Higher Mediterranean diet adherence is associated with lower odds of metabolic dysfunction-associated steatotic liver disease in Greek adults: A noninvasive population-based assessment

This study aimed to investigate MASLD prevalence from the general adult population, using validated noninvasive tools (NITs). We hypothesized that higher adherence to the Mediterranean diet, is inversely associated with the presence of MASLD. The study included Hellenic National Nutrition and Health Survey (HNNHS) participants with available biomarkers (N = 1022, 38.1% males). MASLD presence was indirectly assessed through the Liver Fat Score (LFS) while metabolic dysfunction-associated steatohepatitis (elevated metabolic markers consistent with steatohepatitis risk) was differentiated using the index of nonalcoholic steatohepatitis (NASH-ION). Multiple logistic regression models were performed to evaluate associations between MASLD and various factors. Estimated MASLD prevalence was 17.3% (n = 155). Among these individuals, 56.3% indicated the presence of elevated metabolic markers, consistent with steatohepatitis risk. Each one-point increase in MedDietScore was associated with 6% lower odds of MASLD without steatohepatitis (OR: 0.94, 95% CI: 0.90-0.99). Overweight and obesity significantly increased the odds of MASLD in all age groups: 19-39.9 years (OR: 4.79, 95% CI: 3.07-7.28), 40-59.9 years (OR: 3.54, 95% CI: 2.05-6.13), and 60+ years (OR: 5.41, 95% CI: 2.64-11.07) although Mediterranean diet adherence appeared to attenuate MASLD risk. High physical activity also decreased likelihood in this age group only (OR: 0.33, 95% CI: 0.15-0.74). The lower prevalence of MASLD with higher Mediterranean diet adherence, especially in younger persons without steatohepatitis highlights the necessity of advocating Mediterranean dietary patterns within public health initiatives to mitigate the prevalence of MASLD in Greece. However, the high presence of metabolic markers likely reflects the high sensitivity of the screening tool used, underscoring a significant underlying metabolic burden (e.g., insulin resistance and obesity) rather than histologically confirmed severe liver disease.