PHYSICAL ACTIVITY AS A LIFESTYLE INTERVENTION IN METABOLIC DYSFUNCTION-ASSOCIATED STEATOTIC LIVER DISEASE (MASLD): A NARRATIVE REVIEW OF HEPATIC AND CARDIOMETABOLIC OUTCOMES
DOI:
https://doi.org/10.31435/ijitss.1(49).2026.5326Keywords:
Metabolic Dysfunction-Associated Steatotic Liver Disease, Physical Activity, Exercise Therapy, Lifestyle Intervention, Hepatic Steatosis, Insulin ResistanceAbstract
This narrative review synthesizes current evidence on physical activity and structured exercise in adults with metabolic dysfunction-associated steatotic liver disease (MASLD), with particular emphasis on aerobic exercise, resistance training, and high-intensity interval training (HIIT). The manuscript was prepared as a structured review of guideline documents, systematic reviews, meta-analyses, randomized controlled trials, and selected observational studies identified primarily through PubMed-based searching and full-text source analysis. Because the overlap between historical non-alcoholic fatty liver disease (NAFLD) and current MASLD populations is nearly complete, earlier NAFLD exercise studies were treated as directly relevant to present-day MASLD. The reviewed literature shows that exercise consistently reduces liver fat, improves cardiorespiratory fitness, enhances insulin sensitivity, and favorably modifies body composition and selected cardiovascular risk markers, often without clinically significant weight loss. Aerobic exercise remains the best-studied modality, but resistance training also appears effective and may be especially valuable in patients with low fitness or concern about muscle loss. HIIT seems feasible and potentially beneficial in selected patients when appropriately supervised. Evidence for direct histological or fibrosis-specific benefit is promising but less robust than the evidence for steatosis and cardiometabolic outcomes. Overall, the findings support physical activity as a central lifestyle intervention in MASLD and highlight the importance of individualized prescription, adherence support, and technology-assisted delivery in future practice.
References
Abdelbasset, W. K., Tantawy, S. A., Kamel, D. M., Alqahtani, B. A., Elnegamy, T. E., & Soliman, G. S. (2020). Effects of high-intensity interval and moderate-intensity continuous aerobic exercise on diabetic obese patients with nonalcoholic fatty liver disease: A comparative randomized controlled trial. Medicine, 99(10), Article e19471. https://doi.org/10.1097/MD.0000000000019471
Babu, A. F., Csader, S., Lok, J., Gómez-Gallego, C., Hanhineva, K., El-Nezami, H., & Schwab, U. (2021). Positive effects of exercise intervention without weight loss and dietary changes in NAFLD-related clinical parameters: A systematic review and meta-analysis. Nutrients, 13(9), Article 3135. https://doi.org/10.3390/nu13093135
Bacchi, E., Negri, C., Targher, G., Faccioli, N., Lanza, M., Zoppini, G., Zanolin, E., Schena, F., Bonora, E., & Moghetti, P. (2013). Both resistance training and aerobic training reduce hepatic fat content in type 2 diabetic subjects with nonalcoholic fatty liver disease: The RAED2 randomized trial. Hepatology, 58(4), 1287–1295. https://doi.org/10.1002/hep.26393
Baker, C. J., Martinez-Huenchullan, S. F., D’Souza, M., Xu, Y., Li, M., & Bi, Y. (2021). Effect of exercise on hepatic steatosis: Are benefits seen without dietary intervention? A systematic review and meta-analysis. Journal of Diabetes, 13(1), 63–77. https://doi.org/10.1111/1753-0407.13086
Chai, X. N., Zhou, B. Q., Ning, N., Pan, T., Xu, F., He, S. H., Chen, N. N., & Sun, M. (2023). Effects of lifestyle intervention on adults with metabolic associated fatty liver disease: A systematic review and meta-analysis. Frontiers in Endocrinology, 14, Article 1081096. https://doi.org/10.3389/fendo.2023.1081096
