Introduction
Methods
Database search
Screening and selection criteria
Parameter | Inclusion criteria | Exclusion criteria |
---|---|---|
Population | 1. Individuals aged ≥ 18 years with NAFLD confirmed | 1. Individuals aged < 18 years and with alcohol-induced hepatic steatosis, with advanced chronic liver disease such as cirrhosis, and using enteral or parenteral nutrition |
2. Mixed-population studies that included, in addition to patients with NAFLD, healthy individuals or those with diseases not separated by groups | ||
3. Animal studies | ||
Intervention or exposure | 1. Interventions of anti-inflammatory dietary patterns including all mode of deliveries such as direct meal deliveries and dietary advice provided by trained professionals | 1. Anti-inflammatory dietary patterns supplemented with commercial supplements |
2. Interventions involving anti-inflammatory dietary patterns with the manipulation of nutrient composition with a whole diet approach or dietary patterns supplemented with food items | 2. Studies including other interventions in addition to anti-inflammatory dietary patterns | |
3. Exposures to pro-inflammatory dietary patterns assessed | ||
Comparison | 1. The inactive control diet (such as a placebo, no treatment, usual care without dietary advice or a waiting list control) | Not applicable |
2. Comparator diet | ||
Outcomes | 1. NAFLD, hepatic steatosis attenuation, ALT and AST levels | 1. Alcohol-induced hepatic steatosis, other chronic liver diseases such as cirrhosis |
2. Parameters expressed qualitatively | ||
Study design | 1. RCTs, cluster RCTs, pseudo-randomised-controlled trial, non-randomised-controlled clinical trials, cluster trials, prospective cohort studies, retrospective cohort studies | 1. Controlled before-after studies, ITS studies without a control group, cross-sectional studies, case series, case reports, non-study-based sources, narrative reviews and systematic reviews |
2. Interrupted time-series studies with a control group, case–control studies, cross-sectional studies and nested case–control studies | ||
Language | English | Other than English |
Data extraction
Quality assessment
Results
Reference; study design | Sample size | Characteristics | Outcome measurements | Quality assessment (Cochrane RoB 2.0) |
---|---|---|---|---|
Katsagoni et al. (2018) [23] Randomised-controlled trial Greece | Final sample: 35/42 (83% participation) Excluded/withdrew: 7 | Age range: 18–65 years % Sex (F/M): 38/62 | Ultrasonography, anthropometric measures, blood analysis | Low risk of bias |
Marin-Alejandre et al. (2019) [24] Randomised-controlled trial Spain | Final sample: 76/98 (78% participation) Excluded/withdrew: 22 | Mean age: 50 years % Sex (F/M): 48/52 | Ultrasonography, anthropometric measures, blood analysis, MRI | Low risk of bias |
