nutrients

Article
Efficacy of the Mediterranean Diet Containing Different
Macronutrients on Non-Alcoholic Fatty Liver Disease
Vahibe Uluçay Kestane 1,2, * and Murat Baş 3

1 Department of Nutrition and Dietetics, Institute of Health Sciences, Acibadem Mehmet Ali Aydinlar
University, Istanbul 34752, Turkey
2 Department of Nutrition and Dietetics, Institute of Health Sciences, İstanbul Galata University,
Istanbul 34432, Turkey
3 Department of Nutrition and Dietetics, Faculty of Health Sciences, Acibadem Mehmet Ali Aydinlar
University, Istanbul 34752, Turkey
* Correspondence: [email protected]

Abstract: This study aimed to investigate the effects of the typical Mediterranean diet (TMD), low-
carbohydrate Mediterranean diet (LCMD), and low-fat Mediterranean diet (LFMD) on biochemical
findings, fatty liver index (FLI), anthropometric measurements, and body composition in individu-
als with obesity with non-alcoholic fatty liver disease (NAFLD) and insulin resistance. This study
included 63 participants with obesity with insulin resistance diagnosed with NAFLD by ultrasonogra-
phy to investigate the effects of an 8-week energy-restricted TMD, LCMD, and LFMD on biochemical
findings, FLI, fibrosis-4 index (FIB-4), anthropometric measurements, and body composition. Patients
were randomized into three groups and were interviewed face-to-face every week. According to
the food consumption records (baseline end), the difference in the amount of sucrose and total fat
consumed in the TMD group; the difference in energy intake from sucrose, monounsaturated fatty
acids, and oleic acid in the LCMD group; and the difference in energy intake from fiber, sucrose,
monounsaturated and polyunsaturated fatty acids, and cholesterol in the LFMD group showed sig-
nificant correlations with liver enzymes and FLI (p < 0.05). In conclusion, although it has a different
macronutrient composition, the Mediterranean diet may positively affect biochemical parameters
and FLI in individuals with NAFLD, albeit in different ways.
Citation: Uluçay Kestane, V.; Baş, M.
Efficacy of the Mediterranean Diet Keywords: non-alcoholic fatty liver disease; steatohepatitis; Mediterranean diet; liver enzymes; fatty
Containing Different Macronutrients liver index
on Non-Alcoholic Fatty Liver Disease.
Nutrients 2024, 16, 2699. https://
doi.org/10.3390/nu16162699
1. Introduction
Academic Editor: José Antonio
Fernández-López
Non-alcoholic fatty liver disease (NAFLD) is a broad-spectrum disease that includes
steatosis resulting from excessive fat accumulation in the liver, steatohepatitis including
Received: 7 July 2024 ballooning and inflammation in hepatocytes, cirrhosis developing with steatohepatitis, and
Revised: 20 July 2024 hepatocellular carcinoma [1]. The American Association for the Study of Liver Diseases
Accepted: 29 July 2024 (AASL) report stated that NAFLD is observed in 51% of individuals with obesity (body
Published: 14 August 2024
mass index [BMI] > 30 kg/m2 ) [2] and in approximately 75% of individuals with type 2
diabetes [3]. The “double-hit hypothesis”, first proposed by Day et al. in 1998 [4], has been
replaced by the “multiple-hit hypothesis”, which involves multiple interlocking processes,
Copyright: © 2024 by the authors.
including genetic predisposition, environmental factors, dietary habits, insulin resistance,
Licensee MDPI, Basel, Switzerland.
lipotoxicity, oxidative stress, mitochondrial dysfunction and/or endoplasmic reticulum
This article is an open access article
(ER) stress, and changes in the microbiota [5,6]. The diagnosis of NAFLD can be made using
distributed under the terms and a multifaceted clinical evaluation, including a careful anamnesis, physical examination,
conditions of the Creative Commons laboratory findings, liver biopsy, and the most commonly used ultrasonography [7]. How-
Attribution (CC BY) license (https:// ever, NAFLD is now also defined as metabolic dysfunction-associated fatty liver disease
creativecommons.org/licenses/by/ (MAFLD). Until now, the diagnosis of NAFLD required the exclusion of other chronic
4.0/). liver diseases, including “excessive” alcohol intake. As the pathogenic process leading

Nutrients 2024, 16, 2699. https://doi.org/10.3390/nu16162699 https://www.mdpi.com/journal/nutrients

Nutrients 2024, 16, 2699 2 of 17

to MAFLD is now better understood and appears to be caused by an underlying state of

systemic metabolic dysfunction, MAFLD is perceived as an independent disease requiring
a positive diagnosis rather than a “no disease” definition. Therefore, it was felt that this
disease should be defined by its own positive criteria rather than by exclusion criteria. The
proposed criteria for a positive diagnosis of MAFLD are histological, imaging, or blood
biomarker evidence of hepatosteatosis, in addition to one of the following three criteria:
obesity, presence of type 2 diabetes mellitus, or evidence of metabolic dysregulation [8].
However, the term and criteria for NAFLD are used in this article.
The European Association for the Study of the Liver (EASL) reported that the fatty
liver index (FLI) is one of the best-validated steatosis scores. The FLI is associated with
insulin resistance and reliably predicts the presence but not the severity of steatosis [1].
The FLI has 61% sensitivity and 86% specificity in identifying the presence of steatosis [9],
whereas it has 79.8% sensitivity and 71.5% specificity in excluding steatosis at a cut-off point
score of <30 [10]. The fibrosis-4 (FIB-4) index is a clinically useful and simple index used
for identifying patients who are more likely to have cirrhosis (stage 4) [11]. In the FIB-4
score, a cut-off point of 1.3 has 85% sensitivity and 65% specificity in excluding advanced
fibrosis [10].
The high prevalence and complications of NAFLD underline the critical need for a
safe, effective, and widely applicable treatment [12]. Lifestyle modification comprising
a healthy diet, exercise, and body weight loss is reported as the best approach in the
EASL, Italian Association for the Study of the Liver (AISF), Spanish Association for the
Study of the Liver, and Asia Pacific Study Group guidelines; although the macronutrient
content is different, the Mediterranean diet model is mostly recommended [1,11,13–15].
The Mediterranean diet, recognized as an Intangible Cultural Heritage of Humanity by
the United Nations Educational, Scientific and Cultural Organization, was proposed and
developed by Keys in the 1950s, referring to dietary habits observed in Mediterranean
regions [16]. The traditional Mediterranean diet is reported to include high amounts of
olive oil, legumes, cereals, vegetables, fruits, and nuts, moderate amounts of dairy products
such as cheese and yogurt, fish, white meat, eggs, and wine, and finally, low amounts
of meat and meat products [17]. In the Mediterranean diet, fat constitutes 35–45% of the
total energy intake, at least half of which should be from monounsaturated fatty acids
(MUFAs). Carbohydrates constitute 35–40% and protein 15–20% of the energy intake [18].
MUFA decreases blood triglycerides by increasing fatty acid oxidation by activation of
peroxisome proliferator-activated receptor (PPAR)α or by reducing the activation of sterol
regulatory element binding protein and inhibiting lipogenesis. The consumption of olive
oil showed a significant inverse association with tumor necrosis factor-α and vascular cell
adhesion molecule-1 serum levels and improved glycemic tolerance by increased secretion
of glucagon-like peptide-1 [19]. There are several mechanisms of action for the effect of
eicosapentaenoic acid and docosahexaenoic acid on liver fat content: They affect PPARα
and thus promote fatty acid oxidation in the liver; they suppress the expression of two
lipogenic transcription factors, sterol regulatory element binding protein 1c and carbohy-
drate responsive element binding protein, which are involved in de novo lipogenesis of
carbohydrates in hyperinsulinemic states; and their increased incorporation into adipose
tissue mediates adiponectin production and reduces the susceptibility of adipocytes to high
inflammation [20]. For these reasons, the Mediterranean diet can reduce liver steatosis even
without a decrease in body weight [21].
In addition to studies showing positive effects on steatosis, inflammation, and fibrosis,
studies on the prevention of diabetes and cardiovascular diseases observed with NAFLD
also exist [22–24].
This study aimed to investigate the effects of TMD, LCMD, and LFMD on biochemical
findings, FLI, anthropometric measurements, and body composition in individuals with
obesity with NAFLD and insulin resistance.
Nutrients 2024, 16, 2699 3 of 17

