TIME-RESTRICTED eating could offer sustained benefits for people with metabolic dysfunction-associated steatotic liver disease (MASLD) and metabolic dysfunction-associated steatohepatitis (MASH), according to new long-term research.
The prospective, real-world observational study found that time-restricted eating (TRE), a form of intermittent fasting, was associated with greater improvements in liver fat, fibrosis-related measures, and metabolic health than several other commonly used management strategies.
Researchers followed adults with MASLD or clinically suspected MASH who selected one of five management strategies through shared clinical decision-making. These included TRE for participants with MASLD or suspected MASH, Orlistat-supported lifestyle modification, a 1,500-kcal balanced diet, and exercise-focused lifestyle counselling.
Participants following TRE typically restricted their daily caloric intake to an approximately 8-hour eating window.
A total of 197 participants completed 28-48 months of follow-up. Liver fat and fibrosis-related outcomes were monitored using several non-invasive approaches, including controlled attenuation parameter (CAP) and liver stiffness measurement (LSM), alongside validated serum-based indices.
The greatest and most sustained improvements were seen amongst participants following TRE.
Steatosis regression of at least one stage occurred in 75.5% of participants with MASLD following TRE and 62.5% of those with clinically suspected MASH. This compared with 52.9% of participants receiving Orlistat-supported lifestyle modification, 47.2% following the 1,500-kcal diet, and 11% receiving exercise-focused counselling.
Fibrosis regression was observed in 35% of participants in each TRE group, compared with 21% in the Orlistat group and 25% in the balanced-diet group. No participants in the exercise-focused group demonstrated fibrosis regression.
Significant reductions in liver stiffness were also observed only in the TRE groups. Liver stiffness measurement decreased from 7.8 to 6.3 kPa in participants with MASLD and from 14.03 to 9.8 kPa in those with clinically suspected MASH.
TRE was additionally associated with improvements in body weight, glycaemic control, insulin resistance, lipid profiles, and liver enzymes.
The researchers suggest that prolonged fasting periods may provide benefits beyond calorie restriction alone. Proposed mechanisms include improved insulin sensitivity, increased hepatic fatty acid oxidation, and reductions in oxidative and inflammatory stress.
TRE was generally well tolerated, with reported adverse events including hunger, headache, fatigue, dizziness, and changes in bowel habits. No serious adverse events attributable to TRE were reported.
However, the findings do not establish that TRE caused the improvements. Participants selected their own management strategy rather than being randomly assigned, meaning residual confounding and differences in motivation or adherence cannot be excluded. The researchers also relied on non-invasive measures rather than liver biopsy to assess fibrosis.
The authors conclude that TRE could represent a scalable and low-cost lifestyle strategy for metabolic liver disease but emphasise that randomised controlled studies are needed to confirm causality and determine the optimal approach.
Reference
Alqahtani M S et al. Time-restricted eating is associated with sustained improvement in steatosis and fibrosis in MASLD and MASH: a long-term real-world cohort study. BMC Gastroenterology. 2026.
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