A KETOGENIC very low energy diet (VLED) has delivered a 77% reduction in liver fat in people with metabolic dysfunction-associated steatotic liver disease (MASLD), far exceeding the 14% reduction seen with a Mediterranean diet (MD) in a randomised trial.
MASLD is the most common form of liver disease and is characterised by excess fat accumulation in the liver and is strongly linked to obesity and metabolic diseases like type 2 diabetes, making sustained weight loss central to management.
MASLD carries risks ranging from cirrhosis to major adverse cardiovascular events.
Ketogenic VLED Drives Greater Liver Fat Reduction
In this single-centre pilot study of 25 adults with histologically confirmed MASLD and a BMI between 27 and 35 kg/m2, participants were either assigned to either a 12-week ketogenic VLED diet or a MD programme.
The VLED provided 3,151 kJ per day, compared with 8,950 kJ in the MD arm.
At 12 weeks, liver fat measured by MRI fell by 77% in the VLED group compared with 14% in the MD group. Notably, 69% of those on the ketogenic VLED normalised hepatic fat levels, while none in the MD arm reached this endpoint. Liver histology improved in both groups, with a greater reduction in non-alcoholic fatty liver disease activity score in the VLED arm.
Weight Loss Underpins Metabolic Improvements
Participants on the ketogenic VLED achieved a median 13% total body weight loss at 12 weeks, compared with 4% in the MD group. Clinically meaningful weight loss exceeding 10% of total body weight was reached by 71% of VLED participants, versus 10% in the MD group.
Both diets improved insulin sensitivity. The VLED also reduced visceral and subcutaneous fat mass, although lean mass accounted for around one quarter of total weight loss, consistent with expectations for dietary restriction.
From week 13, the VLED group received low-dose semaglutide to support weight maintenance. By week 24, this group sustained a 14% total body weight loss from baseline, compared with 3% in the MD group.
Diet Effect or Weight Loss?
Whether the reduction in hepatic steatosis reflects the ketogenic VLED itself or is primarily driven by the magnitude of weight loss remains unclear. Total body weight loss closely mirrored reductions in fat mass, suggesting that hepatic improvements may largely follow overall weight change.
Implications for MASLD Management
Although the study was consisted of a balanced male-to-female ratio, it was unblinded and included a small sample, limiting wider generalisability. Participants largely had early-stage disease, and the 24-week duration does not address long-term sustainability. The introduction of semaglutide in only the VLED arm further complicates direct comparisons.
Despite these limitations, the findings highlight the ketogenic very low energy diet as a potentially effective and accessible option for rapid weight loss and liver fat reduction in selected patients with MASLD. Combining an intensive dietary phase with pharmacological support may offer a pragmatic strategy for both initiating and maintaining weight loss in clinical practice.
Reference
Farrell AM et al. Very low ketogenic diet vs. Mediterranean diet for MASLD: Superior steatosis reduction in a randomised pilot study. JHEP Rep. 2026;DOI:10.1016/j.jhepr.2026.101787.
Featured image: George Dolgikh on Adobe stock
