Dietary obesity prevention score and the odds of metabolic dysfunction-associated fatty liver disease in children and adolescents with overweight or obesity: a cross-sectional analysis

Metabolic dysfunction-associated fatty liver disease (MAFLD) is increasingly diagnosed in children with overweight or obesity. Diet is a key modifiable factor, yet the role of obesity-preventive dietary patterns in pediatric MAFLD remains unclear. The Dietary Obesity-Prevention Score (DOS) is a food-based index reflecting adherence to a diet favoring obesity prevention, but its association with MAFLD in youth has not been investigated. In this cross-sectional analysis, 505 children and adolescents with overweight or obesity were included. MAFLD was defined as hepatic steatosis on ultrasonography plus BMI-for-age Z-score ≥ 1, consistent with international pediatric consensus criteria. Usual dietary intake was assessed using a validated 147-item food frequency questionnaire, and DOS was calculated from 13 energy-adjusted food groups, including fruits, vegetables, legumes, yogurt, nuts, fish, plant-to-animal protein ratio (protective components), and red meat, processed meats, refined grains, saturated animal fats, ultra-processed products, and sugar-sweetened beverages (adverse components). Multivariable logistic regression estimated odds ratios (ORs) and 95% confidence intervals (CIs) for MAFLD across DOS quartiles and per 1-standard deviation (SD) increase in DOS. MAFLD was present in 196 participants (38.8%). After adjustment for potential confounders, higher DOS was associated with lower MAFLD odds (OR for highest vs. lowest quartile = 0.45; 95% CI 0.25–0.83). Each 1-SD increase in DOS was associated with 29% lower odds of MAFLD (OR = 0.71; 95% CI 0.58–0.86). These associations persisted after additional adjustment for dietary glycemic load, triglycerides, and HOMA-IR. Spline models suggested a graded inverse relationship. In exploratory subgroup analyses, the associations appeared stronger in boys and in children younger than 10 years, though these findings require confirmation in hypothesis-testing studies. Higher adherence to DOS was inversely associated with MAFLD in children and adolescents with overweight or obesity. These findings suggest that dietary modification, if confirmed in longitudinal studies, may represent a promising target for MAFLD prevention in high-risk pediatric populations.