Exercise Prescription in Metabolic Dysfunction - Associated Steatotic Liver Disease: Aerobic Training, Resistance Exercise and High-Intensity Interval Training - A Narrative Review
DOI:
https://doi.org/10.12775/QS.2026.76.75360Keywords
MASLD, MASH, exercise prescription, aerobic exercise, resistance training, high-intensity interval training, hepatic steatosisAbstract
Background. Exercise is a first-line component of care for metabolic dysfunction-associated steatotic liver disease (MASLD), but modality-specific prescriptions remain uncertain.
Aim. To compare evidence for aerobic training, resistance exercise and high-intensity interval training (HIIT), and provide a phenotype-oriented framework for frequency, intensity, time, type, safety and monitoring.
Material and methods. A structured, PubMed-focused narrative search was conducted from database inception to 8 June 2026 using prespecified disease and exercise terms; reference lists of major guidelines, reviews and trials were searched. Adult human guidelines, evidence syntheses and intervention studies were assessed by one reviewer using SANRA-informed narrative methods.
Results. Exercise reduces liver fat and improves cardiorespiratory fitness and several cardiometabolic outcomes, often without clinically significant weight loss. Aerobic and resistance training are both effective; HIIT is time-efficient and generally comparable, not clearly superior, to moderate-intensity continuous training. Evidence for fibrosis regression, histological MASH resolution and long-term clinical events remains limited.
Conclusions. A patient-centered program should usually combine ≥150 min/week of moderate aerobic activity with resistance training on 2-3 non-consecutive days. HIIT is an optional, progressively introduced alternative for appropriately screened patients. Adherence, comorbidity, functional capacity and safety should determine modality selection.
References
1. Rinella ME, Lazarus JV, Ratziu V, Francque SM, Sanyal AJ, Kanwal F, Romero D, Abdelmalek MF, Anstee QM, Arab JP, Arrese M, Bataller R, Beuers U, Boursier J, Bugianesi E, Byrne CD, Castro Narro GE, Chowdhury A, Cortez-Pinto H, Cryer DR, Cusi K, El-Kassas M, Klein S, Eskridge W, Fan J, Gawrieh S, Guy CD, Harrison SA, Kim SU, Koot BG, Korenjak M, Kowdley KV, Lacaille F, Loomba R, Mitchell-Thain R, Morgan TR, Powell EE, Roden M, Romero-Gómez M, Silva M, Singh SP, Sookoian SC, Spearman CW, Tiniakos D, Valenti L, Vos MB, Wong VW, Xanthakos S, Yilmaz Y, Younossi Z, Hobbs A, Villota-Rivas M, Newsome PN, NAFLD Nomenclature consensus group. A multisociety Delphi consensus statement on new fatty liver disease nomenclature. J Hepatol. 2023;79(6):1542–1556. https://doi.org/10.1016/j.jhep.2023.06.003.
2. Kim D, Murag S, Cholankeril G, Cheung A, Harrison SA, Younossi ZM, Ahmed A. Physical activity, measured objectively, is associated with lower mortality in patients with nonalcoholic fatty liver disease. Clin Gastroenterol Hepatol. 2021;19(6):1240–1247.e5. https://doi.org/10.1016/j.cgh.2020.07.023.
3. European Association for the Study of the Liver (EASL); European Association for the Study of Diabetes (EASD); European Association for the Study of Obesity (EASO). EASL–EASD–EASO Clinical Practice Guidelines on the management of metabolic dysfunction-associated steatotic liver disease (MASLD). J Hepatol. 2024;81(3):492–542. https://doi.org/10.1016/j.jhep.2024.04.031.
4. Rinella ME, Neuschwander-Tetri BA, Siddiqui MS, Abdelmalek MF, Caldwell S, Barb D, Kleiner DE, Loomba R. AASLD Practice Guidance on the clinical assessment and management of nonalcoholic fatty liver disease. Hepatology. 2023;77(5):1797–1835. https://doi.org/10.1097/HEP.0000000000000323.
