. 2023 Jul 25;11(7):663–689. doi: 10.1002/ueg2.12443

TABLE 1.

Characteristics and main results of clinical trials testing the effects of different lifestyle interventions on liver outcomes.

Author	Design	Sample size	Group	Mean age (years)	Mean BMI (kg/m²)	Intervention and comparator/control groups	Intervention characteristics	Intervention duration	Primary outcome
Author	Design	Male n (%)	Group	Mean age (years)	Mean BMI (kg/m²)	Intervention and comparator/control groups	Intervention characteristics	Intervention duration	Primary outcome
Mediterranean diet (MD)
Properzi 2018, Australia ³⁰	RCT	48 11 (44%)	NAFLD	53	30.9	Intervention: MD, traditional Cretan diet (40% CHO, 20% PRO, 35%–40% FAT and <10% SFA). Control: Low fat/high CHO (LFD). Based on National Health and Medical Research Council and American Heart Association guidelines (50% CHO, 20% PRO, 30% FAT and <10% SFA).	MD: 750 g nuts and 750 mL olive oil. LFD: 1 kg natural muesli, 200 g low fat snack bars, every 4 weeks.	12 weeks	↓ HS (MRS‐PDFF) ↓ ALT HS RR: −32.4% ± 25.5% versus −25% ± 25.3% (intervention vs. comparator) ns
Katsagoni 2018, Greece ³¹	RCT	63 13 (61.9%)	NAFLD	44 (median)	31.7 (median)	Intervention: MD, based on MD pyramid and Greek guidelines (45% CHO, 20% PRO and 35% FAT). Counseling program, 7 × 60 min every 2 weeks for the first 2 months and every month for the next 4 months. Comparator: MLG: MD + optimal sleep (≥7 and ≤9 h/d) and moderate physical activity (30 min/day). Same counseling program as the intervention group. Control: Standard care (healthy lifestyle).	Calorie restriction: 1500 kcal/d (women); 1800 kcal/d (men). Physical activity: Moderate‐vigorous intensity: Fast or very fast walking, slow or fast running, dancing, tennis.	6 months	↓ LSM (intervention/comparator vs. control) ↓ ALT (comparator vs. control)
Misciagna 2017, Italy ³²	RCT	98 34 (47.2%)	NAFLD	‐	‐	Intervention: MD based on traditional Cretan diet and low glycaemic index foods (≤10% SFA). Brochure was provided. Control: Standard care (healthy lifestyle). Based on INRAN guidelines.		6 months	NAFLD score: Negative interaction between time/intervention ↓ FLI and ALT
Marin‐Alejandre 2019, Spain ³³	RCT	98 23 (46%)	NAFLD	49.2	33.3	Intervention: FLIO‐MD diet, higher meal frequency (7 meals/d) (40%–45% CHO, 25% PRO [mainly vegetable sources] and 30%–35% FAT). Control: Standard care (healthy diet lifestyle). Based on American Heart Association guidelines, 3–5 meals/d (50%–55% CHO, 15% PRO and 30% FAT).	Calorie restriction: 30% calorie less (both). Dietary pattern, FAT: Extra virgin olive oil and omega‐3 fatty acids to the detriment of saturated and trans fats. Physical activity: 10,000 steps/d (both).	6 months	↓ HS, FLI, and ALT (both) ↓ AST (control) HS: −4.2% versus −3.6% (intervention vs. control) ns
Nourian 2020, Iran ³⁴	RCT	82 9 (27.3%)	NAFLD	49.4	32.3	Intervention: MD. Based on the health belief model (HBM). Control: Standard care.	Physical activity: General (MD). Behavior change: HBM (MD).	2 months	↓HS (intervention vs. control) ↓ ALT (intervention), AST (both) ↓ ALT and AST (intervention vs. control)
