**Background:** Nonalcoholic fatty liver disease (NAFLD) is characterized by triglyceride accumulation in hepatocytes (>5%) not due to alcohol consumption, encompassing simple steatosis and nonalcoholic steatohepatitis (NASH). NASH can progress to fibrosis, cirrhosis, and hepatocellular carcinoma in 15% of subjects. NAFLD is strongly associated with obesity, type II diabetes, dyslipidaemia, insulin resistance, and metabolic syndrome. Nutrition plays a critical role in both pathogenesis and prevention, with the Mediterranean diet emerging as a potentially protective dietary pattern due to its richness in fibre, carotenoids, omega-3 fatty acids, polyphenols, and folic acid.
**Methods:** Twenty-two obese or overweight patients (mean age 43 years, range 27–64) with hepatic steatosis confirmed by ultrasound were recruited after screening with the Montreal Cognitive Assessment (MoCA); those scoring below 26 were excluded to avoid confounding from cognitive impairment affecting treatment adherence. Patients were teetotal and nonsmoking. They were placed on a low-calorie diet (1300–1400 Kcal) composed of 20% protein, 25% lipids, and 55% carbohydrates, with specific recommendations including 45–60% carbohydrates (<10% simple sugars), 20–35% lipids (2–4 g/day omega-3), and 20–25% protein. Patients were monitored periodically for six months. Evaluations included eating habits, blood chemistry (fasting glycaemia, total and HDL cholesterol, AST and ALT transaminases), anthropometric parameters (body weight, height, BMI, waist circumference), nutritional status via bioimpedance (fat mass and lean mass), liver ultrasound, oxidative stress markers (malonylaldehyde [MDA] and reduced glutathione [GSH] in plasma), and adherence to the Mediterranean diet using the Mediterranean Adequacy Index (MAI). The MAI was calculated from 18 food groups as the ratio of energy from Mediterranean-typical foods (bread, cereals, legumes, potatoes, vegetables, fresh fruits, nuts, fish, wine, olive oil) to energy from less typical foods (milk, dairy, meat, eggs, animal fats, margarine, sweet beverages, cakes, sugar). The reference MAI value for the Italian Mediterranean population is between 4.0 and 8.5. Active meal management activities (diary compilation, meal preparation, recipe research, menu planning, shopping lists) were incorporated, and MoCA was readministered at study end.
**Key Results:** The comparison between T0 (baseline) and T1 (after 6 months) showed significant differences in clinical variables (p < 0.01). Spearman correlation analysis revealed a significant negative relationship between ALT transaminases and MAI (r = −0.48; p = 0.02). Additionally, a significant positive relationship was found between total cholesterol and MAI (r = −0.57; p = 0.005), and a significant negative relationship between ALT and MAI was also reported as r = −0.56; p = 0.007 in the abstract (the Results section reports r = −0.48; p = 0.02). Patients did not show a significant improvement in cognitive performance as measured by MoCA between T0 and T1.
**Clinical Implications:** The study reinforces that a Mediterranean diet pattern—rich in fibre, carotenoids, polyphenols, omega-3 fatty acids, and folic acid—is inversely correlated with serum ALT transaminase levels, a key marker of liver damage. This suggests that dietary intervention based on Mediterranean diet principles may modulate the prevention, development, and progression of NAFLD in obese and overweight individuals. The lack of significant cognitive improvement may reflect the relatively short intervention period or the small sample size. The authors emphasize that the Mediterranean diet represents not merely a food pattern but a lifestyle encompassing seasonality, conviviality, frugality, and physical activity. Further studies with larger samples are needed to investigate the extent and quality of these effects more deeply.