5. Stine JG, DiJoseph K, Pattison Z, Harrington A, Chinchilli VM, Schmitz KH, Loomba R. Exercise training is associated with treatment response in liver fat content by magnetic resonance imaging independent of clinically significant body weight loss in patients with nonalcoholic fatty liver disease: a systematic review and meta-analysis. Am J Gastroenterol. 2023;118(7):1204–1213. https://doi.org/10.14309/ajg.0000000000002098.
6. Orci LA, Gariani K, Oldani G, Delaune V, Morel P, Toso C. Exercise-based interventions for nonalcoholic fatty liver disease: a meta-analysis and meta-regression. Clin Gastroenterol Hepatol. 2016;14(10):1398–1411. https://doi.org/10.1016/j.cgh.2016.04.036.
7. Keating SE, Hackett DA, George J, Johnson NA. Exercise and non-alcoholic fatty liver disease: a systematic review and meta-analysis. J Hepatol. 2012;57(1):157–166. https://doi.org/10.1016/j.jhep.2012.02.023.
8. Keating SE, Sabag A, Hallsworth K, Hickman IJ, Macdonald GA, Stine JG, George J, Johnson NA. Exercise in the management of metabolic-associated fatty liver disease (MAFLD) in adults: a position statement from Exercise and Sport Science Australia. Sports Med. 2023;53(12):2347–2371. https://doi.org/10.1007/s40279-023-01918-w.
9. Baethge C, Goldbeck-Wood S, Mertens S. SANRA—a scale for the quality assessment of narrative review articles. Res Integr Peer Rev. 2019;4:5. https://doi.org/10.1186/s41073-019-0064-8.
10. Stine JG, Long MT, Corey KE, Sallis RE, Allen AM, Armstrong MJ, Conroy DE, Cuthbertson DJ, Duarte-Rojo A, Hallsworth K, Hickman IJ, Kappus MR, Keating SE, Pugh CJA, Rotman Y, Simon TL, Vilar-Gomez E, Wong VW, Schmitz KH. Physical activity and nonalcoholic fatty liver disease: a roundtable statement from the American College of Sports Medicine. Med Sci Sports Exerc. 2023;55(9):1717–1726. https://doi.org/10.1249/MSS.0000000000003199.
11. Houttu V, Bouts J, Vali Y, Daams J, Grefhorst A, Nieuwdorp M, Holleboom AG. Does aerobic exercise reduce NASH and liver fibrosis in patients with non-alcoholic fatty liver disease? A systematic literature review and meta-analysis. Front Endocrinol (Lausanne). 2022;13:1032164. https://doi.org/10.3389/fendo.2022.1032164.
12. Chen G, Banini B, Do A, Lim JK. The independent effect of exercise on biopsy-proven non-alcoholic fatty liver disease: a systematic review. Clin Mol Hepatol. 2023;29(Suppl):S319–S332. https://doi.org/10.3350/cmh.2022.0366.
13. Caussy C, Reeder SB, Sirlin CB, Loomba R. Noninvasive, quantitative assessment of liver fat by MRI-PDFF as an endpoint in NASH trials. Hepatology. 2018;68(2):763–772. https://doi.org/10.1002/hep.29797.
14. Tamaki N, Munaganuru N, Jung J, Yonan AQ, Loomba RR, Bettencourt R, Ajmera V, Valasek MA, Behling C, Sirlin CB, Loomba R. Clinical utility of 30% relative decline in MRI-PDFF in predicting fibrosis regression in non-alcoholic fatty liver disease. Gut. 2022;71(5):983–990. https://doi.org/10.1136/gutjnl-2021-324264.
