Effect of lifestyle interventions on pediatric obesity: a lifestyle medicine systematic review

Jung Eun Choi; Hee Jeoung Lim; Kyung Hee Kim; Hae Soon Kim

doi:10.3345/cep.2026.00927

Clin Exp Pediatr > Volume 69(9); 2026

Choi, Lim, Kim, and Kim: Effect of lifestyle interventions on pediatric obesity: a lifestyle medicine systematic review

Review Article

Endocrinology

Effect of lifestyle interventions on pediatric obesity: a lifestyle medicine systematic review

Jung Eun Choi, MD, PhD

, Hee Jeoung Lim, MD

, Kyung Hee Kim, MD

, Hae Soon Kim, MD, PhD

Department of Pediatrics, College of Medicine, Ewha Womans University, Seoul, Korea

Corresponding author: Hae Soon Kim, MD, PhD. Department of Pediatrics, Ewha Womans University Seoul Hospital, 260 Gonghang-daero, Gangseo-gu, Seoul 07804, Korea Email: hyesk@ewha.ac.kr

Received June 27, 2026 Revised July 13, 2026 Accepted July 14, 2026

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Clinical and Experimental Pediatrics 2026;69(9):686-693.

Published online: August 27, 2026

DOI: https://doi.org/10.3345/cep.2026.00927

Abstract

Childhood and adolescent obesity are major public health concerns with adverse cardiometabolic outcomes. Lifestyle interventions are the cornerstone of management; however, their effects are often evaluated as single components rather than being within an integrated framework. Lifestyle medicine recently emerged as a comprehensive approach emphasizing multiple health behaviors. This study aimed to evaluate the effects of lifestyle interventions on anthropometric and cardiometabolic outcomes in children and adolescents with overweight or obesity and interpret these findings within the framework of lifestyle medicine. A systematic review was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) 2020 guidelines. PubMed and Web of Science were searched for studies published from January 2019 to March 2026. Eligible studies examined children and adolescents with overweight or obesity who were receiving lifestyle interventions, including physical activity, dietary modification, or multicomponent approaches. The primary outcomes were anthropometric measures, while the secondary outcomes were cardiometabolic parameters. Sixteen studies were ultimately included. Lifestyle interventions were associated with improvements in anthropometric and cardiometabolic outcomes. All 5 exercise-based intervention studies reported improved anthropometric or cardiometabolic outcomes, particularly following high-intensity interval training. Among the 8 dietary intervention studies, 7 reported significant improvements, whereas one found no significant intergroup differences. All 3 multicomponent lifestyle intervention studies demonstrated favorable anthropometric and cardiometabolic outcomes. This analysis demonstrates that lifestyle interventions effectively treat pediatric obesity, with multicomponent approaches showing the greatest benefit. These findings support the importance of integrated lifestyle strategies consistent with lifestyle medicine principles. Further long-term studies are needed to confirm these findings.

Key words: Pediatric obesity, Lifestyle intervention, Lifestyle medicine, Exercise, Diet, Cardiometabolic outcomes

Key message

Lifestyle interventions effectively improve the anthropometric and cardiometabolic outcomes of children and adolescents with overweight or obesity. Multicomponent approaches integrating diet, physical activity, and behavioral strategies demonstrate the most consistent and comprehensive benefits. These findings strongly support the application of lifestyle medicine principles in pediatric obesity management. Long-term integrated interventions addressing multiple health behaviors are needed to ensure sustainable improvements.

Graphical abstract

Introduction

Childhood and adolescent obesity have increased markedly over the past several decades and are now recognized as major public health concerns. According to the World Health Organization, nearly 1 in 3 children worldwide are affected by overweight or obesity [1,2]. In Korea, recent national data indicate that the prevalence of obesity among children and adolescents reached 13.8% in 2023, remaining higher than prepandemic levels [3]. According to the National School Health Examination, the combined prevalence of overweight and obesity among school-aged children increased from 25.8% before the pandemic to 30.8% thereafter, highlighting the growing burden of pediatric excess weight. The prevalence of severe obesity continues to rise as well, posing significant long-term health risks [4].

