Higher Adherence to the Eat–Lancet Diet Is Associated With Reduced Risk of Metabolic Dysfunction–Associated Steatotic Liver Disease: A 5-Year Middle Eastern Cohort Study Publisher



Kamrani F ; Imannezhad M ; Etesami E ; Zamanian N ; Razaz J M ; Davoodi S H ; Homayounfar R ; Nikparast A
Source: Diabetology and Metabolic Syndrome Published:2026

Abstract

Background: Metabolic dysfunction–associated steatotic liver disease (MASLD) is a rapidly increasing metabolic disorder worldwide. Sustainable dietary patterns such as the EAT–Lancet Diet (ELD), designed to promote both human and planetary health, may help prevent MASLD; however, prospective evidence from Middle Eastern populations remains limited. Methods: This prospective cohort study included 5,058 Iranian adults aged 20–70 years from the MMRT study who were free of MASLD at baseline. Dietary intake was assessed using a validated 125‑item food frequency questionnaire, and adherence to the ELD was quantified using the Planetary Health Diet Index (PHDI). Incident MASLD over a 5‑year follow‑up was defined using hepatic steatosis (CAP ≥ 238 dB/m) in the presence of metabolic dysfunction. Multivariable logistic regression, restricted cubic splines, and mediation analyses were applied. Results: During follow‑up, 562 participants developed MASLD, yielding a 5-year cumulative incidence of 11.1%. In fully adjusted models, individuals in the third and fourth quartiles of PHDI had 39% (OR 0.61; 95% CI 0.45–0.81) and 34% (OR 0.66; 95% CI 0.50–0.88) lower odds of MASLD, respectively, compared with the lowest quartile (P‑trend < 0.001). Each one‑standard‑deviation increase in PHDI was associated with a 16% lower MASLD risk (OR 0.84; 95% CI 0.76–0.94). The inverse relationship was largely linear, with a suggestive plateau at higher PHDI scores (P for non-linearity = 0.08). Mediation analyses indicated substantial contributions from dietary fiber (71.4%), HOMA‑IR (69.3%), CAP (53.8%), and CRP (44.0%). Conclusions: Greater adherence to a PHDI was associated with lower MASLD risk in Iranian adults, potentially through improvements in insulin resistance, inflammation, hepatic steatosis, and dietary fiber intake. © The Author(s) 2026.