Is there an 'ideal' diet for patients with NAFLD?

Prophylactic effects of nutrition, dietary strategies, exercise, lifestyle and environment on nonalcoholic fatty liver disease

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is a chronic liver disease and its prevalence has risen sharply. However, whether nutrition, dietary strategies, exercise, lifestyle and environment have preventive value for NAFLD remains unclear.

METHODS

Through searching 4 databases (PubMed, Web of Science, Embase and the Cochrane Library) from inception to January 2025, we selected studies about nutrition, dietary strategies, exercise, lifestyle and environment in the prevention of NAFLD and conducted a narrative review on this topic.

RESULTS

Reasonable nutrient intake encompassing macronutrients and micronutrients have an independent protective relationship with NAFLD. Besides, proper dietary strategies including mediterranean diet, intermittent fasting diet, ketogenic diet, and dietary approaches to stop hypertension diet have their inhibitory effects on the developmental process of NAFLD. Moreover, right exercises including walking, jogging, bicycling, and swimming are recommended for the prevention of NAFLD because they could effectively reduce weight, which is an important risk factor for NAFLD, and improve liver function. In addition, embracing a healthy lifestyle including reducing sedentary behavior, not smoking, sleeping well and brushing teeth regularly is integral since it not only could reduce the risk of NAFLD but also significantly contribute to overall prevention and control. Finally, the environment, including the social and natural environments, plays a potential role in NAFLD prevention.

CONCLUSION

Nutrition, dietary strategies, exercise, lifestyle and environment play an important role in the prevention of NAFLD. Moreover, this review offers comprehensive prevention recommendations for people at high risk of NAFLD.

Lights and Shadows of a Vegetarian Diet in Patients with Metabolic Dysfunction-Associated Steatotic Liver Disease

The prevalence and socioeconomic impact of Metabolic dysfunction-associated steatotic liver disease (MASLD) is increasing. Despite the recent Food and Drug Administration (FDA) approval of Resmetirom as the first drug for patients with Metabolic dysfunction-associated steatohepatitis (MASH) and significant fibrosis, and several ongoing clinical trials, lifestyle changes aimed at achieving sustained weight loss remain a cornerstone in the management of these patients. In addition to regular and structured physical activity, diet is crucial. Several studies have demonstrated the benefits of the Mediterranean diet in this regard, and there is also emerging evidence on the vegetarian diet and its different patterns. This review aims to summarize the currently available evidence on the potential benefits of a vegetarian diet in patients with MASLD, as well as exploring its potential limitations.

PNPLA3 gene variation modulates diet-induced improvement in liver lipid content in type 2 diabetes

BACKGROUND&AIMS

Lifestyle-induced weight reduction remains crucial for managing type 2 diabetes and steatotic liver disease, but its effectiveness varies. We postulated that the G allele in the rs738409 single nucleotide polymorphism within patatin-like phospholipase domain-containing protein 3 (PNPLA3), which associates with metabolic dysfunction-associated steatotic liver disease, also modulates diet-related metabolic effects.

METHODS

Participants with type 2 diabetes were randomized to 8-week hypocaloric diets (energy intake: -1,256 kJ/d of, <30 kcal% fat): high in cereal fiber and coffee excluding red meat (HF-RM + C; n = 16), or low in cereal fiber, devoid of coffee, but high in red meat (LF + RM-C; n = 15). Whole-body insulin sensitivity (M value) was assessed using [2H]glucose and hyperinsulinemic-normoglycemic clamps, hepatic lipid content (HCL) and body fat volumes by magnetic resonance spectroscopy/imaging before and after intervention.

RESULTS

Despite comparable weight loss, HCL decreased more in non-carriers (-65 %) than in G-allele carriers (-36 %) upon HF-RM + C diet (both p < 0.05 vs baseline and between groups), but only among non-carriers (-46 %, p < 0.05 vs baseline) upon LF + RM-C. Upon HF-RM + C diet, increase in insulin sensitivity was not different between carriers (+27 % p = 0.051 from baseline) and non-carriers (+21 %, p = 0.032 from baseline), p > 0.05 for between-group comparison. Upon LF + RM-C diet, both groups equally improved their whole-body insulin sensitivity (+42 % for non-carriers and +37 % for carriers, p < 0.05 vs baseline). Upon HF-RM + C diet, non-carriers decreased circulating interleukin-18 from baseline by -31 %, whereas, upon LF + RM-C diet, non-carriers decreased circulating anti-inflammatory interleukin-1 receptor antagonist levels by 14 % (both p < 0.05 vs baseline).

CONCLUSIONS

Humans with the PNPLA3 G-allele show modified dietary-induced effects on steatotic liver disease in type 2 diabetes despite body weight reduction. Registration at Clinicaltrials.gov, Identifier number: NCT01409330.

The microenvironment in the development of MASLD-MASH-HCC and associated therapeutic in MASH-HCC

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a series of obesity-related metabolic liver diseases, ranging from relatively benign hepatic steatosis to metabolic-associated steatohepatitis (MASH). With the changes in lifestyle, its incidence and prevalence have risen to epidemic proportions globally. In recent years, an increasing amount of evidence has indicated that the hepatic microenvironment is involved in the pathophysiological processes of MASH-induced liver fibrosis and the formation of hepatocellular carcinoma (HCC). The hepatic microenvironment is composed of various parenchymal and non-parenchymal cells, which communicate with each other through various factors. In this review, we focus on the changes in hepatocytes, cholangiocytes, liver sinusoidal endothelial cells (LSECs), hepatic stellate cells (HSCs), Kupffer cells (KC), dendritic cells (DC), neutrophils, monocytes, T and B lymphocytes, natural killer cells (NK), natural killer T cells (NKT), mucosal-associated invariant T cells (MAIT), γδT cells, and gut microbiota during the progression of MASLD. Furthermore, we discuss promising therapeutic strategies targeting the microenvironment of MASLD-MASH-HCC.

Vegetal oil-based ketogenic diet improves inflammation and fibrosis in experimental metabolic dysfunction-associated steatohepatitis

BACKGROUND AND AIMS

Metabolic dysfunction-associated steatohepatitis (MASH) represents a growing cause of liver cirrhosis and hepatocellular carcinoma (HCC). However, effective therapy for MASH is still lacking. Despite recent studies suggest that ketosis might improve MASH evolution, the mechanisms involved have not been explored since common ketogenic diets cause severe steatohepatitis in mice. In this study, we have investigated the capacity of a new-formulated ketogenic diet (KD) containing vegetal fat in improving liver alterations associated with experimental MASH.

METHODS

MASH was induced in C57BL/6 mice by feeding a cholesterol-enriched Western Diet (WD) for up to 16 weeks, followed by switching animals to KD for an additional eight weeks.