15. Stine JG, Munaganuru N, Barnard A, Wang JL, Kaulback K, Argo CK, Singh S, Fowler KJ, Sirlin CB, Loomba R. Change in MRI-PDFF and histologic response in patients with nonalcoholic steatohepatitis: a systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2021;19(11):2274–2283.e5. https://doi.org/10.1016/j.cgh.2020.08.061.
16. Xue Y, Peng Y, Zhang L, Ba Y, Jin G, Liu G. Effect of different exercise modalities on nonalcoholic fatty liver disease: a systematic review and network meta-analysis. Sci Rep. 2024;14(1):6212. https://doi.org/10.1038/s41598-024-51470-4.
17. Hejazi K, Hackett D. Effect of exercise on liver function and insulin resistance markers in patients with non-alcoholic fatty liver disease: a systematic review and meta-analysis of randomized controlled trials. J Clin Med. 2023;12(8):3011. https://doi.org/10.3390/jcm12083011.
18. Wang ST, Zheng J, Peng HW, Cai XL, Pan XT, Li HQ, Hong QZ, Peng XE. Physical activity intervention for non-diabetic patients with non-alcoholic fatty liver disease: a meta-analysis of randomized controlled trials. BMC Gastroenterol. 2020;20(1):66. https://doi.org/10.1186/s12876-020-01204-3.
19. Nam H, Yoo JJ, Cho Y, Kang SH, Ahn SB, Lee HW, Jun DW, Song DS, Choi M. Effect of exercise-based interventions in nonalcoholic fatty liver disease: a systematic review with meta-analysis. Dig Liver Dis. 2023;55(9):1178–1186. https://doi.org/10.1016/j.dld.2022.12.013.
20. Stine JG, Schreibman IR, Faust AJ, Dahmus J, Stern B, Soriano C, Rivas G, Hummer B, Kimball SR, Geyer NR, Chinchilli VM, Loomba R, Schmitz K, Sciamanna C. NASHFit: a randomized controlled trial of an exercise training program to reduce clotting risk in patients with NASH. Hepatology. 2022;76(1):172–185. https://doi.org/10.1002/hep.32274.
21. Harris SJ, Smith N, Hummer B, Schreibman IR, Faust AJ, Geyer NR, Chinchilli VM, Sciamanna C, Loomba R, Stine JG. Exercise training improves serum biomarkers of liver fibroinflammation in patients with metabolic dysfunction-associated steatohepatitis. Liver Int. 2024;44(2):532–540. https://doi.org/10.1111/liv.15769.
22. Keating SE, Croci I, Wallen MP, Cox ER, Thuzar M, Pham U, Mielke GI, Coombes JS, Macdonald GA, Hickman IJ. High-intensity interval training is safe, feasible and efficacious in nonalcoholic steatohepatitis: a randomized controlled trial. Dig Dis Sci. 2023;68(5):2123–2139. https://doi.org/10.1007/s10620-022-07779-z.
23. Hallsworth K, Fattakhova G, Hollingsworth KG, Thoma C, Moore S, Taylor R, Day CP, Trenell MI. Resistance exercise reduces liver fat and its mediators in non-alcoholic fatty liver disease independent of weight loss. Gut. 2011;60(9):1278–1283. https://doi.org/10.1136/gut.2011.242073.
24. Bacchi E, Negri C, Targher G, Faccioli N, Lanza M, Zoppini G, Zanolin E, Schena F, Bonora E, Moghetti P. Both resistance training and aerobic training reduce hepatic fat content in type 2 diabetic subjects with nonalcoholic fatty liver disease (the RAED2 randomized trial). Hepatology. 2013;58(4):1287–1295. https://doi.org/10.1002/hep.26393.
25. Zelber-Sagi S, Buch A, Yeshua H, Vaisman N, Webb M, Harari G, Kis O, Fliss-Isakov N, Izkhakov E, Halpern Z, Santo E, Oren R, Shibolet O. Effect of resistance training on non-alcoholic fatty-liver disease: a randomized-clinical trial. World J Gastroenterol. 2014;20(15):4382–4392. https://doi.org/10.3748/wjg.v20.i15.4382.
