Time-restricted eating is associated with sustained improvement in steatosis and fibrosis in MASLD and MASH: a long-term real-world cohort study

Time-restricted eating (TRE), a form of intermittent fasting, has demonstrated favorable short-term metabolic effects in patients with metabolic dysfunction-associated steatotic liver disease (MASLD). However, evidence regarding its long-term effects on hepatic steatosis, fibrosis, and metabolic outcomes remains limited. We evaluated the long-term hepatic and metabolic outcomes associated with TRE in adults with MASLD and clinically suspected metabolic dysfunction-associated steatohepatitis (MASH). In this prospective real-world observational cohort study, adults with MASLD or clinically suspected MASH selected one of five routine management strategies through shared clinical decision-making, including TRE, Orlistat-supported lifestyle modification, a 1500-kcal balanced diet, or exercise-focused lifestyle counselling. Participants were followed for 28–48 months. Primary outcomes were longitudinal changes in hepatic steatosis, fibrosis-related measures, and metabolic parameters. Hepatic steatosis and fibrosis were assessed using controlled attenuation parameter (CAP), liver stiffness measurement (LSM), and validated non-invasive fibrosis indices. Longitudinal analyses used multivariable linear mixed-effects models adjusted for predefined covariates, with inverse probability of treatment weighting (IPTW) performed as a sensitivity analysis. A total of 197 participants completed the follow-up. TRE was associated with the greatest and most sustained improvements in hepatic steatosis, fibrosis-related measures, and metabolic outcomes. Both TRE groups demonstrated substantial improvements in CAP and LSM, accompanied by steatosis regression in 75.5% of participants with MASLD and 62.5% with clinically suspected MASH, while fibrosis regression occurred in 35% of participants in both groups. Concordant improvement was observed across multiple independent imaging- and serum-based fibrosis assessments. Orlistat-supported lifestyle modification and a 1500-kcal balanced diet were associated with modest improvements, whereas exercise-focused lifestyle counseling produced minimal hepatic benefit. Findings remained consistent after multivariable adjustment and IPTW sensitivity analyses despite clinically relevant baseline differences between the management groups. In this long-term real-world observational cohort, TRE was associated with durable improvement in hepatic steatosis, fibrosis-related measures, and metabolic dysfunction in adults with MASLD and clinically suspected MASH. Concordant improvement across multiple independent non-invasive fibrosis assessments supports the potential role of TRE as a sustainable lifestyle strategy for metabolic liver disease. Randomized controlled trials are warranted to confirm causality. ISRCTN74413912 (registration date: January 26, 2026).