Copyright ©The Author(s) 2022.
World J Gastroenterol. Jul 21, 2022; 28(27): 3314-3333
Published online Jul 21, 2022. doi: 10.3748/wjg.v28.i27.3314
Table 1 Association between the Mediterranean dietary patterns and nonalcoholic fatty liver disease
Assess adherence to the MD
Food groups associated with lower risk NAFLD
Study design
Number of patients and age range
Main results
Entezari et al[40]Iran MDS↑ Intake nuts and fruits, vegetables, legumes, high MUFA/PUFA ratio, cereals and fish. ↓ EI, low-fat dairy and meats C-C247 (43.7% male); 18–55 yr↑ Adherence to MD was associated with ↓ risk of NAFLD after controlling for age (OR: 0.40, 95%CI: 0.17–0.95) and sex, diabetes, PA and supplement intake (OR: 0.36, 95%CI: 0.15–0.89). This association disappeared after adjusting for BMI, WHR (OR: 0.70, 95%CI: 0.25–1.97)↓, After controlling for anthropometrical variables ↔
Giraldi et al[41]ItalyMDS↑ Legumes consumption ↓ risk of NAFLD (OR: 0.62; 95%CI: 0.38-0.99) and ↑ fish intake ↓ risk of NAFLD (OR: 0.38; 95%CI: 0.17-0.85) C-C815 (371 with NAFLD); 59 ± 16 yr; 444 controls; 45 ± 14 yr↑ Adherence to the MD was associated with ↓ risk of NAFLD (OR: 0.83; 95%CI: 0.71-0.98) after controlling for age, sex, EI, diabetes status, smoking status, BMI and PA
Baratta et al[42]ItalyMD questionnaire↓ Meat intake C-S584 patients (61.8% males) with cardiometabolic risk factors screened for the presence of liver steatosis; 56.2 ± 12.4 yr↑ Adherence to MD was associated with ↓ risk of NAFLD (intermediate vs low tertile OR: 0.12; P < 0.05; high vs low tertile OR: 0.09; P < 0.05)
Aller[45]Spain 14-item MD assessment tool-C-S82 NAFLD patients (42.7% low and 57.3% high steatosis grade, 68.3% steatohepatitis and 51.2% liver fibrosis mean age 44 + 11 yr↑ Adherence to MD was associated with ↓ likelihood of having steatohepatitis OR: 0.43; 95%CI: 0.29-0.64 and steatosis OR: 0.42; 95%CI: 0.26- 0.70
Park et al[46]United States; 5 targeted racial/ethnic groups: African American, Native Hawaiian, Japanese American, Latino and WhiteAlternate MDS-Nested C-C2959 with NAFLD (509 with cirrhosis; 2450 without cirrhosis) and 29292 controls; mean age 44.2 + 11.3 yr↑ Adherence to MD was not associated with lower NAFLD risk
Chan et al[47]Hong Kong of ChinaMDS↑ Vegetables and legumes, fruits and dried fruits, vitamin C C-S797 (41.7% males) 27.6% had a fatty liver aged ≥ 18 yrMDS was not associated with the prevalence of NAFLD
Kontogianni et al[44]GreeceMDS-C-S73 overweight/obese patients with NAFLD (69% males) vs 58 age-sex- and BMI matched controls; mean age 45 yrNo difference in the MDS was observed between patients and controls. One unit increase in the MDS was associated with ↓ likelihood of having NASH (OR: 0.64; 95%CI: 0.45-0.92), after controlling for sex and abdominal fat
Table 2 Characteristics of the observational studies on the association between different dietary patterns and nonalcoholic fatty liver disease
Dietary pattern
Food items in dietary patterns
Type of study
N, age
Main results
Oddy et al[52]AustraliaWesternTakeaway foods, confectionery, red meat, refined grains, processed meats, chips, sauces, full-fat dairy products and soft drinksP995. FFQ completed at 14 yr and liver ultrasound at 17 yr Higher western pattern score at 14 yr was associated with ↑ risk of NAFLD at 17 yr (OR: 1.59; 95%CI: 1.17–2.14; P < 0.05) before adjustment to BMI