Abbate, 2021, Spain ³⁵	RCT	128 27 (60.8%)	NAFLD	52.3	34.3	Intervention: MD. Higher meal frequency (7 meals/d) (40%–45% CHO [low glycaemic index] 25% PRO [mainly veg PRO] and 30%–35% FAT [mainly MUFA and PUFA]). Comparator: MD physical activity group, meal frequency (4–5 meals/d) 35%–40% FAT (8%–10% SFA, >20% MUFA, >10% PUFA and >300 mg/day of cholesterol), 20% PRO, 40%–45% CHO low glycaemic index). Control: Standard care (healthy diet lifestyle). Based on AASLD guidelines (45%–65% CHO, 10%–35% PRO and 30%–35% FAT).	Calorie restriction: 25%–30% deficit (both). Physical activity: 10,000 steps/d (both).	6 months	↓ HS (intervention vs. control) ↓ ALT (both) ↓ AST (control) HS: (intervention: −6.6% vs. control: −4.9%)
Yaskolka Meir 2021, Israel ³⁶	RCT	294 87 (88.8%)	Central obesity/dyslipidaemia NAFLD (62%)	50.5	31.3	Intervention: Green MD (<40 g/d CHO then 80 g/day, ∼40% FAT [PUFA and MUFA]) and polyphenol‐rich products. Restriction on processed and red meat. Physical activity. Comparator: MD diet rich in vegetables, with poultry and fish replacing beef and lamb. Control: Standard care in addition to physical activity.	Diet food: 28 g/d walnuts (MD + MD green groups); 3–4 cups/d green tea and 100 g/d wolffia globosa (mankai strain) as green shake replacing dinner (MD green); lunch. Calorie restriction: 1200–1400 kcal/d (women); 1500–1800 kcal/d (men) (MD and Green MD groups). Physical activity: Aerobic/resistance 45–60 min/3–4 d/week (all).	18 months	↓ HS (intervention vs. comparator/control) ↓ ALT (intervention/comparator vs. control) ↓ AST (intervention/comparator) Median HS: (intervention: −2% vs. comparator: −1.1% and control: −0.7%)
Gepner 2018, Israel ³⁷	RCT	278 12,589.9%	Central obesity/dyslipidaemia NAFLD (53%)	47.4	30.9	Intervention: MD/low carbohydrate diet. <40 g/d CHO (2 months) then gradual increase ≤70 g/day with 1 polyphenol‐rich product (from 3 m). Comparator: Low‐fat/high CHO 30% FAT, ≤10% SFA and ≤300 mg/d cholesterol.	Diet food: 28 g/d walnuts (MD). Physical activity: 60 min/month educational workshop. Aerobic/resistance 30–60 min/3 d/week (for those randomized after 6 months) (both).	18 months	↓ HS (intervention vs. comparator)
Mazzotti 2018, Italy ³⁸	CCT	716 186 (66.9%)	NAFLD	46	33.7	Intervention: MD Web‐based intervention reproduces group sessions with interactive games, tests and mail contacts. Comparator: MD Group‐based multi‐disciplinary intervention. (5 × 120 min/week sessions).	Calorie restriction: General (both). Physical activity (both). Behavior change: Motivational interviewing; stimulus control; and weight loss maintenance strategies (both).	24 months	↓ FLI, FIB‐4 and ALT (both) ↓ FLI (intervention vs. comparator)
Dorosti 2020, Iran ³⁹	RCT	47 21 (44.7%)	NAFLD	43.1	32.5	Intervention: MD component Increased whole grain intake (≥1/2 of cereal servings/d). Control: Standard care (healthy diet lifestyle).	No advice on calorie allowances, physical activity or behavior changes (both).	12 weeks	↓ HS, ALT, and AST (intervention vs. control)
Shidfar 2018, Iran ⁴⁰	RCT	53 13 (61.9%)	NAFLD	46.1	29.6	Intervention: MD component Increased olive oil intake (20% of total fat). Control: Standard care (healthy diet lifestyle) All: 50% CHO, 20% PRO and 30% FAT.	Calorie restriction: Personalized calorie deficit (both). Olive oil dosage supplied (MD component).	12 weeks	↓ HS and AST (intervention) ↓ ALT (both) ↓ ALT and AST (intervention vs. control)
Rezaei 2019, Iran ⁴¹	RCT	66 12 (37.5%)	NAFLD	46.3	30.6	Intervention: MD component Increased olive oil intake (20 g/d). Comparator: Increased sunflower oil intake (20 g/d). All: 50–55% CHO, 10%–15% PRO and 30%–35% FAT.	Diet food: Olive oil and sunflower oil dosages provided (both). Calorie restriction: 500 kcal/day deficit. Physical activity: Moderate intensity 30–40 min/day (both).	12 weeks	↓ HS and AST (both) ↓ ALT (comparator) ↓ HS (intervention vs. comparator)