RESULTS

We observed that KD administration greatly increased ketone body production and significantly reduced liver and body weights. Moreover, liver proteomic analysis and functional tests evidenced an improved glucose and lipid metabolism along with insulin resistance in KD-fed mice. These metabolic effects were associated with an amelioration in MASH-associated gut dysbiosis and with an improvement of hepatic steatosis, parenchymal injury and liver fibrosis. From the mechanistic point of view mice receiving KD showed a significant reduction in liver TREM2-positive monocyte-derived macrophages forming crown-like aggregates along with a lowering in the hepatic expression of pro-inflammatory/pro-fibrogenic markers such as CCL2, IL-12, CD11b, α1-procollagen, TGF-β1, osteopontin, and galectin-3. Consistently, in vitro experiments showed that β-hydroxybutyrate supplementation reduced TREM2 and galectin-3 expression by cultured Raw 264.7 macrophages.

CONCLUSIONS

Altogether, these results indicate that ketogenic diet based on vegetal fat effectively improves MASH metabolic derangements and steatohepatitis, and it might represent a potential therapeutic strategy in this disease.

The effect of chitosan supplementation on liver function, hepatic steatosis predictors, and metabolic indicators in adults with non-alcoholic fatty liver disease: a randomized, double-blinded, placebo-controlled, clinical trial

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is a disease with high complications. An increment in dietary fiber consumption is an approach to NAFLD management, and chitosan as dietary fiber can play a role in the management of NAFLD. Thus, the present study aimed to investigate the effect of chitosan supplementation on liver function, hepatic steatosis predictors, and metabolic indices in adults with NAFLD.

METHODS

Seventy-two adults with NAFLD were randomly assigned to consume either 1.5 g/day chitosan or placebo along with a low-calorie (- 500 kcal/day) diet for 8 weeks in a parallel, randomized, double-blinded, placebo-controlled, clinical trial. Participants were assessed for dietary intake, physical activity, and anthropometric indices. Blood samples were taken to measure fasting blood sugar (FBS), cholesterol, triglycerides, high- and low-density lipoprotein (HDL and LDL). Liver function indices including alanine aminotransferase (ALT), aspartate transaminase (AST), and gamma-glutamyltransferase (GGT) were evaluated using blood samples as the primary outcomes. Fatty liver index (FLI), hepatic steatosis index (HSI), and triglyceride-glucose index (TyG) were calculated as hepatic steatosis predictors' indices.

RESULTS

After 8 weeks of study, 66 participants finished the study. In comparison with placebo, chitosan supplementation reduced weight (P = 0.041), waist circumference (P = 0.049), AST (P = 0.040), ALT (P = 0.001), and GGT (P = 0.028). Although the reduction of FBS, triglycerides, cholesterol, LDL, FLI, HSI, and TyG, and increment in HDL was higher in the chitosan group, the results were not significant (P > 0.05).

CONCLUSIONS

Eight-week supplementation with 1.5 g/day chitosan along with a low-calorie diet could possibly reduce weight, waist circumference, AST, ALT, and GGT, and ameliorate NAFLD. Further investigations are recommended. Trial registration The trial was registered at IRCT.ir as IRCT20140502017522N4 (March 2023).

Assessment of ChatGPT-generated medical Arabic responses for patients with metabolic dysfunction-associated steatotic liver disease

BACKGROUND AND AIM

Artificial intelligence (AI)-powered chatbots, such as Chat Generative Pretrained Transformer (ChatGPT), have shown promising results in healthcare settings. These tools can help patients obtain real-time responses to queries, ensuring immediate access to relevant information. The study aimed to explore the potential use of ChatGPT-generated medical Arabic responses for patients with metabolic dysfunction-associated steatotic liver disease (MASLD).

METHODS

An English patient questionnaire on MASLD was translated to Arabic. The Arabic questions were then entered into ChatGPT 3.5 on November 12, 2023. The responses were evaluated for accuracy, completeness, and comprehensibility by 10 Saudi MASLD experts who were native Arabic speakers. Likert scales were used to evaluate: 1) Accuracy, 2) Completeness, and 3) Comprehensibility. The questions were grouped into 3 domains: (1) Specialist referral, (2) Lifestyle, and (3) Physical activity.

RESULTS

Accuracy mean score was 4.9 ± 0.94 on a 6-point Likert scale corresponding to "Nearly all correct." Kendall's coefficient of concordance (KCC) ranged from 0.025 to 0.649, with a mean of 0.28, indicating moderate agreement between all 10 experts. Mean completeness score was 2.4 ± 0.53 on a 3-point Likert scale corresponding to "Comprehensive" (KCC: 0.03-0.553; mean: 0.22). Comprehensibility mean score was 2.74 ± 0.52 on a 3-point Likert scale, which indicates the responses were "Easy to understand" (KCC: 0.00-0.447; mean: 0.25).

CONCLUSION

MASLD experts found that ChatGPT responses were accurate, complete, and comprehensible. The results support the increasing trend of leveraging the power of AI chatbots to revolutionize the dissemination of information for patients with MASLD. However, many AI-powered chatbots require further enhancement of scientific content to avoid the risks of circulating medical misinformation.

The role of dietary modification in the prevention and management of metabolic dysfunction-associated fatty liver disease: An international multidisciplinary expert consensus

Metabolic dysfunction-associated fatty liver disease (MAFLD) or metabolic dysfunction-associated steatotic liver disease (MASLD), has become the leading cause of chronic liver disease worldwide. Optimal dietary intervention strategies for MAFLD are not standardized. This study aimed to achieve consensus on prevention of MAFLD through dietary modification. A multidisciplinary panel of 55 international experts, including specialists in hepatology, gastroenterology, dietetics, endocrinology and other medical specialties from six continents collaborated in a Delphi-based consensus development process. The consensus statements covered aspects ranging from epidemiology to mechanisms, management, and dietary recommendations for MAFLD. The recommended dietary strategies emphasize adherence to a balanced diet with controlled energy intake and personalized nutritional interventions, such as calorie restriction, high-protein, or low-carbohydrate diets. Specific dietary advice encouraged increasing the consumption of whole grains, plant-based proteins, fish, seafood, low-fat or fat-free dairy products, liquid plant oils, and deeply colored fruits and vegetables. Concurrently, it advised reducing the intake of red and processed meats, saturated and trans fats, ultra-processed foods, added sugars, and alcohol. Additionally, maintaining the Mediterranean or DASH diet, minimizing sedentary behavior, and engaging in regular physical activity are recommended. These consensus statements lay the foundation for customized dietary guidelines and proposing avenues for further research on nutrition and MAFLD.