Charatcharoenwitthaya, P., Kuljiratitikal, K., Aksornchanya, O., Chaiyasoot, K., Bandidniyamanon, W., & Charatcharoenwitthaya, N. (2021). Moderate-intensity aerobic vs resistance exercise and dietary modification in patients with nonalcoholic fatty liver disease: A randomized clinical trial. Clinical and Translational Gastroenterology, 12(3), Article e00316. https://doi.org/10.14309/ctg.0000000000000316
Cheng, S., Ge, J., Zhao, C., Le, S., Yang, Y., Ke, D., Wu, N., Tan, X., Zhang, X., Du, X., Sun, J., Wang, R., Shi, Y., Borra, R. J. H., Parkkola, R., Wiklund, P., & Lu, D. (2017). Effect of aerobic exercise and diet on liver fat in pre-diabetic patients with non-alcoholic-fatty-liver-disease: A randomized controlled trial. Scientific Reports, 7, Article 15952. https://doi.org/10.1038/s41598-017-16159-x
Duell, P. B., Welty, F. K., Miller, M., Chait, A., Hammond, G., Ahmad, Z., Cohen, D. E., Horton, J. D., Pressman, G. S., & Toth, P. P. (2022). Nonalcoholic fatty liver disease and cardiovascular risk: A scientific statement from the American Heart Association. Arteriosclerosis, Thrombosis, and Vascular Biology, 42, e168–e185. https://doi.org/10.1161/ATV.0000000000000153
European Association for the Study of the Liver, European Association for the Study of Diabetes, & European Association for the Study of Obesity. (2024). EASL-EASD-EASO clinical practice guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). Journal of Hepatology, 81(3), 492–542. https://doi.org/10.1016/j.jhep.2024.04.031
Fernández, T., Viñuela, M., Vidal, C., & Barrera, F. (2022). Lifestyle changes in patients with non-alcoholic fatty liver disease: A systematic review and meta-analysis. PLOS ONE, 17(2), Article e0263931. https://doi.org/10.1371/journal.pone.0263931
Gerber, L., Otgonsuren, M., Mishra, A., Escheik, C., Birerdinc, A., Stepanova, M., & Younossi, Z. M. (2012). Non-alcoholic fatty liver disease is associated with low level of physical activity: A population-based study. Alimentary Pharmacology & Therapeutics, 36(8), 772–781. https://doi.org/10.1111/apt.12038
Hallsworth, K., Fattakhova, G., Hollingsworth, K. G., Thoma, C., Moore, S., Taylor, R., Day, C. P., & Trenell, M. I. (2011). Resistance exercise reduces liver fat and its mediators in non-alcoholic fatty liver disease independent of weight loss. Gut, 60(9), 1278–1283. https://doi.org/10.1136/gut.2011.242073
Harris, S. J., Smith, N., Hummer, B., Schreibman, I. R., Faust, A. J., Geyer, N. R., Chinchilli, V. M., Sciamanna, C., Loomba, R., & Stine, J. G. (2024). Exercise training improves serum biomarkers of liver fibroinflammation in patients with metabolic dysfunction-associated steatohepatitis. Liver International, 44(2), 532–540. https://doi.org/10.1111/liv.15769
Hashida, R., Kawaguchi, T., Bekki, M., Omoto, M., Matsuse, H., Nago, T., Takano, Y., Ueno, T., Koga, H., George, J., Shiba, N., & Torimura, T. (2017). Aerobic vs. resistance exercise in non-alcoholic fatty liver disease: A systematic review. Journal of Hepatology, 66(1), 142–152. https://doi.org/10.1016/j.jhep.2016.08.023
Heinle, J. W., DiJoseph, K., Sabag, A., Oh, S., Kimball, S. R., Keating, S., & Stine, J. G. (2023). Exercise is medicine for nonalcoholic fatty liver disease: Exploration of putative mechanisms. Nutrients, 15(11), Article 2452. https://doi.org/10.3390/nu15112452
Houghton, D., Thoma, C., Hallsworth, K., Cassidy, S., Hardy, T., Burt, A. D., Tiniakos, D., Hollingsworth, K. G., Taylor, R., Day, C. P., McPherson, S., Anstee, Q. M., & Trenell, M. I. (2017). Exercise reduces liver lipids and visceral adiposity in patients with nonalcoholic steatohepatitis in a randomized controlled trial. Clinical Gastroenterology and Hepatology, 15(1), 96–102.e3. https://doi.org/10.1016/j.cgh.2016.07.031