Naimimohasses 2022, Iran ⁴²	CCT	50 7 (46.7%)	NAFLD	58	33.9	Intervention: MD, weekly group meetings. Comparator: Exercise, 3–5 aerobic exercise/week, increasing in number over time. Session's duration of 21–42 min. Supervised (2) and unsupervised sessions. Control: Standard of care.	MD: High fiber content, low glycaemic load CHO, and replacement of saturated fat with MUFA and PUFA. Increasing whole foods, fish, nuts/seeds, legumes, vegetables, and complex CHO, and reducing meat and processed foods. AE: Intensity of exercise 40%–75% HRR. Exercises on treadmills, cycle ergometers, and elliptical trainers.	12 weeks	↓ CAP (intervention and comparator) ↓ LS, FAST score and FIB‐4 (all) ↓ ALT (all) ↓ AST (control and intervention)
George 2022, Australia ⁴³	RCT	42 8 (42%)	NAFLD	52.6	31.6	Intervention: Based on traditional Cretan diet. FAT 44% (>50% MUFA), 33% CHO, 15%–20% PRO and up to 5% from alcohol (<20 g/day). Three face to face visits (baseline, week 6 and 12) + 3 phone calls. Comparator: LFD based on the recommendations of Australian Dietary Guidelines and the Heart foundation. FAT 30%, CHO 50%, PRO 20%. Three face to face visits (baseline, week 6 and 12) + 3 phone calls.	MD: Hampers including extra virgin olive oil and nuts for the intervention duration, as well as canned fish and legumes, to model the diet and showcase examples of appropriate staple foods and a Mediterranean diet cookbook. LFD: Received $20 AUD Coles supermarket vouchers at each face‐to‐face appointment to be spent on key staple foods outlined in the dietary recommendations.	12 weeks	↓ IHL and LSM (ns between intervention and comparator)
Ghetti 2019, Brazil ⁴⁴	RCT	40 12 (60%)	NASH	48.3	30.1	Intervention: Cal restricted dietary intervention. Based on American Dietetic Association guidelines and nutritional orientation (food guide Brazil) nutritional orientation + individualized diet. CHO: 47%, FAT: 28%, PRO: 25%. Control: Only nutritional orientation.	Calorie restriction: 500–750 kcal/d deficit	3 months	↓ ALT and AST (intervention) ↓ AST (intervention vs. control)
Marin‐Alejandre 2021, Spain ⁴⁵	RCT	98 27 (54%)	NAFLD	49.2	33.3	Intervention: FLIO diet: CR of 30% of the total energy requirements, higher meal frequency (7 meals/d) 40%–45% CHO (low glycaemic index), 25% PRO (mostly from vegetable sources), 30%–35% FAT (extra virgin olive oil, omega‐3 PUFA, low saturated and trans‐fat). Control: 55% CHO, 15% PRO, 30% FAT (healthy fatty acid profile) based on the AHA guidelines.		6 months	↓ BW in intervention and control Secondary (↓ ALT, FLI, LSM in intervention)
Calorie restriction diet (CR)
Wong, 2013, Hong Kong ⁴⁶	RCT	154 41 (52%)	NAFLD	51	25.5	Intervention: Calorie‐restricted dietary intervention. Based on American Dietetic association guidelines. Control: Standard care (healthy diet lifestyle).	Calorie restriction: General. Physical activity: Moderate intensity/resistance training 30 min/3–5 days/week. Behavior change: Coping with risky situations.	12 months	↓ HS, LSM and ALT (intervention vs. control) HS: −6.7% ± 6.1% versus −2.1% ± 6.4% (intervention vs. control)