Non-alcoholic fatty liver disease: The importance of physical activity and nutrition education-A randomized controlled study

BACKGROUND AND AIM

Non-alcoholic fatty liver disease (NAFLD) is characterized by the accumulation of excess fat in the liver, causing liver cell damage, increased inflammation, and weight gain. Despite its high prevalence, diagnosis and follow-up of the disease is difficult. Irisin, a slimming myokine produced in response to physical activity (PA), exhibits anti-inflammatory and anti-obesity effects. This study aimed to investigate changes in irisin levels, inflammation markers (tumor necrosis factor-α [TNF-α] and interleukin-6 [IL-6]), and myeloid differentiation factor-2 (MD2) levels in NAFLD, as well as anthropometric and routine biochemical parameters, by providing PA recommendations and nutrition education (NE) to individuals diagnosed with NAFLD over a period of 12 weeks.

METHODS

The study included 62 patients diagnosed with NAFLD who did not use alcohol. They were divided into groups: PA, NE, both (NE + PA), and untreated (control) patients. Patients receiving NE were provided with 1-h NE sessions every 4 weeks for 12 weeks, and their personal information, nutritional status, 24-h retrospective food consumption record, and anthropometric measurements were recorded at the beginning (day 0) and end (week 12) of the study. The PA group was recommended aerobic walking for 30 min, 5 days a week. At the beginning (day 0) and end (week 12) of the study, patients' anthropometric and routine biochemical tests were conducted, and irisin, MD2, TNF-α, and IL-6 levels were measured using the ELISA method.

RESULTS

All groups were similar in demographic characteristics and dietary habits. After 12 weeks, there were no significant differences in biochemical parameters among the groups. Glucose levels increased in the untreated group but decreased in the PA and PA + NE groups compared to baseline, with a significant decrease in the PA group. Insulin levels significantly decreased in the NE group. The PA + NE group showed decreased aspartate aminotransferase (AST), gamma-glutamyl transferase, alkaline phosphatase, total cholesterol, low-density lipoprotein, and triglyceride levels and significant decrease in ALT levels. AST decreased significantly in the PA group while high-density lipoprotein increased significantly. There were no statistically significant differences between the groups in irisin, MD2, IL-6, and TNF-α levels. After 12 weeks, irisin levels significantly increased in nutrition and PA groups except the untreated group. There were no statistically significant differences in IL-6 and MD2 levels compared with baseline after 12 weeks. PA recommendations alone were not effective in observing significant changes in anthropometric measurements in individuals with NAFLD. It was detected that only nutritional recommendations provided a significant decrease in body fat ratio but were insufficient for the change in other anthropometric measurements. In the group where NE and PA were recommended together, a significant decrease in anthropometric measurements was found. The NE group significantly reduced their energy and carbohydrates (%EI) intake after 12 weeks of intervention compared with the baseline.

CONCLUSION

NE and PA recommendations led to improvements in liver-related biochemical parameters and significant reductions in anthropometric measurements among individuals with NAFLD. Moreover, patients receiving NE experienced a decrease in energy and carbohydrates intake as a percentage of total energy intake (%EI). Increased irisin levels in NE, PA, and NE + PA groups may have contributed to the decrease in body fat percentage.

Association of ultra-processed food intake with severe non-alcoholic fatty liver disease: a prospective study of 143073 UK Biobank participants

BACKGROUND

Previous studies indicate a link between non-alcoholic fatty liver disease (NAFLD) and unhealthy dietary patterns or nutrient intake. However, it remains unclear whether ultra-processed foods (UPF) contribute to an increased risk of NAFLD. This study aimed to explore how ultra-processed food consumption correlates with severe NAFLD using the UK Biobank data.

METHODS

This prospective cohort study included 143,073 participants from the UK Biobank. UPF consumption levels were determined using the NOVA classification and quantified from 24-h dietary recall data. The association between UPF consumption and severe NAFLD (hospitalization or death) was initially examined using Cox proportional hazards models with intake quartiles. Nonlinear associations were investigated using penalized cubic splines fitted in the Cox proportional hazards models. Adjustments were made for general characteristics, sociodemographic factors, body mass index (BMI), and lifestyle.

RESULTS

Throughout the median follow-up period of 10.5 years, 1,445 participants developed severe NAFLD. The adjusted models indicated a significant increase in severe NAFLD risk in higher UPF intake groups compared to the lowest quartile (HR: 1.26 [95% CI: 1.11-1.43]). Subgroup analysis revealed that individuals with a BMI of 25 or higher were at greater risk in the highest quartile of UPF consumption. Sensitivity analyses yielded results consistent with these findings.

CONCLUSION

Higher consumption of UPF is associated with an increased risk of severe NAFLD. Reducing the intake of UPF can be a potential approach to lower the risk of NAFLD.

Spinal cord injury-induced metabolic impairment and steatohepatitis develops in non-obese rats and is exacerbated by premorbid obesity

Impaired sensorimotor functions are prominent complications of spinal cord injury (SCI). A clinically important but less obvious consequence is development of metabolic syndrome (MetS), including increased adiposity, hyperglycemia/insulin resistance, and hyperlipidemia. MetS predisposes SCI individuals to earlier and more severe diabetes and cardiovascular disease compared to the general population, which trigger life-threatening complications (e.g., stroke, myocardial infarcts). Although each comorbidity is known to be a risk factor for diabetes and other health problems in obese individuals, their relative contribution or perceived importance in propagating systemic pathology after SCI has received less attention. This could be explained by an incomplete understanding of MetS promoted by SCI compared with that from the canonical trigger diet-induced obesity (DIO). Thus, here we compared metabolic-related outcomes after SCI in lean rats to those of uninjured rats with DIO. Surprisingly, SCI-induced MetS features were equal to or greater than those in obese uninjured rats, including insulin resistance, endotoxemia, hyperlipidemia, liver inflammation and steatosis. Considering the endemic nature of obesity, we also evaluated the effect of premorbid obesity in rats receiving SCI; the combination of DIO + SCI exacerbated MetS and liver pathology compared to either alone, suggesting that obese individuals that sustain a SCI are especially vulnerable to metabolic dysfunction. Notably, premorbid obesity also exacerbated intraspinal lesion pathology and worsened locomotor recovery after SCI. Overall, these results highlight that normal metabolic function requires intact spinal circuitry and that SCI is not just a sensory-motor disorder, but also has significant metabolic consequences.