Marin-Alejandre et al. (2021) [25] Randomised-controlled trial Spain | Final sample: 58/98 (59% Participation) Excluded/withdrew: 40 | Mean age: 50 years % Sex (F/M): 48/52 | Ultrasonography, anthropometric measures, blood analysis, MRI | Low risk of bias |
Properzi et al. (2018) [26] Randomised-controlled trial Australia | Final sample: 48/51 (94% participation) Excluded/withdrew: 3 | Mean age: 52 years % Sex (F/M): 49/51 | Ultrasonography, anthropometric measures, blood analysis, MRS | Low risk of bias |
Razavi Zade et al. (2016) [27] Randomised-controlled trial Iran | Final sample: 60/75 (80% participation) Excluded/withdrew: 15 | Mean age: 41 years % Sex (F/M): 50/50 | Ultrasound, anthropometric measures, blood analysis | Low risk of bias |
Ristic-Medic et al. (2020) [28] Randomised-controlled trial Serbia | Final sample: 24/27 (89% participation) Excluded/withdrew: 3 | Mean age: 34 years % Sex (F/M): 0/100 | Ultrasonography, anthropometric measures, blood analysis | Low risk of bias |
Ryan et al. (2013) [29] Crossover randomised-controlled trial Australia | Final sample: 12/12 (100% participation) Excluded/withdrew: 0 | Mean age: 55 years % Sex (F/M): 50/50 | Ultrasonography, MRI, H-MRS, blood analysis and anthropometric measures | Some concerns |
Risk of bias analysis
Primary outcomes
Article | Results | Summary | ||
---|---|---|---|---|
Katsagoni et al. (2018) [23] | Baseline → 6 months | MD (energy restricted) | Control (energy/macronutrient equivalent) | In a 6-month study on the effects of a Mediterranean diet and lifestyle weight loss programme in patients with NAFLD, Mediterranean diet significantly improved liver stiffness, BMI, LDL and non-HDL cholesterol but did not improve other liver function outcomes compared to the control group. All other secondary outcomes showed no significant difference after the programme |
Primary | ||||
ALT (U/I) | 51 (30–73) → 34 (24–46)‡ | 44 (24–64) → 44 (32–58)‡ | ||
GGT (U/I) | 65 (28–96) → 40 (23–64)‡ | 64 (34–170) → 73 (31–166)‡ | ||
Liver stiffness (kPa)§ | 6.6 (5.5–9.8) → 6.2 (5.1–9.9)‡ | 7.8 (5.5–10.9) → 8.0 (6.1–11.1)‡ | ||
NAFLD fibrosis score | − 2.36 ± 1.3 → − 2.38 ± 1.5‡ | − 2.19 ± 1.4 → -2.21 ± 1.1‡ | ||
Secondary | ||||
Weight (kg) | 96.7 (79.6–101) → 83.0 (75.3–98.0)‡ | 89.3 (79.4–95.2) → 86.4 (78.4–95.0)‡ | ||
BMI (kg/m2) | 31.67(27.4–33.6) → 28.21(25.9–31.5)‡ | 30.04 (28.2–33.1) → 29.49 (27.8–32.9)‡ | ||
Abnormal WC (n) | 76.2 (16%) → 47.6 (10%)‡ | 90.5 (19%) → 76.2 (16%)‡ | ||
HOMA-IR | 3.4 (1.9–5.1) → 2.6 (1.7–4.1)‡ | 2.5 (1.7–4.0) → 2.5 (1.4–3.6)‡ | ||
TC (mmol/L) | 5.1 ± 1.3 → 4.8 ± 1.2‡ | 5.3 ± 1.0 → 5.6 ± 1.2 ‡ | ||
HDL (mmol/L) | 1.0 (0.9–1.5) → 1.1 (1.0–1.6)‡ | 1.1 (0.9–1.5) → 1.1 (0.9–1.6)‡ | ||