Keating, S. E., Croci, I., Wallen, M. P., Cox, E. R., Thuzar, M., Pham, U., Mielke, G. I., Coombes, J. S., Macdonald, G. A., & Hickman, I. J. (2023). High-intensity interval training is safe, feasible and efficacious in nonalcoholic steatohepatitis: A randomized controlled trial. Digestive Diseases and Sciences, 68(5), 2123–2139. https://doi.org/10.1007/s10620-022-07779-z
Keating, S. E., Hackett, D. A., Parker, H. M., O’Connor, H. T., Gerofi, J. A., Sainsbury, A., Baker, M. K., Chuter, V. H., Caterson, I. D., George, J., & Johnson, N. A. (2015). Effect of aerobic exercise training dose on liver fat and visceral adiposity. Journal of Hepatology, 63(1), 174–182. https://doi.org/10.1016/j.jhep.2015.02.022
Marjot, T., Armstrong, M. J., & Stine, J. G. (2025). Skeletal muscle and MASLD: Mechanistic and clinical insights. Hepatology Communications, 9, Article e0711. https://doi.org/10.1097/HC9.0000000000000711
Medeiros, D. G., Ferreira, L. F., Lamp, J. S., & da Rosa, L. H. T. (2025). The impact of resistance training in patients diagnosed with metabolic dysfunction-associated steatotic liver disease: A systematic review. European Journal of Gastroenterology & Hepatology, 37(2), 129–136. https://doi.org/10.1097/MEG.0000000000002887
Oh, S., So, R., Shida, T., Matsuo, T., Kim, B., Akiyama, K., Isobe, T., Okamoto, Y., Tanaka, K., & Shoda, J. (2017). High-intensity aerobic exercise improves both hepatic fat content and stiffness in sedentary obese men with nonalcoholic fatty liver disease. Scientific Reports, 7, Article 43029. https://doi.org/10.1038/srep43029
O’Gorman, P., Naimimohasses, S., Monaghan, A., Kennedy, M., Melo, A. M., Ní Fhloinn, D., Doherty, D. G., Beddy, P., Finn, S. P., Moore, J. B., Gormley, J., & Norris, S. (2020). Improvement in histological endpoints of MAFLD following a 12-week aerobic exercise intervention. Alimentary Pharmacology & Therapeutics, 52(8), 1387–1398. https://doi.org/10.1111/apt.15989
Rinella, M. E., Lazarus, J. V., Ratziu, V., Francque, S. M., Sanyal, A. J., Kanwal, F., Romero, D., Abdelmalek, M. F., Anstee, Q. M., Arab, J. P., Arrese, M., Bataller, R., Beuers, U., Boursier, J., Bugianesi, E., Byrne, C. D., Castro Narro, G. E., Chowdhury, A., Cortez-Pinto, H., ... Newsome, P. N. (2023). A multisociety Delphi consensus statement on new fatty liver disease nomenclature. Journal of Hepatology, 79(6), 1542–1556. https://doi.org/10.1016/j.jhep.2023.06.003
Rinella, M. E., Neuschwander-Tetri, B. A., Siddiqui, M. S., Abdelmalek, M. F., Caldwell, S., Barb, D., Kleiner, D. E., & Loomba, R. (2023). AASLD practice guidance on the clinical assessment and management of nonalcoholic fatty liver disease. Hepatology, 77(5), 1797–1835. https://doi.org/10.1097/HEP.0000000000000323
Sabag, A., Barr, L., Armour, M., Armstrong, A., Baker, C. J., Twigg, S. M., Chang, D., Hackett, D. A., Keating, S. E., George, J., & Johnson, N. A. (2022). The effect of high-intensity interval training vs moderate-intensity continuous training on liver fat: A systematic review and meta-analysis. Journal of Clinical Endocrinology & Metabolism, 107(3), 862–881. https://doi.org/10.1210/clinem/dgab795
Smart, N. A., King, N., McFarlane, J. R., Graham, P. L., & Dieberg, G. (2018). Effect of exercise training on liver function in adults who are overweight or exhibit fatty liver disease: A systematic review and meta-analysis. British Journal of Sports Medicine, 52(13), 834–843. https://doi.org/10.1136/bjsports-2016-096197
