Higher Mediterranean diet adherence is associated with lower odds of metabolic dysfunction-associated steatotic liver disease in Greek adults: A noninvasive population-based assessment

• Metabolic dysfunction-associated steatotic liver disease (MASLD) prevalence is 17.3% in Greek adults. • Overweight and obesity are the primary risk factors for MASLD in all age groups. • MASLD was assessed using validated non-invasive tools that account for metabolic dysfunction-associated steatohepatitis (MASH). • Each 1-point increase in Mediterranean Diet Score (MedDietScore) reduces MASLD odds by 6% in younger adults. This study aimed to investigate MASLD prevalence from the general adult population, using validated non-invasive tools (NITs). We hypothesized that higher adherence to the Mediterranean diet, is inversely associated with the presence of MASLD. The study included Hellenic National Nutrition and Health Survey (HNNHS) participants with available biomarkers (N=1022, 38.1% males). MASLD presence was indirectly assessed through the Liver Fat Score (LFS) while metabolic dysfunction-associated steatohepatitis (elevated metabolic markers consistent with steatohepatitis risk) was differentiated using the index of non-alcoholic steatohepatitis (NASH-ION). Multiple logistic regression models were performed to evaluate associations between MASLD and various factors. Estimated MASLD prevalence was 17.3% (n=155). Among these individuals, 56.3% indicated the presence of elevated metabolic markers, consistent with steatohepatitis risk. Each one-point increase in MedDietScore was associated with 6% lower odds of MASLD without steatohepatitis (OR: 0.94, 95% CI: 0.90-0.99). Overweight and obesity significantly increased the odds of MASLD in all age groups: 19-39.9 years (OR: 4.79, 95% CI: 3.07-7.28), 40-59.9 years (OR: 3.54, 95% CI: 2.05-6.13), and 60+ years (OR: 5.41, 95% CI: 2.64-11.07) although Mediterranean diet adherence appeared to attenuate MASLD risk. High physical activity also decreased likelihood in this age group only (OR: 0.33, 95% CI: 0.15-0.74). The lower prevalence of MASLD with higher Mediterranean diet adherence, especially in younger persons without steatohepatitis highlights the necessity of advocating Mediterranean dietary patterns within public health initiatives to mitigate the prevalence of MASLD in Greece. However, the high presence of metabolic markers likely reflects the high sensitivity of the screening tool used, underscoring a significant underlying metabolic burden (e.g., insulin resistance and obesity) rather than histologically confirmed severe liver disease. This graphical abstract illustrates the prevalence and associated factors of MASLD among Greek adults from the HNNHS. MASLD prevalence was 17.3% (n=155) with 56.3% of cases showing elevated metabolic markers consistent with steatohepatitis risk. Overweight and obesity increased MASLD odds 3.5-5.4-fold, while higher Mediterranean diet adherence reduced odds by 6% per one-point MedDietScore increase, particularly among younger adults without steatohepatitis. Abbreviations: HNNHS, Hellenic National Nutrition and Health Survey; LFS, Liver Fat Score; MASLD, metabolic dysfunction-associated steatotic liver disease; MedDietScore, Mediterranean Diet Score; NASH-ION, Index of Non-Alcoholic Steatohepatitis.