Total ultra-processed food intake and selected food-group exposures in relation to non-alcoholic fatty liver disease: a systematic review and meta-analysis

Abstract

Background Ultra-processed food (UPF) consumption has been linked to cardiometabolic diseases, but the association with non-alcoholic fatty liver disease (NAFLD) remains unclear. Moreover, whether all UPFs confer similar risk is unknown. Objective To systematically review and meta-analyze the association between total UPF intake (strictly defined by NOVA classification) and selected UPF-related food-group exposures [red/processed meat and sugar-sweetened beverages (SSBs)] and NAFLD risk in adults. Methods We searched PubMed, Web of Science, and Cochrane Library up to March 31, 2026, for observational studies reporting adjusted effect estimates for total UPF intake or selected food-group exposures and NAFLD. Study quality was assessed using the Newcastle-Ottawa Scale (NOS) or AHRQ criteria. Random-effects models pooled odds ratios (ORs) comparing highest vs. lowest intake categories. Subgroup and sensitivity analyses explored heterogeneity. Results Twenty-four studies were included in the systematic review. Of these, nine studies (5 prospective cohorts, 4 cross-sectional) comprising 250,349 participants were included for total UPF intake. Higher total UPF consumption was associated with a 26% increased NAFLD risk (pooled OR = 1.26; 95% CI: 1.16–1.37; I2 = 53%; P < 0.001). Red/processed meat consumption (6 studies) showed a stronger association (pooled OR = 1.70; 95% CI: 1.29–2.24; I2 = 76%; P < 0.001). SSB consumption (3 studies) was associated with a 50% increased risk (pooled OR = 1.50; 95% CI: 1.23–1.84; I2 = 0%; P < 0.001). Sensitivity analyses confirmed robustness. Conclusion Total UPF intake is associated with a moderate increase in NAFLD risk. Red/processed meat and sugar-sweetened beverages show stronger associations, suggesting that dietary recommendations may prioritize these high-risk food groups, although blanket avoidance of all UPFs is not directly supported by the current data.