2. Materials and Methods

2.1. Study Design and Participants
This study was conducted on 63 participants aged between 18 and 65 years who were
insulin resistant and obese (BMI ≥ 30 kg/m2 ), diagnosed with NAFLD by ultrasonography,
and admitted to the Department of Internal Medicine and General Surgery at Manavgat
State Hospital between June 2021 and September 2022. Individuals who drink alcohol
meet the exclusion criteria for NAFLD according to the EASL guidelines [1]; moreover,
individuals with types 1 or 2 diabetes, kidney disease, inflammatory bowel disease, cancer,
and thyroid dysfunction; are pregnant or breastfeeding; have undergone any surgery in
the last 3 months; have taken omega-3, probiotic, vitamin D, and vitamin E supplements
in the last 3 months; or are taking insulin or antibiotics were excluded from this study.
There are studies showing that probiotics, omega-3, and vitamins D and E have a positive
effect on hepatic steatosis and liver enzymes [12,25–31]. Ethics committee permission
was obtained for this experimental study by Acıbadem Mehmet Ali Aydınlar University
Medical Research Evaluation Board (ATADEK) (decision number: 2021-09/63). Patients
were assigned to the groups by simple random sampling without bias according to the
order of admission to the clinical nutrition center, and the dietitian administered “the
typical Mediterranean diet (TMD)” to group 1, “the low-carbohydrate Mediterranean diet
(LCMD)” to group 2, and “the low-fat Mediterranean diet (LFMD)” to group 3 for 8 weeks.
This study spanned a total of 9 weeks, with a pre-interview for each patient.

2.2. Dietary Intervention and Monitoring

In the preliminary interview, NAFLD and Mediterranean diets were explained to the
patients, and a 14-item questionnaire form was applied to determine the general dietary
habits of the individuals. After information about food groups, portions, and weight were
explained visually and in writing, the food frequency questionnaire was distributed [32],
and the Mediterranean Diet Adherence Scale (MEDAS) form was administered [33]. For
the other interview, participants were asked to write their food consumption records for
3 days, including 2 days on weekdays (not consecutive days) and 1 day on weekends,
on the food consumption record form [32] with the amounts and bring them in week 1
when the nutritional treatment would start. After anthropometric measurements and body
analysis of the participants, total energy requirements were calculated using the Mifflin–St.
Jeor equation [34,35], and physical activity coefficient and then dietary interventions with
the following macronutrient distribution were applied to the participants by reducing
500 calories of energy. For 8 weeks, feedback was received from the participants who were
interviewed face-to-face at the clinical nutrition center every week, and adjustments were
made to their diets according to the groups they were in. Food consumption records were
taken at the beginning, week 4, and the end of the study.
TMD: 40–45% carbohydrate, 15–20% protein, and 35–40% fat;
LCMD: ≤35% carbohydrate, 15–20% protein, and >45% fat;
LFMD: ≥55% carbohydrate, 15–20% protein, and 20–25% fat.
In all diet types, attention was paid to ensure that the energy intake from saturated
fat was <10%, and care was taken to consume at least three portions of vegetables and
2–4 portions of fruits per day and fish twice a week [36]. The meal pattern of the patients
was determined as 3 main meals and 2–3 snacks. The obtained food consumption frequen-
cies and food consumption records were analyzed using the BEBIS version 9 program
(Nutrition Information System, Istanbul, Türkiye) [37].

2.3. Anthropometric and General Characteristics

In this study, participants’ body weight, body fat mass and percentage, abdominal
fat mass, visceral fat, and BMI were analyzed using InBody 270 bioelectrical impedance
analysis for 9 weeks. Waist and hip circumferences were measured, and the waist/hip
circumference ratio was calculated. For waist circumference measurement, the tape was
Nutrients 2024, 16, 2699 4 of 17

placed midway between the iliac crest and the costal margin of the lower rib and kept
horizontal. Participants were asked to look forward and exhale, and the measurement was
taken at the end of expiration. For hip circumference measurement, the tape was placed at
the widest part of the participant’s hip and below the iliac crest.
In the 23-item questionnaire form for determining the general characteristics of the par-
ticipants, demographic characteristics, health information, probiotic use, vitamin–mineral
supplementation, alcohol and cigarette use, previous dietary treatment, and the symptoms
and grade of NAFLD as measured using ultrasonography were recorded.

2.4. Physical Activity Assessment

Participants were asked to record their physical activities in minutes within 24 h in the
pre-interview and bring them in week 1 when nutritional treatment would be started, and
their physical activity levels were evaluated [32]. It was emphasized that they should not
change their physical activity during the 8-week study.