Obesity can develop early in life and often persists into adulthood, contributing to increased risks of chronic diseases such as type 2 diabetes mellitus and metabolic dysfunction-associated steatotic liver disease [5-7]. Pediatric obesity is now recognized as a complex and multifactorial disease influenced by genetic, behavioral, and environmental factors including dietary patterns, physical inactivity, sleep disturbances, and psychosocial determinants [8].

In recent years, lifestyle medicine has emerged as an evidence-based and comprehensive approach to preventing and managing chronic diseases. The American College of Lifestyle Medicine (ACLM) defines lifestyle medicine as the use of evidence-based therapeutic approaches—including a predominantly whole-food, plant-based diet, regular physical activity, adequate sleep, stress management, avoidance of risky substances, and positive social connections—to prevent, treat, and often reverse chronic diseases [9,10]. This framework emphasizes the integration of multiple health behaviors rather than isolated interventions.

Accumulating evidence suggests that lifestyle interventions can improve both anthropometric outcomes, such as body mass index (BMI) and body weight, and cardiometabolic parameters, including blood pressure, lipid profiles, and glucose metabolism. Multicomponent interventions combining diet, physical activity, and behavioral modification appear to provide greater benefits than single-component approaches [11-14]. However, most existing studies have focused on individual components of lifestyle change, while fewer have explicitly examined these interventions within the broader framework of lifestyle medicine.

Therefore, this systematic review aimed to synthesize current evidence on lifestyle interventions for pediatric obesity, with focus on their effects on anthropometric and cardiometabolic outcomes, and contextualize these findings within the emerging framework of lifestyle medicine.

Methods

1. Search strategy

This systematic review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) 2020 guidelines [15]. The study selection process is presented in Fig. 1. A comprehensive literature search was performed on March 6, 2026, of the PubMed and Web of Science databases. The PubMed search strategy was developed based on 3 key concepts: (1) population (children and adolescents with obesity); (2) interventions (physical activity, exercise, diet, and lifestyle interventions); and (3) outcomes (metabolic syndrome, insulin resistance, hypertension, and dyslipidemia) using both text words and MeSH (medical subject headings) terms.

These terms were combined using Boolean operators (#1 AND #2 OR #3). Filters were applied to include only English language studies including human subjects published since January 1, 2019, and exclude nonoriginal articles such as editorials, comments, letters, and reviews. Only studies published in peer-reviewed journals indexed in the Science Citation Index Expanded were included.

The search period was limited to studies published from 2019 onward to capture the most recent evidence on lifestyle interventions for pediatric obesity. Earlier evidence was already summarized in previous systematic reviews and meta-analyses, and our objective was to evaluate contemporary studies reflecting current lifestyle medicine concepts and obesity management strategies.

2. Eligibility criteria

Studies were included if they met the following criteria: (1) participants were children or adolescents aged ≤18 years with overweight or obesity; (2) the intervention consisted of nonpharmacological lifestyle modifications, including diet, physical activity, exercise, or behavioral interventions; (3) the study reported outcomes related to obesity or cardiometabolic health, such as BMI, body weight, waist circumference, blood pressure, lipid profile, glucose metabolism, or insulin resistance; and (4) overweight and obesity were defined according to the criteria used in each individual study, including BMI percentile-based definitions, BMI z scores, or country-specific pediatric obesity criteria.

3. Study selection

A total of 6,794 studies were identified through the database search (2,493 from PubMed, 4,301 from the Web of Science). After the removal of 2,615 duplicate records, 4,179 studies remained for the title and abstract screening.

The title and abstract screening were performed independently by 2 reviewers (JEC and HJL) using the Rayyan web-based application. Studies that were clearly irrelevant—including animal studies, case reports, and other nonoriginal article types—were excluded. The full texts of the remaining 121 articles were then independently assessed by the 2 reviewers. Any discrepancies were resolved through discussion.

A total of 34 studies were selected for the detailed evaluation. Finally, 16 studies were included in the qualitative synthesis. The study selection process is presented in Fig. 1.

4. Data extraction

The data were extracted independently by the 2 reviewers onto a standardized data extraction form. Any discrepancies were resolved through discussion. The following information was collected from each study: first author, publication year, country, study design, number of participants, participant characteristics, intervention type, control group, interventional duration, and main outcomes.

