Healthy Lifestyle and Metabolic Dysfunction-Associated Steatotic Liver Disease: A Study of the Efficacy of Fatty Liver Regression

Abstract

INTRODUCTION:

Obesity is the primary cause of metabolic dysfunction-associated steatotic liver disease (MASLD). Healthy lifestyle management has potential value in the treatment of MASLD.

METHODS:

A total of 150 patients with MASLD diagnosed at the Health Management Center of our hospital were enrolled and randomly divided into a traditional treatment (control group, n = 75) and a healthy lifestyle group (observation group, n = 75). All patients underwent a 3-month intervention. Data on general information, body composition, glucose metabolism, lipid metabolism, and inflammatory factors were analyzed.

RESULTS:

The difference in the change in fatty liver grade was statistically significant (P < 0.05). There were statistically significant differences in treatment efficiency for physical conditions (P < 0.05), including body fat mass, body mass index, body weight, waist circumference, and waist-to-hip ratio. In addition, there were statistically significant differences in treatment efficiency for scales such as the Diet Rating Scale, Emotional Stress Scale, and Global Physical Activity Questionnaire (P < 0.05). Differences in treatment efficiency for body fat parameters, including percentage of body fat, visceral fat area, aspartate aminotransferase, and diastolic blood pressure, were also statistically significant (P < 0.05). After treatment, statistically significant differences were observed in interferon-γ, insulin, low-density lipoprotein cholesterol, triglycerides, and tumor necrosis factor-α (P < 0.05).

DISCUSSION:

Our study indicates that a healthy lifestyle can effectively promote the reduction of fatty liver grade in patients with MASLD, demonstrating positive effects in improving lipid metabolism and inflammatory responses in these patients.

INTRODUCTION

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a chronic liver disease with potentially harmful effects on human health. It is recognized as a “multisystem” disease that coexists with metabolic disturbances and hepatic steatosis; if not controlled promptly, some cases of MASLD can progress to liver fibrosis, cirrhosis, and even hepatocellular carcinoma (1). MASLD has become a global epidemic, with approximately 1.2 billion people worldwide affected, and more than 170,000 people die annually from its complications (2). The prevalence of MASLD has increased by 50.4% in the past 30 years, and about 4% of cases will advance to cirrhosis, which will result in a rapid rise in the need for liver transplants (3). Over the past 30 years, the incidence rate of MASLD has increased by more than 15%, and the number of MASLD-related deaths has tripled; it is projected that by 2030, the mortality rate associated with MASLD will increase significantly, reaching above 65% (4). According to studies, the prevalence of MASLD is significantly higher in obese patients compared with those with normal weight, and patients with a higher degree of obesity face an elevated risk of liver complications. In addition, the all-cause mortality rate for MASLD is more than 3 times higher in severely obese patients compared with those who are overweight (5). Therefore, obesity exacerbates the adverse outcomes of MASLD, to mitigate the aggravation of MASLD caused by obesity, and weight loss has garnered widespread attention in recent years as an effective treatment strategy.

Dietary restrictions (6), weight loss medications (7), and bariatric surgery (8) are common weight-reduction measures that have demonstrated some effectiveness in managing the progression of MASLD. Although weight loss through medication and surgery can be effective in treating MASLD, there is a high recurrence rate. Currently, early clinical-related holistic approaches represent the best option for improving MASLD (9). Comprehensive healthy lifestyle management is an integrated and personalized health management approach. After a health assessment, a health management plan is formulated, and the execution of this plan is supervised. Regular evaluations are conducted, thereby integrating health management into daily life to achieve a healthy lifestyle (10). Comprehensive healthy lifestyle management is essential to improve patients' metabolic disorders and metabolic syndrome, promote the regression of MASLD, and increase the life expectancy of patients with MASLD (10). Previous studies have shown that the more consistently a healthy lifestyle is adhered to, the lower the risk of hypertension (11), diabetes (12), and cardiovascular diseases becomes (13). The relationship between a healthy lifestyle and the regression of MASLD is currently poorly supported by research.

The main goal of this study is to assess how a 3-month healthy lifestyle intervention affects glycemic and lipid metabolic markers, inflammatory parameters, hepatic steatosis, and body composition data in patients with MASLD. Explain how interventions promoting a healthy lifestyle can help MASLD regress.

METHODS

Patient population

This study collected data from 172 patients who underwent B-mode ultrasonography at the Health Management Center of our hospital between January 2022 and December 2024. Among them, 19 patients did not meet the diagnostic criteria for MASLD, and 3 patients refused to sign the informed consent. Ultimately, 150 patients were included in the final study. Random numbers were generated for each patient using the SPSS random number generator, and 2 random groups were created through visual binning: the traditional treatment group (control group, n = 75) and the healthy lifestyle group (observation group, n = 75). Every subject gave their free assent and signed informed consent forms, and the study was authorized by the Ethics Committee of our University (Approval Number: 2024-KY-079).

Inclusion criteria: (i) According to the “EASL-EASD-EASO Clinical Practice Guidelines on the Management of MASLD” clinicopathological syndrome, which is defined by hepatocyte steatosis and fat accumulation brought on by metabolic dysfunction, the patient satisfies the diagnostic criteria for MASLD based on the B-mode ultrasound diagnosis (14). (ii) Aged 18–50 years old. (iii) No history of regular exercise in the past 6 months. (iv) Body mass index (BMI) ≥24 kg/m² indicates simple obesity. (v) No severe cardiovascular and cerebrovascular diseases, no severe gastrointestinal diseases, no severe liver or kidney function impairment, no severe cognitive impairment, etc.

Exclusion criteria: (i) Pregnant women, lactating mothers, etc. (ii) History of alcoholism or excessive alcohol consumption. (iii) History of medication use, specifically the use of drugs associated with steatosis or steatohepatitis. (iv) Presence of cirrhosis or chronic liver disease. (v) Presence of systemic infectious diseases, severe malignant tumors, and autoimmune diseases. (vi) Failure to sign the informed consent form.

After the examination, a 3-month follow-up was conducted, and there were no dropouts among all patients during the follow-up period.