Dysbiosis and nutrition in steatotic liver disease: addressing the unrecognized small intestinal bacterial overgrowth (SIBO) challenge

Steatotic liver disease (SLD) is characterized by hepatic fat accumulation, potentially causing major consequences such as liver decompensation. Currently, we lack medications for the treatment of SLD. Therapeutic recommendations for patients include a hypocaloric diet, weight loss, and physical activity. In particular, the Mediterranean diet is frequently recommended. However, this diet might exacerbate intestinal problems in a subset of patients with coexisting small intestinal bacterial overgrowth (SIBO). Previous studies have reported that SIBO is more predominant in patients with fatty liver than in healthy individuals. Both our research and the findings of others have highlighted a challenge related to nutritional therapy in patients with fatty liver who also suffer from SIBO inasmuch as SIBO induces several phenomena (like bloating or abdominal pain) that can adversely affect patients' quality of life and might be exacerbated by the Mediterranean diet. This may lower their adherence to the intervention. As a solution, we suggest introducing additional diagnostics (e.g., breath test) in patients with SLD who complain of SIBO-like symptoms. The next step is to modify their diets temporarily starting with several weeks of "elimination and sanitation." This would involve restricting products rich in fermentable sugars and polyols, while simultaneously treating the bacterial overgrowth. In summary, while the hypocaloric Mediterranean diet is beneficial for patients with fatty liver, those with coexisting SIBO may experience exacerbated symptoms. It is vital to consider additional diagnostics and dietary modifications for this subset of patients to address both liver and intestinal health concurrently.

The first MASH drug therapy on the horizon: Current perspectives of resmetirom

The rising prevalence of metabolic dysfunction-associated steatotic liver disease (MASLD) poses a significant global health challenge, affecting over 30% of adults worldwide. MASLD is linked to increased mortality rates and substantial healthcare costs, primarily driven by its progression to metabolic dysfunction-associated steatohepatitis (MASH), which can lead to severe liver complications including cirrhosis and hepatocellular carcinoma. Despite its growing burden, effective pharmacotherapy for MASLD/MASH has been lacking until the recent conditional approval of resmetirom by the FDA. Resmetirom, a liver-targeted thyroid hormone receptor-β selective drug, has shown promise in clinical trials for treating non-cirrhotic MASH with moderate to advanced fibrosis. It has demonstrated efficacy in reducing hepatic fat content, improving liver histology (both MASH resolution and fibrosis improvement), and ameliorating biomarkers of liver damage without significant effects on body weight or glucose metabolism. Notably, resmetirom also exhibits favourable effects on circulating lipids, potentially reducing cardiovascular risk in MASLD/MASH patients. The safety profile of resmetirom appears acceptable, with gastrointestinal adverse events being the most common, though generally mild or moderate. However, long-term surveillance is warranted to monitor for potential risks related to thyroid, gonadal, or bone diseases. Clinical implementation of resmetirom faces challenges in patient selection and monitoring treatment response, and will heavily rely on non-invasive tests for liver fibrosis assessment. Nonetheless, resmetirom represents a landmark breakthrough in MASLD/MASH treatment, paving the way for future therapeutic strategies aiming to mitigate the multifaceted risks associated with this complex metabolic liver disease.

Evaluation of ChatGPT as a Counselling Tool for Italian-Speaking MASLD Patients: Assessment of Accuracy, Completeness and Comprehensibility

BACKGROUND

Artificial intelligence (AI)-based chatbots have shown promise in providing counseling to patients with metabolic dysfunction-associated steatotic liver disease (MASLD). While ChatGPT3.5 has demonstrated the ability to comprehensively answer MASLD-related questions in English, its accuracy remains suboptimal. Whether language influences these results is unclear. This study aims to assess ChatGPT's performance as a counseling tool for Italian MASLD patients.

METHODS

Thirteen Italian experts rated the accuracy, completeness and comprehensibility of ChatGPT3.5 in answering 15 MASLD-related questions in Italian using a six-point accuracy, three-point completeness and three-point comprehensibility Likert's scale.

RESULTS

Mean scores for accuracy, completeness and comprehensibility were 4.57 ± 0.42, 2.14 ± 0.31 and 2.91 ± 0.07, respectively. The physical activity domain achieved the highest mean scores for accuracy and completeness, whereas the specialist referral domain achieved the lowest. Overall, Fleiss's coefficient of concordance for accuracy, completeness and comprehensibility across all 15 questions was 0.016, 0.075 and -0.010, respectively. Age and academic role of the evaluators did not influence the scores. The results were not significantly different from our previous study focusing on English.

CONCLUSION

Language does not appear to affect ChatGPT's ability to provide comprehensible and complete counseling to MASLD patients, but accuracy remains suboptimal in certain domains.

The Interplay between Endocrine-Disrupting Chemicals and the Epigenome towards Metabolic Dysfunction-Associated Steatotic Liver Disease: A Comprehensive Review

Metabolic dysfunction-associated steatotic liver disease (MASLD), described as the most prominent cause of chronic liver disease worldwide, has emerged as a significant public health issue, posing a considerable challenge for most countries. Endocrine-disrupting chemicals (EDCs), commonly found in daily use items and foods, are able to interfere with nuclear receptors (NRs) and disturb hormonal signaling and mitochondrial function, leading, among other metabolic disorders, to MASLD. EDCs have also been proposed to cause transgenerationally inherited alterations leading to increased disease susceptibility. In this review, we are focusing on the most prominent linking pathways between EDCs and MASLD, their role in the induction of epigenetic transgenerational inheritance of the disease as well as up-to-date practices aimed at reducing their impact.

Association of the habitual dietary intake with the fatty liver index and effect modification by metabotypes in the population-based KORA-Fit study

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is an emerging threat for public health with diet being a major risk factor in disease development and progression. However, the effects of habitual food consumption on fatty liver are still inconclusive as well as the proposed role of the individuals' metabolic profiles. Therefore, the aim of our study is to examine the associations between diet and NAFLD with an emphasis on the influence of specific metabotypes in the general population.

METHODS

A total of 689 participants (304 men and 385 women) of the KORA-Fit (S4) survey, a follow-up study of the population-based KORA cohort study running in the Region of Augsburg, Germany, were included in this analysis. Dietary information was derived from repeated 24-h food lists and a food frequency questionnaire. The intake of energy and energy-providing nutrients were calculated using the national food composition database. The presence of fatty liver was quantified by the fatty liver index (FLI), and metabotypes were calculated using K-means clustering. Multivariable linear regression models were used for the analysis of habitual food groups and FLI; for the evaluation of macronutrients, energy substitution models were applied.

RESULTS

A higher consumption of nuts and whole grains, and a better diet quality (according to Alternate Healthy Eating Index and Mediterranean Diet Score) were associated with lower FLI values, while the intake of soft drinks, meat, fish and eggs were associated with a higher FLI. The isocaloric substitution of carbohydrates with polyunsaturated fatty acids was associated with a decreased FLI, while substitution with monounsaturated fatty acids and protein showed increased FLI. Statistically significant interactions with the metabotype were observed for most food groups.

CONCLUSION

The consumption of plant-based food groups, including nuts and whole grains, and diet quality, were associated with lower FLI values, whereas the intake of soft drinks and products of animal origin (meat, fish, eggs) were associated with a higher FLI. The observed statistically significant interactions with the metabotype for most food groups could help to develop targeted prevention strategies on a population-based level if confirmed in independent prospective studies.