26. Keating SE, Hackett DA, Parker HM, O'Connor HT, Gerofi JA, Sainsbury A, Baker MK, Chuter VH, Caterson ID, George J, Johnson NA. Effect of aerobic exercise training dose on liver fat and visceral adiposity. J Hepatol. 2015;63(1):174–182. https://doi.org/10.1016/j.jhep.2015.02.022.
27. Shamsoddini A, Sobhani V, Ghamar Chehreh ME, Alavian SM, Zaree A. Effect of aerobic and resistance exercise training on liver enzymes and hepatic fat in Iranian men with nonalcoholic fatty liver disease. Hepat Mon. 2015;15(10):e31434. https://doi.org/10.5812/hepatmon.31434.
28. Hallsworth K, Thoma C, Hollingsworth KG, Cassidy S, Anstee QM, Day CP, Trenell MI. Modified high-intensity interval training reduces liver fat and improves cardiac function in non-alcoholic fatty liver disease: a randomized controlled trial. Clin Sci (Lond). 2015;129(12):1097–1105. https://doi.org/10.1042/CS20150308.
29. Zhang HJ, He J, Pan LL, Ma ZM, Han CK, Chen CS, Chen Z, Han HW, Chen S, Sun Q, Zhang JF, Li ZB, Yang SY, Li XJ, Li XY. Effects of moderate and vigorous exercise on nonalcoholic fatty liver disease: a randomized clinical trial. JAMA Intern Med. 2016;176(8):1074–1082. https://doi.org/10.1001/jamainternmed.2016.3202.
30. Cuthbertson DJ, Shojaee-Moradie F, Sprung VS, Jones H, Pugh CJ, Richardson P, Kemp GJ, Barrett M, Jackson NC, Thomas EL, Bell JD, Umpleby AM. Dissociation between exercise-induced reduction in liver fat and changes in hepatic and peripheral glucose homoeostasis in obese patients with non-alcoholic fatty liver disease. Clin Sci (Lond). 2016;130(2):93–104. https://doi.org/10.1042/CS20150447.
31. Houghton D, Thoma C, Hallsworth K, Cassidy S, Hardy T, Burt AD, Tiniakos D, Hollingsworth KG, Taylor R, Day CP, McPherson S, Anstee QM, Trenell MI. Exercise reduces liver lipids and visceral adiposity in patients with nonalcoholic steatohepatitis in a randomized controlled trial. Clin Gastroenterol Hepatol. 2017;15(1):96–102.e3. https://doi.org/10.1016/j.cgh.2016.07.031.
32. Oh S, So R, Shida T, Matsuo T, Kim B, Akiyama K, Isobe T, Okamoto Y, Tanaka K, Shoda J. High-intensity aerobic exercise improves both hepatic fat content and stiffness in sedentary obese men with nonalcoholic fatty liver disease. Sci Rep. 2017;7:43029. https://doi.org/10.1038/srep43029.
33. Winn NC, Liu Y, Rector RS, Parks EJ, Ibdah JA, Kanaley JA. Energy-matched moderate and high intensity exercise training improves nonalcoholic fatty liver disease risk independent of changes in body mass or abdominal adiposity—a randomized trial. Metabolism. 2018;78:128–140. https://doi.org/10.1016/j.metabol.2017.08.012.
34. Abdelbasset WK, Tantawy SA, Kamel DM, Alqahtani BA, Soliman GS. A randomized controlled trial on the effectiveness of 8-week high-intensity interval exercise on intrahepatic triglycerides, visceral lipids, and health-related quality of life in diabetic obese patients with nonalcoholic fatty liver disease. Medicine (Baltimore). 2019;98(12):e14918. https://doi.org/10.1097/MD.0000000000014918.