2.5. Diagnosis, Biochemical Parameters, and Calculated Indexes

Participants referred to the radiology clinic for ultrasonography at the start of the
study were diagnosed as having mild adiposity (grade 1), moderate adiposity (grade 2),
and severe adiposity (grade 3) according to the ultrasonographic appearance of fatty infil-
tration. Blood samples collected twice from the participants, at the start of the study and at
the end of the eighth week, were examined in the Biochemistry Laboratory of Manavgat
State Hospital; the standards and reference values in this laboratory were taken as the
basis. In the morning blood samples of the participants after an overnight fast (10–12 h)
following dinner, liver enzyme (alanine transaminase [ALT], aspartate aminotransferase
[AST], and gamma-glutamyl transferase [GGT]), creatine kinase, total bilirubin, direct
bilirubin, hepatitis serology (hepatitis B surface antigen, anti-HBs, and anti-HCV), glycated
hemoglobin, fasting blood glucose, fasting insulin, insulin resistance (HOMA-IR), triglyc-
eride, total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL),
triiodothyronine (T3), thyroxine (T4), thyroid-stimulating hormone, and C reactive protein
levels were measured, and total cholesterol/HDL cholesterol ratios were calculated [1].
FLI and FIB-4 scores, which are used for differentiating steatosis (Table 1) and ad-
vanced fibrosis using available serum parameters, were calculated [38].

Table 1. Fatty liver index chart [39,40].

FLI Risk Diagnosis

<30 Low Fatty liver is excluded
30–<60 Uncertain Fatty liver can neither be ignored nor excluded
≥60 High Fatty liver

The FLI was calculated as follows: (e(0.953×ln(TG)+0.139×BMI+0.718×ln(GGT)+0.053×WC−15.745) )/

(1+ e(0.953×ln(TG)+0.139×BMI+0.718×ln(GGT)+0.053×WC−15.745) ) × 100 [39].
FIB-4 score: (age × AST)/platelet value × (ALT)1/2 [41].
FIB-4 score ≤ 1.3: advanced fibrosis is unlikely.
FIB-4 score > 1.3–<2.67: uncertain.
FIB-4 score ≥ 2.67: patients probably have advanced fibrosis [11,41,42].

2.6. Statistical Analyses

In the study, considering two-time variables and three groups, type I error probability
α = 0.05, effect size medium effect (0.35), and a targeted power of the test 1 − β = 0.80, the
sample size required for statistical analyses was calculated as a total of 63 participants for
the three groups, with 21 participants for each group.
Nutrients 2024, 16, 2699 5 of 17

All data were recorded and analyzed using Statistical Package for Social Sciences
(SPSS version 22.0, IBM, Armonk, NY, USA). To determine the normality of the distribution,
the Shapiro–Wilk test, kurtosis and skewness values, which are other assumptions of a
normal distribution, and histogram graphs were used. An independent sample t-test
was used to compare two independent groups, and a paired sample t-test was used to
analyze the difference between two related numerical variables. One-way analysis of
variance was used to compare more than two independent groups, and the Tukey test,
one of the multiple comparison tests, was used to determine the source of the difference.
Chi-square and Fisher’s exact tests were applied for the relationship between categorical
independent variables, and McNemar’s test was applied for the relationship between
dependent categorical variables. To examine the relationship between numerical variables,
the Pearson correlation coefficient was used. The significance of the findings was evaluated
at the p < 0.05 level.

3. Results
The 8-week medical nutrition intervention was completed with a total of 63 partici-
pants. Demographic characteristics, NAFLD grade, physical activity, and MEDAS showed
similar distributions in the groups (Table 2).

Table 2. Distribution of general characteristics of participants by groups at the start of the study.

TMD (n = 21) LCMD (n = 21) LFMD (n = 21)

n % n % n % p
Sex
Females 14 66.67 13 61.90 11 52.38
0.82
Males 7 33.33 8 38.10 10 47.62
Marital status
Married 14 66.67 17 80.95 12 57.14
0.31
Single 7 33.33 4 19.05 9 42.86
Age (years)
X ± SD 39.48 ± 9.17 39.71 ± 10.34 38.62 ± 9.39 0.43
NAFLD grade
Grade 1 14 66.67 14 66.67 14 66.67
1.00
Grade 2 7 33.33 7 33.33 7 33.33
Physical activity duration (min/week)
X ± SD 168.13 ± 17.72 171.25 ± 44.22 163.33 ± 20.46 0.96
PAL
X ± SD 1.38 ± 0.05 1.41 ± 0.07 1.38 ± 0.05 0.18
F = 1.75
MEDAS score
X ± SD 5.52 ± 1.81 5.48 ± 1.75 4.52 ± 1.36 0.83
F = 0.19
X, mean; SD, standard deviation; F, one-way analysis of variance; MEDAS, Mediterranean Diet Adherence Scale;
LCMD group, low-carbohydrate Mediterranean diet group; LFMD group, low-fat Mediterranean diet group; TMD
group, typical Mediterranean diet group; PAL, physical activity level; p, baseline differences between groups.

3.1. Participant Food Intake

The evaluation of the changes in dietary macronutrient intake of the groups at the start
and end of the study is presented in Table 3. At the end of the study, energy, carbohydrate
(g), sucrose (g), protein (g), total fat (g), saturated fatty acid (g), percentage of energy
from saturated fat (%), and cholesterol (g) decreased in all three diet groups (p < 0.05). As
expected, the percentage of energy from carbohydrates, total fat, and fatty acids showed a
statistically significant difference between the groups (p < 0.05).
Nutrients 2024, 16, 2699 6 of 17

Table 3. Evaluation of the changes in macronutrients of participants at the start and end of the study by groups.

