Isocaloric-restricted traditional Jiangnan diet combined with physical exercise on non-alcoholic fatty liver disease: a randomized controlled trial

Nonalcoholic fatty liver disease (NAFLD) is a major global health challenge, yet culturally tailored dietary interventions for Chinese populations remain understudied. This study aimed to evaluate the benefits of an isocaloric-restricted traditional Jiangnan diet (TJD) compared to a control diet (CD), with or without moderate-intensity physical exercise, on NAFLD. In this 6-month randomized controlled trial, 228 overweight/obese patients with MRI-confirmed NAFLD recruited from Wannan Medical College Yijishan Hospital were randomly assigned to four groups: CD, CD-PA, TJD, or TJD-PA. The exercise protocol consisted of 35-minute moderate-intensity interval training (50%–70% heart rate range) performed 3–5 times per week. The primary outcome was the absolute percentage change in body weight. Secondary outcomes included changes in liver steatosis and stiffness measured by FibroScan. Data were analyzed using linear mixed-effects models following an intention-to-treat principle. After 6 months of interventions, weight loss was significant across all groups (Ptime < 0.001), with no significant group differences. Although no differences were observed among the four groups in glucose metabolism or lipid profile changes, the TJD-PA group showed significantly greater improvements in liver stiffness measurement (LSM, -0.38 kPa, 95% CI, -0.41 to -0.36), controlled attenuation parameter (CAP, -34.39 dB/m, 95% CI, -40.07 to -28.71), waist circumference (-5.20 cm, 95% CI, -5.32 to -5.09), and body fat percentage (-1.35%, 95% CI, -1.43 to -1.26) compared to the other three groups. These findings suggest that while isocaloric restriction effectively drives weight loss, the synergy between TJD and physical activity provides superior benefits in mitigating hepatic steatosis, fibrosis, and abdominal adiposity, offering a potent lifestyle strategy for NAFLD management in Chinese adults. Chinese Clinical Trial Registry (ChiCTR) under registration (ChiCTR2500106462).