systematic search from 2016 to 2023 across PubMed, Embase, Web of Science, and Cochrane databases was conducted to identify studies reporting on the role of the DASH diet in MASLD. Standard meta-analysis methods were employed using a random-effects model. Heterogeneity was assessed by I2 statistics.

RESULTS

We identified five randomized controlled trials meeting inclusion criteria, involving 280 participants (140 in the DASH group and 140 in the control group). Mean ages were approximately 41 years, and the proportions of women were similar between groups. Compared with controls, the DASH diet group had a significantly reduced risk of grade 0 and 1 liver fibrosis (RR 1.21, 95% CI 1.04-1.41, p = 0.01). They also showed lower levels of aspartate aminotransferase (MD -4.81, 95% CI -6.98 to -2.64, p < 0.0001), alanine aminotransferase (MD -10.31, 95% CI -13.82 to -6.80, p < 0.00001), body mass index (MD -0.74, 95% CI -1.45 to -0.03, p = 0.04), and cholesterol-to-high-density lipoprotein ratio (MD -0.40, 95% CI -0.68 to -0.11, p = 0.006). No significant differences were found for weight, waist and hip circumference, total cholesterol, low-density lipoprotein, or high-density lipoprotein levels. Heterogeneity was low for most outcomes (I2 = 0%).

CONCLUSION

Based on our meta-analysis of five randomized controlled trials, the DASH diet may reduce MASLD progression. These findings suggest it could be an effective dietary intervention for MASLD management.

Social Determinants of Health Associated With Metabolic Dysfunction-Associated Steatotic Liver Disease Prevalence and Severity: A Systematic Review and Meta-Analysis

INTRODUCTION

Social determinants of health (SDOHs) affect disease risk and severity leading to health disparities. SDOH impacting metabolic dysfunction-associated steatotic liver disease (MASLD) prevalence and severity are poorly characterized, and results are conflicting. The aim of this systematic review and meta-analysis was to assess the impact of individual SDOH factors on MASLD burden for adults in the United States.

METHODS

We searched MEDLINE, Embase, and Cochrane databases per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies from January 2010 to May 2024 were included. Quantitative studies of adults in the United States that evaluated SDOH beyond race/ethnicity were included. Outcomes included prevalence of MASLD, metabolic dysfunction-associated steatohepatitis (MASH), MASH-associated advanced fibrosis or cirrhosis, and clinical outcomes.

RESULTS

We identified 18 studies comprising 547,634 total subjects from 11 unique cohorts. Nine studies evaluated MASLD prevalence, 3 MASH prevalence, 6 MASH-associated advanced fibrosis/cirrhosis prevalence, and 9 clinical outcomes. High-diet quality was the most consistent SDOH factor associated with both MASLD and MASH-associated advanced fibrosis/cirrhosis prevalence (summarized odds ratio of 0.76, P < 0.01, and 0.74, P < 0.01, respectively). Lower income was most consistently associated with risk of clinical outcomes (significant in 3/9 studies).

DISCUSSION

Diet quality was the most consistent SDOH associated with disease prevalence and severity in MASLD, with other SDOH showing inconsistent associations. Prospective assessments using consensus, validated tools to assess the impact of specific SDOH on MASLD burden in heterogenous patient populations are needed to inform public health interventions.

Association of dietary quality and mortality in the non-alcoholic fatty liver disease and advanced fibrosis populations: NHANES 2005-2018

Background

Nonalcoholic fatty liver disease (NAFLD) has emerged as a significant global health concern, with advanced fibrosis increasing mortality risks. Despite the abundance of dietary guidelines for managing NAFLD, the precise impact of diet quality on mortality among individuals with advanced fibrosis remains elusive. This study aims to explore the influence of five dietary quality indexes on mortality among NAFLD patients and advanced fibrosis patients.