1 2 3 Between-Group
TMD (n = 21) LCMD (n = 21) LFMD (n = 21)
Macronutrient Intervention Status Comparison Difference
X ± SD X ± SD X ± SD
X ± SD
Pre-intervention 3248.45 ± 459.96 3209.79 ± 525.43 3366.13 ± 575.26 F = 0.51; p = 0.60
Energy (kcal) Post-intervention 1718.68 ± 260.12 1803.20 ± 324.59 1785.72 ± 319.72 F = 0.46; p = 0.64
Intra-group comparison t = 19.25; p = 0.00 t = 19.00; p = 0.00 t = 17.28; p = 0.00
Pre-intervention 345.78 ± 58.20 358.31 ± 62.54 362.89 ± 53.26 F = 0.49; p = 0.62
Carbohydrate (g) Post-intervention 174.95 ± 25.70 148.54 ± 27.01 241.81 ± 42.73 F = 45.28; p = 0.00 2 < 1, 3 and 1 < 3
Intra-group comparison t = 13.94; p = 0.00 t = 20.54; p = 0.00 t = 12.08; p = 0.00
Pre-intervention 43.55 ± 4.37 45.67 ± 3.35 44.38 ± 2.95 F = 1.84; p = 0.17
Carbohydrate (%) Post-intervention 42.10 ± 1.14 34.05 ± 0.67 55.71 ± 0.56 F = 3681.93; p = 0.00 1, 2 < 3 and 2 < 1
Intra-group comparison t = 1.44; p = 0.17 t = 14.37; p = 0.00 t = −18.62; p = 0.00
Pre-intervention 31.25 ± 6.07 30.37 ± 5.96 30.49 ± 6.69 F = 0.12; p = 0.88
Fiber (gr) Post-intervention 37.89 ± 4.92 38.30 ± 6.13 56.15 ± 14.41 F = 25.42; p = 0.00 1, 2 < 3
Intra-group comparison t = −3.47; p = 0.00 t = −4.46; p = 0.00 t = −7.57; p = 0.00
Pre-intervention 77.90 ± 27.55 84.07 ± 28.49 78.98 ± 24.77 F = 0.31; p = 0.73
Sucrose (g) Post-intervention 26.96 ± 7.35 24.59 ± 6.37 28.51 ± 8,20 F = 1.52; p = 0.23
Intra-group comparison t = 8.66; p = 0.00 t = 9.68; p = 0.00 t = 9.26; p = 0.00
Pre-intervention 116.67 ± 20.22 117.86 ± 21.01 123.14 ± 23.15 F = 0.54; p = 0.59
Protein (g) Post-intervention 80.08 ± 13.02 81.51 ± 14.55 83.84 ± 16.04 F = 0.36; p = 0.70
Intra-group comparison t = 10.25; p = 0.00 t = 13.14; p = 0.00 t = 8.81; p = 0.00
Pre-intervention 14.74 ± 1.95 15.21 ± 1.79 14.93 ± 1.32 F = 0.41; p = 0.66
Protein (%) Post-intervention 19.14 ± 1.01 18.71 ± 0.85 19.33 ± 0.66 F = 2.91; p = 0.06
Intra-group comparison t = −8.59; p = 0.00 t = −8.42; p = 0.00 t = −12.73; p = 0.00
Pre-intervention 152.28 ± 27.06 142.11 ± 29.78 154.88 ± 34.40 F = 1.02; p = 0.37
Total fat (g) Post-intervention 73.94 ± 11.56 94.37 ± 17.43 49.78 ± 9.21 F = 60.06; p = 0.00 1, 3 < 2 and 3 < 1
Intra-group comparison t = 16.20; p = 0.00 t = 8.52; p = 0.00 t = 17.21; p = 0.00
Pre-intervention 41.57 ± 3,84 39.21 ± 3.64 40.74 ± 3,02 F = 2.43; p = 0.10
Total fat (%) Post-intervention 38.71 ± 1.06 47.14 ± 0.91 24.90 ± 0.30 F = 3905.36; p = 0.00 1, 3 < 2 and 3 < 1
Intra-group comparison t = 3.11; p = 0.01 t = −8.60; p = 0.00 t = 24.45; p = 0.00
Nutrients 2024, 16, 2699 7 of 17

Table 3. Cont.

1 2 3 Between-Group
TMD (n = 21) LCMD (n = 21) LFMD (n = 21)
Macronutrient Intervention Status Comparison Difference
X ± SD X ± SD X ± SD
X ± SD
Pre-intervention 16.57 ± 2.25 16.15 ± 2.25 16.55 ± 2.52 F = 0.22; p = 0.81
Saturated fatty acid (%) Post-intervention 7.93 ± 0.49 8.85 ± 0.47 4.29 ± 0.45 F = 545.73; p = 0.00 1, 3 < 2 and 3 < 1
Intra-group comparison t = 18.22; p = 0.00 t = 14.15; p = 0.00 t = 21.73; p = 0.00
Pre-intervention 16.20 ± 2.11 14.85 ± 1.98 15.02 ± 2.18 F = 2.57; p = 0.09
Monounsaturated fatty
Post-intervention 19.46 ± 1.25 25.88 ± 0.83 14.77 ± 0.53 F = 773.02; p = 0.00 1, 3 < 2 and 3 < 1
acid (%)
Intra-group comparison t = −6.94; p = 0.00 t = −24.51; p = 0.00 t = 0.52; p = 0.61
Pre-intervention 14.64 ± 1.95 13.25 ± 1.91 13.44 ± 2.07 F = 3.03; p = 0.06
Oleic acid (%) Post-intervention 18.40 ± 1.43 25.14 ± 0.86 14.35 ± 0.65 F = 582.44; p = 0.00 1, 3 < 2 and 3 < 1
Intra-group comparison t = −7.46; p = 0.00 t = −27.90; p = 0.00 t = −1.95; p = 0.06
Pre-intervention 6.40 ± 1.84 5.84 ± 1.41 6.71 ± 2.16 F = 1.22; p = 0.30
Polyunsaturated fatty
Post-intervention 9.06 ± 0.78 9.51 ± 0.98 4.32 ± 0.57 F = 274.56; p = 0.00 3 < 1, 2
acid (%)
Intra-group comparison t = −7.74; p = 0.00 t = −9.31; p = 0.00 t = 4,85; p = 0.00
Pre-intervention 609.25 ± 164.18 530.22 ± 115.77 601.34 ± 186.70 F = 1.59; p = 0.21
Cholesterol (mg) Post-intervention 93.93 ± 22.44 101.22 ± 23.81 67.60 ± 18.76 F = 13.85; p = 0.00 1, 3 < 2 and 3 < 1
Intra-group comparison t = 14.89; p = 0.00 t = 16.90; p = 0.00 t = 13.22; p = 0.00
X, mean; SD, standard deviation; F, one-way analysis of variance; t, paired sample t-test; 1 , typical Mediterranean diet group; 2 , low-carbohydrate Mediterranean diet group; 3 , low-fat
Mediterranean diet group.
Nutrients 2024, 16, 2699 8 of 17

3.2. Participants’ Anthropometric Measurements

No statistically significant difference was observed between the groups in terms of
body composition and anthropometric measurements at the start and end of the study
(p > 0.05). At the end of the study, body weight, BMI, waist circumference, hip circumfer-
ence, waist/hip circumference ratio, body fat mass and percentage, abdominal fat mass,
and visceral fat were significantly reduced in all three diet groups (p < 0.05) (Table 4).