35. Charatcharoenwitthaya P, Kuljiratitikal K, Aksornchanya O, Chaiyasoot K, Bandidniyamanon W, Charatcharoenwitthaya N. Moderate-intensity aerobic vs resistance exercise and dietary modification in patients with nonalcoholic fatty liver disease: a randomized clinical trial. Clin Transl Gastroenterol. 2021;12(3):e00316. https://doi.org/10.14309/ctg.0000000000000316.
36. Houttu V, Boulund U, Troelstra M, Csader S, Stols-Gonçalves D, Mak AL, Dijk AV, Bouts J, Winkelmeijer M, Verdoes X, van den Berg-Faay S, Lek D, Ronteltap T, de Haan F, Jorstad H, Männistö V, Savonen K, Pentikäinen H, Hanhineva K, Babu AF, Panagiotou G, van Delden O, Verheij J, Doukas M, Nederveen A, Schwab U, Grefhorst A, Nieuwdorp M, Holleboom AG. Deep phenotyping of patients with MASLD upon high-intensity interval training. JHEP Rep. 2025;7(3):101289. https://doi.org/10.1016/j.jhepr.2024.101289.
37. Garber CE, Blissmer B, Deschenes MR, Franklin BA, Lamonte MJ, Lee IM, Nieman DC, Swain DP, American College of Sports Medicine. American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: guidance for prescribing exercise. Med Sci Sports Exerc. 2011;43(7):1334–1359. https://doi.org/10.1249/MSS.0b013e318213fefb.
38. Shojaee-Moradie F, Cuthbertson DJ, Barrett M, Jackson NC, Herring R, Thomas EL, Bell J, Kemp GJ, Wright J, Umpleby AM. Exercise training reduces liver fat and increases rates of VLDL clearance but not VLDL production in NAFLD. J Clin Endocrinol Metab. 2016;101(11):4219–4228. https://doi.org/10.1210/jc.2016-2353.
39. Hashida R, Kawaguchi T, Bekki M, Omoto M, Matsuse H, Nago T, Takano Y, Ueno T, Koga H, George J, Shiba N, Torimura T. Aerobic vs resistance exercise in non-alcoholic fatty liver disease: a systematic review. J Hepatol. 2017;66(1):142–152. https://doi.org/10.1016/j.jhep.2016.08.023.
40. Medeiros DG, Ferreira LF, Lamp JDS, Telles da Rosa LH. The impact of resistance training in patients diagnosed with metabolic dysfunction-associated steatotic liver disease: a systematic review. Eur J Gastroenterol Hepatol. 2025;37(2):129–136. https://doi.org/10.1097/MEG.0000000000002887.
41. Slentz CA, Bateman LA, Willis LH, Shields AT, Tanner CJ, Piner LW, Hawk VH, Muehlbauer MJ, Samsa GP, Nelson RC, Huffman KM, Bales CW, Houmard JA, Kraus WE. Effects of aerobic vs resistance training on visceral and liver fat stores, liver enzymes, and insulin resistance by HOMA in overweight adults from STRRIDE AT/RT. Am J Physiol Endocrinol Metab. 2011;301(5):E1033–E1039. https://doi.org/10.1152/ajpendo.00291.2011.
42. Abdelbasset WK, Tantawy SA, Kamel DM, Alqahtani BA, Elnegamy TE, Soliman GS, Ibrahim AA. Effects of high-intensity interval and moderate-intensity continuous aerobic exercise on diabetic obese patients with nonalcoholic fatty liver disease: a comparative randomized controlled trial. Medicine (Baltimore). 2020;99(10):e19471. https://doi.org/10.1097/MD.0000000000019471.
43. Sabag A, Barr L, Armour M, Armstrong A, Baker CJ, Twigg SM, Chang D, Hackett DA, Keating SE, George J, Johnson NA. The effect of high-intensity interval training vs moderate-intensity continuous training on liver fat: a systematic review and meta-analysis. J Clin Endocrinol Metab. 2022;107(3):862–881. https://doi.org/10.1210/clinem/dgab795.