Stine, J. G., DiJoseph, K., Pattison, Z., Harrington, A., Chinchilli, V. M., Schmitz, K. H., & Loomba, R. (2023). Exercise training is associated with treatment response in liver fat content by magnetic resonance imaging independent of clinically significant body weight loss in patients with nonalcoholic fatty liver disease: A systematic review and meta-analysis. American Journal of Gastroenterology, 118(7), 1204–1213. https://doi.org/10.14309/ajg.0000000000002098
Stine, J. G., Long, M. T., Corey, K. E., Sallis, R. E., Allen, A. M., Armstrong, M. J., Conroy, D. E., Cuthbertson, D. J., Duarte-Rojo, A., Hallsworth, K., Hickman, I. J., Kappus, M. R., Keating, S. E., Pugh, C. J. A., Rotman, Y., Simon, T. G., Vilar-Gomez, E., Wong, V. W.-S., & Schmitz, K. H. (2023). American College of Sports Medicine (ACSM) international multidisciplinary roundtable report on physical activity and nonalcoholic fatty liver disease. Hepatology Communications, 7(4), Article e0108. https://doi.org/10.1097/HC9.0000000000000108
Stine, J. G., Munaganuru, N., Barnard, A., Wang, J. L., Kaulback, K., Argo, C. K., Singh, S., Fowler, K. J., Sirlin, C. B., & Loomba, R. (2021). Change in MRI-PDFF and histologic response in patients with nonalcoholic steatohepatitis: A systematic review and meta-analysis. Clinical Gastroenterology and Hepatology, 19(11), 2274–2283.e5. https://doi.org/10.1016/j.cgh.2020.08.061
Stine, J. G., Schreibman, I. R., Faust, A. J., Dahmus, J., Stern, B., Soriano, C., Rivas, G., Hummer, B., Kimball, S. R., Geyer, N. R., Chinchilli, V. M., Loomba, R., Schmitz, K., & Sciamanna, C. (2022). NASHFit: A randomized controlled trial of an exercise training program to reduce clotting risk in patients with NASH. Hepatology, 76(1), 172–185. https://doi.org/10.1002/hep.32274
Stine, J. G., Soriano, C., Schreibman, I., Rivas, G., Hummer, B., Yoo, E., Schmitz, K., & Sciamanna, C. (2021). Breaking down barriers to physical activity in patients with nonalcoholic fatty liver disease. Digestive Diseases and Sciences, 66(10), 3604–3611. https://doi.org/10.1007/s10620-020-06673-w
Stine, J. G., Welles, J. E., Keating, S., Hussaini, Z., Soriano, C., Heinle, J. W., Geyer, N., Chinchilli, V. M., Loomba, R., & Kimball, S. R. (2023). Serum fibroblast growth factor 21 is markedly decreased following exercise training in patients with biopsy-proven nonalcoholic steatohepatitis. Nutrients, 15(6), Article 1481. https://doi.org/10.3390/nu15061481
Tamaki, N., Munaganuru, N., Jung, J., Yonan, A. Q., Loomba, R. R., Bettencourt, R., Ajmera, V., Valasek, M. A., Behling, C., Sirlin, C. B., & Loomba, R. (2022). Clinical utility of 30% relative decline in MRI-PDFF in predicting fibrosis regression in non-alcoholic fatty liver disease. Gut, 71(5), 983–990. https://doi.org/10.1136/gutjnl-2021-324264
Younossi, Z. M., Paik, J. M., Stepanova, M., Ong, J., Alqahtani, S., & Henry, L. (2024). Clinical profiles and mortality rates are similar for metabolic dysfunction-associated steatotic liver disease and non-alcoholic fatty liver disease. Journal of Hepatology, 80(5), 694–701. https://doi.org/10.1016/j.jhep.2024.01.014
Zhang, H.-J., He, J., Pan, L.-L., Ma, Z.-M., Han, C.-K., Chen, C.-S., Chen, Z., Han, H.-W., Chen, S., Sun, Q., Zhang, J.-F., Li, Z.-B., Yang, S.-Y., Li, X.-J., & Li, X.-Y. (2016). Effects of moderate and vigorous exercise on nonalcoholic fatty liver disease: A randomized clinical trial. JAMA Internal Medicine, 176(8), 1074–1082. https://doi.org/10.1001/jamainternmed.2016.3202
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Copyright (c) 2026 Anna Szot, Michał Babicz, Kamil Chudzicki, Wiktor Czyżewski, Daria Danielczyk, Natalia Malatyńska, Oliwer Műller, Jagoda Pałubska, Katarzyna Rosa, Agata Słoma
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