Low-carbohydrate diets reduce cardiovascular risk factor levels in patients with metabolic dysfunction-associated steatotic liver disease: a systematic review and meta-analysis of randomized controlled trials

Background: Low-carbohydrate diets (LCDs) are increasingly advocated for the treatment of metabolic dysfunction-associated steatotic liver disease (MASLD); however, their cardiovascular safety profile remains controversial. This analysis aims to evaluate the effects of LCDs on cardiovascular risk factors in MASLD patients. Methods: PubMed, Cochrane Library, Web of Science, and Scopus were searched from inception to March 19, 2025. Two reviewers independently conducted data extraction. Meta-analyses were performed using fixed-effects or random-effects models, as determined by the heterogeneity of the included studies. Outcomes included blood pressure, glycemic markers, lipid profiles, and anthropometric indicators. Subgroup analyses explored carbohydrate thresholds (<26% vs. ≥26%) and intervention durations (<24 weeks vs. ≥24 weeks). Results: Sixteen RCTs comprising 1,056 participants were included. LCDs significantly reduced glycated hemoglobin (HbA1c: SMD, -0.27; 95% CI, -0.47 to -0.07), triglyceride (TG: SMD, -0.20; 95% CI, -0.34 to -0.06), body weight (SMD, -0.19; 95% CI, -0.36 to -0.03), and body mass index (BMI: SMD, -0.28; 95% CI, -0.42 to -0.14). Stricter carbohydrate restriction (<26% energy) further improved systolic/diastolic blood pressure, homeostatic model assessment insulin resistance index (HOMA-IR), HbA1c, TG, body weight, BMI, and waist circumference. Short-term interventions (<24 weeks) lowered HbA1c, TG, and BMI. Conclusion: This systematic review and meta-analysis found that LCDs are associated with improvements in cardiometabolic risk factors among patients with MASLD. Furthermore, short-term implementation of a strict carbohydrate-restricted dietary regimen may yield additional clinical benefits. Future research should prioritize: standardized nutrient assessment, enhanced adherence strategies, and cardiovascular endpoint trials. Systematic review registration: PROSPERO: CRD42024603432; https://www.crd.york.ac.uk/PROSPERO/view/CRD42024603432.