Dong 2016, China ⁴⁷	RCT	280 141 (100%)	NAFLD	56.7	26	Intervention: Calorie‐restricted dietary 50%–60% CHO, 15%–20% PRO, 23%–30% FAT. Physical activity. Counseling by phone calls every 3 months. Control: Standard care (habitual diet). Physical activity. Counseling once/year.	Calorie restriction: BMI‐dependent calorie balance (overweight, obese, 25–35 calories/kg/day; normal BMI 30–35 calories/kg/day) (calorie restricted). Physical activity: Moderate (60–80% of target HR)‐vigorous (>80% of target HR) 30–60 min/3–4 days/week (calorie restricted).	2 years	↓ HS, ALT and FLI (intervention) (intervention vs. control) ↓ NFS, both
Promrat 2010, USA ⁴⁸	RCT	31 14 (66.7%)	NASH	48.9	33.9	Intervention: Cal‐restricted dietary intervention. Based on American Heart Association; American Diabetic Association; American College of sports medicine, and fluid guide pyramid. Sessions every week for the first 6 months, then biweekly for months 7–12. Control: Standard care (healthy diet lifestyle) sessions every 12 weeks.	Diet food: Commercial portion‐controlled foods (calorie restricted). Calorie restriction: 1000–1200 kcal/d <91 kg BW 1200–1500 kcal/d >91 kg BW (cal restricted). Physical activity: Moderate intensity 200 min/week. Unsupervised. Behavior change: Stimulus control, problem solving and relapse prevention (cal restricted).	48 weeks	↓ HS, NAS, and ALT (intervention vs. control) ↓ Ballooning injury and AST (both) HS: −1.1 ± 0.8% versus −0.3% ± 0.8% (intervention vs. control)
Cheng 2017, China ⁴⁹	RCT	115 7 (24.1%)	NAFLD	60	26.4	Intervention: Cal restricted dietary intervention. Fiber enriched diet + aerobic exercise (AED group). Comparator: AE group and diet groups. Control: Standard care (habitual diet).	Diet food: Lunch as 30%–40% of total energy intake/d (37%–40% CHO, 9–13 g fiber, 5 g soluble fiber, 25%–27% PRO, 35%–37% FAT) meals prepared at the canteen of Shangai University. AE: 2–3 times/week, supervised. (Nordic brisk walking + stretching) 30–60 min/session.	8.6 months	↓ HS (intervention) HS RR: −47.9% (AED), −24.4% (AE), −23.2% (diet group) and 20.9% (control)
Johari 2019, Malaysia ⁵⁰	RCT	43 24 (72.7%)	NAFLD	45.3	31.6	Intervention: Modified alternate‐day calorie restriction (MACR group). Control: Standard care (habitual diet).	Calorie restriction: Restrict 70% of their calorie requirements between 2 and 8 p.m. (on fast days) and ad libitum (on non‐fast days).	8 weeks	↓ HS, LSM, ALT and AST (intervention) ↓ HS, LSM and ALT (intervention vs. control)
Shojasaadat 2019, Iran ⁵¹	RCT	114 19 (45.7%)	NAFLD	41	31.7	Intervention: Low energy diet intervention. 52% CHO, 18% PRO, and 30% FAT. Comparator: N‐3 PUFA, 2500 mg/d fish oil. Control: Standard care (habitual diet).	Calorie restriction: 350–700 kcal/d deficit.	12 weeks	↓ AST (intervention)
Atefi 2022, Iran ⁵²	RCT	60 0	NAFLD	38.9	30.9	Intervention: CR (500 kcal less) and sesame oil. CHO: 50%–55%, PRO: 14%–18%, FAT: 27%–32%. Control: CHO: 50%–55%, PRO: 14%–18%, FAT: 27%–32%, hypocaloric diet and sunflower oil.	Dietary pattern: 30 g of oil/day.	12 weeks	↓ Fatty liver grade (both) (intervention vs. control)
Asghari 2022, Iran ⁵³	RCT	60 20 (67%)	NAFLD	40.1	31.3	Intervention: CR, 500–1000 kcal based on BW. CHO: 53%, PRO: 17%, FAT: 30%. Control: Healthy eating, according to the food guide pyramid and the Obesity Education Initiative Expert Panel.		12 weeks	↓ ALT and AST only in intervention
Arefhosseini 2011, Iran ⁵⁴	RCT	44 12 (54.5%)	NAFLD	38	28.9	Intervention: 500 kcal deficit, CHO: 55%, FAT: 25%, PRO: 25%. Comparator: 500 kcal deficit, CHO: 40, FAT: 40, PRO: 20.			↓ Of grade of hepatic steatosis (both)
