{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,15]],"date-time":"2026-10-15T18:56:16Z","timestamp":1792090576404,"version":"4.4.0"},"reference-count":82,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2025,12,20]],"date-time":"2025-12-20T00:00:00Z","timestamp":1766188800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100011096","name":"DOST-PCHRD","doi-asserted-by":"crossref","id":[{"id":"10.13039\/501100011096","id-type":"DOI","asserted-by":"crossref"}]},{"name":"O-liver Project"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Nutrients"],"abstract":"<jats:p>Background\/Objectives: Metabolic dysfunction-associated steatotic liver disease (MASLD) is now the most prevalent chronic liver disorder among children and adolescents, mirroring the rise in pediatric obesity. The Mediterranean diet (MD) has demonstrated anti-inflammatory, antioxidant, and beneficial effects on different health outcomes across different life stages. The MD\u2019s effect has been explored in adult MASLD, but there is limited information on the pediatric population. However, evidence on pediatric MASLD should be explored given its rising prevalence. Therefore, the aim of this review is to collect human studies assessing the effect of MD interventions on pediatric MASLD, focusing on key pathophysiological mechanisms. It also examines other interventions, including specific energy\/macronutrient prescriptions, nutrition education or counseling, and physical activity components. Methods: A comprehensive search of PubMed, Scopus, and Web of Science was conducted using terms related to the Mediterranean diet, nutrition education, physical activity, pediatrics, and MASLD\/NAFLD. Pre-determined inclusion and exclusion criteria were used to collect eligible studies to be included in the review. Study quality was assessed using the Academy of Nutrition and Dietetics Quality Criteria Checklist. Screening, data extraction, and appraisal were performed independently, with discrepancies resolved through discussion, and the findings were synthesized qualitatively. Results: This review synthesizes findings from eight human studies evaluating the impact of the MD, alone or integrated with structured exercise and nutrition education, on pediatric MASLD. Interventions consistently demonstrated reductions in hepatic steatosis, liver stiffness, and fibrosis markers, alongside improvements in inflammatory cytokines, oxidative stress defenses, and liver enzymes. The MD also enhanced lipid and glycemic profiles, lowering triglycerides, total cholesterol, and insulin resistance indices. Nutrition education and family-centered approaches improved adherence, while structured, enjoyable physical activity enhanced outcomes and long-term sustainability. Conclusions: Collectively, the MD, particularly when combined with exercise and tailored education, offers a safe, effective, and comprehensive lifestyle intervention for pediatric MASLD. Nonetheless, current evidence remains limited by small sample sizes, heterogeneity in protocols, and short follow-ups. Larger, multicenter randomized trials with standardized designs are needed to establish best practices and long-term efficacy.<\/jats:p>","DOI":"10.3390\/nu18010028","type":"journal-article","created":{"date-parts":[[2025,12,22]],"date-time":"2025-12-22T08:35:27Z","timestamp":1766392527000},"page":"28","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":10,"title":["The Impact of the Mediterranean Diet, Physical Activity, and Nutrition Education on Pediatric Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD): A Review"],"prefix":"10.3390","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-3625-6775","authenticated-orcid":false,"given":"Melvin","family":"Bernardino","sequence":"first","affiliation":[{"name":"MASLD Unit, Fondazione Italiana Fegato, 34149 Trieste, Italy"},{"name":"Department of Life Sciences, University of Trieste, 34100 Trieste, Italy"},{"name":"Philippine Council for Health Research and Development, Department of Science and Technology, Taguig City 1631, Philippines"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6596-7595","authenticated-orcid":false,"given":"Claudio","family":"Tiribelli","sequence":"additional","affiliation":[{"name":"MASLD Unit, Fondazione Italiana Fegato, 34149 Trieste, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4251-3547","authenticated-orcid":false,"given":"Natalia","family":"Rosso","sequence":"additional","affiliation":[{"name":"MASLD Unit, Fondazione Italiana Fegato, 34149 Trieste, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,12,20]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1204","DOI":"10.1002\/hep.32228","article-title":"Global burden of NAFLD and chronic liver disease among adolescents and young adults","volume":"75","author":"Paik","year":"2022","journal-title":"Hepatology"},{"key":"ref_2","first-page":"e934134","article-title":"A Review of the Increasing Prevalence of Metabolic-Associated Fatty Liver Disease (MAFLD) in Children and Adolescents Worldwide and in Mexico and the Implications for Public Health","volume":"27","year":"2021","journal-title":"Med. 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