Association between Dietary Acid Load and Risk of Metabolic Dysfunction-Associated Steatotic Liver Disease in Patients with Type 2 Diabetes

Zahra Yari^1*Hesam Bakhshi²Niayesh Naghshi²Danial Fotros²Azita Hekmatdoost²Marieh Salavatizadeh²Samira Soltanieh³Hossein Poustchi⁴Mohammad Ebrahim Khamseh⁵

• ¹National Nutrition and Food Technology Research Institute, Tehran, Iran
• ²Department of Clinical Nutrition and Dietetics, School of Nutrition Sciences and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Alborz, Iran
• ³Department of Nutrition and Food Science, College of Liberal Arts and Sciences, Wayne State University, Detroit, Michigan, United States
• ⁴Digestive Oncology Research Center, Digestive Disease Research Institute, Tehran University of Medical Sciences, Tehran, Alborz, Iran
• ⁵Institute of Endocrinology and Metabolism, Tehran University of Medical Sciences, Tehran, Alborz, Iran

Objective. Considering the high prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) among patients with type 2 diabetes and its associated complications, this study aimed to investigate the relationship between dietary acid load (DAL) and the risk of MASLD in patients with diabetes.Methods. This cross sectional study was conducted on 200 patients aged 18 to 70 with type 2 diabetes. Of whom, 133 participants were diagnosed with MASLD based on transit elastography (Fibroscan). For biochemical evaluation of liver enzymes, lipid profile, and fasting blood sugar, venous blood samples were collected after 10-12 hours of fasting. Dietary acid load was determined using a 147-item food frequency questionnaire based on PRAL (potential renal acid load) and NEAP (net endogenous acid production).Results. A total of 108 women and 92 men with an average age of 52.2 years and an average body mass index of 28.8 kg/m 2 participated in the study. After adjusting for confounders, the risk of MASLD in the third tertile of PRAL was 3.1 times higher than the first tertile (OR = 3.1, 95% CI = 1.2 -7.7). After adjusting for all confounding factors, participants in the highest tertile of NEAP had nearly seven times the chance of developing MASLD compared to those in the lowest tertile, which was statistically significant (OR = 7.3, 95% CI = 2.6 -20.3). Overall, the data analysis revealed a significant direct relationship between both PRAL (P trend = 0.016) and NEAP (P trend < 0.001) with the risk of MASLD.Our analysis revealed that a higher dietary acid load is associated with an increased risk of MASLD and liver steatosis in patients with type 2 diabetes.