Dose‒response relationship between exercise and hepatic steatosis: A systematic review with Bayesian network meta-analysis of randomized controlled trials

• There is a non-linear dose‒response relationship between exercise dose and hepatic steatosis. • The minimum dose for clinical significance is 460 MET-min/week, with cost-effective benefits at 630 MET-min/week and effects plateauing above 850 MET-min/week. • Combined aerobic-resistance exercise offered both efficacy and dose advantages, with 640 MET-min/week identified as the optimal prescription for MASLD patients. • It is necessary to recommend exercise prescriptions based on individual characteristics to maximize individual benefits. Current guidelines offer unclear recommendations on exercise types and doses for metabolic dysfunction-associated steatotic liver disease (MASLD). This study aimed to: (a) identify the most effective exercise type; (b) model the dose‒response relationship between exercise and hepatic steatosis; (c) determine the minimum clinically significant dose. We searched PubMed, Web of Science, Embase, the Cochrane Library, CINAHL, Scopus, Rehabilitation & Sports Medicine Source, clinicaltrials.gov, CNKI, Wanfang, VIP, and Sinomed databases from establishment to May 27, 2025 for randomized controlled trials on exercise interventions in MASLD. Network meta-analysis and dose‒response network meta-analysis were used. Among 24 studies (961 participants), combined aerobic-resistance exercise showed the highest surface under the cumulative ranking curve (0.81). A non-linear dose‒response revealed benefits plateauing at 630 metabolic equivalents (MET)-min/week (mean = –0.68, 95%CI: –0.95 to –0.40) and peaking at 850 MET-min/week (mean = –0.72, 95%CI: –0.97 to –0.49). Optimal doses were 640 MET-min/week for combined aerobic-resistance exercise, 880 for high-intensity circuit training, and 590 for moderate-intensity continuous training. High-intensity interval training showed progressive benefits, while resistance exercise required exceeding 640 MET-min/week. The minimum clinically significant dose was 460 MET-min/week, but combined aerobic-resistance exercise achieved this at only 130 MET-min/week. A non-linear curve underscores key dose thresholds for efficacy and safety: 460 (minimum), 630 (cost-effective), and 850 MET-min/week (plateau). These equate to moderate-intensity exercise (4.5 METs) for 20, 30, or 40 min 5 times/week, or vigorous-intensity exercise (7.5 METs) for 30 min 2, 3 or 4 times/week. Combined aerobic-resistance exercise offered both efficacy and dose advantages.