Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD) and metabolic dysfunction-associated steatohepatitis (MASH) are now recognized as high-risk health conditions for people living with diabetes.
Two out of three individuals with type 2 diabetes are affected by liver steatosis.¹ In May 2025, the American Diabetes Association (ADA) published a consensus report, which emphasized recommendations for early diagnosis, long-term monitoring, and highlighted lifestyle interventions as critical in preventing progression to cirrhosis.¹
In the past year, two medications have been approved for the treatment of MASH; however, lifestyle change remains at the foundation of treatment. These changes focus on improving dietary quality, increasing physical activity, promoting weight loss, and reducing sedentary behaviors.
Nutrition Therapy Approaches
Nutrition therapy, ideally guided by a registered dietitian nutritionist and reinforced by the entire diabetes care team, needs to be individualized to each person’s social, cultural, and financial needs.¹ Ivancovsky Wajcman et al. ² published a fascinating review of different country’s MASLD management guidelines summarizing recommended lifestyle interventions, their findings indicated many similarities with only a few differences.
Most groups recommended evidence-based eating patterns with the following themes:
- High in fiber and focused on whole food consumption, while reducing saturated fat, added sugars, and ultra-processed foods.¹
- Reduction of commercially produced fructose consumption was recommended as high fructose intake has been associated with greater fibrosis severity, independent of total calorie intake.
- A few guidelines specifically called out reduction/avoidance of regular soda consumption emphasizing that consuming more than four servings of regular sodas per week was associated with a 45% higher risk of developing MASLD. ³
- In contrast, coffee consumption, whether caffeinated or not, has been shown in meta-analyses to reduce MASLD risk when intake exceeds three cups per day. Guidelines suggested consumption of greater than 2-3 cups per day. (Can I get a whoot for my daily coffee habit).
- Similar to the ADA Standards of Care for diabetes management, focusing on shifting towards water consumption and reducing the consumption of sugar-sweetened beverages has shown improved outcomes.
Other Recommended Eating Patterns & Physical Activity
The Mediterranean diet eating pattern is recommended in the MASLD/MASH ADA consensus report as well as the EASL–EASD–EASO Clinical Practice Guidelines ¹,²,³ due to its relationship with improving diet quality and evidence of hepatic and cardiovascular health benefits, even without weight loss.
Other dietary patterns, such as the low-fat, low-carbohydrate, Dietary Approaches to Stop Hypertension, high protein, meal replacement, and intermittent fasting, have also been shown to be comparable strategies to improve steatosis due to weight loss.¹
In people with overweight and obesity, the magnitude of weight loss has been associated with improving glycemic management, insulin sensitivity, as well as histological improvements in MASH.¹
Weight reduction over 5% has been associated with reduced steatosis, and greater weight loss of 7-10% has been shown to reverse steatohepatitis and liver fibrosis.¹,²,³ However, it is recognized that achieving long-term weight reduction may be challenging.³
Avoidance of alcohol is recommended for individuals with moderate fibrosis, as even modest use may aggravate injury.
Physical Activity, Stress Reduction & Sleep
Physical activity, including aerobic and resistance training, has independent effects beyond weight loss: decreasing intrahepatic fat, improving cardiovascular risk, improving insulin sensitivity, and supporting weight‐loss maintenance. Guidelines generally recommend greater than or equal to 150 minutes per week of moderate intensity (or equivalent) and resistance activities 2-3 times per week, with greater benefit when increasing activity.
However, reducing sedentary time and breaking up prolonged sitting bouts can be effective ways to reach this goal.¹,³ Emerging evidence highlights the importance of stress reduction, adequate sleep and treatment of sleep apnea, and management of comorbidities such as dyslipidemia and hypertension, due to their impact on liver steatosis, inflammation, and fibrosis.¹,²
FDA-Approved Medications
Until recently, there were no FDA-approved medications specifically for MASH; treatment was either off-label or targeted at comorbidities such as weight reduction or lipid and glycemic management. However, in the past 2 years, two different medications have been released to address MASH. In March 2024, the FDA approved resmetirom (brand name Rezdiffra) for adults with noncirrhotic MASH to be prescribed in conjunction with lifestyle therapy. 4 In August 2025, the FDA approved semaglutide (brand name Wegovy) for the treatment of MASH and moderate to advanced liver fibrosis. 5
MASLD and MASH
MASLD and MASH are high-risk health conditions for people with diabetes, with approximately 10-30% progressing to advanced liver disease, including cirrhosis.³ While new FDA-approved medications such as resmetirom and semaglutide offer promising options, lifestyle modification remains a cornerstone treatment.
As diabetes healthcare professionals, we are uniquely positioned to implement evidence-based strategies into the individualized care plan.
We can screen, educate, and empower individuals living with diabetes to take proactive steps that protect liver health, improve metabolic outcomes, and prevent progression to cirrhosis. Through nutrition and lifestyle therapy, pharmacotherapy, and incorporating broad strategies into DSMES services (¹) we can strengthen prevention and outcomes.
References
- Cusi K, Abdelmalek MF, Apovian CM, et al. Metabolic Dysfunction–Associated Steatotic Liver Disease (MASLD) in people with diabetes: the need for screening and early intervention. A consensus report of the American Diabetes Association. Diabetes Care.
2025;48(7):1057-1082. doi:10.2337/dci24-0094 - Ivancovsky Wajcman D, Byrne CJ, Dillon JF, et al. A narrative review of lifestyle management guidelines for metabolic dysfunction-associated steatotic liver disease. Hepatology. Published online August 15, 2024.doi:10.1097/HEP.0000000000001058
- Tacke F, et al. EASL–EASD–EASO clinical practice guidelines on the management of metabolic dysfunction–associated steatotic liver disease (MASLD). J Hepatol. 2024;81(3):492-542.doi:10.1016/j.jhep.2024.05.010
- US Food and Drug Administration. FDA approves first treatment for patients with liver scarring due to fatty liver disease. Published March 14, 2024. Accessed September 19, 2025. https://www.fda.gov/news-events/press-announcements/fda-approves-first-treatment-patients-liver-scarring-due-fatty-liver-disease
- US Food and Drug Administration. FDA approves treatment for serious liver disease known
as “MASH.” Published March 14, 2024. Accessed September 19, 2025. https://www.fda.gov/drugs/news-events-human-drugs/fda-approves-treatment-serious-liver-disease-known-mash
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