Definition

In metabolic-associated steatotic liver disease (MA-SLD), fat accumulation in the liver is accompanied by a metabolic risk profile, including obesity, lipid metabolism disorders, prediabetes, or diabetes mellitus ¹. If inflammation is also present in the liver tissue, the condition is classified as metabolic-associated steatohepatitis.
This inflammation can lead to progressive scarring (fibrosis) of the liver and, in severe cases, to cirrhosis. Diagnosis of metabolic-associated steatotic liver disease involves imaging techniques (e.g., ultrasound, CT), laboratory tests, and/or liver biopsy, following the exclusion of other liver diseases (e.g., alcohol-associated, viral, autoimmune, or drug-toxic liver diseases) ².
Recently, GLP-1 analogues have gained popularity for supporting weight loss due to their efficacy, including in the management of steatohepatitis ³.

Impact on Nutritional Status

MA-SLD is often linked to obesity and associated metabolic risk factors such as insulin resistance, type 2 diabetes mellitus, and hypertension. The accumulation of hepatic triglycerides can contribute to hyperglycemia, hypertriglyceridemia, and hyperinsulinemia ⁴. Patients with MA-SLD have a higher mortality rate compared to the general healthy population ⁵.

The primary therapeutic goal is to reduce hepatic fat content through exercise and nutritional therapy. A weight loss target of 7-10% of body weight, or approximately 0.5-1 kg per week, is recommended ^6,7. Greater weight loss is associated with more significant histological improvements, and reductions exceeding 10% of body weight can positively impact fibrosis ⁷.

Nutrient requirements of patients with metabolic steatohepatitis. Adjustments are necessary for malnourished patients, physical activity and age of patients. The adjusted body weight (ADJ) applies as the weight from a BMI of 28, otherwise the body weight before admission to hospital.  
BW = body weight; d = day; EE = enteral nutrition; PN = parenteral nutrition 

Aims of Nutritional Therapy

• Reduction of hepatic fat through weight loss in individuals with obesity or overweight
• Prevention of malnutrition or nutrient deficiencies
• Improvement of liver enzymes and histology (reduction of necroinflammation)
• Reduction of alcohol consumption (in fibrosis: abstinence or only small daily amounts)

Energy and protein requirements should be covered by oral nutrition whenever possible. If less than 75% of the requirement is met through dietary enrichment, snacks, or sip feeds, enteral nutrition should be introduced as a supplement no later than five days. Complementary parenteral nutrition should be initiated if less than 75% of the requirement is covered by enteral and/or oral nutrition. For detailed guidance, refer to the chapter on enteral and parenteral nutrition.

Oral Nutrition

To achieve weight loss without loss of fat-free body mass in overweight or obese individuals, a hypocaloric diet with increased protein intake combined with physical activity is recommended ^6,7. For individuals with normal weight, the goal should be weight maintenance while increasing physical activity to enhance insulin sensitivity and reduce steatosis ⁷. The Mediterranean diet has shown comparable benefits in previous studies, reducing cardiovascular disease risk and diabetes development ⁷. Alcohol consumption should be minimized (avoiding daily consumption or limiting to small amounts) to lower comorbidities and improve liver histology ⁷.

Practical Advice (if indicated)

• Recommended meal composition to meet reduced energy and increased protein requirements:
  • Include a protein supplement with every main meal, incorporating both animal and plant-based protein sources, adjusted to individual protein requirements.
  • Reduce consumption of energy-dense foods such as sugary drinks, fruit juices, sweets/desserts, high-fat foods (e.g., fried or breaded dishes), and salty snacks.
• Increase physical activity and regular exercise

Enteral Nutrition

For patients with a BMI <30 kg/m² who cannot meet their energy needs orally, even with oral nutritional supplements (ONS) or sip feeds, hypercaloric (≥1.5 kcal/mL) enteral nutrition should be administered via nasojejunal tubes. Nasogastric administration is an alternative only in exceptional cases ¹¹.

For patients with a BMI ≥30 kg/m², a hypocaloric diet with increased protein intake is recommended, following the same principles as oral nutrition ¹¹.

Parenteral Nutrition

Water-soluble and fat-soluble vitamins, as well as trace elements, should be administered daily at least at the recommended daily dose when parenteral nutrition begins. Complete parenteral nutrition is indicated if the fasting period exceeds 72 hours ⁶.

Standard nutrient solutions are recommended for both enteral and parenteral nutrition, as no studies to date have demonstrated superior efficacy of specialty products.

Special Considerations

• Consideration of comorbidities in the prognosis, as there is a strong association between MA-SLD, cardiovascular mortality, and diabetes risk ¹².
• Encourage increased physical activity, even in individuals with normal weight, to enhance insulin sensitivity and reduce steatosis ¹².
• Advise patients with celiac-related liver steatosis to follow a gluten-free diet with guidance from the clinical nutrition team to improve liver enzymes and histology ⁶.
• The clinical benefits of supplements such as resveratrol, vitamin C, coenzyme Q10, and omega-3 fatty acids remain scientifically inconclusive ¹².
• Supplementation of 800 IU α-tocopherol (vitamin E) may support improvements in liver enzyme levels and histology in patients with metabolic-associated steatohepatitis who do not have diabetes mellitus ¹².
• Supplementation of selected probiotics or synbiotics can help improve liver enzyme levels ¹².

Medications/Supplements

• Fat-Soluble Vitamins: Vitamin E, possibly Vitamin D
• GLP-1 Analogues: To support weight loss and metabolic improvement
• Probiotics/Synbiotics