5. Outcomes of interest

The primary outcomes of interest were changes in anthropometric measures, including BMI, BMI standard deviation score, or BMI z score, body weight, and waist circumference, and body composition measures such as body fat percentage and fat mass. Secondary outcomes included cardiometabolic parameters such as blood pressure, lipid profile, glucose metabolism, insulin resistance, and other relevant metabolic biomarkers.

6. Quality assessment

A formal risk-of-bias assessment was conducted of all included studies. Randomized controlled trials (RCTs) were evaluated using the Cochrane Risk of Bias 2 tool, whereas nonrandomized studies were assessed using the Risk Of Bias In Non-randomized Studies - of Interventions tool. Overall judgments were categorized as low risk, some concerns, or high risk of bias for RCTs and as low, moderate, serious, or critical risk of bias for nonrandomized studies. The results of the quality assessment are presented in Supplementary Table 1 [16-31].

Results

1. Study selection process

After the screening of 6,794 records, 16 studies met the eligibility criteria and were included in the final qualitative synthesis (Fig. 1).

2. Study characteristics

The included studies were conducted across various countries, including China, the United States, European countries, and others, and involved children and adolescents with overweight or obesity. The sample sizes ranged from small pilot trials to large cluster randomized studies, while the interventional durations varied from short-term (4–12 weeks) to long-term (up to 2 years). The interventions were categorized into 3 main types: exercise-based, dietary, and multicomponent lifestyle combining diet, physical activity, and behavioral strategies. Multicomponent interventions included 2 or more components such as diet, physical activity, or behavioral strategies. The characteristics of the included studies are summarized in Table 1 [16-31].

3. Effects of exercise-based interventions

All 5 exercise-based interventions demonstrated beneficial effects on the subjects' anthropometric and cardiometabolic outcomes, with favorable effects reported in all included exercise-based studies. High-intensity interval training (HIIT) and interval training were associated with reductions in BMI, adiposity, and insulin resistance along with improvements in cardiorespiratory fitness [16,17]. For example, one HIIT study reported mean reductions of BMI, 1.8 kg/m²; low-density lipoprotein cholesterol, 17.2%; and Homeostatic Model Assessment of Insulin Resistance (HOMA-IR), 27.3% after 12 weeks of intervention [16]. HIIT showed greater improvements than moderate-intensity exercise, while combined training approaches further improved the subjects' cardiovascular and endothelial function [19].

Recreational exercise, such as soccer-based programs, improved lipid profiles and reduced the prevalence of metabolic syndrome [18]. Additional structured exercise interventions, including physiotherapy-based programs, demonstrated improvements in blood pressure, insulin resistance, and cardiopulmonary function [20].

4. Effects of dietary interventions

Among the 8 dietary intervention studies, 7 reported favorable anthropometric and/or cardiometabolic outcomes, whereas the other reported no significant intergroup differences. Interventions promoting healthy dietary patterns and improved dietary quality were associated with favorable changes in body weight, body composition measures, and blood pressure, with Dietary Approaches to Stop Hypertension (DASH) diet-based approaches representing one such intervention [21]. In one DASH trial, mean systolic blood pressure decreased from 105 to 97.7 mmHg after 8 weeks of intervention [22]. Fiber-based interventions improved glycemic control and insulin resistance, with HOMA-IR reductions ranging from 26% to 43% compared with controls [23]. Among the evaluated dietary interventions, Mediterranean-style dietary approaches were associated with improvements in insulin resistance, hepatic steatosis, and other metabolic parameters [25,26]. The sugar-restriction interventions demonstrated improvements in hepatic and metabolic outcomes including reductions in hepatic fat, insulin levels, and de novo lipogenesis [27]. However, some dietary interventions showed no significant intergroup differences in cardiometabolic outcomes, suggesting that overall dietary patterns may be more important than individual components [28].

5. Effects of multicomponent lifestyle interventions

All 3 multicomponent interventions combining diet, physical activity, and behavioral strategies across all included studies demonstrated improvements in anthropometric and cardiometabolic outcomes. Favorable outcomes were reported in all multicomponent lifestyle intervention studies. School- and family-based interventions significantly improved blood pressure and obesity-related outcomes [29,30]. Lifestyle interventions combining dietary and physical activity components improved body composition, metabolic outcomes, and even biomarkers such as telomere length [31].

