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There is a lack of further risk stratification and evidence for secondary interventions in populations that have undergone primary prevention. This was a prospective cohort study involving 53106 physically active vulnerable individuals from the UK Biobank. We combined vitamin D with cumulative dietary risk scores to evaluate its predictive value. Correlation and predictive power were assessed using restricted cubic spline (RCS) analysis, corrected Cox models, stratified analysis, Kaplan\u2013Meier analysis, and Harrell's c-index. During 12.7\u00a0years of follow-up, there were 870, 1317 new-onset metabolic dysfunction-associated fatty liver disease (MAFLD) and mortality. RCS analysis revealed a J-shaped negative or positive correlation in vitamin D and dietary risk score respectively. The hazard ratios (95% confidence interval) for MAFLD and mortality in the vitamin D deficiency and high dietary risk groups were 1.80 (1.45\u20132.24) and 1.99 (1.67\u20132.38), compared to those with no vitamin D deficiency and low dietary risk. Kaplan\u2013Meier analysis suggested vulnerable individuals with vitamin D deficiency and a poor diet were at a higher risk of disease in the future. Further, separate analyses of vitamin D and dietary risk scores did not demonstrate better efficacy. The combination of vitamin D and dietary risk score offers a more effective method for assessing disease risk in vulnerable populations. This provides evidence for secondary guidance following exercise interventions, which is significant for older population.<\/jats:p>\n                  <jats:p>\n                    <jats:bold>Graphical abstract<\/jats:bold>\n                  <\/jats:p>","DOI":"10.1007\/s11357-025-01762-y","type":"journal-article","created":{"date-parts":[[2025,7,1]],"date-time":"2025-07-01T14:49:10Z","timestamp":1751381350000},"page":"1771-1785","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":6,"title":["Combined effects of vitamin D and cumulative dietary risk score on fatty liver and mortality in vulnerable individuals: a prospective analysis from the UK Biobank"],"prefix":"10.1007","volume":"48","author":[{"given":"Xiaoyan","family":"Wang","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yongqi","family":"Liang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chenxi","family":"Jin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jingjing","family":"Liang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yining","family":"Xu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2706-9599","authenticated-orcid":false,"given":"Xianbo","family":"Wu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1409-4645","authenticated-orcid":false,"given":"Mengchen","family":"Zou","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2025,7,1]]},"reference":[{"issue":"10206","key":"1762_CR1","doi-asserted-by":"publisher","first-page":"1365","DOI":"10.1016\/S0140-6736(19)31786-6","volume":"394","author":"EO Hoogendijk","year":"2019","unstructured":"Hoogendijk EO, Afilalo J, Ensrud KE, Kowal P, Onder G, Fried LP. 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The UKB was approved by the Northwest Multi-Center Research Ethics Committee and all participants provided written informed consent.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics"}},{"value":"Informed consent was obtained from all subjects involved in the study.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Informed consent"}},{"value":"Not applicable.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"Mengchen Zou is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.","order":5,"name":"Ethics","group":{"name":"EthicsHeading","label":"Guarantors"}},{"value":"The authors declare that they have no competing interests.","order":6,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}]}}