Garousi 2021, Iran ⁵⁵	RCT	80 15 (40.5%)	NAFLD	43.5	32	Intervention: 500 kcal deficit, lacto‐ovo‐vegetarian diet (LOV‐D). CHO: 50%–55%, PRO: 15%–20%, FAT: 25%–30%. Control: CHO: 50%–55%, PRO: 15%–20%, FAT: 25%–30%. Based on the food pyramid.	LOV‐D: Restraining in the consumption of meat and meat products, poultry, fish and seafood, and flesh of any other animal. Included protein sources from egg (24%), dairy (19%), gluten (26%), soy (16%), nuts (8%), vegetables, and fruits (7%). Control: 18% of protein sources from meat and meat products, poultry, fish and seafood, and flesh of any other animal.	3 months	↓ ALT, AST (both) (intervention vs. control)
Wong 2018, Hong Kong ⁵⁶	RCT	77 BMI <25: 23 (59%) BMI >25: 16 (42%)	NAFLD	BMI <25: 50.8 BMI >25: 51.7	‐	Intervention: Reducing calorie intake and increasing energy expenditure. Individual education at 2 community centers, 1 session/week during the first 4 months then monthly. Exercise instructor designed a suitable exercise regime. Control: Routine care. Advises to reduce fat and CHO intake, and to exercise 3 times/week (30 min of session).		12 months	Remission of NAFLD (IHTG, H‐MRS) Non obese (67% vs. 18%) Obese (61% vs. 21%) (intervention vs. control)
Time‐restricted eating (TRE)
Cai 2019, China ⁵⁷	RCT	271 29 (69.5%)	NAFLD	33.6	26.8	Intervention: Alternate‐day fasting (ADF), fast day (24 H): 25% of the baseline energy needs, based on the American Heart Association guidelines (30% kcal from FAT, 15% kcal from PRO, 55% kcal from CHO). Comparator: TRE, 16 h of fasting (food and beverages that included energy). Control: 80% of their energy need without any advice or restrictions on their usual lifestyle patterns.	No physical activity or behavioral advice provided.	12 weeks	No change in LSM (both)
Varkaneh HK 2022, Iran ⁵⁸	RCT	52 12 (57.1%)	NAFLD	46.4	30.4	Intervention: 5:2 diet, 5 days normal food, 2 consecutive days fasting. On fasting days, 25% of recommended calorie intake from 12–2 p.m. (30% FAT, 15% PRO, 55% CHO). Control: 30% FAT, 15% PRO, 55% CHO.		12 weeks	↓ ALT (both, intervention vs. control) ↓ AST GGT (intervention) ↓ CAP (both) (intervention vs. control) ↓ Fibrosis score (intervention) (intervention vs. control)
Mari 2021, Israel ⁵⁹	CCT	155 39 (52.7%)	NAFLD	51.8	36.7	Intervention: Ramadan fasting. Control: No fasting.		4 weeks	↓ NFS
Low carbohydrate (LCH)—Low fat diet (LFD)
Jang 2018, South Korea ⁶⁰	RCT	106 LCH: ‐ LFD: ‐	NAFLD	LCH: 43.6 LFD: 42.4	LCH: 27.3 LFD: 27.1	Intervention: LCH: 25 kcal/kg of ideal BW, 50%–60% CHO, 20%–25% PRO, 20%–25% FAT. Comparator: LFD: 25 kcal/kg of ideal BW, 60%–70% CHO, 15%–20% PRO, 15%–20% FAT.	Booklet with informations regarding calorie intake, macronutrient composition and specific food consumption patterns was proposed.	8 weeks	↓ ALT (both, significant greater reduction with LCH) ↓ Liver/spleen ratio (greater reduction with LCH)
Kani AH 2014, Iran ⁶¹	RCT	45 7 (46.7%)	NAFLD	48.5	31.3	Intervention: CR‐LCH + soy, 30 g of soy nut instead of 30 g of red meat. Comparator: CR‐LCH, 45% CHO, 35% FAT, 20% PRO. Control: Low calorie diet, CR, 300–500 kcal deficit according to the BMI. 55% CHO, 15% PRO, 30% FAT.	Moderate daily physical activity of 30 min	8 weeks	↓ ALT (all)
Eckard 2013, USA ⁶²	RCT	56 6 (50%)	NAFLD (biopsy‐proven)	44	32.7	Intervention: LFD with moderate exercise (FAT 20%, 60% CHO, 20% PRO). Comparators: a) Moderate fat low processed carbohydrate diet (30% FAT, 50% CHO, 20% PRO) b) Moderate exercise only. Control: Standard care.	Supplemental materials were provided to patients with healthy cooking, grocery shopping, and dining out. Received a set of measuring cups and spoons and were also instructed on estimating portion sizes using the MyPyramid serving size guidelines. Physical activity (intervention, a) and b)): Exercise program, based on FITT (frequency, intensity, time and type) principles. 20–60 min, 4–7 days/week in a supervised environment.	6 months	↓ NAS score (ns for control)