LDL (mmol/L)§ | 3.2 ± 1.0 → 2.9 ± 0.9‡ | 3.3 ± 0.9 → 3.6 ± 1.0‡ | ||
Marin-Alejandre et al. (2019) [24] | Baseline → 6 months | FLiO diet (energy restricted) | AHA diet (energy restricted) | In patients with NAFLD and overweight or obesity, both calorie-restricted AHA and FLiO diets improved primary and secondary outcomes at 6 months. The FLiO diet provided greater benefit to primary outcomes; however, both diets had a similar effect on secondary outcomes. The FLiO group maintained a significant decrease in ALT, liver fat, TE liver stiffness at 24 months compared to baseline values, whilst no significant changes were observed in the AHA group after 24 months. There was no difference in hepatic parameters between groups when adjusted for weight loss |
Primary | ||||
AST (IU/L) | 25.5 ± 11 → 21.6 ± 6 | |||
ALT (IU/L) | 33.3 ± 18 → 21.7 ± 9 | 33.1 ± 17 → 22.9 ± 9 | ||
GGT (IU/L) | 40.9 ± 29 → 28.3 ± 23 | |||
Steatosis degree | 1.5 ± 0.6 → 0.7 ± 0.6 | 1.5 ± 0.7 → 0.8 ± 0.7 | ||
Liver fat (%) | 7.0 ± 5 → 2.8 ± 3 | 7.4 ± 5 → 3.8 ± 3 | ||
TE liver stiffness (kPa) | ||||
FLI | 76.9 ± 21 → 47.9 ± 24 | 80.4 ± 16 → 54.4 ± 24 | ||
Adiponectin (μg/mL)§ | 6.6 ± 2 → 9.5 ± 4 | 6.7 ± 2 → 8.0 ± 3 | ||
HSI | 45.2 ± 5 → 39.1 ± 4 | 45.1 ± 5 → 39.9 ± 5 | ||
Secondary | ||||
Weight (kg) | 95.1 ± 14 → 86.6 ± 13 | 94.4 ± 14 → 84.2 ± 13 | ||
BMI (kg/m2) | 33.3 ± 4 → 30.1 ± 4 | 33.7 ± 4 → 30.2 ± 4 | ||
WC (cm) | 108 ± 9 → 99 ± 10 | 110 ± 10 → 99 ± 15 | ||
TC (mg/dL) | 197 ± 35 → 185 ± 41 | 192 ± 40 → 177 ± 43 | ||
HDL-C (mg/dL) | ||||
LDL-C (mg/dL) | ||||
Triglycerides (mg/dL) | 129 ± 62 → 91 ± 59 | 129 ± 66 → 99 ± 41 | ||
HOMA-IR | 4.2 ± 2 → 2.6 ± 2 | 4.6 ± 3 → 2.7 ± 2 | ||
Marin-Alejandre et al. (2021) [25] | Baseline → 12 months | |||
Primary | ||||
AST (IU/L)§ | 23.9 ± 8 → 20.6 ± 8 | 25.5 ± 11 → 25.1 ± 9* | ||
ALT (IU/L) | 33.3 ± 18 → 24.4 ± 13 | 33.1 ± 17 → 25.7 ± 11 | ||
GGT (IU/L) | 40.9 ± 29 → 31.4 ± 20 | |||
Steatosis degree | 1.5 ± 0.6 → 0.6 ± 0.7 | 1.5 ± 0.7 → 1.0 ± 0.9 | ||
Liver fat (%) | 7.0 ± 5 → 5.6 ± 6 | 7.4 ± 5 → 5.1 ± 4 | ||
TE liver stiffness (kPa) | 5.2 ± 2 → 4.4 ± 1 | |||
FLI§ | 76.9 ± 21 → 51.0 ± 26 | 80.4 ± 16 → 62.7 ± 24 | ||
Adiponectin (μg/mL) | 6.6 ± 2 → 8.8 ± 3 | 6.7 ± 2 → 8.3 ± 4 | ||
HSI | 45.2 ± 5 → 40.5 ± 5 | 45.1 ± 5 → 40.7 ± 7 | ||
Secondary | ||||
Weight (kg) | 95.1 ± 14 → 86.3 ± 13 | 94.4 ± 14 → 87.3 ± 15 | ||
BMI (kg/m2) | 33.3 ± 4 → 30.1 ± 4 | 33.7 ± 4 → 31.2 ± 5 | ||
WC (cm) | 108 ± 9 → 98 ± 10 | 110 ± 10 → 102 ± 11 | ||
TC (mg/dL) | 197 ± 35 → 180 ± 34 | |||
HDL-C (mg/dL) | 53.8 ± 12 → 57.3 ± 13 | |||
LDL-C (mg/dL) | 118 ± 30 → 104 ± 29 | |||
Triglycerides (mg/dL)§ | 129 ± 62 → 93 ± 41 | 129 ± 66 → 117 ± 49* | ||
HOMA-IR | 4.2 ± 2 → 3.0 ± 3 | 4.6 ± 3 → 3.3 ± 2 | ||
Baseline → 24 months | ||||
Primary | ||||
AST (IU/L) | ||||
