Abstract / Summary
Metabolic dysfunction-associated steatotic liver disease (MASLD), strongly linked to metabolic syndrome, is a growing global health concern. Lifestyle interventions are key to its management, yet the specific lifestyle recommendations in Clinical Practice Guidelines (CPGs) have not been systematically examined. This study aimed to evaluate the consistency, variation, and quality of lifestyle recommendations in MASLD/MASH CPGs. A comprehensive systematic search of major databases and guideline repositories (inception to 11 June 2025) was conducted without language restrictions. Guideline quality was appraised using the AGREE-II instrument. Of 863 records, 20 CPGs from 17 countries and 3 regions met the criteria. All included lifestyle recommendations, mainly on diet and physical activity. Most diet guidance focused on calorie reduction (70%) and the Mediterranean diet (55%). Physical activity recommendations were less detailed, covering aerobic exercise (50%), resistance training (35%), and varying guidance on intensity, duration, and frequency. Alcohol intake was addressed in 12 CPGs (60%). In total, 75 dietary and 30 physical activity recommendations were extracted. Among dietary recommendations, 11% were supported by first-level evidence and 31% by second-level; for physical activity, 27% were first-level and 33% second-level. AGREE II median domain scores were: Scope and Purpose 73.9%, Stakeholder Involvement 51.4%, Rigor of Development 24.7%, Clarity 86.4%, Applicability 17.7%, and Editorial Independence 47.9%. MASLD/MASH guidelines consistently endorse caloric restriction and the Mediterranean diet, but other lifestyle recommendations vary and rely on limited high-quality evidence. Low AGREE-II rigor and applicability scores underscore the need for more harmonized, evidence-based frameworks for lifestyle guidance. CRD420251138462 • Most CPGs prioritize caloric restriction (70%) and the Mediterranean diet (55%) as primary diet recommendations. • Physical activity guidance often lacks detail regarding optimal exercise intensity, frequency, and duration for treatment. • Only 11% of dietary and 27% of physical activity recommendations are supported by first-level evidence. • Guidelines scored high in clarity but low in methodological rigor and practical applicability. • There is a need for harmonized, evidence-based frameworks and tools to improve CPGs, particularly, lifestyles implementation.