6. Overall synthesis of findings

Overall, the lifestyle interventions were consistently associated with improved anthropometric and cardiometabolic outcomes in children and adolescents with overweight or obesity. Among the different intervention types, the multicomponent interventions tended to show more consistent and comprehensive benefits, followed by exercise-based and dietary interventions. Higher-intensity exercise and specific dietary approaches, such as sugar restriction and increased fiber intake, may provide additional metabolic benefits.

Discussion

1. Summary of evidence

This systematic review evaluated the effects of lifestyle interventions on the anthropometric and cardiometabolic outcomes of children and adolescents with overweight or obesity. Overall, the lifestyle interventions were associated with meaningful improvements in body composition and metabolic health. Reductions in BMI, body fat, and waist circumference were consistently observed along with improvements in blood pressure, lipid profiles, and insulin resistance. The multicomponent interventions were associated with favorable anthropometric and cardiometabolic outcomes across all included studies. However, the interpretation of their relative effectiveness should be made cautiously because the intervention duration and characteristics differed substantially across studies.

Importantly, these findings align with the broader framework of lifestyle medicine, which emphasizes the integration of multiple health behaviors—including physical activity, nutrition, sleep, stress management, and behavioral modification—as a comprehensive approach to chronic disease prevention and management [9,10].

2. Interpretation of findings

The exercise-based interventions showed robust and consistent benefits across studies. In particular, HIIT appeared to confer greater improvements in cardiorespiratory fitness and metabolic parameters compared with moderate-intensity continuous exercise. These effects may be explained by enhanced insulin sensitivity, improved mitochondrial function, and increased post-exercise energy expenditure. Within the context of lifestyle medicine, structured physical activity represents a core therapeutic pillar as emphasized by the ACLM, and our findings further support its central role in pediatric obesity management [9,10,13].

The dietary interventions demonstrated beneficial but more variable effects depending on intervention type and structure. Structured dietary patterns, such as the DASH or Mediterranean diet, were generally associated with improvements in blood pressure and metabolic profiles [21,25,26]. In contrast, interventions targeting single dietary components showed less consistent results [24,28], suggesting that overall dietary quality and patterns are more important than isolated nutrient modifications. This perspective is consistent with lifestyle medicine principles, which prioritize whole-food, predominantly plant-based dietary patterns [10].

The multicomponent interventions combining diet, physical activity, and behavioral strategies showed the most consistent and comprehensive benefits. This finding reflects the multifactorial nature of pediatric obesity and strongly supports the lifestyle medicine approach, which advocates for the simultaneous modification of multiple health behaviors [9,10,12,13]. Behavioral components, including family involvement and structured counseling, likely enhance adherence and facilitate long-term habit formation. These elements correspond to key domains of lifestyle medicine, such as behavior change techniques, social support, and environmental modification [10,14].

Notably, although most included studies focused on diet and physical activity, other important components of lifestyle medicine—such as sleep optimization, stress management, and reducing sedentary behavior—were less frequently addressed. The ACLM identifies these domains as essential pillars of lifestyle medicine [10]; their limited inclusion in the current studies highlights an important gap in the evidence base.

The variability in study outcomes may be explained by differences in interventional duration, intensity, and adherence as well as participant characteristics. For example, shorter interventions may be insufficient to produce sustained metabolic changes, while the inconsistent implementation of behavioral components may limit their effectiveness. The heterogeneity in outcome measures and study populations further complicates direct interstudy comparisons.

Overall, our findings are consistent with those of previous literature demonstrating the benefits of lifestyle interventions in pediatric obesity [9,12,13]. However, this review extends the prior work by highlighting the added value of integrated multicomponent approaches and situating these findings within the broader conceptual framework of lifestyle medicine as defined by the ACLM [10].

3. Study strengths and limitations

This study has 2 primary strengths. First, it included a broad range of recent interventional studies with focus on RCTs and provided an up-to-date synthesis of current evidence. Second, by examining different types of interventions, we were able to contextualize our findings within the established framework of lifestyle medicine [10].