Razavi 2016, Iran ⁶³	RCT	60 15 (50%)	NAFLD	39.7	28.5	Intervention: CR‐DASH diet, 350–700 kcal less based on the BMI, 52%–55% CHO, 16%–18% PRO, 30% FAT. Control: Calorie restricted, 52%–55% CHO, 16%–18% PRO, 30% FAT.	Dietary pattern: DASH diet rich in fruits, vegetables, whole grains, and low‐fat dairy products and low saturated fats, cholesterol, refined grains and sweets. Sodium <2400 mg/d.	8 weeks	↓ Grade of fatty liver (control and intervention) ↓ ALT (intervention) (intervention vs. control)
Sun 2012, China ⁶⁴	RCT	1087 464 (64.1%)	NAFLD	39.9	37.7	Intervention: Low fat diet: CHO: 55%, 30% FAT, 15% PRO. No calorie restriction. Physical activity. Control: Basic education about NAFLD and principles of healthy eating, physical activity and weight control.	Physical activity: Walking, jogging, stair climbing.	12 months	↓ ALT
Sun 2022, China ⁶⁵	RCT	63 19 (65.5%)	NAFLD	39.8	28.6	Intervention: HPLG: PRO 40%–45%, CHO 20%–25%, FAT 30%–35% with restricted energy content. Control: 10%–20% PRO, CHO 50%–65%, FAT 20%–30%, same energy restriction.		12 weeks	↓ CAP (both) (intervention vs. control)
Rodriguez‐Hernandez 2011, Spain ⁶⁶	RCT (not controlled)	59 0	NAFLD	46.3	38.7	Intervention: LCD, PRO 27%, FAT 28%, CHO 45% Comparator: LFD 21% FAT, <10% saturated fat, 25% PRO, 54% CHO		6 months	↓ ALT (both)
Internet‐based approaches
Vilar‐Gomez 2019, USA ⁶⁷	CCT	349 87 (33.2%)	NAFLD	53.8	40.4	Intervention: Comprehensive continuous care intervention (CCI), encouraging nutritional ketosis. Control: Usual care based on the American Diabetes Association recommendations.	CCI: Remote personal health coach and medical providers, either on site or via web‐based educational content.	12 months	↓ N‐LFS (intervention) ↓ NFS (intervention vs. group)
Physical activity approaches
Zelber‐Sagi 2014, Israel ⁶⁸	RCT	82 16 (48.5%)	NAFLD	46.3	30.8	Intervention: Resistance training (3 times weekly) based on the ACSM 2009 position paper on “progression models in resistance training for healthy adults” in a community setting. Load was gradually increased by 2%–10% in the following training sessions according to the patient's ability. Patients received a comprehensive booklet. They were advised no to perform aerobic training. Control: Home stretching. Patients received a comprehensive booklet.	Resistance training: Leg press, leg extension, leg curl, seated chest press, seated rowing, latissimus pull down, biceps curl and shoulder press with 8–12 repetitions, three sets for each exercise with 1–2 min rest between sets, for a total duration of about 40 min. Phone call every 2 weeks. Control: The program included eight stretching exercises for the major muscle/tendon groups using the static stretching technique. The participants performed four repetitions of these static stretches each lasting 20 s. Each session was performed on three non‐consecutive days a week.	3 months	↓ Liver steatosis (intervention vs. control)