44. Fu J, Liu C, Yang L, Zhang B, Zhou R, Deng C, Zhang H, Kong J, Li J, Shi J. Effect of high-intensity interval training on clinical parameters in patients with metabolic dysfunction-associated steatotic liver disease: a systematic review and meta-analysis of randomized controlled trials. Eur J Gastroenterol Hepatol. 2025;37(7):789–798. https://doi.org/10.1097/MEG.0000000000002964.
45. Riebe D, Franklin BA, Thompson PD, Garber CE, Whitfield GP, Magal M, Pescatello LS. Updating ACSM's recommendations for exercise preparticipation health screening. Med Sci Sports Exerc. 2015;47(11):2473–2479. https://doi.org/10.1249/MSS.0000000000000664.
46. Colberg SR, Sigal RJ, Yardley JE, Riddell MC, Dunstan DW, Dempsey PC, Horton ES, Castorino K, Tate DF. Physical activity/exercise and diabetes: a position statement of the American Diabetes Association. Diabetes Care. 2016;39(11):2065–2079. https://doi.org/10.2337/dc16-1728.
47. Kanaley JA, Colberg SR, Corcoran MH, Malin SK, Rodriguez NR, Crespo CJ, Kirwan JP, Zierath JR. Exercise/physical activity in individuals with type 2 diabetes: a consensus statement from the American College of Sports Medicine. Med Sci Sports Exerc. 2022;54(2):353–368. https://doi.org/10.1249/MSS.0000000000002800.
48. Taylor JL, Holland DJ, Spathis JG, Beetham KS, Wisløff U, Keating SE, Coombes JS. Guidelines for the delivery and monitoring of high intensity interval training in clinical populations. Prog Cardiovasc Dis. 2019;62(2):140–146. https://doi.org/10.1016/j.pcad.2019.01.004.
49. Heinle JW, DiJoseph K, Sabag A, Oh S, Kimball SR, Keating S, Stine JG. Exercise is medicine for nonalcoholic fatty liver disease: exploration of putative mechanisms. Nutrients. 2023;15(11):2452. https://doi.org/10.3390/nu15112452.
50. Thyfault JP, Rector RS. Exercise combats hepatic steatosis: potential mechanisms and clinical implications. Diabetes. 2020;69(4):517–524. https://doi.org/10.2337/dbi18-0043.
51. O'Gorman P, Naimimohasses S, Monaghan A, Kennedy M, Melo AM, Ní Fhloinn D, Doherty DG, Beddy P, Finn SP, Moore JB, Gormley J, Norris S. Improvement in histological endpoints of MAFLD following a 12-week aerobic exercise intervention. Aliment Pharmacol Ther. 2020;52(8):1387–1398. https://doi.org/10.1111/apt.15989.
52. Channapragada T, Batra S, Hummer BL, Chinchilli VM, Huang D, Loomba R, Schreibman IR, Stine JG. Aerobic exercise training leads to MASH resolution as defined by the MASH Resolution Index. Dig Dis Sci. 2026;71(2):628–635. https://doi.org/10.1007/s10620-025-09361-9.
53. Pugh CJ, Sprung VS, Jones H, Richardson P, Shojaee-Moradie F, Umpleby AM, Green DJ, Cable NT, Trenell MI, Kemp GJ, Cuthbertson DJ. Exercise-induced improvements in liver fat and endothelial function are not sustained 12 months following cessation of exercise supervision in nonalcoholic fatty liver disease. Int J Obes (Lond). 2016;40(12):1927–1930. https://doi.org/10.1038/ijo.2016.123.
54. Lai JC, Tandon P, Bernal W, Tapper EB, Ekong U, Dasarathy S, Carey EJ. Malnutrition, frailty, and sarcopenia in patients with cirrhosis: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021;74(3):1611–1644. https://doi.org/10.1002/hep.32049.
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