Detection method

All patients underwent liver ultrasound monitoring performed by the same physician. Based on the liver ultrasound echogenic characteristics, the following grades were classified: (i) Normal: Echogenicity resembles that of the kidney cortex. (ii) Grade I: Visible around the diaphragm and portal vein, mild steatosis, and elevated liver echogenicity. (iii) Grade II: No diaphragm blockage, moderate steatosis, elevated liver echogenicity, and ambiguous echogenicity surrounding the portal vein. (iv) Grade III: Blurred diaphragm, ambiguous echogenicity surrounding the portal vein, severe steatosis, and enhanced hepatic echogenicity (15).

The human body composition ratio is analyzed using a body composition analyzer (In Body720, Biospace, Korea). Before the test, participants must be in a fasting state, having emptied their bladder and bowels, and they should remove their outerwear, as well as metal items such as watches and necklaces. They are then instructed to stand barefoot on the footplate electrodes, holding the handheld handle electrode sections in both hands. The instrument is operated by a uniformly trained nutritionist.

Under fasting conditions in the morning, 12 mL of fasting venous blood was drawn from each participant to measure parameters of glucose metabolism, lipid metabolism, liver function, and inflammatory factors. 3 mL of whole blood was taken for blood glucose parameter measurement using the AU5800 fully automatic biochemical analyzer (Beckman Coulter Laboratory Systems [Suzhou] Co., Ltd.). The remaining 9 mL of whole blood was subjected to centrifugation (3,500 revolutions per minute, 15 minutes, with a centrifuge radius of 8 cm). 3 mL of serum was then taken for lipid metabolism parameter measurement using the enzyme-linked immunosorbent assay (kit provided by Beckman Coulter, Inc.). Another 3 mL of serum was taken for liver function index measurement using the AU5800 fully automatic biochemical analyzer. The final 3 mL of serum was used for the detection of inflammatory factors by enzyme-linked immunosorbent assay.

All patients were asked to self-administer the Global Physical Activity Questionnaire (GPAQ) (Table 1) (16), the Emotional Stress Scale (ESS) (Table 2) (17), and the Dietary Rating Scale (DRS) (Table 3) (18). Higher scores on these scales indicate better performance in physical activity, emotional well-being, and dietary habits.

Table 1.

Global Physical Activity Questionnaire

The following questions will ask you about playing various sports. Even if you think you are a nonathletic person, please answer the following questions carefully.
Score	1 point	2 points	3 points
1. You basically sit or stand at work and do not move for more than 10 min at a time.	Yes	Infrequent	No
2. Does your job involve strenuous activities such as heavy lifting, digging, or construction work for at least 10 min at a time?	Yes	Infrequent	No
3. How many days of the week do you spend at work?	Full	Half and above	Less than half
4. How many days of the week do you participate in strenuous activities that are part of your job description?	Full	Half and above	Less than half
5. Does your job involve moderate-intensity activities? Such as brisk walking or carrying light objects? At least 10 min at a time.	Yes	Infrequent	No
6. How many days of the week do you engage in moderate-intensity activities at work?	Full	Half and above	Less than half
7. On the days of the week that you perform a moderate-intensity activity process, how long does moderate-intensity activity take?	80% and above	40%–80%	Less than 40%
8. How long do you usually work each day?	More than 10 hr	8∼10 hr	Less than 8 hr
9. Do you commute on foot or by bicycle for at least 10 min continuously?	Yes	Infrequent	No
10. On how many days of the week do you usually walk or bike for more than 10 min?	Barely	Infrequent	Everyday
11. How long do you spend walking or biking each day?	Barely	10∼20 min	20 min and above
12. Does your recreation, exercise, or leisure time consist primarily of sitting, lying down, or standing, with no more than 10 min of activity at a time?	Yes	Infrequent	No
13. Do you perform any strenuous exercise such as running and lifting weights in your leisure time? Does each session last at least 10 min?	Yes	Infrequent	No
14. During the week, how much of your leisure time is spent on strenuous activities?	Barely	Less than 5%	5% and above
15. How long does it typically take to do strenuous activity each day?	Barely	Less than half an hour	Half an hour and more
16. Do you do any moderate-intensity activities such as brisk walking and cycling for at least 10 min at a time during your leisure time.	Yes	Infrequent	No
17. During the week, how much of your leisure time is devoted to moderate-intensity activities?	Barely	Less than 5%	5% and above
18. How long does it typically take to do moderate-intensity activity each day?	Barely	Less than half an hour	Half an hour and more

Table 2.

Emotional Stress Scale

Please fill in the form according to the real situation in the past 3 months. (1 = strongly disagree, 2 = disagree, 3 = slightly disagree, 4 = slightly agree, 5 = agree, and 6 = strongly agree)
Items	1 point	2 points	3 points	4 points	5 points	6 points
Enthusiastic/optimistic
Like myself
Positive growth/change
Long-term goals
Feel happy/content
Aware of strength/weakness
Look forward to future
Set realistic goals
Know what is important
Respect accomplishment
Find days challenging
Life has purpose
Satisfying environment
Praise others easily
Enjoy touching
Maintain meaningful interpersonal relationships
Time with close friends
Express concern/love
Touch/am touched
Daily relaxation time
Aware of stress sources
Meditation/relaxation
Relax muscles before sleep
Pleasant bedtime thoughts
Express feelings
No need to use pressure control methods

Table 3.

Dietary Rating Scale

Please fill in the form according to the real situation in the past 3 months. (1 = never, 2 = on occasion, 3 = usually, and 4 = surely)
Items	1 point	2 points	3 points	4 points
1. Do you pay attention to the amount of food on your plate?
2. Do you check food labels before buying products?
3. Do you count the calories in your meals?
4. Do you limit fat in your diet?
5. Do you like to cook?
6. Do you eat organic?
7. Do you eat whole grain products?
8. Do you eat a lot of vegetables?
9. Do you regularly consume protein (fish, shrimp, etc.)?
10. Do you eat a lot of roughage?
11. Consuming sweets on a daily basis.
12. Do you avoid packaged or fast foods?
13. You do not drink soft drinks?
14. Do you avoid eating during times of stress or disappointment?
15. Do you avoid overeating when you are out with friends?
16. Do you eat at the same time every day?
17. Are you careful not to miss a meal each day?
18. Did you have a good breakfast?
19. Do you eat breakfast at the same time every day?
20. Do you eat lunch at the same time every day?
21. Do you eat dinner at the same time every day?
22. You would not eat very much for dinner.
23. You do not snack after dinner.
24. You do not eat before you go to bed.

