{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,4]],"date-time":"2026-09-04T15:11:45Z","timestamp":1788534705729,"version":"build-2803163510"},"reference-count":89,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,4]],"date-time":"2026-09-04T00:00:00Z","timestamp":1788480000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Nutr."],"abstract":"<jats:p>Metabolic dysfunction-associated steatotic liver disease (MASLD) is common and clinically heterogeneous, with fibrosis stage serving as a major determinant of long-term liver-related risk. This focused narrative review evaluates ketogenic dietary interventions and intermittent fasting as metabolic-switching strategies while explicitly distinguishing conventional or eucaloric ketogenic diets, very-low-energy ketogenic therapy, non-ketogenic low-carbohydrate diets, and distinct fasting protocols. Both approaches can reduce body weight, improve insulin sensitivity, and decrease hepatic steatosis in selected patients, but much of the human evidence is short-term and protocol-dependent. Mechanistic effects attributed to beta-hydroxybutyrate, including inflammasome inhibition, histone modification, and mitochondrial signaling, are supported predominantly by cell and animal studies and have not been directly confirmed in patients with MASLD. The gut-liver axis provides a biologically plausible link through intestinal permeability, microbial metabolites, bile acid signaling, and hepatic innate immunity; however, direct human evidence that ketogenic diets or intermittent fasting restore gut-barrier function remains limited. No trial has directly compared a well-defined ketogenic intervention with documented nutritional ketosis against intermittent fasting. Therefore, relative efficacy, durability, adherence, and weight-loss-independent effects remain uncertain. Clinical use should prioritize fibrosis risk stratification, nutritional adequacy, comorbidity-specific safety, and integration with evidence-based lifestyle and pharmacologic care.<\/jats:p>","DOI":"10.3389\/fnut.2026.1860047","type":"journal-article","created":{"date-parts":[[2026,9,4]],"date-time":"2026-09-04T14:11:41Z","timestamp":1788531101000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Metabolic switching in MASLD: therapeutic roles of ketogenic diet, intermittent fasting, and the gut-liver axis"],"prefix":"10.3389","volume":"13","author":[{"given":"Purvi Kaur","family":"Khanuja","sequence":"first","affiliation":[{"name":"University of North Carolina","place":["Chapel Hill, NC, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vrinda","family":"Mohan","sequence":"additional","affiliation":[{"name":"Department of Medicine, Kasturba Medical College","place":["Manipal, India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alejandro","family":"Perez Martinez","sequence":"additional","affiliation":[{"name":"Instituto Tecnol\u00f3gico de Estudios Superiores de Monterrey","place":["Guadalajara, Mexico"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Milind","family":"Nellutla","sequence":"additional","affiliation":[{"name":"MNR Medical College & Hospital","place":["Sangareddy, Telangana, India"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mariam","family":"Alamgir","sequence":"additional","affiliation":[{"name":"School of Medicine, St. George's University","place":["True Blue, Grenada"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ayesha","family":"Anjum","sequence":"additional","affiliation":[{"name":"Fatima Memorial Hospital, College of Medicine and Dentistry","place":["Lahore, Pakistan"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fadi Ali","family":"Jamaleddin Ahmad","sequence":"additional","affiliation":[{"name":"The University of New Mexico School of Medicine","place":["Albuquerque, NM, United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Taiwo Shola","family":"Oguntona","sequence":"additional","affiliation":[{"name":"Lagos State University College of Medicine, Ikeja","place":["Lagos, Nigeria"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hussam Ahmed","family":"Mohamed Ali Saari","sequence":"additional","affiliation":[{"name":"Department of Medicine, Privolzhsky Research Medical University","place":["Nizhny Novgorod, Russia"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dakshayini","family":"Suresh","sequence":"additional","affiliation":[{"name":"Department of Medicine, University Hospitals Plymouth NHS Trust","place":["Plymouth, United 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