Proinflammatory Diets Linked to Higher MASLD, MetALD Mortality

Patients with metabolic dysfunction–associated steatotic liver disease (MASLD) who consumed proinflammatory diets had approximately twice the risk of all-cause mortality, whereas antioxidant-rich diets were associated with better survival across steatotic liver disease (SLD) subtypes, according to a recent analysis published in Food Science & Nutrition.¹

Why Diet Quality Matters Across Steatotic Liver Disease

The 2023 multisociety SLD nomenclature created a new category for patients with MASLD who drink moderate amounts of alcohol, defined as 30-60 g/day for men and 20-50 g/day for women.² Under these criteria, patients are now classified as having metabolic dysfunction and alcohol-associated liver disease (MetALD), a subgroup linked to higher mortality and more severe liver outcomes than MASLD alone.

With the FDA approvals of resmetirom (Rezdiffra; Madrigal Pharmaceuticals) and semaglutide (Wegovy; Novo Nordisk), patients with metabolic dysfunction–associated steatohepatitis (the more advanced form of MASLD) and liver fibrosis have more treatment options.^3,4 Although dietary change also remains central to guideline recommendations, little evidence exists on how the inflammatory and antioxidant quality of a diet affects long-term survival across SLD subtypes, particularly MetALD.¹

To address this gap, investigators analyzed data from 3048 adults with SLD, specifically 2146 with MASLD and 902 with MetALD, from the National Health and Nutrition Examination Survey between 2005 and 2018, with mortality tracked through December 31, 2019. Diets were scored from two 24-hour dietary recalls using 3 indices, the first being the Dietary Inflammatory Index (DII), in which higher scores indicate a more pro-inflammatory diet. The other 2 were antioxidant measures, the Composite Dietary Antioxidant Index (CDAI) and the Dietary Antioxidant Quality Score (DAQS), both based on intake of vitamins A, C, and E, zinc, selenium, and carotenoids.

Inflammatory Diets Tracked With Higher Mortality

During follow-up, 306 participants died, 248 with MASLD and 58 with MetALD. In fully adjusted models of the overall SLD population, patients in the highest DII tertile had about twice the risk of all-cause death as those in the lowest (HR, 2.04; 95% CI, 1.28-3.27). In addition, those in the highest tertiles of CDAI (HR, 0.44; 95% CI, 0.26-0.74) and DAQS (HR, 0.57; 95% CI, 0.35-0.92) had lower risk.

Results were similar among patients with MASLD. In this group, a high DII was associated with elevated mortality (HR, 1.97; 95% CI, 1.12-3.47), whereas high CDAI (HR, 0.50; 95% CI, 0.28-0.89) and DAQS (HR, 0.47; 95% CI, 0.24-0.93) scores were associated with lower mortality. In MetALD, the DII association was stronger, with elevated risk in both the middle (HR, 4.95; 95% CI, 1.87-13.15) and highest (HR, 3.91; 95% CI, 1.46-10.49) tertiles. By contrast, the antioxidant indices trended toward lower mortality in MetALD but did not reach statistical significance, which the authors attributed partly to the small number of deaths in this subgroup.

Associations with cardiovascular mortality were less consistent, and most did not reach statistical significance. DAQS was the most consistent of the 3, with patients in its highest tertile having lower cardiovascular mortality (HR, 0.42; 95% CI, 0.24-0.74).

Diet Quality Linked to Lower Mortality Across SLD Subtypes

In a joint analysis, compared with patients with MASLD and the poorest diets, high DAQS scores were associated with lower mortality in both MASLD (HR, 0.38; 95% CI, 0.19-0.75) and MetALD (HR, 0.19; 95% CI, 0.08-0.46). Patients with MetALD and the least inflammatory diets also had lower mortality risk (HR, 0.16; 95% CI, 0.08-0.33). The authors highlighted, however, that patients with MetALD in this cohort were younger on average (48.9 vs 51.6 years) and scored better on all 3 dietary indices at baseline, which may reflect greater health awareness in this group and could partly explain the risk differences.

The associations were strongest in patients with little fibrosis, defined as a Fibrosis-4 (FIB-4) index below 1.3. They weakened as fibrosis advanced, with the DII association losing significance among patients with a FIB-4 above 2.67. Exploratory mediation analyses in MASLD found that platelet count and the platelet-to-high-density lipoprotein cholesterol ratio were involved in the diet-mortality associations. Because the direct and indirect effects ran in opposite directions, the authors characterized this pattern as inconsistent mediation rather than a true mediating role; no mediation was observed in MetALD.

What the Findings Mean for MASLD Care

Based on these findings, the authors argued that improving dietary quality among patients with MetALD should be prioritized alongside counseling to reduce alcohol intake. Their suggested dietary changes include replacing refined grains with whole grains, limiting fried foods and processed red meat, and eating more vegetables, fruits, legumes, and berries.

The fibrosis findings align with recent calls for routine risk stratification in primary care, in which patients flagged as at risk would receive lifestyle changes concurrently with approved medications.⁵ They also build on recent evidence that fibrosis severity, rather than body weight, drives MASLD prognosis.⁶

The authors, however, acknowledged several limitations.¹ Dietary data were self-reported and drawn from 24-hour recalls, which could not capture the long-term type or amount of alcohol consumed. In addition, with only 58 deaths, the MetALD subgroup had limited statistical power.

“All in all, even in the context of moderate alcohol consumption, maintaining high antioxidant intake and low inflammatory intake appears to be associated with reduced mortality risk, suggesting that optimizing dietary habits could serve as a beneficial strategy for improving outcomes in individuals with MetALD,” they concluded. “Nevertheless, these findings remain preliminary and require further validation in large population cohorts.”

References

1. Lyu H, Chen H, Zhan Z, et al. Differential associations of Dietary Inflammatory Index and dietary antioxidant indices with mortality risk from MASLD/MetALD: results from a large population-based study. Food Sci Nutr. 2026;14(10):e72429. doi:10.1002/fsn3.72429
2. Canivet CM, Boursier J, Loomba R. New nomenclature for nonalcoholic fatty liver disease: understanding metabolic dysfunction-associated steatotic liver disease, metabolic dysfunction, and alcohol-associated liver disease, and their implications in clinical practice. Semin Liver Dis. 2024;44(1):35-42. doi:10.1055/s-0044-1785196
3. Joszt L. FDA approves resmetirom, first treatment for NASH with liver fibrosis. AJMC^®. March 14, 2024. Accessed October 15, 2026. https://www.ajmc.com/view/fda-approves-resmetirom-first-treatment-for-nash-with-liver-fibrosis
4. Klein HE. FDA approves semaglutide for MASH with fibrosis. AJMC. August 18, 2025. Accessed October 15, 2026. https://www.ajmc.com/view/fda-approves-semaglutide-for-mash-with-fibrosis
5. Joszt L, Younossi ZM. MASH outcomes hinge on risk stratification, coverage: Zobair Younossi, MD. AJMC. October 14, 2026. Accessed October 15, 2026. https://www.ajmc.com/view/mash-outcomes-hinge-on-risk-stratification-coverage-zobair-younossi-md
6. McCormick B. Lean MASLD carries similar risk as overweight, obese disease. AJMC. October 7, 2026. Accessed October 15, 2026. https://www.ajmc.com/view/lean-masld-carries-similar-risk-as-overweight-obese-disease