Intervention measures

Control group: Participants underwent a 3-month weight loss treatment program. They engaged in aerobic exercises (jogging, walking, swimming, etc.) 3 times a week, ensuring each session lasted for 30 minutes. In addition, they took 1 oral capsule (0.12 g) of Orlistat (manufactured by Chongqing Huasen Pharmaceutical Co., Ltd.) daily, 1 hour after lunch. During the treatment period, participants were advised to avoid sugary and fried foods, reduce their intake of rice and noodles, and abstain from smoking and alcohol consumption. The weight of patients is recorded every month.

Observation group: Participants underwent a 3-month healthy lifestyle intervention program, which encompassed 3 aspects: diet, exercise, and daily schedule. Dietary: Body surface area, which can be computed using the following method, determines the required water intake: Height (cm)*weight (kg)/3,600 is the body surface area. The ideal body weight (BW), which can be computed as follows, is the basis for calculating energy intake. For men, the ideal BW is equal to height (cm) – 105, whereas for women, it is equal to [height (cm) – 100]*0.85. Daily caloric intake (kcal) is calculated as: Ideal BW (kg)*Caloric requirement per kg of ideal BW (Table 4). A dietary plan is designed to be low in cholesterol, low in calories, high in vitamins, and high in dietary fiber. For every patient, the daily consumption of carbohydrates should make up between 50% and 60% of total calories, the daily intake of protein should be between 15% and 20%, and the daily intake of fat should be between 20% and 25% of total calories, along with 30–35 g of fiber. In addition, participants take 1 oral capsule (0.12 g) of Orlistat daily, 1 hour after lunch. During the first month, special attention is given to the speed and extent of weight loss, with timely adjustments made as needed. After this, weekly phone interviews are conducted to monitor the progress of patients. Exercise: Participants engage in exercise 3 times a week, scheduled on Wednesdays, Fridays, and Sundays. Adjustments are made as needed because of inclement weather or personal health reasons. For the first 2 weeks, the training program consists of a 5-minute warm-up, followed by 20 minutes of treadmill exercise at 60%–70% of the maximum heart rate, and ending with a 5-minute cool-down (stretching or jogging). After 2 weeks, the treadmill exercise duration is increased by 10 minutes, with subsequent 10-minute increments every 2 weeks, until reaching 60 minutes by the third month. All exercise sessions are recorded, and weekly phone interviews are conducted to monitor the progress and health status of the patients. Track the weight loss progress of patients each month. Daily schedule: Participants are advised to refrain from smoking and excessive alcohol consumption. The recommended daily schedule is outlined in Table 5. The dietary choices and consumption recommendations are shown in Table 6, developed based on the 2010 Dietary Guidelines (19). Recording daily life activities, with a weekly phone interview scheduled, aims to monitor adherence to the timetable and overall health status.

Table 4.

Adult daily energy supply scale (kcal/kg ideal weight)

Weight	Bedridden	Light physical activity	Moderate physical activity	Heavy physical activity
Emaciated	20∼25	35	40	40∼45
Normal	15∼20	30	35	40
Overweight or obese	15	20∼25	30	35

Table 5.

Suggested daily schedule

Time	Event	Specific schedule recommendations
7:00 am	Get up
7:20–8:00 am	Breakfast	Breakfast is best eaten 20–30 min after waking up, 7:00–8:00 am is recommended.
8:00–9:30 am	Work
9:30–10:00 am	Rest	Eat a moderate amount of fruit, yogurt, nuts, etc. for energy.
10:00–12:00 am	Work	Recommended working hours in the morning 3.5 hr.
12:00–12:30 pm	Lunch	The half hour at lunch must be your own. It is not for work, or a troubled mind, or an unbalanced state of mind.
12:30–13:30 pm	Rest	Naps are recommended to be no longer than half an hour.
13:30–15:30 pm	Work
15:30–16:00 pm	Rest	Relax your body and get some energy.
16:00–18:00 pm	Work	Recommended working hours in the afternoon 4∼4.5 hr.
18:00–18:30 pm	Dinner	Suggested time for dinner is 5–7 pm. Don't go to bed for 4 hr after dinner to allow enough time for food to digest.
18:30–22:00 pm	Free arrangement	You can arrange work within 1 hr, but you need to do 1 hr of exercise. You can also read books, newspapers, watch TV, etc.
22:00 pm	Take a shower	Take a hot bath, the proper lowering of body temperature helps relaxation and sleep.
22:30–7:00 am	Sleep	8–8.5 hr.

Table 6.