Accuracy, Reliability, and Comprehensibility of ChatGPT-Generated Medical Responses for Patients With Nonalcoholic Fatty Liver Disease

Nonalcoholic fatty liver disease (NAFLD) is an increasing global health problem and is expected to become the leading indication for liver transplantation.1 There are no approved NAFLD-specific pharmacotherapies, and lifestyle modification is the primary recommended therapy.2 Innovative approaches to facilitate the implementation and long-term maintenance of lifestyle changes are needed to address the challenging and complex nature of the management of NAFLD, which recently was renamed as metabolic dysfunction-associated steatotic liver disease, to overcome the limitations and stigma of the previous name.3,4 Artificial intelligence (AI)-powered chatbots have been shown to provide effective personalized support and education to patients, with the potential to complement health care resources. The OpenAI Foundation's AI chatbot, Chat Generative Pretrained Transformer (ChatGPT), has attracted worldwide attention for its remarkable performance in question-answer tasks.5-7 This study evaluated the accuracy, completeness, and comprehensiveness of chatGPT's responses to NAFLD-related questions, with the aim of assessing its performance in addressing patients' queries about the disease and lifestyle behaviors.

Liver fibrosis in NAFLD/NASH: from pathophysiology towards diagnostic and therapeutic strategies

Liver fibrosis, as an excess deposition of extracellular matrix (ECM) components, results from chronic liver injury as well as persistent activation of inflammatory response and of fibrogenesis. Liver fibrosis is a major determinant for chronic liver disease (CLD) progression and in the last two decades our understanding on the major molecular and cellular mechanisms underlying the fibrogenic progression of CLD has dramatically improved, boosting pre-clinical studies and clinical trials designed to find novel therapeutic approaches. From these studies several critical concepts have emerged, starting to reveal the complexity of the pro-fibrotic microenvironment which involves very complex, dynamic and interrelated interactions between different hepatic and extrahepatic cell populations. This review will offer first a recapitulation of established and novel pathophysiological basic principles and concepts by intentionally focus the attention on NAFLD/NASH, a metabolic-related form of CLD with a high impact on the general population and emerging as a leading cause of CLD worldwide. NAFLD/NASH-related pro-inflammatory and profibrogenic mechanisms will be analysed as well as novel information on cells, mediators and signalling pathways which have taken advantage from novel methodological approaches and techniques (single cell genomics, imaging mass cytometry, novel in vitro two- and three-dimensional models, etc.). We will next offer an overview on recent advancement in diagnostic and prognostic tools, including serum biomarkers and polygenic scores, to support the analysis of liver biopsies. Finally, this review will provide an analysis of current and emerging therapies for the treatment of NAFLD/NASH patients.

Effect of Intermittent Fasting on Lipid Profile, Anthropometric and Hepatic Markers in Non-Alcoholic Fatty Liver Disease (NAFLD): A Systematic Review

BACKGROUND

The first-line treatment for non-alcoholic fatty liver disease (NAFLD) is lifestyle modification; this should accompany any pharmacological intervention. Intermittent fasting (IF) has shown benefits over metabolic and cardiovascular parameters. Non-religious IF includes Time-Restricted Feeding (TRF), Alternate-Day Fasting (ADF), and 5:2 IF interventions.

OBJECTIVE

To evaluate the effects of IF on anthropometric, liver damage, and lipid profile markers in subjects with NAFLD.

METHODS

A bibliographic search was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using PubMed and Scopus databases.

RESULTS

Five studies involving 470 patients with NAFLD were included. In relation to anthropometric markers, all the articles reported body weight reduction (2.48-7.63%), but only ADF and 5:2 IF reported a body weight reduction >5%; also, all the articles reported fat mass reduction. Concerning hepatic markers, all the articles reported a reduction in hepatic steatosis and alanine aminotransferase activity, but no changes in fat-free mass and high-density lipoprotein cholesterol levels. There were variable results on fibrosis, other liver enzymes, waist circumference and body mass index, as well as the levels of triglycerides, total cholesterol, and low-density lipoprotein cholesterol.

CONCLUSION

Any form of IF could be potentially beneficial for NAFLD treatment and some associated cardiometabolic parameters. However, it is necessary to evaluate the effects and safety of IF in long-term studies involving a higher number of participants with different stages of NAFLD. The effect of IF on NAFLD-associated vascular risk also needs evaluation.

Taiwan Association for the Study of the Liver-Taiwan Society of Cardiology Taiwan position statement for the management of metabolic dysfunction- associated fatty liver disease and cardiovascular diseases

Metabolic dysfunction-associated fatty liver disease (MAFLD) is an increasingly common liver disease worldwide. MAFLD is diagnosed based on the presence of steatosis on images, histological findings, or serum marker levels as well as the presence of at least one of the three metabolic features: overweight/obesity, type 2 diabetes mellitus, and metabolic risk factors. MAFLD is not only a liver disease but also a factor contributing to or related to cardiovascular diseases (CVD), which is the major etiology responsible for morbidity and mortality in patients with MAFLD. Hence, understanding the association between MAFLD and CVD, surveillance and risk stratification of MAFLD in patients with CVD, and assessment of the current status of MAFLD management are urgent requirements for both hepatologists and cardiologists. This Taiwan position statement reviews the literature and provides suggestions regarding the epidemiology, etiology, risk factors, risk stratification, nonpharmacological interventions, and potential drug treatments of MAFLD, focusing on its association with CVD.

Nutrition assessment and MASH severity in children using the Healthy Eating Index

BACKGROUND

Pediatric metabolic-associated fatty liver disease (MAFLD) is a global health problem, with lifestyle modification as its major therapeutic strategy. Rigorous characterization of dietary content on MAFLD in children is lacking. We hypothesized an objectively measured healthier diet would positively modulate MAFLD.

METHODS

Diet was assessed using the Nutrition Data System for Research in children enrolled from 10 tertiary clinical centers to determine the Healthy Eating Index (HEI, 0-100) and individual food components.

RESULTS

In all, 119 children were included (13.3 ± 2.7 y), 80 (67%) male, 67 (18%) White, and 90 (76%) Hispanic, with an average body mass index Z-score of 2.2 ± 0.5. Diet was classified as low HEI < 47.94 (n = 39), mid HEI ≥ 47.94 and < 58.89 (n = 41), or high HEI ≥ 58.89 (n=39). Children with high HEI (healthier diet) had lower body weight (p = 0.005) and more favorable lipids. Mean serum triglycerides for low, mid, and high HEI were 163, 148, and 120 mg/dL, respectively; p = 0.04 mid versus high, p = 0.01 low versus high. Mean HDL was 38, 41 and 43 mg/dL; p = 0.02 low vs high. Less severe steatosis was noted with added sugar ≤ 10% of calories (p = 0.03). Higher lobular inflammation is associated with a higher percentage of calories from fat (OR (95% CI) = 0.95 (0.91-1.00), p = 0.04).