3.3. Participants’ Biochemical Parameters and Indexes

At the end of the study, the levels of fasting blood glucose, insulin, insulin resistance,
liver enzymes, LDL cholesterol, total cholesterol, total cholesterol/HDL cholesterol ratio,
FLI, and FIB-4 scores significantly decreased in the three diet groups (p < 0.05), whereas
HDL cholesterol levels increased (p < 0.05). The TMD group had significantly lower mean
AST and GGT values than the other two groups (p < 0.05). Moreover, the TMD group had a
lower mean FLI score than the LCMD group (p < 0.05) and a lower mean FIB-4 score than
the LFMD group (p < 0.05) (Table 5).

3.4. Effects of Macronutrient Changes on the Alterations in Biochemical Parameters

In the TMD group, a positive correlation was noted between the change in the amount
of sucrose consumed and the change in the FLI score (r = 0.65, p = 0.001) and between
the change in the amount of total fat (g) and the changes in ALT (r = 0.56, p = 0.007), AST
(r = 0.46, p = 0.03), and GGT values (r = 0.47, p = 0.03) (Table 6).
In the LCMD group, a negative correlation was observed between the change in
carbohydrate (g) consumed and the change in the FLI score (r = −0.52, p = 0.01), and a
positive and moderately significant correlation was noted between the change in sucrose
(g) and the changes in ALT (r = 0.49, p = 0.02) and AST (r = 0.47, p = 0.01). A positive
correlation was noted between the changes in protein amount (g) and ALT (r = 0.45,
p = 0.04), and a negative correlation was observed between the change in the FLI score
(r = −0.59, p = 0.005). A positive correlation was noted between the change in energy intake
from monounsaturated fatty acids and the change in the FLI score (r = 0.44, p = 0.04), and a
positive correlation was noted between the change in cholesterol and the change in ALT
values (r = 0.51, p = 0.01).
The change in the amount of fiber consumed was significantly positively correlated
with the change in the FLI score (r = 0.45, p = 0.03) in the LFMD group. A positive correlation
was observed between the change in sucrose and the changes in AST and GGT values
(r = 0.43, p = 0.04), and a positive correlation was noted between the change in total fat
and the change in the FLI score (r = 0.45, p = 0.03). The change in energy intake from
monounsaturated fatty acids was positively correlated with the changes in ALT (r = 0.45,
p = 0.03) and GGT values (r = 0.43, p = 0.04), whereas a similar relationship was observed
with the change in oleic acid values.
The change in the FLI score (r = 0.46, p = 0.03) was positively associated with the
change in energy intake from polyunsaturated fatty acids. A positive correlation was noted
between the change in the FLI score (r = 0.66, p = 0.001) (r = 0.64, p = 0.002) and the changes
in energy intake from saturated fatty acids and cholesterol intake.
Nutrients 2024, 16, 2699 9 of 17

Table 4. Evaluation of body compositions and anthropometric measurements of participants at the start and end of the study.

Body Composition 1 2 3 Between-Group

TMD (n = 21) LCMD (n = 21) LFMD (n = 21)
Anthropometric Intervention Status Comparison Difference
X ± SD X ± SD X ± SD
Measurements X ± SD
Pre-intervention 91.90 ± 10.94 93.71 ± 12.36 94.12 ± 11.44 F = 0.40; p = 0.67
Body weight (kg) Post-intervention 84.43 ± 10.34 86.87 ± 12.15 86.71 ± 10.87 F = 0.17; p = 0.84
Intra-group comparison t = 23.93; p = 0.00 t = 19.02; p = 0.00 t = 32.61; p = 0.00
Pre-intervention 32.30 ± 1.08 32.46 ± 1.68 32.34 ± 1.19 F = 0.22; p = 0.81
BMI (kg/m2 ) Post-intervention 29.74 ± 1.22 30.08 ± 1.67 29.80 ± 1.23 F = 0.28; p = 0.76
Intra-group comparison t = 27.26; p = 0.00 t = 17,04; p = 0.00 t = 38.39; p = 0.00
Pre-intervention 109.93 ± 7.40 114.71 ± 14.78 111.19 ± 6,55 F = 0.31; p = 0.73
Waist circumference (cm) Post-intervention 100.52 ± 7.35 106.10 ± 13.81 102.21 ± 6.81 F = 0.30; p = 0.74
Intra-group comparison t = 22.90; p = 0.00 t = 14.80; p = 0.00 t = 24.21; p = 0.00
Pre-intervention 106.71 ± 6.66 113.90 ± 11.36 108.05 ± 8.90 F = 0.08; p = 0.92
Hip circumference (cm) Post-intervention 100.90 ± 6.60 108.10 ± 10.69 102.38 ± 8.89 F = 0.52; p = 0.60
Intra-group comparison t = 20.06; p = 0.00 t = 17.90; p = 0.00 t = 17.68; p = 0.00
Pre-intervention 1.03 ± 0.07 1.01 ± 0.12 1.03 ± 0.06 F = 0.35; p = 0.70
Waist/hip circumference Post-intervention 1.00 ± 0.07 0.98 ± 0.13 0.99 ± 0.05 F = 0.36; p = 0.70
Intra-group comparison t = 4.35; p = 0.00 t = 6.24; p = 0.00 t = 6.25; p = 0.00
Pre-intervention 40.14 ± 6.14 38.97 ± 6.22 37.99 ± 7.96 F = 1.77; p = 0.18
Body fat percentage (%) Post-intervention 35.52 ± 6.58 35.24 ± 5.94 33.92 ± 8.61 F = 0.69; p = 0.50
Intra-group comparison t = 13.64; p = 0.00 t = 13.45; p = 0.00 t = 17.90; p = 0.00
Pre-intervention 18.91 ± 1.84 18.42 ± 2.53 18.10 ± 2.65 F = 0.62; p = 0.54
Abdominal fat mass (kg) Post-intervention 15.30 ± 2.12 14.91 ± 2.37 14.41 ± 2.81 F = 0.69; p = 0.50
Intra-group comparison t = 17.69; p = 0.00 t = 16.10; p = 0.00 t = 20.68; p = 0.00
X, mean; SD, standard deviation; F, one-way analysis of variance; t, paired sample t-test; 1 , typical Mediterranean diet group; 2 , low-carbohydrate Mediterranean diet group; 3 , low-fat
Mediterranean diet group.
Nutrients 2024, 16, 2699 10 of 17

Table 5. Evaluation of the biochemical parameters of participants at the start and end of the study by groups.