Food selection and dietary recommendations

The diet plan recommends foods.
Grains and potatoes	Vegetables	Beans	Lipids and proteins	Fruits
Various coarse grain flours, starches, coarse grain noodles, millet, rice, black rice, purple rice, brown rice, highland barley, purple sweet potatoes, potatoes, taro, oats, etc.	Lettuce, Chinese cabbage, bamboo shoots, radishes, lotus roots, zucchini, corn, tomatoes, kelp, mushrooms, cucumbers, eggplants, pumpkins, white gourds, broccoli, wood ear mushrooms, green beans, onions, cauliflower, garlic sprouts, garlic seedlings, etc.	Bean sprouts, dried bean curd, tofu, bean curd skin, etc.	Lean pork, lean beef, skinless chicken, lean lamb, cod, crucian carp, shrimp, carp, eggs, etc.	Dragon fruit, apple, grapefruit, strawberry, peach, pear, pineapple, etc.
Dietary recommendations.
1. The daily energy intake for adults is 1,600–1,800 kcal. 2. Consume at least 15 different types of food daily and at least 30 different types of food weekly. 3. The daily carbohydrate intake should account for 50%–60% of the total energy intake. Reduce the consumption of rice and noodles as staple foods, and appropriately increase dietary fiber intake. The daily intake of fresh vegetables and fruits should be 500–800 g. Protein should account for 10%–20% of the total intake. Salt intake should not exceed 5 g, and cooking oil should not exceed 25–30 g. 4. All foods should primarily be steamed or boiled, with reduced oil and salt usage. Minimize the use of condiments and decrease sugar intake.
Breakfast	Lunch		Dinner
1. Accounting for 30% of the total daily calories. 2. The meal should include 3 types of foods: (i) those rich in carbohydrates; (ii) those rich in protein; and (iii) those rich in vitamins and minerals. 3. Key points to note are (i) breakfast should be consumed early, with a four-hour gap between breakfast and lunch; (ii) avoid greasy foods; (iii) do not overeat; (iv) when feeling hungry, one can have a snack after 2 hr, such as fruit or nuts.	1. Accounting for 40% of the total daily calories. 2. This meal should include: (i) 20%–30% carbohydrates; (ii) a substantial amount of dietary fiber, accounting for 40%–50%; (iii) 10%–20% protein; and (iv) approximately 10% high-quality fats. 3. Points to note are (i) consume lean meat in moderation; (ii) if possible, it is recommended to pair with Oolong tea.		1. Accounting for 30% of the total daily calories. 2. This meal should include (i) coarse grain staples such as corn and oats; (ii) protein sources such as shrimp and salmon; and (iii) fruits to supplement vitamins. 3. Points to note are: (i) this meal should be consumed no later than 7 pm; (ii) you should not feel full after eating; and (iii) avoid excessive oil and salt, as high oil and salt intake can induce obesity.

Observation indicators

The general information of patients as baseline information, including gender, age, occupation, smoking habits, alcohol consumption, water intake, sleep patterns, BW, BMI, waist circumference (WC), and waist-hip ratio, (WHR) were collected and analyzed for both groups.

Body composition measurements were recorded for participants at baseline and 3 months after the intervention. These measurements included BW, BMI, percentage of body fat, visceral fat area, WC, WHR, body fat mass (BF), skeletal muscle mass, and body moisture content.

At baseline and 3 months after the intervention, metabolic parameters related to glucose and lipid metabolism were recorded for participants. These included alanine aminotransferase, aspartate aminotransferase (AST), triglycerides (TG), total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol (LDL-C), blood urea nitrogen, creatinine, uric acid, fasting blood glucose, diastolic blood pressure (DBP), systolic blood pressure, insulin, and Homeostasis Model Assessment of Insulin Resistance (HOMA-IR).

At baseline and 3 months after the intervention, inflammatory markers were recorded for participants. These included white blood cell count, C-reactive protein, platelet count, interleukin-6, interleukin-10, tumor necrosis factor-α (TNF-α), and interferon-gamma (IFN-γ).

In addition, the grade of fatty liver, GPAQ scores, ESS scores, and DRS scores were recorded and analyzed for both groups at baseline and 3 months after the intervention.

Statistical analysis

The software SPSS 27.0 (IBM Corporation, Armonk, NY) was used for data analysis. The Levene test was used to look at homogeneity of variance, and the Shapiro-Wilk test was used to evaluate normal distribution for continuous measurement data. When data satisfied the requirements for a normal distribution, they were subjected to Student t test analysis and displayed as mean ± SD ($\stackrel{\circledR }{x}\pm s$). The Mann–Whitney U test was used to assess and report quartiles for data that did not fit the normal distribution criteria. As long as the predicted frequency was >5 and the sample size was at least 40, categorical variables were expressed as n (%) and subjected to Pearson χ² analysis. At P < 0.05, statistical significance was established.

Ethics statement and informed consent

This study was reviewed and approved by Nanhua Hospital Ethics Committee, which is connected to the University of South China, approval number (2024-KY-079). All participants signed informed consent forms.

RESULTS

Characteristics of patients in the baseline period

The baseline characteristics of the patients, as presented in Table 7, showed that there were no statistically significant differences in terms of gender, age, occupation, drinking and smoking behaviors, water intake, sleep patterns, BW, BMI, WC, and WHR between the 2 groups (P > 0.05). This indicated that the study adhered to the principle of a single variable, ensuring the authenticity and accuracy of subsequent research.

Table 7.

Characteristics of patients in the baseline period

Variables	Control group	Observation group	t/χ2	P
Age, yr	35.32 ± 6.77	35.96 ± 6.24	−0.602	0.548
Alcohol consumption			0.167	0.683
Yes	16 (21.33)	14 (18.67)
No	59 (78.67)	61 (81.33)
Body mass index, kg/m2	29.70 ± 1.74	30.15 ± 1.39	−1.753	0.082
Body weight, kg	85.99 ± 7.40	86.55 ± 8.15	−0.444	0.658
Gender			0.273	0.601
Male	52 (69.33)	49 (65.33)
Female	23 (30.67)	26 (34.67)
Occupation			0.132	0.716
Employee	55 (73.33)	53 (70.67)
Self-employed	20 (26.67)	22 (29.33)
Sleep patterns			0.361	0.835
Sleep well	49 (65.33)	49 (65.33)
Sleep averagely	19 (25.33)	17 (22.67)
Sleep poorly	7 (9.33)	9 (12.00)
Smoking habits			1.430	0.232
Yes	52 (69.33)	45 (60.00)
No	23 (30.67)	30 (40.00)
Water intake			1.454	0.483
Drink little water	19 (25.33)	14 (18.67)
Drink normally	40 (53.33)	47 (62.67)
Drinking a lot of water	16 (21.33)	14 (18.67)
Waist circumference, cm	98.89 ± 7.38	99.33 ± 7.84	−0.352	0.726
Waist-to-hip ratio	1.00 ± 0.03	1.01 ± 0.04	−1.887	0.061

Grade of fatty liver

Table 8 shows the baseline and 3-month intervention grade of fatty liver as well as statistically evaluated changes in the grade of fatty liver before and after the intervention. According to the findings, there were 45 patients in the control group whose fatty liver grade had not changed, 25 patients whose grade had decreased by 1 grade, and 5 patients whose grade had decreased by 2 grades. In comparison, there were 10 patients with a 2-grade decline, 43 patients with a 1-grade decrease, and 22 patients in the observation group whose fatty liver grade had not changed. There was a statistically significant difference in the fatty liver grade change between the control group and the observation group (P < 0.05).