CONCLUSIONS

In children with MAFLD, high HEI is associated with lower body weight and more favorable lipids, while added sugar and fat intake has individual histologic features. Differential consumption of major dietary components may modify both metabolic risk factors and histologic liver injury, highlighting the importance of objective diet assessments in children with MAFLD.

Association of dietary inflammatory potential and non-alcoholic fatty liver disease in US adults

OBJECTIVES

Long-term inflammatory effects of diet may elevate the risk of non-alcoholic fatty liver disease (NAFLD). The present study aims to investigate dietary patterns associated with inflammation and whether such diets were associated with the risk of NAFLD.

METHODS

Data were collected from the 2017-2018 National Health and Nutrition Examination Survey. Dietary intake was obtained through two 24-hour dietary recall interviews, and levels of inflammatory biomarkers were assessed in blood samples. NAFLD was defined as a controlled attenuation parameter (CAP) ≥ 274 dB/m. Reduced-rank regression (RRR) analysis was used to derive sex-specific inflammatory dietary patterns (IDPs). Logistic regression analysis was used to examine the association between IDPs and NAFLD.

RESULTS

A total of 3570 participants were included in this study. We identified the IDP characterized by higher intake of added sugars, and lower intake of fruits, vegetables, whole grains, seafood high in n -3 fatty acids, soybean products, nuts, seeds, yogurt, and oils. After multivariate adjustment, the highest tertile of the IDP scores had a significantly higher risk of NAFLD than the lowest tertile [odds ratio (OR) = 1.884, 95% confidence interval (CI) = 1.003-3.539, P for trend = 0.044 for males; OR = 1.597, 95% CI = 1.129-2.257, P for trend = 0.010 for females].

CONCLUSION

Overall, the IDP was positively associated with the prevalence of NAFLD. The findings may provide dietary prevention strategies for controlling chronic inflammation and further preventing NAFLD.

Identification and validation of disulfidptosis-associated molecular clusters in non-alcoholic fatty liver disease

Objective: Non-alcoholic fatty liver disease (NAFLD) is the most prevalent liver disease in the world, and its pathogenesis is not fully understood. Disulfidptosis is the most recently reported form of cell death and may be associated with NAFLD progression. Our study aimed to explore the molecular clusters associated with disulfidptosis in NAFLD and to construct a predictive model. Methods: First, we analyzed the expression profile of the disulfidptosis regulators and immune characteristics in NAFLD. Using 104 NAFLD samples, we investigated molecular clusters based on differentially expressed disulfidptosis-related genes, along with the related immune cell infiltration. Cluster-specific differentially expressed genes were then identified by using the WGCNA method. We also evaluated the performance of four machine learning models before choosing the optimal machine model for diagnosis. Nomogram, calibration curves, decision curve analysis, and external datasets were used to confirm the prediction effectiveness. Finally, the expression levels of the biomarkers were assessed in a mouse model of a high-fat diet. Results: Two differentially expressed DRGs were identified between healthy and NAFLD patients. We revealed the expression profile of DRGs in NAFLD and the correlation with 22 immune cells. In NAFLD, two clusters of molecules connected to disulfidptosis were defined. Significant immunological heterogeneity was shown by immune infiltration analysis among the various clusters. A significant amount of immunological infiltration was seen in Cluster 1. Functional analysis revealed that Cluster 1 differentially expressed genes were strongly linked to energy metabolism and immune control. The highest discriminatory performance was demonstrated by the SVM model, which had a higher area under the curve, relatively small residual and root mean square errors. Nomograms, calibration curves, and decision curve analyses were used to show how accurate the prediction of NAFLD was. Further analysis revealed that the expression of three model-related genes was significantly associated with the level of multiple immune cells. In animal experiments, the expression trends of DDO, FRK and TMEM19 were consistent with the results of bioinformatics analysis. Conclusion: This study systematically elucidated the complex relationship between disulfidptosis and NAFLD and developed a promising predictive model to assess the risk of disease in patients with disulfidptosis subtypes and NAFLD.

Non-alcoholic fatty liver disease: Dietary and nutraceutical approaches

Non-alcoholic fatty liver disease (NAFLD), defined as the presence of fat accumulation in imaging or histology in more than 5% of hepatocytes and exclusion of other causes for secondary hepatic fat accumulation, is one of the major causes of chronic liver disease worldwide. Metabolic syndrome is associated with an increased risk of progression from NAFLD to non-alcoholic steatohepatitis (NASH), fibrosis, and forthcoming liver failure. Also, genetic predisposition contributes to the risk of NAFLD development. This review explores the role of diets and nutraceuticals in delaying the development and the evolution of NAFLD to chronic liver disease. The Mediterranean diet, high-protein diet, low-carbohydrate/high-fat diet, high-carbohydrate/low-fat diet, and intermittent fasting are the dietary approaches investigated given the presence of relevant literature data. Moreover, this review focused on nutraceuticals with proven efficacy in ameliorating NAFLD and grouped them into four different categories: plant-based nutraceuticals (Ascophyllum nodosum and Fucus vesiculosus, Silymarin, Berberine, Curcumin, Resveratrol, Nigella sativa, Quercetin), vitamin-like substances (vitamin E, vitamin D, vitamin C, coenzyme Q10, inositol), fatty acids (omega-3), and microbiota-management tools (probiotics).

The Replacement of Only One Portion of Starchy Carbohydrates with Green Leafy Vegetables Regresses Mid and Advanced Stages of NAFLD: Results from a Prospective Pilot Study

