Highlights
- Adherence to the Planetary Health Diet Index (PHDI) is inversely associated with the risk of metabolic dysfunction-associated steatotic liver disease (MASLD).
- Global country-level data suggests a non-linear, U-shaped association with maximum protection observed at a PHDI score of 50.69.
- Individual-level analysis (NHANES) demonstrates a robust linear relationship where higher PHDI adherence correlates with lower MASLD incidence.
- Sociodemographic disparities exist, with lower adherence noted among men, younger populations, and rural residents, identifying key targets for public health intervention.
The Intersection of Environmental Sustainability and Metabolic Health
The global healthcare landscape is currently facing two simultaneous crises: the rapid escalation of metabolic dysfunction-associated steatotic liver disease (MASLD)—formerly known as non-alcoholic fatty liver disease (NAFLD)—and the urgent requirement for sustainable food systems to mitigate environmental degradation. MASLD has become the leading cause of chronic liver disease worldwide, closely linked to obesity, type 2 diabetes, and dyslipidemia. Concurrently, the EAT-Lancet Commission has proposed the ‘Planetary Health Diet’ as a framework to optimize human health while remaining within planetary boundaries.
Recent research published in Frontiers in Nutrition by Liu et al. (2025) provides a critical bridge between these two domains. By evaluating the Planetary Health Diet Index (PHDI), a tool designed to measure compliance with the EAT-Lancet dietary recommendations, researchers have identified a clear protective role for this sustainable eating pattern against the development and progression of MASLD.
Study Design and Methodological Framework
To capture a comprehensive view of the relationship between diet and liver health, the investigators utilized a sophisticated multi-level analytical framework. This approach allowed for the examination of both broad geographical trends and granular individual behaviors.
Country-Level Analysis
The research team employed generalized additive mixed models (GAMMs) to analyze longitudinal data spanning from 1990 to 2018. This dataset integrated information from the Global Dietary Database (GDD) and the Global Burden of Disease (GBD) study. By utilizing GAMMs, the researchers could account for temporal trends and potential non-linear relationships across different nations and demographic subgroups.
Individual-Level Analysis
To validate the global findings, the study incorporated data from the National Health and Nutrition Examination Survey (NHANES). Multivariable regression models were applied to this cohort to assess the association between PHDI scores and MASLD status. These models were rigorously adjusted for confounding variables, including age, sex, socioeconomic status, physical activity, and total caloric intake, to ensure the independence of the dietary association.
Key Findings: Global Trends and Non-linear Dynamics
The longitudinal analysis of data from 1990 to 2018 revealed significant shifts in PHDI adherence across the globe. While overall adherence remains suboptimal, progressive improvements were noted in specific populations. Older adults (75 years and above), urban dwellers, and individuals with higher educational attainment showed the most marked increases in PHDI scores. Notably, the study found that women consistently demonstrated higher adherence to the planetary health diet than men across most regions.
The global-level analysis using GAMMs yielded a particularly intriguing result: a non-linear, U-shaped partial effect curve regarding MASLD incidence. The data indicated that while increasing PHDI scores generally reduced MASLD risk, there was an ‘optimal’ adherence point. After adjusting for various confounders, the maximum protective association was reached at a PHDI score of 50.69. This suggests that while a plant-forward, sustainable diet is highly beneficial, the relationship between diet and liver health at a population level may be influenced by complex socio-economic and environmental factors that require further investigation.
Individual-Level Evidence: Linear Protection
In contrast to the U-shaped curve found at the country level, the individual-level analysis from the NHANES cohort revealed a clear, linear inverse relationship. As individual PHDI scores increased, the likelihood of having MASLD decreased significantly. This linear protection highlights the clinical relevance of the EAT-Lancet recommendations for individual patients.
The Planetary Health Diet emphasizes a high intake of whole grains, legumes, nuts, fruits, and vegetables, while significantly limiting red meat, processed sugars, and saturated fats. The individual-level data suggests that every incremental improvement toward this dietary pattern provides measurable benefits in reducing hepatic steatosis and metabolic dysfunction.
Expert Commentary and Mechanistic Insights
The protective effect of the PHDI against MASLD is biologically plausible and aligns with our current understanding of hepatic pathophysiology. The planetary health diet is inherently high in dietary fiber and phytonutrients, which are known to modulate the gut-liver axis and reduce systemic inflammation. By replacing saturated fats from animal sources with unsaturated fats from plants and nuts, the diet helps improve insulin sensitivity and reduces the lipotoxic burden on hepatocytes.
Furthermore, the reduction in processed sugars—a hallmark of the PHDI—limits the substrate for de novo lipogenesis in the liver. Clinical experts note that the study’s findings reinforce the ‘food as medicine’ paradigm, suggesting that dietary interventions can serve as a primary strategy for both environmental stewardship and chronic disease prevention. However, it is important to acknowledge the study’s limitations, such as the reliance on self-reported dietary data and the observational nature of the research, which precludes a definitive statement on causality.
Conclusion: A Path Forward for Public Health
The research by Liu et al. underscores the necessity of targeted public health interventions to improve dietary adherence, particularly among younger populations, men, and those in rural areas where adherence is currently lowest. As the global burden of MASLD continues to rise, the Planetary Health Diet Index offers a scientifically backed and environmentally responsible framework for dietary guidelines.
Moving forward, longitudinal research and clinical trials are needed to establish causal links and to develop culturally adapted implementation strategies. By aligning human nutritional needs with the health of the planet, clinicians and policymakers can address two of the most pressing challenges of the 21st century simultaneously.
References
Liu ZQ, Zhou BG, Fang JW, Yu Y, Jiang X, Chen XY, Wang WJ, Fu XY, Xia JL, Liu BJ, Guo TM, Zhang M, Ding YB. Protective role of the planetary health diet index against metabolic dysfunction-associated steatotic liver disease: global and individual evidence. Front Nutr. 2025;12:1673662. doi: 10.3389/fnut.2025.1673662.