HealthyWhole grains, fruit, vegetables, legumes, fishA healthy diet at 14 yr appeared protective against NAFLD at 17 yr in centrally obese adolescents (OR: 0.63; 95%CI 0.41-0.96; P < 0.05)
Salehi-Sahlabadi et al[34]IranWesternFast foods, soft drinks, processed meat, high-fat dairy products, hydrogenated fats, mayonnaise, salty snacks, sugar sweetened desserts, organ meats and refined grainsC-C675 (450 with NAFLD) NAFLD: 38.6 ± 8.7 yr; Controls: 37.9 ± 8.9 yrThe western pattern was associated with ↑ risk for NAFLD after adjustment for age, sex, BMI, PA, SES and EI
HealthyFish, skinless poultry, low-fat dairy, fresh fruits, natural juices, canned fruits, dried fruits, vegetables, nuts, olive and garlicA healthy pattern was associated with ↓ risk for NAFLD, after controlling for mentioned variables
TraditionalRed meat, organ meats, skinless poultry, eggs, yogurt drink, tea, legumes, tomato sauce, sugar sweetened-desserts, potato, condiments, salt, pickles and brothLack of association between traditional pattern and risk of NAFLD adjusted for mentioned variables
Chung et al[60]KoreaWestern and high-carbohydrateProcessed meats, bread, soft drinks, pork, noodles, beef, cakes, snacks, beef soup, sugar, coffee, chicken, processed fish and refined grainsC-S1190 (331 with NAFLD) NAFLD: 53 ± 9 yr; Controls: 51 ± 10 yrLack of association between Western/high-carbohydrate pattern and risk of NAFLD after adjustment for age, sex, WC, smoking status, EI, diabetes and hypertension
TraditionalVegetables; fermented vegetables such as kimchi and jjangajji; fish and seafood; mush-rooms; fermented, processed, natural soybeans↑ Adherence to the traditional pattern was associated with ↑ risk of NAFLD (OR: 1.85; 95%CI: 1.11-3.08; P < 0.05) after controlling for mentioned variables
Simple mealFruits, root and yellow vegetables, eggs, dairy products and nuts↑ Adherence to the simple meal pattern was associated with ↓ risk of NAFLD (OR: 0.59; 95%CI: 0.34-1.00; P < 0.05), after controlling for mentioned variables
Dehghanseresht et al[54]IranOrdinarySweets, oils, fruits, white meats, refined grains, tea and coffee, salt, biscuits, snacks as well as red and organ meatsC-C244 (122 with NAFLD) aged 19–70 yr↑ Adherence to the ordinary pattern was associated with ↑ risk of NAFLD; P < 0.001
TraditionalRed and organ meats, dairy products, condiments, salt, tea and coffee and low intake of fruits↑ Adherence to the traditional pattern was associated with ↑ risk of NAFLD P < 0.001
Vegetables and dairy (healthy pattern) Vegetables, whole grains, legumes and nuts and dairy products↑ Adherence to the vegetables and dairy pattern was ↓ association with NAFLD risk (OR: 0.23; 95%CI: 0.09–0.58; P < 0.05)
Fast foodSauces, pickles, fast foods, soft drinks, snacks and biscuitsNo association between Fast food patterns and the risk of NAFLD
Yang et al[57]ChinaTraditional ChineseStaple food, coarse grains, fruits, eggs, fish and shrimp, milk and teaC-S999 (345 with NAFLD) aged 45–60 yrNo association between traditional pattern and the risk of NAFLD
Animal foodKelp/seaweed and mushroom, pork, beef, mutton, poultry, cooked meat, eggs, fish and shrimp, beans and greaseAfter controlling for potential confounders, animal food patterns had ↑ prevalence rate for NAFLD (PR: 1.35; 95%CI: 1.06–1.72; P < 0.05
Grains-vegetables (healthy pattern)Coarse grains, tubers, vegetables, mushroom and kelp/seaweed, cooked meat and beansAfter adjustment for BMI, a vegetable pattern had ↓ prevalence rate for NAFLD (PR: 0.78; 95%CI: 0.62–0.98, P < 0.05).