ALT (IU/L)§ | 33.3 ± 18 → 21.8 ± 7 | 33.1 ± 17 → 25.7 ± 11* | ||
GGT (IU/L) | ||||
Steatosis degree | 1.5 ± 0.6 → 0.5 ± 0.6 | 1.5 ± 0.7 → 0.9 ± 0.9 | ||
Liver fat (%) | 7.0 ± 5 → 4.5 ± 3 | |||
TE liver stiffness (kPa)§ | 4.7 ± 2 → 3.7 ± 1 | 5.2 ± 2 → 4.4 ± 1* | ||
FLI§ | 76.9 ± 21 → 56.8 ± 27 | 80.4 ± 16 → 69.2 ± 26 | ||
Adiponectin (μg/mL)§ | 6.6 ± 2 → 10.6 ± 3 | 6.7 ± 2 → 8.4 ± 3 | ||
HSI | 45.2 ± 5 → 39.7 ± 5 | 45.1 ± 5 → 42.4 ± 7 | ||
Secondary | ||||
Weight (kg) | 95.1 ± 14 → 89.1 ± 13 | 94.4 ± 14 → 89.8 ± 16 | ||
BMI (kg/m2) | 33.3 ± 4 → 30.8 ± 4 | 33.7 ± 4 → 32.1 ± 5 | ||
WC (cm)§ | 108 ± 9 → 102 ± 11 | 110 ± 10 → 108 ± 13* | ||
TC (mg/dL) | ||||
HDL-C (mg/dL)§ | 53.8 ± 12 → 57.3 ± 13* | 51.9 ± 14 → 52.8 ± 14* | ||
LDL-C (mg/dL) | ||||
Triglycerides (mg/dL) | ||||
HOMA-IR | 4.2 ± 2 → 2.6 ± 2 | 4.6 ± 3 → 3.4 ± 2 | ||
Properzi et al. (2018) [26] | Baseline → 12 weeks | MD | LF diet | There was no significant difference in hepatic steatosis between ad libitum Mediterranean or low-fat diet over 12 weeks. Both diets led to a similar degree of reduction in hepatic steatosis (and resolution of NAFLD. The Mediterranean diet significantly reduced ALT, GGT, raw hepatic fat, body weight, waist circumference, BMI, total cholesterol and HbA1c |
Primary | ||||
ALT (IU/L) | 77 ± 51 → 69 ± 47 | 68 ± 66 → 56 ± 45 | ||
GGT (IU/L) | 102 ± 120 → 83 ± 99 | |||
Raw hepatic fat (%) | 34.2 ± 16.3 → 24.0 ± 14.7 | |||
HepaScore | ||||
Liver stiffness (kPa) | ||||
Secondary | ||||
Weight (kg) | 89.3 ± 12.7 → 87.3 ± 12.5 | 81.3 ± 13.3 → 79.6 ± 13.5 | ||
WC (cm)§ | 105.6 ± 10.3 → 102.9 ± 10.4 | 98.0 ± 12.0 → 93.9 ± 10.6 | ||
BMI (kg/m2) | 31.8 ± 4.0 → 31.1 ± 4.0 | 30.1 ± 5.69 → 29.5 ± 5.8 | ||
TC (mg/dL) | 184.8 ± 49.9 → 175.2 ± 49.5 | |||
Triglyceride (mg/dL) | 165.6 ± 76.2 → 144.2 ± 76.2 | |||
HDL-C (mg/dL) | ||||
LDL-C (mg/dL) | ||||
HOMA-IR | 2.76 ± 1.52 → 2.95 ± 4.32 | |||
Razavi Zade et al. (2016) [27] | Baseline → 8 weeks | DASH diet (energy restricted) | Control (energy/macronutrient equivalent) | In patients with NAFLD and overweight or obesity, adherence to a calorie-restricted DASH diet for 8 weeks showed significant beneficial effect on serum liver enzymes, inflammatory markers, anthropometric indices, markers of insulin metabolism, cholesterol, and triglycerides. A greater percentage of patients in the DASH group decreased NAFLD grade than control |
Primary | ||||
AST (IU/L) | 42.7 ± 34.1 → 32.0 ± 16.6 | |||
ALT (IU/L)§ | 36.4 ± 19.1 → 28.0 ± 20.8 | |||
ALP (IU/L)§ | 206.2 ± 54.8 → 179.9 ± 55.9 | |||
hs-CRP (ng/mL)§ | 4823.1 ± 3358.9 → 3598.4 ± 2752.6 | 4957.0 ± 3421.8 → 4637.5 ± 2872.0* | ||
TAC (mmol/L | ||||
GSH (μmol/L)§ | 585.0 ± 78.8 → 652.8 ± 144.4 | 586.1 ± 81.6 → 590.6 ± 93.1* | ||
MDA (μmol/L)§ | 3.5 ± 0.6 → 3.2 ± 0.3 | 3.2 ± 0.4 → 3.1 ± 0.5* | ||