Table 8.

Grade of fatty liver

Group	Grade of fatty liver	Baseline N (%)	Postintervention N (%)	Changes, N	χ2	P
Control group	Normal	0 (0.00)	12 (16.00)	Without change: 45	14.327	<0.001*
	Stage 1	45 (60.00)	44 (58.67)	1° reduction: 25
	Stage 2	16 (21.33)	17 (22.67)	2° reduction: 5
	Stage 3	14 (18.67)	2 (2.67)
Observation group	Normal	0 (0.00)	33 (44.00)	Without change: 22
	Stage 1	48 (64.00)	36 (48.00)	1° reduction: 43
	Stage 2	18 (24.00)	6 (8.00)	2° reduction: 10
	Stage 3	9 (12.00)	0 (0.00)

^*P value for the change in fatty liver grade in the observation group relative to the control group by using the χ² test, P < 0.05 indicates that the difference is statistically significant.

Body composition data and self-measurement scale data

After 3 months of intervention, there were statistically significant changes between the 2 groups in terms of BF, body moisture content, BMI, BW, ESS, GPAQ, skeletal muscle mass, WC, and WHR (P < 0.05), as indicated by the data from the body composition and self-measurement scale, as presented in Table 9. Before and after the intervention, the effectiveness of the treatment was assessed for the 2 groups, and statistically significant differences were seen in BF, BMI, BW, DRS, ESS, GPAQ, percentage of body fat, visceral fat area, WC, and WHR (P < 0.05). In this study, BW and BMI were also recorded at 1 month and 2 months after intervention. The results indicated that there were no statistically significant differences in BW and BMI between the 2 groups at both 1 month and 2 months after surgery (P > 0.05). These variations showed that the intervention significantly affected these parameters for both groups.

Table 9.

Body composition data and self-measurement scale data

Variables	Control group	Observation group	t/Z	P
Body fat mass, kg
Baseline	30.00 (28.15, 32.24)	30.85 (29.06, 32.55)	−1.274	0.203
Postintervention	28.52 (27.03, 30.67)	27.39 (26.07, 29.75)	−2.753	0.006*
Treatment effect	−1.37 (−1.66, −1.07)	−3.17 (−3.92, −2.76)	−10.109	<0.001**
Body moisture content, kg
Baseline	10.13 ± 3.35	10.95 ± 2.54	−1.705	0.090
Postintervention	11.71 ± 3.89	13.87 ± 3.59	−3.539	<0.001*
Treatment effect	1.58 ± 4.61	2.92 ± 4.07	−1.879	0.062
Body mass index, kg/m2
Baseline	29.70 ± 1.74	30.15 ± 1.39	−1.753	0.082
After 1 mo	29.30 ± 1.66	29.37 ± 1.42	−0.280	0.780
After 2 mo	29.01 ± 1.65	28.67 ± 1.36	1.396	0.165
Postintervention	28.75 ± 1.61	28.10 ± 1.35	2.679	0.008*
Treatment effect	−0.914 (−1.16, −0.58)	−1.97 (−2.41, −1.58)	−8.944	<0.001**
Body weight, kg
Baseline	85.99 ± 7.40	86.55 ± 8.15	−0.444	0.658
After 1 mo	84.83 ± 7.18	84.31 ± 8.02	0.418	0.677
After 2 mo	83.99 ± 7.04	82.29 ± 7.73	1.412	0.160
Postintervention	83.32 ± 6.94	80.66 ± 7.69	2.231	0.027*
Treatment effect	−2.62 (−3.35, −1.76)	−5.69 (−7.13, −4.63)	−9.179	<0.001**
Dietary Rating Scale
Baseline	47.00 (41.00, 55.00)	45.00 (35.00, 53.00)	−1.350	0.177
Postintervention	62.43 ± 11.82	66.09 ± 10.93	−1.973	0.050
Treatment effect	13.00 (4.00, 24.00)	20.00 (12.00, 28.00)	−3.110	0.002**
Emotional Stress Scale
Baseline	82.04 ± 13.33	87.33 ± 15.61	−2.233	0.027*
Postintervention	114.97 ± 14.61	130.55 ± 15.79	−6.268	<0.001*
Treatment effect	32.93 ± 18.72	43.21 ± 21.18	−3.149	0.002**
Global Physical Activity Questionnaire
Baseline	35.00 (30.00, 40.00)	33.00 (30.00, 40.00)	−1.109	0.268
Postintervention	41.41 ± 5.91	43.87 ± 5.87	−2.551	0.012*
Treatment effect	6.00 (2.00, 9.00)	9.00 (6.00, 14.00)	−3.840	<0.001**
Percentage of body fat
Baseline	35.46 ± 2.31	35.78 ± 1.79	−0.970	0.334
Postintervention	34.90 ± 2.28	34.24 ± 1.95	1.904	0.059
Treatment effect	−0.53 (−0.71, −0.40)	−1.44 (−1.93, −1.07)	−8.508	<0.001**
Skeletal muscle mass, kg
Baseline	30.87 ± 5.75	31.46 ± 5.11	−0.666	0.507
Postintervention	29.65 ± 4.82	31.34 ± 4.81	−2.147	0.033*
Treatment effect	−1.21 ± 0.53	−0.12 ± 0.52	−1.473	0.143
Visceral fat area, cm2
Baseline	186.71 ± 68.74	197.49 ± 72.29	−0.936	0.351
Postintervention	141.36 ± 54.20	138.36 ± 52.23	0.345	0.731
Treatment effect	−13.92 (−70.43, −4.11)	30.35 (−105.17, −8.40)	−2.231	0.026**
Waist circumference, cm
Baseline	98.89 ± 7.38	99.33 ± 7.84	−0.352	0.726
Postintervention	97.69 ± 7.46	93.24 ± 7.35	3.687	<0.001*
Treatment effect	−0.87 (−0.34, −1.66)	−5.67 (−4.02, −7.70)	−9.583	<0.001**
Waist-to-hip ratio
Baseline	1.00 ± 0.03	1.01 ± 0.04	−1.887	0.061
Postintervention	0.99 ± 0.03	0.95 ± 0.04	6.363	<0.001*
Treatment effect	−0.01 (−0.02, 0.00)	−0.05 (−0.07, −0.03)	−9.143	<0.001**

Treatment effect = postintervention – baseline.