However, several study limitations should also be considered. First, there was substantial heterogeneity among the included studies in terms of intervention type, duration, and outcome measures, which limits direct comparisons. Second, many studies had relatively short follow-up periods, preventing the assessment of long-term sustainability—an essential component of lifestyle medicine. Third, most studies focused primarily on diet and exercise with limited evaluations of other lifestyle medicine domains such as sleep, stress, and psychosocial factors. Fourth, developmental stage and pubertal status were not consistently reported across studies and, therefore, could not be systematically evaluated. Finally, variability in adherence and implementation fidelity may have influenced the outcomes. It remains unclear whether the favorable outcomes observed in the multicomponent interventions are attributable to the inclusion of multiple lifestyle components and/or their generally longer duration.

4. Clinical implications

The findings of this review support the role of lifestyle interventions as a cornerstone in the management of pediatric overweight and obesity and reinforce the relevance of lifestyle medicine as a comprehensive clinical approach. Structured exercise programs, particularly those incorporating HIIT, may provide significant metabolic benefits, while dietary interventions should emphasize overall dietary patterns rather than isolated nutrient restriction [21,22,26].

Importantly, the multicomponent interventions aligned with lifestyle medicine principles, which should be prioritized in clinical practice. These interventions include integrated strategies that address physical activity, nutrition, behavioral modification, and family involvement [11-14]. Expanding interventions to include additional lifestyle medicine components—such as sleep hygiene, stress management, and reducing sedentary behavior—as recommended by the ACLM may further enhance interventional effectiveness and sustainability [10].

5. Future research directions

Future studies should aim to develop and evaluate comprehensive lifestyle medicine-based interventions that incorporate all major domains of healthy living as outlined by the ACLM [10]. Large-scale long-term RCTs are needed to assess the sustainability of these interventions as well as their impact on long-term health outcomes.

Conclusion

Lifestyle interventions effectively improve anthropometric and cardiometabolic outcomes of children and adolescents with overweight or obesity. The multicomponent interventions were associated with favorable anthropometric and cardiometabolic outcomes and were well aligned with lifestyle medicine principles. Future efforts should focus on implementing comprehensive, sustainable, and individualized lifestyle medicine approaches to optimize pediatric obesity management.

Supplementary material

Supplementary Table 1 is available at https://doi.org/10.3345/cep.2026.00927.

Supplementary Table 1.

Risk-of-bias assessment of included studies

cep-2026-00927-Supplementary-Table-1.pdf

Footnotes

Conflicts of interest

No potential conflict of interest relevant to this article was reported.

Funding

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Acknowledgments

Artificial intelligence (AI) tools were used to support manuscript preparation. Rayyan AI was used to assist with literature screening during the study selection process. Gamma AI was used to support the preparation of the graphical abstract. ChatGPT (OpenAI, GPT-5.5) was used to assist with English language editing and improvement of manuscript readability. All outputs generated by these tools were reviewed, verified, and edited by the authors. The authors take full responsibility for the content, interpretation, and integrity of the manuscript.

Author contribution

Conceptualization: JEC, HJL, HSK; Data curation: JEC, HJL, KHK, HSK; Formal analysis: JEC; Methodology: JEC, HJL, KHK, HSK; Project administration: JEC, HSK; Visualization: JEC, HSK; Writing - original draft: JEC; Writing - review & editing: HSK

Fig. 1.

Flow diagram summarizing the literature search and selection process. WoS, Web of Science.

Table 1.

Characteristics of included studies of lifestyle interventions delivered to children and adolescents with overweight or obesity

