Higher Adherence to the Mediterranean Diet Is Associated with a Lower Risk of Steatotic, Alcohol-Related, and Metabolic Dysfunction-Associated Steatotic Liver Disease: A Retrospective Analysis

Abstract

Background and aims: Metabolic liver disease is associated with obesity, insulin resistance, cardiovascular disease, and metabolic disorders. A Mediterranean diet (MD), known for its anti-inflammatory and antioxidant properties, is effective in managing various chronic diseases, including liver diseases. This study aimed to explore the influence of adherence to the MD on the risk of chronic metabolic diseases, including steatotic liver disease (SLD), metabolic dysfunction-associated steatotic liver disease (MASLD), and alcohol-related liver diseases (ALDs).

Methods: This retrospective cohort study analyzed 5395 individuals from a single center between 2020 and 2022, grouped by adherence to the MD using the Korean Mediterranean Diet Adherence Score (K-MEDAS). MASLD score, ALD, and cardiovascular risk factors were also assessed. Statistical analyses were performed using 1:1 exact matching and multiple regression to compare the less adherent (K-MEDAS 0-7) and highly adherent (K-MEDAS 8-13) groups.

Results: Adjusting for confounding variables, high adherence to the MD was significantly associated with lower rates of SLD (odds ratio [OR] 0.818, 95% confidence interval [CI] 0.700-0.957, p = 0.012), MASLD (OR 0.839, 95% CI 0.714-0.986, p = 0.033), and ALD (OR 0.677, 95% CI 0.671-0.683, p < 0.001). Post-propensity score matching analysis revealed that the highly adherent group exhibited significantly lower triglyceride levels, triglyceride and glucose index, atherogenic Index of Plasma, and Framingham risk scores than the less adherent group.

Conclusions: Good adherence to the MD considerably reduces the risk of SLD, MASLD, and ALD, underscoring its protective effects and potential to prevent metabolic liver diseases and their complications.

Keywords: Mediterranean diet adherence; alcohol-related liver disease; metabolic dysfunction-associated steatotic liver disease; steatotic liver disease.

Figure 1

Flow chart of participants. This chart shows the inclusion flowchart of the study participants. After exclusion, participants were divided into two groups according to their adherence to the Mediterranean diet score: the least adherent (K-MEDAS 0–7) and highly adherent (K-MEDAS 8–13). K-MEDAS: Korean Mediterranean Diet Adherence Score [17].

Figure 2

Prevalence of (A) SLD, (B) MASLD, and (C) ALD according to MD adherence. The bar graph illustrates the incidence of each metabolic liver condition in percentage across different levels of MD adherence: green bars represent the total participants, red bars represent the less adherent group, and blue bars represent the highly adherent group. The line graph overlays the Framingham score for each metabolic liver condition, also categorized by MD adherence. Significant values are indicated with an asterisk in the figure. MD, Mediterranean diet; SLD, steatotic liver disease; MASLD, metabolic dysfunction-associated steatotic liver disease; ALD, alcohol-related liver disease.

Figure 3

Subgroup analysis of metabolic liver diseases. (a) Forest plot for association between SLD and clinical & metabolic conditions. (b) Forest plot for association between MASLD and clinical & metabolic conditions. OR, odds ratio; CI, confidence interval. p-value by a generalized mixed model with a logit link.