1 2 3 Between-Group
TMD (n = 21) LCMD (n = 21) LFMD (n = 21)
Biochemical Parameters Intervention Status Comparison Difference
X ± SD X ± SD X ± SD
X ± SD
Pre-intervention 123.29 ± 17.08 117.14 ± 13.33 114.14 ± 13.47 F = 2.10; p = 0.13
Fasting blood glucose
Post-intervention 106.05 ± 13.67 103.05 ± 10.93 102.71 ± 10.79 F = 0.50; p = 0.61
(mg/dL)
Intra-group comparison t = 11.26; p = 0.01 t = 9.61; p = 0.01 t = 8.38; p = 0.01
Pre-intervention 4.24 ± 0.70 3.85 ± 0.70 4.24 ± 1.00 F = 1.60; p = 0.21
HOMA-IR Post-intervention 2.38 ± 0.46 2.50 ± 0.55 2.67 ± 0.80 F = 1.17; p = 0.32
Intra-group comparison t = 18.32; p = 0.01 t = 15.05; p = 0.01 t = 18.38; p = 0.01
Pre-intervention 69.19 ± 14.48 66.38 ± 11.36 68.67 ± 15.30 F = 0.25; p = 0.78
ALT (U/L) Post-intervention 48.52 ± 9.00 51.43 ± 6.34 51.95 ± 10.79 F = 0.90; p = 0.41
Intra-group comparison t = 11.00; p = 0.01 t = 7.60; p = 0.01 t = 9.66; p = 0.01
Pre-intervention 42.19 ± 13.36 45.71 ± 14.62 50.43 ± 16.50 F = 1.62; p = 0.21
AST (U/L) Post-intervention 26.76 ± 7.08 34.90 ± 8.17 37.24 ± 10.60 F = 8.31; p = 0.01 1 < 2, 3
Intra-group comparison t = 7.90; p = 0.01 t = 6.14; p = 0.01 t = 7.29; p = 0.01
Pre-intervention 35.38 ± 7.05 39.33 ± 11.13 43.29 ± 12.10 F = 3.08; p = 0.05 1<3
GGT (U/L) Post-intervention 20.81 ± 5.73 31.24 ± 8.17 30.76 ± 8.26 F = 13.02; p = 0.01 1 < 2, 3
Intra-group comparison t = 10.81; p = 0.01 t = 7.11; p = 0.01 t = 9.06; p = 0.01
Pre-intervention 85.62 ± 7.34 87.90 ± 8.79 88.71 ± 4.77 F = 1.06; p = 0.35
FLI Post-intervention 60.38 ± 13.15 71.95 ± 17.18 68.71 ± 10.97 F = 3.82; p = 0.03 1<2
Intra-group comparison t = 13.97; p = 0.01 t = 7.90; p = 0.01 t = 13.53; p = 0.01
Pre-intervention 0.61 ± 0.22 0.73 ± 0.28 0.73 ± 0.22 F = 1.64; p = 0.20
FIB-4 Post-intervention 0.48 ± 0.16 0.61 ± 0.20 0.62 ± 0.17 F = 4.10; p = 0.02 1<3
Intra-group comparison t = 6.84; p = 0.01 t = 4.59; p = 0.01 t = 5.53; p = 0.01
X, mean; SD, standard deviation; F, one-way analysis of variance; t, paired sample t-test; ALT, alanine aminotransferase; AST, aspartate aminotransferase; FLI, fatty liver index; FIB-4,
fibrosis-4 score; GGT, gamma-glutamyl transferase. 1 , typical Mediterranean diet group; 2 , low-carbohydrate Mediterranean diet group; 3 , low-fat Mediterranean diet group.
Nutrients 2024, 16, 2699 11 of 17

Table 6. Relationship between changes in liver enzyme values and FLI scores of the groups at the
beginning and end of the study, and the change values of macronutrients.

1 TMD (n = 21) 2 LCMD (n = 21) 3 LFMD (n = 21)

X ± SD X ± SD X ± SD
ALT AST GGT FLI ALT AST GGT FLI ALT AST GGT FLI

Carbohydrate (g) r 0.41 0.29 0.43 0.38 0.42 0.28 0.16 −0.52 −0.15 −0.34 −0.29 0.24
p 0.06 0.19 0.05 0.89 0.054 0.21 0.47 0.01 0.50 0.12 0.19 0.29

Carbohydrate (%) r 0.02 −0.49 0.09 0.17 0.21 0.20 0.38 −0.18 0.08 −0.01 −0.07 −0.16
p 0.90 0.83 0.68 0.44 0.35 0.36 0.84 0.42 0.71 0.94 0.73 0.46

Fiber (g) r 0.22 0.04 0.21 −0.17 0.15 0.12 0.06 −0.03 0.08 0.07 0.08 0.45
p 0.32 0.86 0.34 0.46 0.50 0.57 0.77 0.87 0.70 0.75 0.70 0.03

Sucrose (g) r 0.24 0.20 0.33 0.65 0.49 0.47 0.26 −0.31 0.12 0.43 0.43 0.28
p 0.28 0.37 0.13 0.001 0.02 0.01 0.24 0.17 0.35 0.04 0.04 0.20

Protein (g) r 0.15 0.31 0.08 −0.19 0.45 0.23 −0.13 −0.59 −0.14 −0.22 −0.16 0.09
p 0.51 0.16 0.71 0.40 0.04 0.29 0.56 0.005 0.53 0.31 0.48 0.68

Protein (%)
r −0.31 −0.10 −0.33 −0.40 0.19 0.09 −0.04 −0.35 −0.10 −0.09 −0.12 −0.23
p 0.17 0.66 0.13 0.07 0.39 0.67 0.86 0.11 0.65 0.68 0.59 0.30

Total fat (g) r 0.56 0.46 0.47 0.27 −0.13 −0.14 −0.25 0.06 −0.10 −0.16 −0.5 0.45
p 0.007 0.03 0.03 0.22 0.54 0.52 0.25 0.77 0.65 0.46 0.80 0.03

Total fat (%)

r 0.16 0.14 0.08 0.01 −0.27 −0.20 −0.30 0.27 −0.05 0.02 0.11 0.24
p 0.47 0.54 0.72 0.94 0.23 0.36 0.18 0.22 0.81 0.90 0.61 0.29

SFA (%)
r 0.32 0.19 0.19 0.28 −0.25 0.14 0.23 0.29 0.26 −0.28 0.24 0.66
p 0.15 0.40 0.39 0.21 0.26 0.53 0.31 0.22 0.25 0.20 0.28 0.001
r 0.11 0.18 0.09 0.12 0.26 0.24 0.29 0.44 0.45 0.39 0.43 0.09
MUFA (%) p 0.61 0.42 0.69 0.60 0.25 0.28 0.20 0.04 0.03 0.07 0.04 0.66
r 0.03 0.08 0.01 0.08 0.30 0.28 0.30 0.42 0.50 0.43 0.43 0.09
Oleic acid (%) p 0.87 0.72 0.97 0.71 0.18 0.20 0.17 0.052 0.02 0.05 0.02 0.66

