Adherence to the Mediterranean Diet to prevent or delay hepatic steatosis: a longitudinal analysis within the PREDIMED study

Raquel Cueto Galán^1,2Andres Fontalba-Navas^1,2,3*Mario Gutierrez-Bedmar^1,2Miguel Ruiz-Canela^4,5Miguel Ángel Martinez-Gonzalez^4,6Lilian Alves^7,8Nancy Babio^4,8,9MONTSERRAT FITO COLOMER^10,4Emilio Ros^11,12,4Miquel Fiol^13,14,4Ramon Estruch^15,4Fernando Arós^16,4Luis Serra-Majem^17,4Xavier Pintó^18,4Carlos Muñoz-Bravo^1,2ANTONIO GARCIA-RODRIGUEZ^1,2Enrique Gómez-Gracia^1,2

• ¹Biomedical Research Institute of Malaga, University of Malaga, Málaga, Andalusia, Spain
• ²Department of Public Health and Psychiatry, School of Medicine, University of Málaga, Málaga, Spain
• ³Antequera Hospital, Antequera, Spain
• ⁴CIBER Fisiopatología Obesidad y Nutrición (CIBEROBN), Madrid, Madrid, Spain
• ⁵Department of Preventive Medicine and Public Health, School of Medicine, University of Navarra, Pamplona, Navarre, Spain
• ⁶Department of Nutrition, School of Public Health, Harvard University, Boston, Massachusetts, United States
• ⁷Gastroenterology Department, Hospital Salut Sant Joan, Reus, Spain
• ⁸Pere Virgili Health Research Institute (IISPV), Tarragona, Catalonia, Spain
• ⁹University of Rovira i Virgili, Tarragona, Catalonia, Spain
• ¹⁰Hospital del Mar Medical Research Institute (IMIM), Barcelona, Catalonia, Spain
• ¹¹Hospital Clinic of Barcelona, Barcelona, Catalonia, Spain
• ¹²August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Catalonia, Spain
• ¹³Hospital Universitario Son Espases, Palma de Mallorca, Spain
• ¹⁴Balearic Islands Health Research Institute (IdISBa), Palma de Mallorca, Balearic Islands, Spain
• ¹⁵Department of Internal Medicine, IDIBAPS, Hospital Clínic, University of Barcelona, Barcelona, Spain
• ¹⁶Department of Cardiology, Hospital Universitario de Álava, Vitoria, Spain
• ¹⁷Research Institute in Biomedical and Health Sciences, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
• ¹⁸Department of Internal Medicine, Bellvitge University Hospital, Barcelona, Balearic Islands, Spain

Little is known about the potential preventive effect of adherence to the Mediterranean diet (MedDiet) on the development of metabolic dysfunctionassociated steatotic liver disease (MASLD). AIM: To determine the impact of adherence to the MedDiet on the progression of MASLD, measured by the hepatic steatosis index (HSI), at baseline and annually over a 5-year follow-up period, as part of the PREvención con DIeta MEDiterránea (PREDIMED) study. METHOD: Participants from the PREDIMED study cohort with sufficient available data (n=3,145) were examined annually over a five-year period. Adherence to the MedDiet was evaluated using the Mediterranean Diet Adherence Screener (MEDAS) questionnaire, and the presence/severity of hepatic steatosis was determined according to the HSI. Linear mixed models were employed to analyse the association between the study variables and the HSI.The participants (57% female, 43% male) had a mean age of 67.2 (SD 6.2) years. Among the cardiovascular risk factors considered, the mean BMI was 29.81 (SD 3.62), 47% of participants had type 2 diabetes, 70% had hypercholesterolaemia and 84% had hypertension. During the five-year study, adherence to the MedDiet and physical activity generally increased, whereas alcohol consumption, calorie intake, tobacco use, hypercholesterolaemia and hypertension all decreased. The fully-adjusted multivariate model reflected a statistically significant decrease in the HSI per unit increase in adherence to the MedDiet (β = -0.075; 95% CI: -0.128, -0.021).CONCLUSIONS: In patients at high cardiovascular risk, adherence to the MedDiet is significantly associated with the HSI. This longitudinal finding highlights the important role of the MedDiet in delaying or slowing the progression of MASLD, contributing to both its prevention and management.