S2421 Dietary Approaches to Stop Hypertension (DASH) for Metabolically Associated Liver Steatosis Disease: Systematic Review, Meta-Analysis, and Trial Sequential Analysis

Introduction: Metabolic Associated Liver Steatosis Disease (MALSD) is a common metabolic disorder with few non-drug treatments. The Dietary Approaches to Stop Hypertension (DASH) diet, known for heart health, is being studied for its effects on the liver, metabolism, and body measurements in MALSD patients. Methods: We included randomized controlled trials (RCTs) by searching PubMed, Web of Science, SCOPUS, Cochrane, and Embase through May 10, 2025. The primary outcome was liver fibrosis. Secondary outcomes included liver enzymes, anthropometric measures, lipid panel, and fasting blood sugar. We pooled dichotomous data using the risk ratio (RR) and continuous data using the mean difference (MD), with a 95% confidence interval (CI). Trial sequential analysis (TSA) was conducted to investigate the robustness of the results. PROSPERO ID: CRD420251060329. Results: We included 5 RCTs with a total of 280 patients. DASH diet did not affect liver fibrosis change (MD = -0.51, 95% CI: -1.07 to 0.05; P = 0.0762), patients with grade 0–1 liver fibrosis (RR = 1.37, 95% CI: 0.91 to 2.07; P = 0.13), and grade 2–3 fibrosis (RR = 0.60, 95% CI: 0.35 to 1.03; P = 0.06). The DASH diet significantly reduced alanine aminotransferase (MD = -7.31, 95% CI: -10.82 to -3.80; P < 0.0001) and aspartate aminotransferase (MD = -4.74, 95% CI: -7.29 to -2.19; P = 0.0003). The total cholesterol/HDL ratio improved significantly (MD = -0.42, 95% CI: -0.73 to -0.11; P = 0.01). Still, changes in total cholesterol (P = 0.40), LDL (MD = -4.80, 95% CI: -14.39 to 4.79; P = 0.32), and triglycerides (P = 0.16) were not significant. BMI decreased modestly (MD = -1.32, 95% CI: -3.69 to 1.05; P = 0.03), while weight (P = 0.93), waist circumference (P = 0.93), and fasting blood sugar (P = 0.99) remained unchanged. Trial sequential analysis supported conclusive effects on alanine aminotransferase and aspartate aminotransferase, while evidence for BMI remained inconclusive. Conclusion: The DASH diet did not improve liver fibrosis but improved liver enzymes and cholesterol/HDL ratio and modestly lowered BMI in MALSD patients, supporting its potential role in liver and metabolic management.