Physical activity support or weight loss counseling for nonalcoholic fatty liver disease?

Evaluating the RESET care program: Advancing towards scalable and effective healthcare solutions for metabolic dysfunction-associated liver disease

In this article, we discuss the recently published article by Soni et al. This study explores the effectiveness of a comprehensive digital health program, RESET care, which integrates personalized dietary plans, structured exercise, and cognitive behavioral therapy delivered through a mobile app equipped with Internet of Things devices such as body composition analyzers and smartwatches. Metabolic dysfunction-associated liver disease (MASLD), a global health burden affecting approximately 25% of the population, demands sustainable lifestyle modifications as its primary management strategy. The study reports that 100% of participants in the comprehensive intervention group (diet + exercise + cognitive behavioral therapy) achieved a weight reduction ≥ 7% (6.99 ± 2.98 kg, 7.00% ± 3.39%; P = 0.002), a clinically significant threshold for MASLD improvement. In addition, participants showed a mean weight reduction of 6.99 kg (101.10 ± 17.85 vs 94.11 ± 17.38, P < 0.001) and a body mass index reduction of 2.18 kg/m² (32.90 ± 3.02 vs 30.72 ± 3.41, P < 0.001). These results underscore the potential of digital health platforms to provide scalable, evidence-based solutions for the treatment of MASLD. While these results highlight the potential of digital platforms in the scalable and personalized management of MASLD, the small study sample size and short duration of follow-up limit the generalizability of the results. Future large-scale, long-term trials are needed to confirm sustained benefits, cost-effectiveness, and broader applicability. This letter contextualizes the study within the evolving landscape of MASLD management and emphasizes the clinical implications of integrating digital technologies into standard care.

Effectiveness of RESET care program: A real-world-evidence on managing non-alcoholic fatty liver disease through digital health interventions

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) management requires sustainable lifestyle modifications. This study aimed to evaluate the effectiveness of the RESET care plan, a comprehensive program that is an integrated personalized diet, exercise, and cognitive behavior therapy, delivered via MyTatva's digital health application enabled through a body composition analyzer (BCA) and smartwatch.

AIM

To evaluates the effectiveness of the comprehensive program delivered via MyTatva's digital health app enabled through internet of thing devices.

METHODS

This retrospective observational study analyzed deidentified data from 22 participants enrolled in the MyTatva RESET care program. Participants were divided into three groups: Group A, diet plan; Group B, diet + exercise plan; and Group C, diet + exercise + cognitive behavioral therapy plan. Participants were provided with a BCA and smartwatch for continuous monitoring of anthropometric parameters. Statistical analysis, including one-way ANOVA and post-hoc Tukey's Honest Significant Difference test, was conducted to compare mean changes in anthropometric parameters across the groups.

RESULTS

All intervention groups showed significant improvement across all anthropometric parameters. Group C showed the most significant improvements, with mean weight reduction of 7% or more (6.99 ± 2.98 kg, 7.00% ± 3.39%; P = 0.002) from baseline, a benchmark associated with improved NAFLD conditions. Post-hoc analysis revealed that Group C had significantly greater improvements than Groups A and B. Weight reduction was observed in 85.7% of Group A participants, 77.8% of Group B participants, and 100% of Group C participants.

CONCLUSION

The comprehensive RESET care plan achieved a 7% weight reduction in 12 weeks, demonstrating its effectiveness in managing NAFLD. These results support adopting digitally supported, patient-centric approaches for NAFLD treatment.

A narrative review of lifestyle management guidelines for metabolic dysfunction-associated steatotic liver disease

BACKGROUND AND AIMS

Metabolic dysfunction-associated steatotic liver disease management guidelines have been published worldwide; we aimed to summarize, categorize, and compare their lifestyle intervention recommendations.