Study	Study design	Participants	Intervention	Control	Duration	Main outcomes
Exercise-based interventions
Meng et al. (2022), China [16]	RCT, 3 arms	Adolescents with obesity (n=36; mean age, 11.2 yr)	HIIT, 3 sessions/wk	Nonexercise; moderate training	12 Wk	↓BMI, ↓adiposity, ↓LDL, ↓IR; ↑fitness
Racil et al. (2025), Tunisia [17]	RCT, 3 arms	Girls with severe obesity (n=35; mean age, 14.4 yr)	Interval training, 3 sessions/wk	Nonexercise	8 Wk	↓BMI, ↓BP, ↓glucose; ↑fitness
Vasconcellos et al. (2021), Brazil [18]	RCT (pilot), 2 arms	Adolescents with MetS (n=13; age, 13–17 yr)	Recreational soccer 3 sessions/wk	Nonexercise	12 Wk	↑HDL, ↓TG; ↓MetS prevalence
Wang et al. (2025), China/Poland [19]	RCT, 3 arms	Overweight children (n=90; age, 9–12 yr)	HIIT±diet	Moderate-intensity continuous training	9 Wk	↓BMI, ↓lipids; ↑CV function
Tsakona et al. (2025), Greece [20]	Non-RCT	Children/adolescents with morbid obesity (n=31; age, 5–18 yr)	Physiotherapy + stress management	Usual physical activity with exercise advice	16 Wk	↓BMI, ↓BP, ↓IR; ↑HDL
Dietary interventions
Rasaei et al. (2025), Iran [21]	RCT	Overweight/obese (n=58; age, 8–12 yr)	DASH diet	Standard diet	8 Wk	↓Weight, ↓WC, ↓BMI
Rasaei et al. (2025), Iran [22]	RCT	Overweight/obese (n=58; age, 8–12 yr)	DASH diet (sodium-restricted)	Usual diet	8 Wk	↓SBP, ↓DBP
Abdallah et al. (2025), Egypt [23]	RCT, 3 arms	Children with obesity (n=111; age, 6–13 yr)	Fiber supplementation/diet	General lifestyle counseling only	8 Wk	↓Glucose, ↓insulin, ↓BMI
Schmidt et al. (2023), USA [24]	RCT	Adolescents with obesity (n= 105; age, 11–18 yr),	Sugar reduction (≤10% energy)	Dietitian-led control	12 Wk	↓TG, ↓TNF-α; ↑β-cell function
Blancas-Sánchez et al. (2022), Spain [25]	RCT (pilot)	Children with prediabetes (n= 29; age, ~10 yr)	Mediterranean diet, education	Standard advice	20 Wk	↓HbA1c, ↓insulin, ↓WC
Yurtdaş et al. (2022), Turkey [26]	RCT	Adolescents with MASLD (n=44; age, 11–18 yr)	Mediterranean diet	Low-fat diet	12 Wk	↓BMI, ↓steatosis, ↓IR
Cohen et al. (2021), USA [27]	RCT	Boys with MASLD (n=29; age, 11–16 yr)	Low free-sugar diet	Usual diet	8 Wk	↓Hepatic fat, ↓insulin, ↓ALT
Skelly et al. (2021), Canada [28]	RCT	Adolescent girls with overweight or obesity (n=46; age, 10–18 yr)	High dairy intake	Low dairy intake	12 Wk	No significant change
Multicomponent lifestyle interventions
Xu et al. (2020), China [29]	Cluster RCT	School children from high-obesity schools (n=6,764; age, 7–13 yr)	School-based lifestyle program (nutrition education, PA, parent involvement)	Usual school	1 Yr	↓SBP, ↓ high BP incidence
Xu et al. (2020), China [29]	Cluster RCT			Practice (standard school curriculum)	1 Yr	↓SBP, ↓ high BP incidence
Jain et al. (2022), India [30]	RCT, 3 arms	Overweight/obese (n=109; age, 8–15 yr)	Comprehensive Yoga program + diet	Standard weight management	18 Wk	↓WC, ↓SBP, ↓HOMA-IR
Ojeda-Rodríguez et al. (2020), Spain [31]	RCT	Children with abdominal obesity (n=87; age, 7–16 yr)	Mediterranean diet + PA + behavioral counseling	Standard pediatric dietary recommendations	12 Mo	↓BMI-SDS, ↓fat mass, ↑telomere length

RCT, randomized controlled trial; HIIT, high-intensity interval training; BMI, body mass index; LDL, low-density lipoprotein; IR, insulin resistance; BP, blood pressure; MetS, metabolic syndrome; HDL, high-density lipoprotein; TG, triglycerides; CV, cardiovascular; DASH, Dietary Approaches to Stop Hypertension; WC, waist circumference; SBP, systolic blood pressure; DBP, diastolic blood pressure; BMI, body mass index; TNF-α, tumor necrosis factor-alpha; HbA1c, glycated hemoglobin; MASLD, metabolic dysfunction-associated steatotic liver disease; ALT, alanine aminotransferase; PA, physical activity; HOMA-IR, Homeostatic Model Assessment of Insulin Resistance; BMI-SDS, BMI standard deviation score.

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