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Call to action: Tailor lifestyle interventions for NAFLD to patients
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WASHINGTON — Lifestyle interventions such as diet and exercise are a critical part of prevention and treatment of nonalcoholic fatty liver disease and nonalcoholic steatohepatitis, more so than pharmacotherapy or endoscopic interventions at this moment, according to an expert at Digestive Disease Week 2018.
“My task today is to get everyone reinvigorated about the role of diet and exercise in the treatment of NAFLD and NASH,” Monica Konerman, MD, director of the Michigan Medicine NAFLD Clinic, said during her presentation. “With all of the new trials in pharmacotherapy and the exciting bariatric endoscopic interventions, people don’t tend to get as excited about diet and exercise, but hopefully that will change.”
Konerman discussed data supporting outcomes of lifestyle interventions for treatment of NAFLD and NASH. Results of a meta-analysis of eight randomized control trials and a 12-month prospective trial showed that 5% or more weight loss improved steatosis, 7% or more weight loss improved NAFLD activity sore, and 10% weight loss or more improved all components of NASH including fibrosis.
Specific diet, Konerman explained, does not matter as much as adherence to calorie restriction, which has been associated with mobilization of hepatic steatosis. Additionally, no data has shown that diet alone without weight loss leads to remission of NASH or fibrosis. The suggested starting point for calorie reduction is a 30% restriction of their current intake.
Two other points on diet that Konerman discussed included the recent data that showed a significant association between consumption of high fructose corn syrup and red and processed meats with a higher risk for NAFLD and NASH. In contrast, low carbohydrate and Mediterranean diets have shown reduced risk for NAFLD and reduction in obesity and hepatis steatosis.
Regarding physical activity, Konerman showed data that 54% to 64% of patients with NAFLD or NASH report minimal physical activity. U.S. guidelines for physical activity recommend 150 minutes or more per week of moderate intensity exercise, 75 minutes or more per week of vigorous intensity exercise, or an equivalent combination.
According to another meta-analysis, Konerman stated that even in the absence of weight loss, exercise leads to a 20% to 30% relative risk reduction in intrahepatic lipid content.
“How can you translate this into your everyday clinical practice to help your patients?” Konerman said. “The major point to emphasize is that you really have to tailor your recommendations to an individual patient’s needs, preferences and limitations. What one individual is going to be able to do is much different than what someone else may be able to do.”
Konerman’s take-away points for implementation included: assess for gaps in patient knowledge; objectively evaluate and track physical activity and diet; and use pre-existing interventions and tools such as nutritionists and programs designed for diabetes, metabolic syndrome and obesity. – by Talitha Bennett
Reference:
Konerman M, et al. Abstract Sp87. Presented at: Digestive Disease Week; June 2-5, 2018; Washington, D.C.
Disclosure: Konerman reports no relevant financial disclosures. Please see the DDW faculty disclosure index for a list of all other authors’ relevant financial disclosures.
Perspective
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Paul Y. Kwo, MD
Lifestyle modifications remain an important backbone of management in the patient with NAFLD. With so many different diets available, it is important to stay focused on reducing total caloric intake to reduce weight and it is weight loss with diet that will lead to reductions in steatosis inflammation and fibrosis.
As noted, physical activity in those with NAFLD is minimal and effort should be undertaken to increase the level of physical activity. The best data come from a large Korean study that demonstrated that patients who maintain physical activity of more than 150 minutes per week or increase activity level by more than 60 minutes per week had more reduction in AST and ALT levels regardless of changes in weight. This can be a marked lifestyle transition for those with nonalcoholic fatty liver disease, but also must be part of how patients with fatty liver disease are managed. Multidisciplinary teams are going to be increasingly important in the management of NAFLD, which is the most common form of chronic liver disease in the United States.
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