Management of Obesity in Liver Cirrhosis: A Delicate Balance of Risks and Benefits

Metabolic dysfunction-associated steatotic liver disease (MASLD) has emerged as a major global cause of chronic liver disease and is closely associated with obesity and metabolic syndrome. Obesity contributes to MASLD progression and increases the risk of liver fibrosis, cirrhosis, and hepatocellular carcinoma. However, the management of obesity in patients with cirrhosis is complex, as the catabolic state characteristic of cirrhosis predisposes patients to sarcopenia, malnutrition, and frailty. Excessive weight reduction may therefore worsen muscle loss and adversely affect clinical outcomes. Accordingly, obesity management in cirrhosis should prioritize not only weight reduction but also optimizing body composition by preserving muscle mass and physical function. A comprehensive assessment of nutritional status, sarcopenia, and frailty is essential before initiating weight management strategies. Lifestyle interventions are the cornerstone of therapy and include individualized nutritional support and exercise programs. Moderate caloric restriction with adequate protein intake is recommended for patients with compensated cirrhosis, whereas maintenance of nutritional status is prioritized in those with sarcopenia or decompensated cirrhosis. Pharmacological therapies, such as glucagon-like peptide-1 receptor agonists, demonstrate potential benefits in MASLD; however, evidence in established cirrhosis remains limited. Bariatric surgery should be considered in carefully selected patients with compensated cirrhosis. Overall, obesity management in MASLD-related cirrhosis requires an individualized, multidisciplinary approach.