High-saltRice, pickled vegetables, processed meat, bacon, salted duck egg, salted fish and teaNo association between high salt and the risk of NAFLD
Jia et al[65]ChinaHigh-carbohydrate/sweetFruits, cakes and candied fruitsC-S4365 (1339 with NAFLD: adults↑ Adherence to a high-carbohydrate/sweet pattern was associated with ↑ the prevalence of NAFLD in females but not in males↑ only in females not in males
Kalafati et al[55]GreeceFast foodEnergy-dense foods rich in saturated fat and sugar and included fast foods, sweetened soft drinks, fried potatoes and savory and puff pastry snacksC-C351 (134 with NAFLD) Case: 50.0 ± 10.5 yr; Control 44.0 ± 11.0 yr↑ Adherence to a fast-food pattern was associated with ↑ odds for NAFLD after adjustment for age, sex, EI, PA, pack-yr smoked, education, MS (P < 0.01)
Prudent (healthy pattern)Oil-based cooked vegetables, legumes, potatoes, fruits, vegetables and fatty fish↑ Adherence to the prudent pattern was associated with ↓ TG and uric acid levels (β: -5.96; P < 0.05; β: -0.15; P < 0.05, respectively)
High-proteinRed meat, poultry, eggsThe high protein pattern was not associated with any NAFLD-related biomarker
The unsaturated FANuts, chocolate and other foods rich in unsaturated FAIndividuals in the second quartile of the unsaturated FA pattern had ↓ odds of developing NAFLD vs the first quartile after being adjusted for mentioned confounders (P < 0.05)
Tutunchi et al[56]IranHealthyVegetables, legumes, fruits and low-fat dairy productsC-C210 (105 with NAFLD) Cases 46 ± 9 yr; Controls 45 ± 9 yrA healthy pattern was associated with ↓ odds of NAFLD (OR: 0.34; 95%CI: 0.16–0.81) after controlling for sex, education, PA, BMI, WC
WesternSweet, hydrogenated fat, red and processed meat and soft drink dietary patterns↑ Adherence to the western pattern was related to ↑ risk of NAFLD (OR: 2.68; 95%CI: 1.31–4.16), after controlling to mentioned confounders
Zhang et al[61]ChinaSugar-richStrawberry, kiwi fruit, persimmon, sweets, candied fruits, Chinese cakesP17360 free from NAFLD at baseline; During a median follow-up of 4.2 yr, 4034 with NAFLD, aged > 18 yrAfter adjusting for age, sex, BMI, smoking, alcohol, education, occupation, income, PA, EI, personal and family history of the disease, depressive symptoms, dietary supplement use, inflammation markers, WHR and each other dietary pattern score, the sugar-rich pattern was associated with ↑ risk of NAFLD (HR: 1.11; 95%CI 1.01, 1.23)
Vegetable (healthy pattern)Cucumber, green leafy vegetables, Chinese cabbage, celery, pumpkinAfter adjusting for mentioned confounders, vegetable diet was associated with ↓ risk of NAFLD (HR 0.96; 95%CI: 0.86, 1.07)
Animal foodAnimal organs, animal blood, preserved eggs, instant noodles, pork skin, sausageAfter adjusting for mentioned confounders, animal food diet was associated with ↑ risk of NAFLD (HR: 1.22; 95%CI: 1.10, 1.36)
Alferink et al[62]The NetherlandsVegetable and fish (healthy pattern)Vegetables, poultry, fish and fruitP963 (343 with NAFLD) Baseline: 71.0 yr; Follow-up: 75 yrNo associations between vegetable and fish diet and NAFLD
Red meat and alcoholRed, refined or organ meat, salty snacks and beer or spirits and low intake of fruit and teaNo associations between red meat and alcohol pattern and NAFLD
TraditionalVegetable oils and stanols and margarine or butter, potatoes, whole grains and sweet snacks or desserts↑ Adherence to the Traditional pattern was associated with ↓ risk of NAFLD (OR: 0.40; 95%CI 0.15–1.00) adjustment for sex, age, baseline education level, PA, EI, alcohol intake and follow-up time, BMI, baseline type 2 diabetes mellitus and baseline hypertension
Salty snacks and saucesSavory food groups such as nuts, legumes, salty snacks and saucesNo associations between salty snacks and sauces pattern and NAFLD
High-fat dairy and refined grainFruit juice, refined grains, high-fat dairy products and sweet snacks or dessertsNo associations between high-fat dairy and refined grain pattern and NAFLD