Methods

This study utilized data from the National Health and Nutrition Examination Survey (NHANES) spanning from 2005 to 2018 to assess dietary quality based on the Alternate Mediterranean Diet (aMED), Healthy Eating Index-2020 (HEI-2020), Dietary Approach to Stop Hypertension (DASH), Alternate Healthy Eating Index (AHEI), and Dietary Inflammatory Index (DII). Weighted Cox proportional hazard regression models along with restricted cubic splines and subgroup analyses were employed in this study.

Results

The analysis encompassed 3,634 NAFLD patients. After a median follow-up of 89 months, it was found that higher scores on the aMED (HR 0.814, 95% CI 0.681-0.972), HEI-2020 (HR 0.984, 95% CI 0.972-0.997), DASH (HR 0.930, 95% CI 0.883-0.979), and AHEI (HR 0.980, 95% CI 0.966-0.995) were associated with lower mortality risks, while DII scores (HR 1.280, 95% CI 1.098-1.493) indicated an increased risk of mortality. Additionally, a nonlinear relationship was identified solely between AHEI scores and all-cause mortality in NAFLD patients. Notably, among patients with advanced fibrosis, HEI-2020 as a categorical variable (T3: HR 0.519, 95% CI 0.280-0.964), DASH as a continuous variable (continuous: HR 0.921, 95% CI 0.849-0.999), AHEI (continuous: HR 0.971, 95% CI 0.945-0.997; T2: HR 0.545, 95% CI 0.310-0.960; T3: HR 0.444, 95% CI 0.245-0.804), and DII (continuous: HR 1.311, 95% CI 1.121-1.534; T3: HR 2.772, 95% CI 1.477-5.202) exhibited significant associations with all-cause mortality. Subgroup analyses revealed an interaction between AHEI scores and sex among NAFLD patients, where higher AHEI scores correlated with lower all-cause mortality in females, but no such association was observed in males. For other dietary quality, subgroup analyses indicated that their relationships with mortality were robust.

Conclusion

Our study suggests that a high-quality diet could potentially mitigate mortality risk in both NAFLD and advanced fibrosis patients.

A cross-sectional study of the association between dietary inflammatory index and glaucoma prevalence in a US population

AIM

To assess the relationship between dietary inflammatory index (DII) and prevalence of glaucoma among individuals aged 40y and above in the United States.

METHODS

Participants were drawn from 2 cycles of the National Health and Nutrition Examination Survey (NHANES, 2005-2008) for a cross-sectional study. DII was calculated from 24-hour dietary recall questionnaire conducted by experienced researchers and data analyzed in R according to the NHANES user guide, "Stratified Multi-stage Probability Sampling". The relationship between DII and glaucoma was evaluated by multi-factor logistic regression analysis and the existence of a non-linear association examined by restricted cubic spline (RCS) analysis.

RESULTS

A total of 5359 subjects were included and the cross-sectional analysis weighted to represent the US population of 109 million. DII was elevated in glaucoma patients (P<0.001) and smoking and alcohol use contributed to significant differences (P<0.001). DII correlated negatively with Healthy Eating Index (HEI)-2015 (Spearman rank correlation coefficient, r=-0.49). RCS analysis showed a linear relationship between DII and glaucoma risk (P of non-linear relationship =0.575).

CONCLUSION

An increased DII is strongly associated with high risk of glaucoma and diet-induced inflammation should be controlled to delay glaucoma progression.

Mediterranean diet for the management of metabolic dysfunction-associated steatotic liver disease in non-Mediterranean, Western countries: What's known and what's needed?

