Dietary management of metabolic dysfunction-associated steatotic liver disease in the era of pharmacotherapy: a narrative review

Purpose: Metabolic dysfunction-associated steatotic liver disease (MASLD) has emerged as the most common chronic liver disease worldwide, and its management increasingly involves pharmacologic options. Despite the expansion of drug therapy, dietary intervention remains a cornerstone of MASLD management across all major guidelines. This review summarizes current evidence on dietary interventions in MASLD, with attention to Korean clinical practice and the evolving role of diet in the era of pharmacotherapy.Current concepts: Weight loss achieved through caloric deficit is the strongest dietary determinant of histologic improvement, with a dose-response relationship: ≥5% weight loss is associated with a reduction in hepatic steatosis, 7%–10% with improvement in hepatic inflammation and metabolic dysfunction-associated steatohepatitis activity, and ≥10% with fibrosis regression. The Mediterranean diet has the most robust randomized evidence and is recommended as the preferred pattern by major guidelines. Key nutrient-level recommendations include limiting sugar-sweetened beverages, ultra-processed foods, and alcohol, while maintaining adequate protein intake. For Korean patients, modifying the existing dietary pattern toward Mediterranean principles—rather than introducing an unfamiliar diet—may be more feasible.Discussion and conclusion: In the pharmacotherapy era, dietary intervention is being redefined. Dietary therapy remains foundational across all disease stages—serving as the primary treatment for patients outside current drug indications and as a concurrent backbone for those receiving approved agents. Pragmatic, repeated counseling that quantifies caloric targets and incorporates self-monitoring tools is likely to improve adherence in everyday practice.