NAFLD Grade I (%) | 20.0 → 66.7 | 26.7 → 63.3 | ||
NAFLD Grade II (%) | 46.7 → 33.3 | 46.7 → 16.7 | ||
NAFLD Grade III (%) | 33.3 → 0.0 | 26.7 → 20.0 | ||
Secondary | ||||
WC (cm)§ | 99.3 ± 8.4 → 95.1 ± 7.7 | 94.9 ± 12.7 → 92.3 ± 12.2 | ||
HOMA-IR§ | 2.9 ± 1.5 → 2.1 ± 1.4 | |||
VLDL-C (mg/dL)§ | 32.9 ± 12.9 → 26.6 ± 10.7 | 31.6 ± 11.6 → 31.7 ± 19.3* | ||
TC (mg/dL) | 187.4 ± 33.9 → 173.4 ± 33.0 | |||
LDL-C (mg/dL) | ||||
HDL-C (mg/dL) | 42.7 ± 5.8 → 46.1 ± 6.0 | |||
Triglycerides (mg/dL)§ | 164.3 ± 64.5 → 133.0 ± 53.7 | 158.1 ± 58.2 → 158.4 ± 96.7* | ||
Ristic-Medic et al. (2020) [28] | Baseline → 12 weeks | MD (energy restricted) | LF diet (energy restricted) | In patients with NAFLD and overweight or obesity, the calorie-restricted Mediterranean and low-fat diet both significantly improved lipid profiles, liver indices, cholesterol, glucose, insulin, and anthropometry. The Mediterranean diet decreased FLI greater than the low-fat diet |
Primary | ||||
AST (IU/L)§ | 32.50 (23.00–32.75) → 20.00 (16.00–21.75) | 35.65 (25–41.50) → 25.50 (18.75–30.75) | ||
ALT (IU/L) | 65.33 ± 23.90 → 27.33 ± 6.46 | 63.17 ± 15.76 → 31.92 ± 11.89 | ||
GGT (IU/L) | 47.42 ± 36.25 → 24.33 ± 11.57 | 42.53 ± 10.48 → 27.08 ± 9.90 | ||
hs-CRP (mg/L) | 1.02 (0.75–2.23) → 0.81 (0.34–1.40) | 2.10 (0.98–3.20) → 0.77 (0.54–1.27) | ||
FLI§ | 81.92 ± 9.95 → 43.17 ± 7.99 | 83.52 ± 10.76 → 55.08 ± 18.22 | ||
HSI | 47.6 ± 4.92 → 39.34 ± 3.24 | 45.85 ± 4.63 → 37.67 ± 4.07 | ||
Secondary | ||||
Weight (kg) | 101.11 ± 9.09 → 91.88 ± 9.48 | 102.12 ± 8.19 → 92.41 ± 8.14 | ||
BMI (kg/m2) | 30.43 ± 1.81 → 27.65 ± 1.80 | 30.17 ± 2.28 → 27.68 ± 2.44 | ||
WC (cm) | 105.67 ± 5.94 → 95.83 ± 5.73 | 107.58 ± 6.96 → 98.83 ± 8.04 | ||
Triglycerides (mmol/L)§ | 1.92 (1.35–2.55) → 1.06 (0.80–1.20) | 2.40 (1.55–2.69) → 1.29 (1.20–1.57) | ||
TC (mmol/L) | 6.00 ± 0.78 → 4.83 ± 0.95 | 6.08 ± 0.69 → 4.81 ± 0.82 | ||
LDL-C (mmol/L) | 3.67 ± 0.72 → 2.88 ± 0.82 | 3.96 ± 0.89 → 3.14 ± 0.85 | ||
HDL-C (mmol/L) | 1.29 ± 0.13 → 1.41 ± 0.15 | 1.22 ± 0.12 → 1.28 ± 0.11 | ||
HOMA-IR | 3.96 (3.40–4.76) → 2.63 (2.28–3.04) | 4.07 (3.45–44.43) → 2.86 (2.53–3.37) | ||
Ryan et al. (2013) [29] | Baseline → 6 weeks | MD | LFHC diet | In subjects on a Mediterranean diet for 6 weeks, there was a significant decrease in intra-hepatic lipid, and insulin. No other significant benefit on both primary and secondary outcomes was reported. In comparison, the control group did not show any significant differences in primary or secondary outcomes |
Primary | ||||
ALT (IU/L) | ||||
GGT (IU/L) | ||||
Intra-hepatic lipid (%) | 14.2 ± 11.7 → 8.6 ± 7.0 | |||
Secondary | ||||
Weight (kg) | ||||
BMI (kg/m2) | ||||
WC (cm) | ||||
HOMA-IR | 4.7 ± 1.6 → 3.0 ± 1.4 | |||
Triglyceride (mg/dL) | ||||
HDL (mg/dL) |