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common liver disease worldwide, affecting 30% of the population in Western countries. MASLD is considered the hepatic manifestation of the metabolic syndrome, pathophysiologically underpinned by insulin resistance and frequently co-exists with hypertension, central obesity and dyslipidaemia. Currently, safe and effective pharmacotherapies for MASLD are limited, making weight loss with lifestyle changes the mainstay therapy. A Mediterranean diet (MedDiet) has emerged as an effective dietary pattern for preventing and managing MASLD, but most studies have been conducted in Mediterranean countries, necessitating further investigation into its benefits in Western populations. Additionally, the effect of holistic multimodal lifestyle interventions, including physical activity combined with the MedDiet, is not well established. Finally, MASLD's widespread prevalence and rapid growth require improved accessibility to interventions. Digital health delivery platforms, designed for remote access, could be a promising approach to providing timely support to individuals with MASLD. This narrative review summarises the current evidence related to the effects of the MedDiet in Western, multicultural populations with MASLD. This includes a detailed description of the composition, prescription and adherence to dietary interventions in terms of how they have been designed and applied. The evidence related to the role of physical activity or exercise interventions prescribed in combination with the MedDiet for MASLD will also be reviewed. Finally, recommendations for the design and delivery of dietary and physical activity or exercise interventions to inform the design of future randomised controlled trials to facilitate the optimal management of MASLD are outlined.

Global Prevalence of Nonalcoholic Fatty Liver Disease: An Updated Review Meta-Analysis comprising a Population of 78 million from 38 Countries

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is a global health challenge, with a rising rate in line with other metabolic diseases. We aimed to assess the global prevalence of NAFLD in adult and pediatric populations.

METHODS

PubMed, Scopus and Web of Science databases were systematically searched up to May 2023. Heterogeneity was assessed using Cochran's Q test and I2 statistics, and random-effects model was used for meta-analysis. Analyses were performed using STATA version 18.

RESULTS

A total of 479 studies with 78,001,755 participants from 38 countries were finally included. The global prevalence of NAFLD was estimated to be 30.2% (95% CI: 28.7-31.7%). Regionally, the prevalence of NAFLD was as follows: Asia 30.9% (95% CI: 29.2-32.6%), Australia 16.1% (95% CI: 9.0-24.8%), Europe 30.2% (95% CI: 25.6-35.0%), North America 29% (95% CI: 25.8-32.3%), and South America 34% (95% CI: 16.9-53.5%). Countries with a higher human development index (HDI) had significantly lower prevalence of NAFLD (coefficient = -0.523, p = 0.005). Globally, the prevalence of NAFLD in men and women was 36.6% (95% CI: 34.7-38.4%) and 25.5% (95% CI: 23.9-27.1%), respectively. The prevalence of NAFLD in adults, adults with obesity, children, and children with obesity was 30.2% (95% CI: 28.8-31.7%), 57.5% (95% CI: 43.6-70.9%), 14.3% (95% CI: 10.3-18.8%), and 38.0% (95% CI: 31.5-44.7%), respectively.

CONCLUSION

The prevalence of NAFLD is remarkably high, particularly in countries with lower HDI. This substantial prevalence in both adults and children underscores the need for disease management protocols to reduce the burden.

NAFLD Fibrosis Progression and Type 2 Diabetes: The Hepatic-Metabolic Interplay

The bidirectional relationship between type 2 diabetes and (non-alcoholic fatty liver disease) NAFLD is indicated by the higher prevalence and worse disease course of one condition in the presence of the other, but also by apparent beneficial effects observed in one, when the other is improved. This is partly explained by their belonging to a multisystemic disease that includes components of the metabolic syndrome and shared pathogenetic mechanisms. Throughout the progression of NAFLD to more advanced stages, complex systemic and local metabolic derangements are involved. During fibrogenesis, a significant metabolic reprogramming occurs in the hepatic stellate cells, hepatocytes, and immune cells, engaging carbohydrate and lipid pathways to support the high-energy-requiring processes. The natural history of NAFLD evolves in a variable and dynamic manner, probably due to the interaction of a variable number of modifiable (diet, physical exercise, microbiota composition, etc.) and non-modifiable (genetics, age, ethnicity, etc.) risk factors that may intervene concomitantly, or subsequently/intermittently in time. This may influence the risk (and rate) of fibrosis progression/regression. The recognition and control of the factors that determine a rapid progression of fibrosis (or its regression) are critical, as the fibrosis stages are associated with the risk of liver-related and all-cause mortality.