PUFA (%)
r −0.02 −0.05 −0.02 −0.39 −0.12 −0.11 −0.17 −0.03 −0.15 0.03 0.02 0.46
p 0.91 0.81 0.92 0.07 0.60 0.61 0.45 0.86 0.50 0.89 0.90 0.03

Cholesterol (mg) r 0.06 0.15 0.14 0.38 0.51 0.15 −0.17 −0.25 0.03 −0.13 −0.08 0.64
p 0.77 0.51 0.95 0.08 0.01 0.50 0.44 0.28 0.87 0.56 0.71 0.002
X, mean; SD, standard deviation; MUFA, monounsaturated fatty acid; PUFA, polyunsaturated fatty acid; SFA,
saturated fatty acid; 1 , typical Mediterranean diet group; 2 , low-carbohydrate Mediterranean diet group; 3 , low-fat
Mediterranean diet group.

4. Discussion
Factors such as metabolic diseases, genetics, environmental factors, sex, age, and
marital status are significant risk factors for NAFLD [43]. The participants of this study
were similar in terms of their general characteristics and NAFLD grades in all groups,
which positively contributed to the analyses conducted in this study. The Mediterranean
diet is recognized worldwide as one of the healthiest dietary patterns because it reduces
the risk of cardiovascular diseases, type 2 diabetes, neurodegenerative diseases, cancer
incidence, and overall mortality [44]. It represents an effective dietary approach in NAFLD
management as it reduces hepatic steatosis and improves elevated liver transaminase
levels. The EASL–EASD–EASO Clinical Practice Guidelines published in 2016 [1] have
recommended adjusting the macronutrient composition for medical nutrition therapy
according to the Mediterranean diet. However, additional large randomized controlled
trials designed to determine the mechanisms underlying the observed effects are needed,
and clarification of the exact dietary pattern associated with the beneficial effects of the
Mediterranean diet on NAFLD has been reported [45]. The Asia Pacific Research Group,
EASL, and AASL have emphasized that individuals with NAFLD should achieve body
weight loss by restricting their daily energy intake by 500–1000 calories, whereas AISF has
emphasized that they should achieve body weight loss by taking low energy intake, such
as 1200–1600 calories/day [13]. In this study, in all three diet groups, individual nutrition
plans were formulated by reducing 500 calories from the energy requirements. In this study,
the macronutrient consumption of all three groups was within the expected range. In the
Nutrients 2024, 16, 2699 12 of 17

diet types recommended for NAFLD treatment, adequate intake of whole grain products
containing high fiber, fruits, vegetables, legumes, and dried nuts is recommended [46].
Although no exact amount of fiber was mentioned, the American Diabetes Associ-
ation’s recommendation of 14 g of fiber for every 1000 kcal of daily dietary intake for
adults [47] was considered for glycemic control and an improved lipid profile. A study
using data from the 2007–2014 National Health and Nutrition Examination Survey revealed
that individuals without NAFLD diagnosis received an average of 216 mg/kg of fiber
per day, whereas individuals with NAFLD received 156 mg/kg (p < 0.001) [48]. At the
start of this study, the amount of fiber intake of participants seemed adequate; however,
it was not at the desired level according to the energy intake. At the end of the interven-
tion, the amount of fiber intake increased and reached optimal levels. At the end of the
study, the LFMD group had significantly higher total fiber, soluble fiber, and insoluble
fiber values than the other two groups (p < 0.05). Excessive saturated fatty acid intake
negatively affected several steps, from insulin resistance to oxidative stress and mitochon-
drial dysfunction, from hepatic ER stress to increased inflammation in the pathogenesis
of NAFLD [49]. Therefore, for NAFLD prevention and treatment, energy intake from
saturated fats is recommended to be <10%, which is consistent with the guidelines and the
results of previous studies [31,50]. Owing to their positive effects on lipid profile, blood
pressure, insulin sensitivity, and glycemic control, monounsaturated fatty acids are the most
suitable alternative to saturated fats. Monounsaturated fatty acids reduce the incidence of
risk factors associated with metabolic syndrome, especially when consumed as part of the
Mediterranean diet [46]. The Spanish Association for the Study of the Liver has reported
that in the presence of steatohepatitis, dietary saturated fatty acid intake should be reduced,
and n-3 polyunsaturated fatty acid and monounsaturated fatty acid intake should be in-
creased [15]. In the Mediterranean diet, monounsaturated fatty acids should constitute at
least 50% of the daily energy intake from fat [18]. Although the intake of monounsaturated
fatty acids, including oleic acid (18:1), increases triglyceride content, it reduces cell stress
and hepatocellular death [15]. At the end of this study (Table 2), the percentage of saturated
fat intake of all participants was below 10%, as targeted, and monounsaturated fatty acids
accounted for 50% of their total fat intake. This result shows that participants in all three
groups increased their consumption of olive oil, which is at the center of the Mediterranean
diet while decreasing other fat sources. In a study conducted by Coppell et al. to examine
the relationship between obesity and the extent of liver damage in NAFLD, ALT and GGT
levels significantly increased with increasing BMI [51]. In addition, another study showed
a significant relationship between waist circumference and waist/hip circumference ratio
and NAFLD [52]. Increased visceral fat and insulin resistance that develop in parallel with
this increase are the two main actors that play a role in the pathogenesis of NAFLD [53]. In a
study, individuals with NAFLD had significantly higher total adipose tissue, subcutaneous
adipose tissue, and visceral adipose tissue than those in the control group, and visceral
adipose tissue area was independently associated with significant fibrosis (F2–F4) in the
multivariate regression analysis [54]. A study conducted by Ristic-Medic et al. observed
that a calorie-restricted Mediterranean diet administered to individuals with NAFLD for
3 months significantly reduced BMI (from 30.43 ± 1.81 to 27.65 ± 1.80 kg/m2 ), waist cir-
cumference (from 105.67 ± 5.94 to 95.83 ± 5.73 cm), and body fat percentage (from 26.17%
± 1.71% to 21.27% ± 3.05%) [55]. At the end of this study, although significant (p < 0.05)
changes were observed in terms of body composition and anthropometric measurements in
all three diet groups, no significant difference was noted between the groups (p > 0.05). Ow-
ing to its high fiber content, the Mediterranean dietary pattern increases fermentation and
short-chain fatty acid production, thereby promoting reduced insulin resistance. Further-
more, the inclusion of foods with a low glycemic index (LGI), the presence of polyphenols
and monounsaturated fatty acids in olive oil, and the increase in omega-3 consumption
have curative effects on hyperinsulinemia [56]. At the end of the ATTICA prospective co-
hort study, which spanned 10 years and included 3042 individuals, the Mediterranean diet
adherence score was significantly negatively associated with diabetes risk [57]. In a study
Nutrients 2024, 16, 2699 13 of 17

