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Nutrition in acute and chronic diseases

Effects of a low free sugar diet on the management of nonalcoholic fatty liver disease: a randomized clinical trial



Although the role of a diet rich in fructose and saccharose in development of nonalcoholic fatty liver disease (NAFLD) is well known, the effects of a low free sugar diet in the management of the disease have not yet been investigated in adult patients with NAFLD. We aimed, therefore, to analyze the effects of a low-free sugar diet on NAFLD main features.


Participants with FibroScan-proven NAFLD were randomized to a 12-week dietary intervention (low free sugar diet or usual diet). The primary outcome was change in hepatic steatosis measurement between baseline and 12 weeks. The secondary outcomes included changes in anthropometric measurements, lipid profile, glycemic indices, liver enzymes, and inflammatory factors.


Forty-three subjects completed the 12-week intervention. Low free sugar diet compared with the usual diet significantly decreased the concentrations of ALT (43.00 ± 27.54 to 27.95 ± 20.77 U/L), TG (172.86 ± 83.04 to 144.19 ± 65.55), TC (155.54 ± 37.55 to 139.86 ± 33.63 mg/dL), FBS (103.95 ± 15.42 to 91.00 ± 14.36 mg/dL), insulin (14.37 ± 5.79 to 8.92 ± 5.43 mU/L), HOMA-IR (3.81 ± 1.80 to 2.06 ± 1.29), hs-CRP (3.80 ± 1.09 to 2.88 ± 0.52 mg/L), TNF-α (4.60 ± 1.54 to 3.41 ± 0.69 pg/mL), NF-kb (3.89 ± 1.34 to 3.35 ± 1.33), as well as resulted in reduced fibrosis score and steatosis score, with increased QUICKI (P < 0.05). The differences in AST, GGT, HDL-C and LDL-C were not significant (P > 0.05).


Low free sugar diet in overweight/obese NAFLD patients may reduce hepatic steatosis and fibrosis while improving glycemic indices, decreasing the concentrations of biomarkers of inflammation, TG, and TC levels.

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Fig. 1: Consort Diagram of the Trial.
Fig. 2: changes in study outcomes in each participants.


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We thank all participants in this study without whom the study was impossible. The study was financially supported by Shahid Beheshti University of Medical Sciences.

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The authors’ responsibilities were as follows—BKH and AH: conceptualized and designed the study and wrote the manuscript; BKH and HK: analyzed the data; BKH, ZY, SMA, BH, AS, and AH: collected the data; HOS and AH: interpreted the data, and provided professional comments; AH: critically revised the manuscript for intellectual content and data accuracy; AH had responsibility for the final content; and all authors read and approved the final manuscript.

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Correspondence to Azita Hekmatdoost.

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Khodami, B., Hatami, B., Yari, Z. et al. Effects of a low free sugar diet on the management of nonalcoholic fatty liver disease: a randomized clinical trial. Eur J Clin Nutr 76, 987–994 (2022).

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