Fakhoury-Sayegh et al[64]LebanonTraditionalVegetables, chickpeas, red beans, lentils, peas, vegetable oil/olivesC-C222 (112 with NAFLD) Cases: 40 ± 6 yr; Controls: 39 ± 13 yr ↑ Adherence to traditional pattern ↓ the odds of NAFLD (OR: 0.30; CI 95%: 0.11–0.86; P < 0.05) adjusted for MS, EI, education, PA, family history, smoking, place of residence and profession
High fruitsFruits and fruit juices↑ Adherence to high fruits pattern ↑ the odds of NAFLD (OR: 4.061; 95%CI: 1.320–12.100, P < 0.05, adjusted for mentioned confounders
The high meat and fast food diet: (Western-like dietary pattern)Meat such as pork, chicken, beef meat and hotdog↑ Adherence to Western pattern ↑ the odds of NAFLD (OR: 4.081; 95%CI: 1.36–12.28, P < 0.05) adjusted for mentioned confounders
Nakashita et al[58]JapanHealthySeaweeds, vegetables, mushrooms, pulses, potatoes and starchesC-S281 men (89 with NAFLD) NAFLD: 62 (57–67) yr; Controls: 61 (56–67) yrA healthy pattern was correlated with the ↓ risk of NAFLD
WesternFats and oils, meat, seasonings, spicesNo correlation between western pattern and NAFLD
SnacksSugars and starches, beverages (tea, coffee, fruit juice, soft drinks), fruitsNo correlation between snacks pattern and NAFLD
Adriano et al[59]BrazilHealthyFruits, vegetables/legumes, white meat, olive oil, margarine, bread/toast (with significant negative loading for beef)C-S229 older adults (74.7% women) NAFLD: 67.0 ± 5.0 yr; Controls: 70.1 ± 7.0 yr↑ Adherence to the healthy pattern was associated with ↓ prevalence of NAFLD (PR: 0.70; 95%CI: 0.50, 0.98, P < 0.05) after adjustment for sex, age, EI, BMI, smoking status, PA, family income and use of hypoglycemic drugs
Regional snacks (Northeast of Brazil)Tea/coffee, dairy products, cassava flour/tapioca/cuscus, butter and olive oil↑ Adherence to the regional snacks pattern was associated with the ↑ prevalence of NAFLD (PR: 1.42; 95%CI: 1.02, 1.92, P < 0.05) after adjustment for mentioned confounders
Energy-denseProcessed cold meats, beef, viscera, sweet products/desserts/sugar, soft drinks, tubers/spaghetti/pastriesNo association between energy density pattern and NAFLD
TraditionalRice, beans, bread/toast, tea/coffee, sweet products/desserts/sugarNo association between traditional pattern and NAFLD
Table 3 Summary of international guidelines on diet for nonalcoholic fatty liver disease patients

EASL/EASD/EASO clinical practice guidelines for the management of NAFLD[48]
ESPEN guideline on clinical nutrition in liver disease[68]
AASLD practice guidance: The diagnosis and management of NAFLD[69,70]
APASL clinical practice guidelines for the management of MAFLD[71]
AGA clinical practice guidelines for diagnosis and management of NAFLD[7]
WGO guidance for NAFLD/NASH[72]
Target for weight loss7%-10%7%-10% (in obese patient); > 10% to improve fibrosis3%-5% (to improve steatosis); 7%-10% for histological improvement7%-10%≥ 5% if steatosis; ≥ 7% if NASH; ≥ 10% if fibrosis5%-10%
Macronutrient composition Low to moderate fat and moderate to higher carbohydrate; low carbohydrate, ketogenic diets or high protein Irrespective of macronutrient composition, MD to improve steatosis and IRLess relevantLow-carbohydrate, low-fat and Mediterranean-type dietsMinimize SFA, ↓ red and processed meatAvoid trans-fats; ↑ omega 3/omega 6 PUFA
Energy restriction Hypocaloric: Reduction of 500-1000 kcal/d target weight loss of 0.5-1.0 kg/wk Hypocaloric diet according to obesity guidance Hypocaloric diet reduction of 500-1000 kcal/dHypocaloric diet reduction of 500-1000 kcal/dHypocaloric: 1200-1500 kcal/d or ↓ from baseline 500-1000 kcal/dHypocaloric: ↓ calories intake 25%
Fructose intake Avoid fructose-containing beverages and foodsAvoid fructose commercially producedAvoid fructose and soft drinks
Coffee intake No liver-related limitations“More likely to benefit health than harm”“More likely to benefit health than harm”
Alcohol intake Risk below (< 30 g men, < 20 g women)AbstainNot consume heavy amountsRestrict