in which individuals with NAFLD were administered a calorie-restricted Mediterranean

diet and a calorie-restricted low-fat diet, no significant difference was noted between the
groups in terms of mean fasting glucose, fasting insulin, and insulin resistance levels [55].
Consistent with previous studies, fasting glucose and insulin resistance significantly de-
creased in all three diet groups at the end of the study (p < 0.05); however, no significant
difference was observed between the groups. An energy-restricted Mediterranean diet
was administered to individuals with NAFLD, and at the end of the study, individuals
with 50% or more compliance with the Mediterranean diet had significantly lower mean
ALT, AST, and GGT levels than those with <50% [58]. In the study examining the effect of
different diet types on ALT levels in individuals with obesity with type 2 diabetes, the first,
second, and third groups were administered the American Diabetes Association diet, LGI
diet, and modified Mediterranean diet (MMD), respectively. Although the mean ALT level
decreased in all groups at the end of the study, the lowest ALT levels were significantly
observed in the MMD group [59]. A 2021 systematic review and meta-analysis emphasized
that without calorie restriction, the Mediterranean diet significantly reduced intrahepatic
lipid content; however, it did not produce significant reductions in ALT, AST, and GGT
values [60]. In contrast, in another systematic review and meta-analysis of randomized
controlled trials published in the same year, the Mediterranean diet significantly decreased
AST and GGT values; however, it had no significant effect on ALT values. However, with
the exclusion of some studies within the scope of the research without publication bias, the
Mediterranean diet improved all liver enzymes, and more randomized controlled studies
were needed [61]. At the end of this study, mean ALT, AST, and GGT values significantly
decreased in all three diet groups (p < 0.05) (Table 5). The AST and GGT endpoints of the
TMD group were significantly lower than those of the other two groups (p < 0.05). As no
significant difference was observed between the mean body weight loss of the groups, it
is believed that the significantly lower mean AST and GGT values of individuals on the
typical Mediterranean diet compared with those in the other two groups may be caused by
the difference in macronutrients. The FLI is a noninvasive biomarker recommended before
liver ultrasonography to confirm steatosis in individuals with suspected NAFLD. Besides
providing convenience in community screening, the FLI has started to be used for the
detection of atherosclerosis, diabetes, and chronic kidney diseases [62]. A meta-analysis of
systematic reviews published in 2022 reported that the FLI scores of individuals following a
calorie-restricted Mediterranean diet protocol were significantly reduced [63]. In the study
in which the Mediterranean diet and low-fat diet interventions were applied, FLI scores
significantly decreased in both groups; however, the decrease in the Mediterranean diet was
significantly higher than that in the other group [55]. In a 10-year prospective cohort study,
patients were examined in three groups: low adherence (<25 points), moderate adherence
(25–35 points), and high adherence (>35 points) to the Mediterranean diet score, and it was
observed that FLI and FIB-4 scores significantly decreased with increasing adherence to
the Mediterranean diet [64]. Another study observed that the fibrosis grade significantly
decreased with an increasing Mediterranean diet compliance score [65]. In this study, FLI
and FIB-4 scores significantly decreased in all three diet groups (p < 0.05). The TMD group
had a lower mean FLI score (p < 0.05) than the LCMD group and a lower mean FIB-4 score
(p < 0.05) than the LFMD group. It is believed that the reason for these differences is that
the biochemical parameters of the participants in the TMD group improved more than
those of the other groups.

5. Conclusions
The results of this study suggested that the Mediterranean diet can positively affect
NAFLD, regardless of macronutrient differences. For example, although the decrease in
sucrose and total fat levels in the TMD group positively affected the FLI score and liver
enzyme levels, the decrease in sucrose and increase in monounsaturated fatty acid and
oleic acid levels in the LCMD group positively affected the FLI score and liver enzyme
levels. In the LFMD group, increased intake of fiber, monounsaturated fatty acids, and
Nutrients 2024, 16, 2699 14 of 17

oleic acids and decreased intake of sucrose, polyunsaturated fatty acids, saturated fatty
acids, and cholesterol positively affected the FLI score and liver enzyme levels.
To better understand the effects of Mediterranean diet types containing different
macronutrients on biochemical parameters and FLI in NAFLD treatment, randomized
controlled trials with longer intervention periods and larger sample sizes are needed.

5.1. Strengths and Limitations of the Study

In the literature, no intervention studies have investigated the effectiveness of the
Mediterranean diet containing different macronutrients on NAFLD with three different
macronutrient patterns. Therefore, this study is the first of its kind.
The strengths of the study can be shown as the preparation of diet lists by meeting face-
to-face with all individuals participating in the study every week in the clinical nutrition
center of the researcher, taking their body composition and 3-day food consumption records,
and evaluating their dietary compliance. The fact that the participants consumed more olive
oil and butter at the beginning of the study owing to the characteristics of their geographical
region and nutritional culture may have prevented the correlations that would arise from
the difference in monounsaturated fatty acid intake during the intervention period from
clearly emerging. The limitations of this study include the inability to determine the
NAFLD grade by ultrasonography at the end of the study and the short intervention period
owing to the coronavirus disease 2019 pandemic.

5.2. Importance and Contribution of the Study

In all three diet groups, different biochemical values varied favorably in relation to
different macronutrients. This result confirmed the hypothesis of the study: TMD, LCMD,
and LFMD positively affect the biochemical findings and FLI of individuals with NAFLD,
and a difference exists between these positive effects.

Author Contributions: Conceptualization, methodology, formal analysis, investigation, data curation,

writing—original draft preparation, writing—review and editing, V.U.K. and M.B.; supervision, M.B.
All authors have read and agreed to the published version of the manuscript.
Funding: This study received no external funding.
Institutional Review Board Statement: The study was conducted in accordance with the Declaration
of Helsinki and approved by the Ethics Committee of Acıbadem Mehmet Ali Aydınlar University
Medical Research Evaluation Board (ATADEK) with the decision number 2021-09/63 on 26 May 2021.
Informed Consent Statement: Informed consent was obtained from all the individuals involved in
the study.
Data Availability Statement: The data obtained in this study are available from the corresponding
author upon request. The data are not publicly available due to ethical reasons.
Conflicts of Interest: The authors declare no conflicts of interest.

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