Dietary approaches to stop hypertension (DASH) diet improves hepatic fibrosis, steatosis and liver enzymes in patients with non-alcoholic fatty liver disease: a randomized controlled trial

PURPOSE

Recent evidence suggests that adherence to dietary approaches to stop hypertension (DASH) diet can be effective in managing non-alcoholic fatty liver disease (NAFLD). We investigated the effect of DASH diet on hepatic fibrosis, steatosis and liver enzymes in patients with NAFLD.

METHODS

This 12-week randomized controlled trial was conducted among seventy patients with NAFLD who were randomly assigned into two groups including intervention group (DASH diet containing 50-55% carbohydrate, 15-20% protein, and 30% total fat) and the control group (a healthy diet containing 50-55% carbohydrate, 15-20% protein, and 30% total fat). Both diets were calorie-restricted (500-700 kcal lower than the energy requirement). The primary outcomes included hepatic fibrosis, hepatic steatosis, alanine transaminase (ALT), aspartate transaminase (AST) and gamma-glutamyl transpeptidase (GGT).

RESULTS

At the baseline, there was no significant difference between two groups in the level of hepatic fibrosis (P = 0.63), hepatic steatosis (P = 0.53), ALT (P = 0.93), AST (P = 0.18) and GGT (P = 0.76). A significant reduction was found in the intervention group compared to the control group in hepatic fibrosis (23 grades reduction vs. 7 grades reduction; P = 0.008) and hepatic steatosis (31 grades reduction vs. 9 grades reduction; P = 0.03) after intervention. In addition, a significant change was observed in the intervention group compared to control group in ALT ( - 8.50 ± 8.98 vs.  - 2.09 ± 7.29; P = 0.002), and AST ( - 5.79 ± 6.83 vs.  - 0.51 ± 6.62; P = 0.002).

CONCLUSIONS

Adherence to DASH diet may be effective in management of NAFLD.

TRIAL REGISTRATION

The trial was registered on 06 February 2022 at Iranian Registry of Clinical Trials (IRCT20170117032026N3) with URL: https://www.irct.ir/trial/60887 .

Dietary and lifestyle oxidative balance scores are independently and jointly associated with nonalcoholic fatty liver disease: a 20 years nationally representative cross-sectional study

BACKGROUND

Oxidative stress is an important contributor to the progression of nonalcoholic fatty liver disease (NAFLD), but whether dietary and lifestyle pro- and antioxidants may have combined or independent effects on NAFLD, and advanced liver fibrosis (AHF) remains unclear. We aimed to elucidate the relationship between a well-established oxidative balance score (OBS) and NAFLD/AHF.

METHODS

This was a cross-sectional study. We included adult participants with complete data from the National Health and Nutrition Examination Survey 1999-2018. Survey-weighted adjusted multivariate regression analyses were used to examine the association of all OBS with NAFLD/AHF. A combination of restricted cubic splines, mediation analysis, stratified analysis, and sensitivity analysis were used to further elucidate these associations.

RESULTS

We included 6,341 eligible adult participants with prevalence of NAFLD and AHF of 30.2 and 13.9%, respectively. In the fully adjusted model, the highest quartile of OBS, dietary OBS, and lifestyle OBS were associated with 65, 55, and 77% reduced risk of NAFLD, respectively, compared with the reference population, respectively. However, all OBS were not associated with the risk of AHF. All OBS were nonlinearly associated with risk of NAFLD and had a more pronounced reduced risk for OBS, dietary OBS, and lifestyle OBS after exceeding 26, 21, and 5 points, respectively. OBS may exert a protective effect indirectly through inflammation, oxidative stress, and glycolipid metabolism markers. Stratification and sensitivity analyses demonstrate the robustness of our findings.

CONCLUSION

All OBS were nonlinearly and negatively associated with NAFLD risk. These effects may exert indirectly through inflammation, oxidative stress, and glycolipid metabolism markers.