^*P value for the difference is statistically significant between the observation group and the control group, P < 0.05.

^**The P value difference in treatment effects between the observation group and the control group is statistically significant, with P < 0.05.

Comparison of glucose metabolism, lipid metabolism, and inflammatory factors between the 2 groups of patients

Table 10 displays the findings of the statistical examination of inflammatory variables, lipid metabolism, and glucose metabolism for the 2 patient groups. After the intervention, AST, blood urea nitrogen, C-reactive protein, DBP, fasting blood glucose, high-density lipoprotein cholesterol, HOMA-IR, IFN-γ, interleukin-6, interleukin-10, insulin, LDL-C, systolic blood pressure, total cholesterol, TG, and TNF-α were shown to differ statistically significantly (P < 0.05) between the 2 groups. Additional statistical analysis was performed to examine the effectiveness of treatment for the 2 groups. The findings demonstrated that there were statistically significant differences (P < 0.05) in insulin, LDL-C, TG, TNF-α, AST, DBP, and IFN-γ between the 2 groups.

Table 10.

Comparison of glucose metabolism, lipid metabolism, and inflammatory factors between the 2 groups of patients

Variables	Control group	Observation group	t/Z	P
Alanine aminotransferase, μmol/L
Baseline	46.39 ± 5.73	47.76 ± 5.08	−1.552	0.123
Postintervention	42.09 ± 4.72	41.88 ± 3.47	0.314	0.754
Treatment effect	−4.29 ± 0.88	−5.88 ± 0.68	1.430	0.155
Aspartate aminotransferase, μmol/L
Baseline	31.72 ± 3.10	31.18 ± 4.23	0.885	0.377
Postintervention	29.62 ± 2.87	26.46 ± 3.38	6.172	<0.001*
Treatment effect	−2.10 ± 0.51	−4.72 ± 0.64	3.219	0.002**
Blood urea nitrogen, mg/dL
Baseline	32.61 ± 4.39	31.45 ± 4.76	1.551	0.123
Postintervention	30.84 ± 6.03	28.58 ± 6.74	2.161	0.032*
Treatment effect	−1.77 ± 0.90	−2.87 ± 0.91	0.859	0.392
Creatinine, mg/dL
Baseline	0.83 ± 0.21	0.79 ± 0.17	1.067	0.288
Postintervention	0.77 ± 0.17	0.74 ± 0.16	1.250	0.213
Treatment effect	−0.06 ± 0.03	−0.06 ± 0.03	0.017	0.987
C-reactive protein, mg/L
Baseline	1.31 ± 0.46	1.34 ± 0.47	−0.455	0.650
Postintervention	2.06 ± 0.69	2.34 ± 0.85	−2.277	0.024*
Treatment effect	0.75 ± 0.87	1.00 ± 1.07	−1.581	0.116
Diastolic blood pressure, mm Hg
Baseline	79.00 ± 5.96	79.04 ± 5.57	−0.052	0.959
Postintervention	74.74 ± 3.14	72.45 ± 4.63	3.544	<0.001*
Treatment effect	−4.26 ± 0.78	−6.60 ± 0.81	2.079	0.039**
Fasting blood glucose, mmol/L
Baseline	94.92 ± 9.81	92.14 ± 10.13	1.707	0.090
Postintervention	91.75 ± 10.33	88.18 ± 8.96	2.256	0.026*
Treatment effect	−3.17 ± 1.60	3.95 ± 1.49	0.358	0.721
High-density lipoprotein cholesterol, mg/dL
Baseline	31.43 ± 6.89	33.21 ± 6.86	−1.585	0.115
Postintervention	35.07 ± 1.87	39.02 ± 1.65	−13.721	<0.001*
Treatment effect	3.64 ± 0.84	5.81 ± 0.83	−1.844	0.067
Homeostasis Model Assessment of Insulin Resistance
Baseline	4.00 ± 0.34	4.05 ± 0.45	−0.855	0.394
Postintervention	3.65 ± 0.52	3.45 ± 0.49	2.507	0.013*
Treatment effect	−0.34 ± 0.07	−0.54 ± 0.09	1.717	0.088
Interferon-γ, μmol/L
Baseline	20.22 ± 4.06	19.92 ± 4.10	0.459	0.647
Postintervention	13.86 ± 3.88	10.29 ± 4.25	5.371	<0.001*
Treatment effect	−6.36 ± 5.18	−9.63 ± 5.93	3.586	<0.001**
Interleukin-6, μmol/L
Baseline	46.43 ± 7.29	45.69 ± 8.75	0.566	0.572
Postintervention	32.13 ± 8.59	28.56 ± 10.22	2.313	0.022*
Treatment effect	−14.31 ± 11.36	−17.13 ± 11.95	0.763	0.140
Interleukin-10, μmol/L
Baseline	38.84 ± 6.66	38.39 ± 7.39	0.393	0.695
Postintervention	20.24 ± 7.53	17.78 ± 7.09	2.064	0.041*
Treatment effect	−18.60 ± 10.62	−20.61 ± 10.78	1.152	0.251
Insulin, IU/mL
Baseline	17.73 ± 1.22	17.51 ± 1.21	1.089	0.278
Postintervention	16.60 ± 1.01	15.41 ± 0.95	7.464	<0.001*
Treatment effect	−1.13 ± 1.56	−2.11 ± 1.62	3.759	<0.001**
Low-density lipoprotein cholesterol, mg/dL
Baseline	110.19 ± 13.23	113.96 ± 12.91	−1.764	0.080
Postintervention	118.44 ± 10.78	121.75 ± 8.86	−2.053	0.042*
Treatment effect	8.25 ± 1.94	7.79 ± 1.82	0.172	0.864
Platelet count, 109/L
Baseline	271.80 ± 63.46	274.02 ± 79.49	−0.189	0.850
Postintervention	227.53 ± 52.28	514.11 ± 47.26	1.608	0.110
Treatment effect	−44.28 ± 9.50	−59.58 ± 10.44	1.084	0.280
Systolic blood pressure, mm Hg
Baseline	129.24 ± 12.47	129.08 ± 9.75	0.087	0.930
Postintervention	125.22 ± 13.47	120.72 ± 12.70	2.106	0.037*
Treatment effect	−4.02 ± 1.87	−8.36 ± 1.61	1.756	0.081
Total cholesterol, mg/dL
Baseline	182.03 ± 5.55	182.88 ± 4.84	−0.998	0.320
Postintervention	189.32 ± 4.13	184.08 ± 6.09	6.164	<0.001*
Treatment effect	3.30 ± 0.95	1.20 ± 0.87	1.631	0.105
Triglycerides, mg/dL
Baseline	198.82 ± 19.31	195.46 ± 14.36	1.208	0.229
Postintervention	186.26 ± 12.80	163.19 ± 12.87	11.004	<0.001*
Treatment effect	−12.56 ± 2.65	−32.26 ± 2.27	5.655	<0.001**
Tumor necrosis factor-α, μmol/L
Baseline	15.10 ± 4.04	15.70 ± 3.94	−0.911	0.364
Postintervention	9.89 ± 3.70	8.38 ± 3.06	2.724	0.007*
Treatment effect	−5.21 ± 5.09	−7.32 ± 5.30	2.479	0.014**
Uric acid, μmol/L
Baseline	315.18 ± 58.27	318.58 ± 60.20	−0.352	0.725
Postintervention	316.43 ± 60.57	300.92 ± 59.68	1.581	0.116
Treatment effect	1.26 ± 0.06	−17.67 ± 0.57	1.437	0.153
White blood cell count, 109/L
Baseline	6.75 ± 1.12	6.72 ± 1.05	0.129	0.898
Postintervention	6.45 ± 1.16	6.24 ± 1.07	1.129	0.261
Treatment effect	−0.30 ± 0.18	−0.48 ± 0.18	0.730	0.467