APPROACH AND RESULTS

We searched metabolic dysfunction-associated steatotic liver disease/NAFLD management guidelines published between January 1, 2013, and June 31, 2024, through databases including PubMed/MEDLINE, Cochrane, and CINAHL. In total, 35 qualifying guidelines were included in the final analysis. Guideline recommendations were categorized into 5 domains (ie, weight reduction goals, physical activity, nutrition, alcohol, and tobacco smoking) and were ranked based on how frequently they appeared. A recommendation was defined as widely adopted if recommended in ≥24 (≥66.6%) of the guidelines. These included increasing physical activity; reducing body weight by 7%-10% to improve steatohepatitis and/or fibrosis; restricting caloric intake; undertaking 150-300 or 75-150 minutes/week of moderate or vigorous-intensity physical activity, respectively; and decreasing consumption of commercially produced fructose. The least mentioned topics, in ≤9 of the guidelines, evaluated environmental determinants of health, mental health, referring patients for psychological or cognitive behavioral therapy, using digital health interventions, and assessing patients' social determinants of health.

CONCLUSIONS

Most guidelines recommend weight reduction through physical activity and improving nutrition, as these have proven positive effects on health outcomes when sustained. However, gaps regarding mental health and the social and environmental determinants of metabolic dysfunction-associated steatotic liver disease were found. To optimize behavioral modifications and treatment, we recommend carrying out studies that will provide further evidence on social support, environmental factors, and mental health, as well as further exploring digital health interventions.

Physical Activity and Nonalcoholic Fatty Liver Disease: A Roundtable Statement from the American College of Sports Medicine

ABSTRACT

Although physical activity (PA) is crucial in the prevention and clinical management of nonalcoholic fatty liver disease, most individuals with this chronic disease are inactive and do not achieve recommended amounts of PA. There is a robust and consistent body of evidence highlighting the benefit of participating in regular PA, including a reduction in liver fat and improvement in body composition, cardiorespiratory fitness, vascular biology, and health-related quality of life. Importantly, the benefits of regular PA can be seen without clinically significant weight loss. At least 150 min of moderate or 75 min of vigorous intensity PA are recommended weekly for all patients with nonalcoholic fatty liver disease, including those with compensated cirrhosis. If a formal exercise training program is prescribed, aerobic exercise with the addition of resistance training is preferred. In this roundtable document, the benefits of PA are discussed, along with recommendations for 1) PA assessment and screening; 2) how best to advise, counsel, and prescribe regular PA; and 3) when to refer to an exercise specialist.

Investigation of movement-related behaviors and energy compensation in people living with liver disease: A scoping review

The importance of integrated movement behaviours (MB, i.e., physical activity [PA], sedentary behaviour, and sleep) and their interdependence for health has been recently discussed in the literature. The proposition that the amount of time spent in any one of these behaviours may impact the amount of time spent in another is supported by the ActivityStat hypothesis. The aim of this review is to (1) to assess whether individuals with liver disease display MB and/or energy (i.e., total energy expenditure [EE], basal EE, resting EE, and activity EE) compensation throughout the day and/or days; and (2) to examine whether a prescribed PA intervention triggers compensatory responses. Documents were included if they focused on people living with liver disease; analysed MB and/or EE components; were data-based; and were published in English. Fifteen documents were included in the final synthesis. The one finding that addressed research question 1 showed no compensatory response. As for research question 2, most of the findings suggest no compensation effects in response to a PA intervention. There is insufficient evidence to support the ActivityStat hypothesis in people living with liver disease. Further research should be conducted to test this hypothesis using standardized methodological procedures.

Effect of rosemary leaf powder with weight loss diet on lipid profile, glycemic status, and liver enzymes in patients with nonalcoholic fatty liver disease: A randomized, double-blind clinical trial

Experimental and some clinical studies have shown beneficial effects of rosemary leaf on liver function and biochemical parameters. The present study aimed to examine the impact of rosemary leaf powder with a weight loss diet in patients with nonalcoholic fatty liver disease. In a randomized double-blinded clinical trial, 110 patients were randomly assigned to receive either 4 g rosemary leaf or placebo (starch) powders for 8 weeks. In addition, all participants in the study were given weight loss diet and physical activity recommendations. Compared with baseline, alanine aminotransferase (p < .001), aspartate aminotransferase (p < .001), alkaline phosphatase (p < .001), gamma glutamyltransferase (p < .001), fasting blood glucose (p < .001), fasting insulin (p < .001), insulin resistance (p < .001), total cholesterol (p = .003), triglyceride (p < .001), low-density lipoprotein cholesterol (p < .001), and anthropometric indices (weight, body mass index, and waist circumferences) decreased significantly in the rosemary and placebo group with weight loss. However, after 8 weeks, no significant difference between the rosemary and placebo groups was detected in the variables as mentioned above except homeostasis model assessment of β-cell dysfunction (p = .014). The findings of the current clinical trial study revealed that rosemary group did produce changes, but they were not statistically different from those produced by the diet/activity intervention alone.

