BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) represents a significant and escalating public health challenge, particularly in obese, sedentary populations. Hybrid exercise training, integrating electrical muscle stimulation (EMS) with voluntary muscle contractions, offers a novel, low-impact therapeutic modality; however, its clinical efficacy remains underexplored. OBJECTIVES: This randomized controlled trial investigated the clinical efficacy of hybrid exercise training in improving hepatic steatosis, liver enzyme profiles, systemic inflammation, and metabolic health in sedentary, obese, middle-aged women with NAFLD. METHODS: Thirty women with ultrasound-confirmed grade 2 to 3 NAFLD were randomized to either six weeks of hybrid exercise training (n = 15) or lifestyle counseling (n = 15). Primary and secondary outcomes included liver steatosis grade, serum liver enzymes (AST, ALT), inflammatory marker IL-6, fasting blood glucose, and anthropometric parameters. RESULTS: Hybrid exercise training led to significant improvements compared with lifestyle counseling. Steatosis grade decreased markedly (-0.80 versus -0.02; p < 0.01; eta2 0.38), accompanied by large reductions in ALT (-31.86 U/L; p < 0.01; eta2 0.65) and AST (-27.46 U/L; p < 0.01; eta2 0.61). IL-6 concentrations declined (-3.0 pg/mL; p < 0.05; eta2 0.42), while anthropometric outcomes improved (body weight -4.51 kg, BMI -1.56 kg/m2, WHR -0.042; all p < 0.01; eta2 >= 0.52). Correlation analyses showed that decreases in IL-6 were strongly associated with improvements in ALT (r -0.72, p < 0.01) and AST (r -0.68, p < 0.01). CONCLUSIONS: Hybrid exercise training is a safe, feasible, and clinically effective intervention for improving liver health and attenuating systemic inflammation in obese women with NAFLD, with strong associations between IL-6 reductions and liver enzyme improvements. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT05231564, Registered on 28 February 2022.

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