What question did this study set out to answer?

To compare the efficacy of a very low energy ketogenic diet and a Mediterranean diet in reducing hepatic steatosis in individuals with MASLD.

February 22, 2026Open Access

Very Low Energy Ketogenic Diet vs Mediterranean Diet for MASLD: Superior Steatosis Reduction in a Randomised Pilot Study

AFAnn FarrellSt Vincent's Hospital TPTonya ParisDeakin University EPEvelyn B. ParrAustralian Catholic University

Key Points

To compare the efficacy of a very low energy ketogenic diet and a Mediterranean diet in reducing hepatic steatosis in individuals with MASLD.
Conducted a pilot randomized controlled trial with adults having histologically confirmed MASLD.
Participants assigned to 12-week VLED (3151 kJ/day) or MD program (8950 kJ/day).
VLED group received low-dose semaglutide starting week 13 for weight maintenance.
Primary outcome was assessed using MRI liver-fat-fraction at 12 weeks; secondary outcomes included body weight loss and liver histology changes.
VLED group achieved a 77% reduction in MRI liver-fat-fraction compared to 14% in the MD group (p<0.01).
VLED produced 13% total body weight loss at week 12 versus 4% in the MD group (p<0.01).
At 24 weeks, VLED group maintained 14% weight loss compared to 3% in the MD group.
Improvement in liver histology was greater in the VLED group with a NAFLD activity score reduction of -2 versus -1 in the MD group (p<0.01).

Abstract

AbstractBackground & Aims Weight loss is the cornerstone of treatment for metabolic dysfunction associated steatotic liver disease (MASLD). This pilot study compared the efficacy and safety of a very low energy ketogenic diet (VLED) versus a Mediterranean diet (MD) in improving hepatic steatosis and liver histology in individuals with overweight or obesity and MASLD. Methods We conducted a pilot randomised controlled trial in adults with histologically confirmed MASLD and BMI 27-35 kg/m2. Participants were assigned to either a 12-week VLED (3151 kJ/day) or MD program (8950 kJ/day) and monitored for 24 weeks. The VLED group received low-dose semaglutide (0.5 mg/weekly) from week 13 for weight maintenance. Primary outcome was change in hepatic steatosis by MRI liver-fat-fraction (MRI-LFF) at 12 weeks. Secondary outcomes included total body weight loss (TBWL) and change in liver histology over 24 weeks. Results The VLED group (n=14) achieved significantly greater reduction in MRI-LFF (-77% relative reduction (IQR 51, 88)) compared to the MD group (n=11, -14% (IQR 0, 30), pConclusions The very low energy diet resulted in significantly greater reduction in hepatic steatosis and weight loss compared to Mediterranean diet. The very low energy diet is widely available, easily accessible and should be more commonly considered for MASLD patients with overweight/obesity. Impact and Implications This pilot randomised control trial provides the first direct comparison between a ketogenic Very Low Energy Diet (VLED) and a Mediterranean diet (MD) for MASLD treatment, demonstrating superior outcomes with the VLED including 77% vs 14% hepatic steatosis reduction and 13% vs 4% weight loss. The growing burden of people who are overweight and obese with early-stage MASLD means that effective dietary weight loss interventions with proven hepatic and metabolic benefits are urgently required. The VLED's accessibility, effectiveness and ease of implementation in clinical practice suggest it should be a more widely considered first-line therapy for MASLD patients with overweight or obesity. Clinical trial registration www.anzctr.org.au trial ID: ACTRN12623000756628

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