Culturally adapted hypocaloric diet improves hepatic steatosis, inflammatory and oxidative biomarkers in Egyptian MASLD patients: a single-arm interventional study.

Background: Metabolic dysfunction-associated steatotic liver disease (MASLD) represents a growing public health challenge in Egypt, driven by westernized dietary patterns, urbanization, and physical inactivity. Despite lifestyle intervention being the first-line management, data on structured hypocaloric diets tailored to Egyptian patients remain limited, particularly regarding their effects on hepatic steatosis, inflammatory pathways, and oxidative stress biomarkers. This study aimed to evaluate the impact of a culturally adapted 6-month hypocaloric diet on hepatic fat reduction, metabolic parameters, inflammatory-oxidative biomarkers, and lifestyle factors in Egyptian MASLD patients, with additional exploration of weight-independent mechanisms.

Methods: In this single-center interventional trial, 30 newly diagnosed MASLD patients received a personalized hypocaloric diet (500-1000 kcal/day deficit). Outcomes measured at baseline and post-intervention included anthropometrics, liver enzymes, metabolic profile, hepatic steatosis (CAP score), inflammatory markers (TNF-α, MDA), antioxidant enzymes (SOD, CAT), and lifestyle behaviors (physical activity, sleep). Advanced statistical analyses included effect size estimation, multivariate regression, mediation analysis, and subgroup comparisons (lean vs. obese MASLD).

Results: After 6 months, patients achieved significant reductions in weight (- 10.9 kg), BMI (- 3.9 kg/m²), and CAP score (- 89.5 dB/m) (all P < 0.001). Liver enzymes improved significantly, with ALT decreasing by - 22.2 U/L and AST by - 21.3 U/L (both P < 0.001). TNF-α (- 88.2 pg/mL, baseline 166.1 pg/mL) and MDA (- 1.1 nmol/mL, baseline 2.7 nmol/mL) decreased markedly, with large effect sizes (CAP: d = 1.9; TNF-α: d = 2.1; MDA: d = 1.4). Antioxidant biomarkers improved significantly, with SOD increasing by 209% (d = 1.8) and CAT by 48.5% (d = 1.2) (both P < 0.001). Although BMI and weight loss were strongly associated with hepatic fat reduction, TNF-α reduction remained an independent predictor of CAP improvement (β = 0.31, P = 0.02), mediating 32% of the diet's effect after adjusting for BMI. Patients achieving ≥ 5% weight loss were 4.2 times more likely to experience ≥ 10% CAP score reduction. Lean MASLD patients (n = 6) exhibited greater improvements in hepatic fat and inflammation despite less weight loss; however, these findings should be interpreted with caution due to the small subgroup size. Dietary adherence strongly correlated with CAP reduction (r = - 0.71, P < 0.001) and antioxidant gains.

Conclusion: A culturally tailored hypocaloric diet effectively improved hepatic steatosis, inflammatory status, and antioxidant capacity in Egyptian MASLD patients. These improvements were partially weight-independent and partially mediated by anti-inflammatory responses. These findings support hypocaloric dietary strategies as a potentially scalable therapeutic option for MASLD management in resource-limited settings, though the absence of a control group limits causal inference, and further evaluation of implementation feasibility and cost-effectiveness is warranted. Additional benefits were also observed in lifestyle behaviors such as physical activity and sleep.