Abdelbasset 2019, Saudi Arabia ⁶⁹	RCT	32 10 (62.5%)	NAFLD	54.4	36.3	Intervention: High‐intensity interval (HII). High intensity aerobic exercise, 3 times/week. Session of 40 min. Control: No exercise program.	HII: Performed on a cycle Ergometer. Five minutes warm‐up followed by three sets of 4‐min cycling sessions at 80%–85% of the VO₂ max with 2‐min interval at 50% of the VO_{2 max} between sets.	8 weeks	↓ IHTG (MRI)
Bacchi 2013, Italy ⁷⁰	RCT	40 12 (70.6%)	NAFLD	56	28.8	Intervention: Resistance training (RT): Three series of 10 repetitions at 70%–80% 1‐RM, with 1 min of recovery between series. Performed at the university setting. Comparator: Aerobic exercise training (AE): Sessions of 60 min at 60%–65% of heart rate. All: Nutritional follow‐up. Maintenance of baseline calorie intake.	RT: Chest press, shoulder press, vertical traction, leg press, leg extension, leg curl, abdominal crunch. Performed at the university setting. AE: Activities such as treadmill, cycle, or elliptical machines.	4 months	↓ hepatic fat (both)
Rezende 2016, Brazil ⁷¹	RCT	40 0	NAFLD	56.2	31.1	Intervention: Exercise training. Supervised aerobic exercise training twice/week. Sessions of 30–50 min with increase in exercise duration every 8 weeks. Control: No exercise. All: Standardized diet, calorie deficit of 500 kcal/d, 35% PRO, 25% FAT and 40% CHO.	Exercise training: Treadmill aerobic exercise.	24 weeks	No significant decrease of liver fat
Zhang 2016, China ⁷²	RCT	220 21 (28.8%)	NAFLD	53.2	27.9	Intervention: Vigorous (5 sessions/week)‐moderate exercise. Six months vigorous exercise program and 6 months moderate exercise program (5 sessions/week). Supervised. Comparator: Moderate exercise. Supervised. Control: No exercise. Attendance to group health education sessions.	Vigorous‐exercise: Treadmill and gradually increased intensity to 35%–80% of their maximum predicted HR. Session of 30 min. Moderate‐exercise: Walking 120 steps/min of 45%–55% of their maximum predicted HR. Session of 30 min. Intervention and comparator: Behavioral component on adherence to exercise programs. All: Group health education sessions (general health knowledge of NAFLD, smoking cessation, and elements of a healthy lifestyle).	12 months	↓ IHTG (intervention, comparator vs. control) No significant difference between intervention and comparator
Abd El‐Kader 2016, Saudi Arabia ⁷³	RCT	100 34 (68%)	NAFLD	50.8	32.4	Intervention: Aerobic exercise (AE) training program and diet regimen. Three sessions (30 min)/week. Based on the recommendations of Aerobic College of Sports medicine. Low calorie diet: PRO 15%, 30%–35% FAT, 50%–55% CHO, ∼1200 kcal/d Control: Ordinary current lifestyle.	AE: Treadmill‐based training program at 65%–75% of the maximum heart rate.	3 months	↓ ALT, AST (only intervention)
Cuthbertson 2016, UK ⁷⁴	RCT	69 23 (76.7%)	NAFLD	50	30.6	Intervention: Supervised exercised. Three times/week 30 min moderate (30% HRR) aerobic exercise (AE). Control: Counseling.	AE: Treadmill, cross‐trainer, bike ergometer, rower.	16 weeks	↓ IHTG (intervention vs. control)
Shamsoddini 2015, Iran ⁷⁵	RCT	30 10 (100%)	NAFLD	45.9	30.6	Intervention: Resistance training (RT), 3 times/week of 45 min session. Supervised. Comparator: Aerobic program (AE), 3 times/week of 45 min session. Control: No exercise training.	RT: Triceps press, biceps curl, calf raise, leg press, leg extension, lat pull down and sit‐ups. AE: Stretching movements + slowly running on treadmill (warm up). Training phase: 2 × 15 min running on treadmill at 60% of maximal heart rate, increased to 75% MHR the following weeks.	8 weeks	↓ hepatic fat in intervention and comparator