Treatment effect = postintervention – baseline.

^*P value for the difference is statistically significant between the observation group and the control group, P < 0.05.

^**The P value difference in treatment effects between the observation group and the control group is statistically significant, with P < 0.05.

DISCUSSION

This study investigated the relationship between comprehensive lifestyle management encompassing exercise, diet, sleep patterns, and emotional aspects, and MASLD. Overall, the findings of this study demonstrate that a holistic healthy lifestyle has a beneficial effect on improving symptoms in patients with MASLD. The results indicate that there was a significant reduction in the grade of fatty liver after the implementation of a healthy lifestyle intervention. In addition, the decrease in BW was evident, and apart from BW loss, the notable reductions in WC and BF also suggest the form of physique has considerable improvement. After specific healthy lifestyle interventions, patients with MASLD showed varied degrees of improvement in body composition, glucose metabolism, lipid metabolism, and inflammatory status, according to our clinical efficacy evaluation study. Compared with traditional weight loss treatments, patients with MASLD exhibited significant improvements in their metabolic profiles after undergoing comprehensive healthy lifestyle interventions. These findings showed that weight loss alone was not enough to improve MASLD and that comprehensive lifestyle therapies were more conducive to the resolution of MASLD.

Many lifestyle factors, such as diet (20), physical activity (21), and smoking (22), have been individually proven to be correlated with the improvement of MASLD. However, lifestyle factors often work synergistically in multiple ways, and studying their individual effects may not yield significant results (10). We proposed a comprehensive lifestyle integration program, focusing on interventions related to exercise, diet, and sleep patterns, to establish a healthy lifestyle management model. The results demonstrated favorable therapeutic outcomes. First, there are significant differences in the effectiveness of traditional weight loss methods and healthy lifestyle interventions in terms of BW, BMI, BF, WC, and WHR. To date, weight loss remains the primary treatment approach for MASLD. Beyond traditional methods such as caloric restriction and exercise for weight reduction (23), adopting a healthier lifestyle is a more viable option. In recent years, although weight loss surgeries and antiobesity medications have emerged as additional means for weight reduction, they pose higher risks of side effects and are thus more challenging to promote (24). A study targeting university students in Peru has shown that adopting a healthy lifestyle has significant effects on overweight and obesity. Whether the obesity is caused by academic pressure, irregular sleep schedules, or sedentary habits, managing with a healthy lifestyle results in noticeable improvements in BMI (25). This is similar to the results of the current study, where both BW and BMI have shown noticeable decreases under the management of a healthy lifestyle. Similarly, in this study, we observed significant improvements in parameters such as WC and WHR, indicating that a healthy lifestyle also has a notable effect on improving posture and appearance. Research indicates that adopting healthy lifestyle habits, which include reducing the intake of high-sugar and high-fat foods, can effectively improve patients' liver health and subcutaneous fat levels, thereby facilitating a decrease in WC and WHR (26). Furthermore, BW loss further contributes to the reduction in WC (27), and a healthy lifestyle has a positive effect on both weight reduction and the improvement of posture.

Apart from the most immediate effect of BW loss, we have also assessed the fatty liver grade in patients with MASLD and observed a significant reduction in the fatty liver grade among those adopting a healthy lifestyle. A previous study, echoing the results of our current findings, demonstrated that higher adherence to diet, BMI, physical activity, smoking cessation, and sleep duration reduced the incidence of MASLD and potentially improved liver function (10). In addition to reducing the incidence of MASLD and alleviating its symptoms, another study has shown that with healthier eating habits, the liver's sensitivity to insulin improves, which enhances sugar and lipid metabolism within the liver and subsequently leads to a decrease in the fatty liver grade associated with MASLD (28). The research by Brooks et al also indicates that low-energy intake can lead to weight loss and slow down the progression of diabetes in patients (29). However, a study on noncommunicable diseases and healthy lifestyles has shown that although a healthy lifestyle can help reduce patients' weight and decrease medication intake, it has limited effectiveness in controlling the disease (30). This may be related to the lack of specific disease-targeted indicators in the study. However, it cannot be denied that the slowing progression of diabetes and improvement in insulin resistance both influence the progression of MASLD to varying degrees. With the promotion of healthy lifestyles, these factors have accelerated the reduction in fatty liver grades.

