Across 14 randomized controlled trials enrolling 1,805 adults with metabolic dysfunction-associated steatotic liver disease (MASLD), two lifestyle approaches outperformed usual care on key metabolic markers. Biomarker-guided personalized dietary management (BPDM) produced the larger weight effect — a mean 6.66 kg body-weight reduction (95% CI −8.47 to −4.86) and a 1.82 kg/m² BMI drop — alongside a meaningful ALT reduction of 6.72 U/L. Behavioral motivation support (BMS) yielded more modest but statistically significant ALT (−7.41 U/L) and BMI (−1.34 kg/m²) improvements. No head-to-head winner emerged between approaches.
The results arrive at a clinically important moment: MASLD now affects roughly one-third of adults globally, yet no approved pharmacological first-line therapy exists, making lifestyle optimization the primary tool. The body-weight reduction seen with BPDM (~6.7 kg) approaches the 7–10% threshold associated with histological liver improvement in prior trials, which is encouraging. However, the authors' own CINeMA confidence rating was "very low" across all 88 network comparisons — a serious caveat driven by sparse networks, heterogeneous outcome instruments, and small trial samples. The PROSPERO registration occurring after the search (a methodological red flag) further limits confidence. Practically, these findings suggest that individualized dietary guidance may offer a modest edge over generic advice for liver enzyme and weight outcomes, but clinicians should treat this as hypothesis-generating, not practice-changing. Adequately powered direct comparison trials are essential before meaningful treatment hierarchies can be drawn.