The gold standard treatment for NAFLD is weight loss and lifestyle interventions, which require a diet enriched in fiber and reduced in sugars and saturated fats. Fibres may be advantageous for NAFLD patients since they reduce and slow the absorption of carbohydrates, lipids, and proteins, lowering the energy density of the meal and increasing their sense of satiety. Furthermore, the polyphenol content and other bioactive compounds of vegetables have antioxidant and anti-inflammatory properties preventing disease progression. The aim of this study is to ascertain the effects of a diet enriched by green leafy vegetables and with a moderate restriction of carbohydrate intake in patients with NAFLD over a three month period. Among the forty patients screened, twenty four patients completed the clinical trial consisting of swapping one portion of carbohydrate-rich food for one portion of green leafy vegetables, and liver and metabolic markers of NAFLD were evaluated. All patients underwent routine blood tests, anthropometric measurements, bioelectrical impedance analysis, fibroscan, and fatty liver index (FLI) evaluation before and at the end of the study. The population under study (n = 24) had a median age of 47.5 (41.5-52.5) years and included mainly women (70.8%). We found that FLI, which is used to predict fatty liver (73 (33-89) vs. 85 (54-95), p < 0.0001) and the FAST score, which is a fibroscan-derived parameter identifying patients at risk of progressive NASH (0.03 (0.02-0.09) vs. 0.05 (0.02-0.15), p = 0.007), were both improved after changes in diet. The BMI (33.3 (28.6-37.3) vs. 35.3 (31.2-39.0), p < 0.0001), WC (106.5 (95.0-112.5) vs. 110.0 (103.0-124.0), p < 0.0001), neck circumference (38.0 (35.0-41.5) vs. 39.5 (38.0-42.5), p < 0.0001), fat mass (32.3 (23.4-40.7) vs. 37.9 (27.7-43.5), p < 0.0001), and extracellular water (17.3 (15.2-20.8) vs. 18.3 (15.9-22.7), p = 0.03) were also all significantly lower after three months of diet. Metabolic parameters linked to NAFLD decreased: HbA1c (36.0 (33.5-39.0) vs. 38.0 (34.0-40.5), p = 0.01), triglycerides (72 (62-90) vs. 90 (64-132), p = 0.03), and the liver markers AST (17 (14-19) vs. 18 (15-27), p = 0.01) and γGT (16 (13-20) vs. 16 (14-27), p = 0.02). In conclusion, replacing only one portion of starchy carbohydrates with one portion of vegetables for a three month period is sufficient to regress, at least in part, both mid and advanced stages of NAFLD. This moderate adjustment of lifestyle habits is easily achievable.

Nutritional and Lifestyle Therapy for NAFLD in People with HIV

HIV infection and nonalcoholic fatty liver disease (NAFLD) are two major epidemics affecting millions of people worldwide. As people with HIV (PWH) age, there is an increased prevalence of metabolic comorbidities, along with unique HIV factors, such as HIV chronic inflammation and life-long exposure to antiretroviral therapy, which leads to a high prevalence of NAFLD. An unhealthy lifestyle, with a high dietary intake of refined carbohydrates, saturated fatty acids, fructose added beverages, and processed red meat, as well as physical inactivity, are known to trigger and promote the progression of NAFLD to nonalcoholic steatohepatitis, liver fibrosis, and hepatocellular carcinoma. Furthermore, with no currently approved pharmacotherapy and a lack of clinical trials that are inclusive of HIV, nutritional and lifestyle approaches still represent the most recommended treatments for PWH with NAFLD. While sharing common features with the general population, NAFLD in PWH displays its own peculiarities that may also reflect different impacts of nutrition and exercise on its onset and treatment. Therefore, in this narrative review, we aimed to explore the role of nutrients in the development of NAFLD in PWH. In addition, we discussed the nutritional and lifestyle approaches to managing NAFLD in the setting of HIV, with insights into the role of gut microbiota and lean NAFLD.

Clinical features and management issues of NAFLD-related HCC: what we know so far

INTRODUCTION

Nonalcoholic fatty liver disease (NAFLD) is replacing viral hepatitis as the leading cause of chronic liver disease and hepatocellular carcinoma (HCC) in many Western countries. NAFLD-associated HCC usually affects older patients with multiple comorbidities, frequently develops in the absence of cirrhosis, and is often diagnosed later with worse chance of survival. The worse prognosis is also due to limited surveillance strategies and a lower efficacy of standard treatments.

AREAS COVERED

We evaluate the available literature to understand the current surveillance strategies and treatment limitations in the workup of NAFLD-associated HCC, focusing on the differences with HCC associated with other liver diseases.

EXPERT OPINION

In this review we discuss epidemiology and risk factors for HCC in NAFLD patients and address key HCC surveillance and management issues. Although most data are still preliminary, the detection of non-cirrhotic NAFLD patients at increased risk for HCC and the potential adoption of novel screening tools could lead to accurate and suitable HCC surveillance and management strategies for NAFLD patients.

Non-alcoholic fatty liver disease: relation to juvenile obesity, lipid profile, and hepatic enzymes

The prevalence of juvenile obesity is increasing, reaching epidemic proportions, presenting a link not only to NAFLD (non-alcoholic fatty liver disease) but to abnormal lipid profiles and liver enzyme abnormalities. Liver ultrasonography is a sensitive and specific tool for the recognition of NAFLD. This study aims to assess the association between NAFLD and juvenile obesity and to determine the other related changes in a set of indicators, including lipid profile abnormalities and serum transaminases. The sample included 470 obese and 210 non-obese individuals aged 6-16. Anthropometric measures were assessed, with the serum lipid profile and liver transaminases, and abdominal ultrasonography was used to detect NAFLD. Fatty liver was found in 38% of the obese subjects and none of the non-obese subjects. Within obese subjects, mean body mass index (BMI) and waist circumference increased significantly in patients with NAFLD compared to those without fatty liver. Moreover, LDL (low-density lipoprotein), CHOL (cholesterol), and serum liver enzymes were significantly higher in the presence of NAFLD. In conclusion, NAFLD commonly associates with juvenile obesity, relating to obesity and the abnormal lipid profile (including elevated CHOL and LDL) among obese people, reflecting elevated liver transaminases, which increase the risk of cirrhosis.

Physiopathology of nonalcoholic fatty liver disease: from diet to nutrigenomics

PURPOSE OF REVIEW

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease worldwide and is strongly associated with metabolic disorders, such as obesity, type 2 diabetes mellitus, and metabolic syndrome, to the extent that a new definition of metabolic associated fatty liver disease has been proposed.

RECENT FINDINGS

Insulin resistance, worsened by a high-fat and high-carbohydrate diet, is the key to the physiopathology of hepatic steatosis. This is driven by several mechanisms that are mostly activated at a genetic level, such as de-novo lipogenesis and triglyceride synthesis. Therefore, many diet regimens have been studied, although significant controversies remain regarding their metabolic effects and long-term sustainability.

SUMMARY

In this review, we summarized the role and effects of the main macronutrients on the development of NAFLD and discussed the molecular mechanisms involved. We also discussed the importance of genetic polymorphisms, epigenetic alterations, and dysbiosis to determine if lifestyle modification and a specific dietary regimen could be an essential part of NAFLD treatment.

Current Evidence Concerning Effects of Ketogenic Diet and Intermittent Fasting in Patients with Nonalcoholic Fatty Liver

Nonalcoholic fatty liver disease (NAFLD) is emerging globally, while no therapeutic medication has been approved as an effective treatment to date, lifestyle intervention through dietary modification and physical exercise plays a critical role in NAFLD management. In terms of dietary modification, Mediterranean diet is the most studied dietary pattern and is recommended in many guidelines, however, it may not be feasible and affordable for many patients. Recently, a ketogenic diet and intermittent fasting have gained public attention and have been studied in the role of weight management. This article reviews specifically whether these trendy dietary patterns have an effect on NAFLD outcomes regarding intrahepatic fat content, fibrosis, and liver enzymes, the scientific rationales behind these particular dietary patterns, as well as the safety concerns in some certain patient groups.