Takahashi 2015, Japan ⁷⁶	CCT	53 9 (29%)	NAFLD	55.5	28.5	Intervention: Resistance training (RT). Session of 20–30 min 3 times/week. Control: Education about dietary restrictions and encourage to participate in regular physical activities according to the American gastroenterological association for NAFLD and the physical activity of health promotion guidelines recommended by the ministry of health, labor and welfare of Japan.	RT: Push‐ups (3 sets of 10) + squats (3 sets of 10).	12 weeks	↓ ALT, hepatic steatosis (only intervention)
Oh 2021, Japan ⁷⁷	CCT	45 24 (100%)	NAFLD	49.7	28.1	Intervention: Aerobic exercise (AE) program. Sessions of 90 min, 3 days/week. Supervised. Comparator: Restriction calorie intake to 1680 kcal/day. Sessions of 90 min once/week by registered dietician. Advises regarding daily physical activity.	AE: Incremental increase over the time. Fast walking and/or light jogging.	3 months	↓ Liver steatosis, liver stiffness, FAST score
Nath 2020, India ⁷⁸	CCT	37 18 (100%)	NAFLD	37.3	26.9	Intervention: Moderate intensity exercise group (AE). Session of 50–60 min, 5–6 sessions/week. MET between 3 and 5.9. Comparator: Low intensity exercise group (AE). MET <3.	AE: Walking, jogging, marching drill, “lathi drill,” and yoga.	6 months	↓ ALT, AST (only significant in the intervention group)
OH 2017, Japan ⁷⁹	RCT	61 19 (100%)	NAFLD	51.2	27.2	Intervention: Resistance training (RT), based on the ACSM 2009 position paper on “progressive models in resistance training for healthy adults.” Comparator: a) HIAT, high‐intensity interval aerobic training, b) MICT, moderate‐intensity continuous aerobic training.	RT: Sit‐ups, leg presses, leg extensions, leg curls, chest presses, seated rows and pull downs. HIAT: Three sets of 3‐min cycling sessions at 80%–85% VO₂ max with a 2 min active rest at 50% VO₂ max between sets. MICT: 40 min of cycling at 60%–65% VO₂ max (40 min, 360 kcal).	12 weeks	↓ Liver fat in intervention and comparators. ↓ Liver stiffness but only in HIAT exercise regimen.
Babu 2022, Finland ⁸⁰	RCT	46 7 (53.8%)	NAFLD	59.9	29.7	Intervention: HIIT, high‐intensity interval training. Twice/week. Session of 40 min with incremental increase to 50 min. Supervised sessions. Individualized exercise training program was prescribed for home (low to moderate intensity aerobic exercise). Control: Sedentary lifestyle. All: Diet habits unchanged.	HIIT: Five bouts of 2–4 min work intervals (at 85% of max W4) interspersed by 3 min of active recovery.	12 weeks	No change regarding liver outcomes.

Note: Number of males, mean age and BMI are data related to the intervention group.

Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; AUD, australian dollars; BW, body weight; CAP, controlled attenuated parameter; CCT, clinical controlled trial; CHO, carbohydrate; FAST score, Fibroscan‐AST score; FIB‐4, fibrosis‐4 index; FLI, fatty liver index; HS, hepatic steatosis; IHL, intrahepatic lipid content; IHTG, intrahepatic triglyceride; LS, liver stiffness; LSM, liver stiffness measurement; MLG, Mediterranean lifestyle group; MRS‐PDFF, magnetic resonance‐spectroscopy‐measured proton density fat fraction; MUFA, monounsaturated fat; NAFLD, non‐alcoholic fatty liver disease; NAS, non‐alcoholic fatty liver disease activity score; NFS, NAFLD fibrosis score; N‐LFS, NAFLD liver fat score; ns, non‐significant; PRO, protein; PUFA, polyunsaturated fat; RCT, randomized controlled trial; RR, relative reduction; SFA, saturated fat.