The Impact of the Mediterranean Diet, Physical Activity, and Nutrition Education on Pediatric Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) - A Review

Sep 30, 2026

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Metabolic dysfunction-associated steatotic liver disease (MASLD) is the leading chronic liver disorder in children and adolescents, reflecting rising pediatric obesity. This review compiles human evidence on Mediterranean diet (MD) interventions for pediatric MASLD and evaluates key pathophysiological mechanisms. Searches of PubMed, Scopus, and Web of Science identified eligible studies under predefined criteria, with quality appraisal using Academy of Nutrition and Dietetics tools and qualitative synthesis. Eight studies showed consistent improvements in hepatic steatosis, stiffness, fibrosis markers, inflammatory cytokines, oxidative defenses, liver enzymes, and lipid/glycemic profiles. Nutrition education supported adherence, and structured physical activity improved long-term sustainability. Evidence is limited by small samples, heterogeneous protocols, and short follow-ups; larger multicenter randomized trials are needed to establish best practices and long-term efficacy.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages20

Reading Time50 min

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Abstract

1. Introduction

Epidemiology and clinical relevance

Dietary pattern and mechanisms

Lifestyle interventions in MASLD

Review The Impact of the Mediterranean Diet, Physical Activity, and Nutrition Education on Pediatric Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD): A Review Melvin Bernardino 1,2,3, *, Claudio Tiribelli 1 and Natalia Rosso 1, * Academic Editor: Naoki Tanaka Received: 28 November 2025 Revised: 12 December 2025 Accepted: 17 December 2025 Published: 20 December 2025 Copyright: © 2025 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license. 1 MASLD Unit, Fondazione Italiana Fegato, 34149 Trieste, Italy; ctliver@fegato.it 2 Department of Life Sciences, University of Trieste, 34100 Trieste, Italy 3 Philippine Council for Health Research and Development, Department of Science and Technology, Taguig City 1631, Philippines * [Correspondence: melvin.bernardino@fegato.it](Correspondence: melvin.bernardino@fegato.it) (M.B.); [natalia.rosso@fegato.it](natalia.rosso@fegato.it) (N.R.) Abstract Background/Objectives: Metabolic dysfunction-associated steatotic liver disease (MASLD) is now the most prevalent chronic liver disorder among children and adolescents, mirroring the rise in pediatric obesity. The Mediterranean diet (MD) has demonstrated antiinflammatory, antioxidant, and beneficial effects on different health outcomes across different life stages. The MD’s effect has been explored in adult MASLD, but there is limited information on the pediatric population. However, evidence on pediatric MASLD should be explored given its rising prevalence. Therefore, the aim of this review is to collect human studies assessing the effect of MD interventions on pediatric MASLD, focusing on key pathophysiological mechanisms. It also examines other interventions, including specific energy/macronutrient prescriptions, nutrition education or counseling, and physical activity components. Methods: A comprehensive search of PubMed, Scopus, and Web of Science was conducted using terms related to the Mediterranean diet, nutrition education, physical activity, pediatrics, and MASLD/NAFLD. Pre-determined inclusion and exclusion criteria were used to collect eligible studies to be included in the review. Study quality was assessed using the Academy of Nutrition and Dietetics Quality Criteria Checklist. Screening, data extraction, and appraisal were performed independently, with discrepancies resolved through discussion, and the findings were synthesized qualitatively. Results: This review synthesizes findings from eight human studies evaluating the impact of the MD, alone or integrated with structured exercise and nutrition education, on pediatric MASLD. Interventions consistently demonstrated reductions in hepatic steatosis, liver stiffness, and fibrosis markers, alongside improvements in inflammatory cytokines, oxidative stress defenses, and liver enzymes. The MD also enhanced lipid and glycemic profiles, lowering triglycerides, total cholesterol, and insulin resistance indices. Nutrition education and family-centered approaches improved adherence, while structured, enjoyable physical activity enhanced outcomes and long-term sustainability. Conclusions: Collectively, the MD, particularly when combined with exercise and tailored education, offers a safe, effective, and comprehensive lifestyle intervention for pediatric MASLD. Nonetheless, current evidence remains limited by small sample sizes, heterogeneity in protocols, and short follow-ups. Larger, multicenter randomized trials with standardized designs are needed to establish best practices and long-term efficacy. Keywords: pediatric MASLD; Mediterranean diet; nutrition education; physical activity; nutrition 1. Introduction Metabolic dysfunction-associated steatotic liver disease (MASLD) has emerged as the most prevalent chronic liver disorder in children and adolescents worldwide [1,2], paralleling the alarming rise in pediatric

FAQs

Why focus on pediatric MASLD and lifestyle interventions?

Pediatric MASLD is increasingly prevalent and is linked to cardiometabolic risk and possible progression to advanced liver disease. Early lifestyle-based management is emphasized because pediatric cases are more responsive than pharmacologic approaches.

What does the review examine regarding the Mediterranean diet?

The review gathers human studies assessing Mediterranean diet interventions for pediatric MASLD. It also considers additional components such as energy/macronutrient prescriptions, nutrition education or counseling, and physical activity.

What outcomes improved across the included studies?

Interventions were associated with reductions in hepatic steatosis, liver stiffness, and fibrosis markers, alongside improvements in inflammatory cytokines, oxidative stress defenses, and liver enzymes. Benefits were also reported in lipid and glycemic profiles, with lower triglycerides, total cholesterol, and insulin resistance indices.

Sep 30, 2026

Uploaded by Elsa