Effects of the 5:2 intermittent fasting diet on non-alcoholic fatty liver disease: A randomized controlled trial

BACKGROUND AND AIMS

Dietary regimens are crucial in the management of non-alcoholic fatty liver disease (NAFLD). The effects of intermittent fasting (IF) have gained attention in this regard, but further research is warranted. Thus, we aimed to ascertain the overall effects of the 5:2 IF diet (5 days a week of normal food intake and 2 consecutive fasting days) in patients with NAFLD compared to a control group (usual diet).

METHODS AND RESULTS

A 12-week randomized controlled trial was performed to evaluate the effects of the 5:2 IF diet on anthropometric indices, body composition, liver indices, serum lipids, glucose metabolism, and inflammatory markers in patients with NAFLD. The IF group (n = 21) decreased body weight (86.65 ± 12.57-82.94 ± 11.60 kg), body mass index (30.42 ± 2.27-29.13 ± 1.95 kg/m2), waist circumference (103.52 ± 6.42-100.52 ± 5.64 cm), fat mass (26.64 ± 5.43-23.85 ± 5.85 kg), fibrosis (6.97 ± 1.94-5.58 ± 1.07 kPa), steatosis scores/CAP (313.09 ± 25.45-289.95 ± 22.36 dB/m), alanine aminotransferase (41.42 ± 20.98-28.38 ± 15.21 U/L), aspartate aminotransferase (34.19 ± 10.88-25.95 ± 7.26 U/L), triglycerides (171.23 ± 39.88-128.04 ± 34.88 mg/dl), high-sensitivity C-reactive protein (2.95 ± 0.62 -2.40 ± 0.64 mg/L), and cytokeratin-18 (1.32 ± 0.06-1.19 ± 0.05 ng/ml) values compared to the baseline and the end of the control group (n = 23)-p ≤ 0.05 were considered as significant. However, the intervention did not change the levels of high-density lipoprotein cholesterol, total cholesterol, low-density lipoprotein cholesterol, fasting blood sugar, insulin, HOMA-IR, and total antioxidant capacity.

CONCLUSION

Adhering to the 5:2 IF diet can reduce weight loss and related parameters (fat mass and anthropometric indicators of obesity), as well as hepatic steatosis, liver enzymes, triglycerides, and inflammatory biomarkers in patients with NAFLD.

Crosstalk between dietary patterns, obesity and nonalcoholic fatty liver disease

The prevalence of nonalcoholic fatty liver disease (NAFLD) is rising worldwide, paralleling the epidemic of obesity. The liver is a key organ for the metabolism of proteins, fats and carbohydrates. Various types of fats and carbohydrates in isocaloric diets differently influence fat accumulation in the liver parenchyma. Therefore, nutrition can manage hepatic and cardiometabolic complications of NAFLD. Even moderately reduced caloric intake, which leads to a weight loss of 5%-10% of initial body weight, is effective in improving liver steatosis and surrogate markers of liver disease status. Among dietary patterns, the Mediterranean diet mostly prevents the onset of NAFLD. Furthermore, this diet is also the most recommended for the treatment of NAFLD patients. However, clinical trials based on the dietary interventions in NAFLD patients are sparse. Since there are only a few studies examining dietary interventions in clinically advanced stages of NAFLD, such as active and fibrotic steatohepatitis, the optimal diet for patients in these stages of the disease must still be determined. In this narrative review, we aimed to critically summarize the associations between different dietary patterns, obesity and prevention/risk for NAFLD, to describe specific dietary interventions' impacts on liver steatosis in adults with NAFLD and to provide an updated overview of dietary recommendations that clinicians potentially need to apply in their daily practice.

Mediterranean Diet: A Tool to Break the Relationship of Atrial Fibrillation with the Metabolic Syndrome and Non-Alcoholic Fatty Liver Disease

Atrial fibrillation (AF) is the most common supraventricular arrhythmia associated with increased cardiovascular and non-cardiovascular morbidity and mortality. As multiple factors may predispose the onset of AF, the prevention of the occurrence, recurrence and complications of this arrhythmia is still challenging. In particular, a high prevalence of cardio-metabolic comorbidities such as the metabolic syndrome (MetS) and in its hepatic manifestation, the non-alcoholic fatty liver disease (NAFLD), have been described in the AF population. A common pathogenetic mechanism linking AF, MetS and NAFLD is represented by oxidative stress. For this reason, in the past decades, numerous studies have investigated the effect of different foods/nutrients with antioxidant properties for the prevention of, and their therapeutic role is still unclear. In this narrative comprehensive review, we will summarize current evidence on (1) the association between AF, MetS and NAFLD (2) the antioxidant role of Mediterranean Diet and its components for the prevention of AF and (3) the effects of Mediterranean Diet on MetS components and NAFLD.

Activation of G protein-coupled receptors by ketone bodies: Clinical implication of the ketogenic diet in metabolic disorders

Ketogenesis takes place in hepatocyte mitochondria where acetyl-CoA derived from fatty acid catabolism is converted to ketone bodies (KB), namely β-hydroxybutyrate (β-OHB), acetoacetate and acetone. KB represent important alternative energy sources under metabolic stress conditions. Ketogenic diets (KDs) are low-carbohydrate, fat-rich eating strategies which have been widely proposed as valid nutritional interventions in several metabolic disorders due to its substantial efficacy in weight loss achievement. Carbohydrate restriction during KD forces the use of FFA, which are subsequently transformed into KB in hepatocytes to provide energy, leading to a significant increase in ketone levels known as "nutritional ketosis". The recent discovery of KB as ligands of G protein-coupled receptors (GPCR) - cellular transducers implicated in a wide range of body functions - has aroused a great interest in understanding whether some of the clinical effects associated to KD consumption might be mediated by the ketone/GPCR axis. Specifically, anti-inflammatory effects associated to KD regimen are presumably due to GPR109A-mediated inhibition of NLRP3 inflammasome by β-OHB, whilst lipid profile amelioration by KDs could be ascribed to the actions of acetoacetate via GPR43 and of β-OHB via GPR109A on lipolysis. Thus, this review will focus on the effects of KD-induced nutritional ketosis potentially mediated by specific GPCRs in metabolic and endocrinological disorders. To discriminate the effects of ketone bodies per se, independently of weight loss, only studies comparing ketogenic vs isocaloric non-ketogenic diets will be considered as well as short-term tolerability and safety of KDs.