Mediterranean Diet Adherence Is Associated With Reduced Liver Fibrosis Risk in Metabolic Dysfunction–Associated Steatotic Liver Disease

BACKGROUND/AIMS: Benefits of the Mediterranean diet (MD) in reducing hepatic steatosis among individuals with metabolic dysfunction-associated steatotic liver disease (MASLD) have been well established. This study aims to evaluate the relationship between MD adherence and liver fibrosis among the MASLD population. METHODS: This cross-sectional study analyzed data from the National Health and Nutrition Examination Survey 2017 to March 2020. Individuals with MASLD were identified based on the vibration-controlled transient elastography-defined steatosis. Participants' MD adherence was evaluated using the alternate Mediterranean diet (aMED) score, with higher scores indicating greater adherence. Risk of significant liver fibrosis was compared between low, moderate, and high aMED groups. RESULTS: Of 2672 MASLD participants, 27.2%, 42.3%, and 30.6% were categorized into low, moderate, and high aMED groups, respectively. After adjusting for the number of cardiometabolic risk factors (CMRFs), physical activity, and other covariates, participants in the high aMED group were associated with a lower risk of significant liver fibrosis compared with those in the low aMED group (aMED 5-9 vs. aMED 0-2: OR = 0.662, 95% confidence interval [CI]: 0.660-0.663; p for trend < 0.0001). In the sensitivity analyses, the protective association of higher MD adherence against the risk of significant liver fibrosis weakened with higher cardiometabolic burden (aMED 5-9: aOR 0.582, 95% CI: 0.580-0.584 [4-5 CMRFs] vs. aOR 0.383, 95% CI: 0.380-0.386 [1 CMRF]). CONCLUSIONS: In MASLD patients, higher MD adherence was associated with lower risk of significant liver fibrosis. Our findings support the recommendation of the MD as a crucial lifestyle intervention to lower the risk of liver fibrosis in this population.