The metabolic results of this study also indicate the beneficial effects of a healthy lifestyle on improving MASLD. By comparing lipid metabolism, glucose metabolism, and inflammatory factors, we found that the metabolic levels of MASLD were significantly elevated after intervention with a healthy lifestyle. In this study, the insulin treatment efficiency in the healthy lifestyle group was significantly better than that in the control group, whereas the treatment efficiency of HOMA-IR was not significant, indicating a reduction in insulin resistance. The study by Arora et al (31) also confirmed that weight loss intervention has a positive effect on improving HOMA-IR. Apart from the aforementioned promotion of insulin absorption by the liver through a low-energy diet (28), the reduced fat content and lighter burden on fat cells resulting from weight loss can decrease the inhibition of insulin in skeletal muscle (32). This is another important reason for the improvement in insulin levels observed in this study. In terms of lipid metabolism, there were significant differences in treatment efficiency for AST and TG between the 2 groups. In a study involving females, after weight loss and lifestyle changes, patients with MASLD exhibited a significant reduction in TG expression, which is similar to the findings of our study (33). International recommendations also suggest that reducing the intake of total fat, saturated fatty acids, trans fatty acids, and fructose is the first step in the treatment of MASLD (34). The correlation between a balanced diet, reduced consumption of fried foods, and regular intake of vegetables and fruits, and abdominal obesity as well as TG levels has long been established (35). It is evident that a healthy lifestyle also has positive effects on lipid metabolism. Furthermore, the difference in treatment efficiency of IFN-γ and TNF-α between the 2 groups demonstrated the positive significance of healthy lifestyle in improving inflammation. This is consistent with similar findings in the study of Ezzat et al (36), where IFN-γ and TNF-α, as proinflammatory factors, were reduced by a healthy lifestyle, thereby mitigating inflammatory reactions. The reduction in inflammatory reactions indicated a decrease in oxidative stress damage within the liver and effectively controls hepatocyte injury and fibrosis (37). An animal study has shown that the reduction of inflammatory cytokines is accompanied by changes in the immune phenotype of the liver, inducing an increase or decrease in T cells, which has a significant impact on the development of MASLD (23). As MASLD continues to evolve, many new treatment approaches are emerging (38). However, it remains undeniable that interventions through diet and exercise within a healthy lifestyle are still the preferred choices for the treatment of MASLD.

In this study, we also conducted statistical analyses on GPAQ, DRS, and ESS. There were significant differences in treatment effects between the control group and the observation group for all 3 assessments. GPAQ is an important instrument for measuring physical activity levels and sedentary time. Because of its high reliability, standardization, and validity, it has been widely used in assessing population physical activity levels in many countries and regions (39). With the rapid development of modern society, sedentary learning and work have become increasingly common. The GPAQ can intuitively demonstrate people's sedentary behavior and physical activity levels, offering high economic efficiency (40). Furthermore, studies have shown that excessive psychological stress can exacerbate weight gain and influence lifestyle choices, leading to the frequent adoption of unhealthy lifestyles. Therefore, assessing the psychological status of patients with MASLD using the ESS can also aid in interventions aimed at promoting healthy lifestyles (41). Through this series of questionnaires, we can also more intuitively observe that patients in the observation group have shown significant improvements in physical activity, diet, and emotional well-being.

Compared with traditional weight loss methods and drug treatments, the healthy lifestyle intervention that combines diet, exercise, and good daily routines has demonstrated a notably better weight loss effect. This may be related to the following 4 factors. First, interventions related to both diet and exercise were performed simultaneously, which proved more effective than emphasizing only one aspect and setting goals for patients (42). Second, frequent consultations were provided to all patients by researchers, which helped maintain their motivation (43). Third, the interventions were grounded on clear theoretical foundations, providing a systematic framework for identifying healthy behaviors (44). Last, targeted interventions were implemented for each patient, helping them become more aware of the effectiveness of healthy living and overcoming bad habits more efficiently (44). Developing a treatment plan based on the aforementioned 4 characteristics would significantly improve the symptoms of MASLD.

Although this study has confirmed from 3 aspects of body composition, lipid metabolism, and inflammation that a healthy lifestyle can help improve MASLD and reduce the grade of fatty liver, there are still some limitations. First, the study period is relatively short, making it difficult to capture the long-term improvement in patients' living conditions. Second, there is a need for further refinement of the dietary plan, particularly regarding the intake of dietary fiber and sugar. Regarding interventions for healthy lifestyle programs, we will continue to extend the follow-up period to provide new theoretical support for long-term efficacy.

Our study indicates that a healthy lifestyle can effectively promote the reduction of fatty liver grade in patients with MASLD, demonstrating positive effects in improving lipid metabolism and inflammatory responses in these patients.

CONFLICTS OF INTEREST

Guarantor of the article: Fen Hu, PhD.

Specific author contributions: Conceptualization, J.W., F.H., and C.H.; methodology, F.H. and C.H.; formal analysis, J.W., J.Z., and Y.Z.; investigation, J.Z., Y.Z., and F.H.; data curation, J.W., F.H., and C.H.; writing—original draft preparation, all authors; writing—review and editing, J.W. and F.H.; supervision, J.W. All authors have read and agreed to the published version of the manuscript.

Financial support: None to report.

Potential competing interests: None to report.

Study Highlights.

WHAT IS KNOWN

• ✓ Comprehensive lifestyle interventions improve metabolic dysfunction-associated steatotic liver disease (MASLD) more than weight loss alone.

• ✓ Lifestyle factors such as diet, exercise, and smoking cessation benefit MASLD.

WHAT IS NEW HERE

• ✓ Holistic lifestyle integration program combining diet, exercise, and routines reduces fatty liver grade.

• ✓ Healthy lifestyle interventions improve multiple MASLD indicators beyond weight loss.