The Visceral Adiposity Index in Non-Alcoholic Fatty Liver Disease and Liver Fibrosis-Systematic Review and Meta-Analysis

(1) Background: In order to avoid a liver biopsy in non-alcoholic fatty liver disease (NAFLD), several noninvasive biomarkers have been studied lately. Therefore, we aimed to evaluate the visceral adiposity index (VAI) in NAFLD and liver fibrosis, in addition to its accuracy in predicting NAFLD and NASH. (2) Methods: We searched PubMed, Embase, Scopus, and Cochrane Library, identifying observational studies assessing the VAI in NAFLD and liver fibrosis. QUADAS-2 was used to evaluate the quality of included studies. The principal summary outcomes were mean difference (MD) and area under the curve (AUC). (3) Results: A total of 24 studies were included in our review. VAI levels were significantly increased in NAFLD (biopsy-proven and ultrasound-diagnosed), simple steatosis vs. controls, and severe steatosis vs. simple steatosis. However, no significant MD was found according to sex, liver fibrosis severity, simple vs. moderate and moderate vs. severe steatosis, pediatric NAFLD, and NASH patients. The VAI predicted NAFLD (AUC 0.767) and NASH (AUC 0.732). (4) Conclusions: The VAI has a predictive value in diagnosing NAFLD and NASH, with significantly increased values in adult NAFLD patients, simple steatosis compared to controls, and severe steatosis compared to simple steatosis.

Lean NAFLD: an underrecognized and challenging disorder in medicine

Classically, Non-Alcoholic Fatty Liver Disease (NAFLD) has been thought to be driven by excessive weight gain and obesity. The overall greater awareness of this disorder has led to its recognition in patients with normal body mass index (BMI). Ongoing research has helped to better understand potential causes of Lean NAFLD, the risks for more advanced disease, and potential therapies. Here we review the recent literature on prevalence, risk factors, severity of disease, and potential therapeutic interventions.

Difference in lifestyle and metabolic profile of non-alcoholic fatty liver disease with raised alanine amino-transferases between obese and non-overweight subjects

A significant proportion of patients with non-alcoholic fatty liver disease (NAFLD) in Asian sub-continent are non-overweight and may have different underlying risk factors, lifestyles and metabolic profiles. Seven hundred fifty patients of NAFLD with raised alanine-amino-transferase (ALT) were divided into non-overweight and obese group based on their body mass index (BMI). Detailed dietary and lifestyle history were obtained through questionnaires and a detailed assessment of metabolic profile and liver stiffness was done. Normal BMI (< 23 kg/m²) was found in 6.6% patients, of which 69.5% had raised ALT. Though the intake of dietary fat and exercise pattern were not different amongst these groups, yet the amount of aerated drinks was higher in obese subjects (12 ± 17 vs. 7 ± 7.5 p = 0.005). Serum low-density lipoprotein (111 ± 25.6 vs. 127.7 ± 32.7 p = 0.04) and insulin resistance based on HOMA-IR > 2 were significantly higher in obese group (4.1 ± 0.36 vs. 2.0 ± 0.15 p = 0.001). Insulin resistance and dyslipidemia were prevalent in 12% and 25% non-overweight patients respectively. Metabolic syndrome was more common in obese subjects. In addition, magnetic resonance elastography showed higher mean liver fat in the obese group with similar hepatic fibrosis. Non-overweight patients with NAFLD had lower insulin resistance and prevalence of dyslipidaemia at similar dietary and exercise pattern.

Lifestyle Intervention on Body Weight and Physical Activity in Patients with Breast Cancer can reduce the Risk of Death in Obese Women: The EMILI Study

Background obesity and sedentary lifestyle have been shown to negatively affect survival in breast cancer (BC). The purpose of this study was to test the efficacy of a lifestyle intervention on body mass index (BMI) and physical activity (PA) levels among BC survivors in Modena, Italy, in order to show an outcome improvement in obese and overweight patients. Methods: This study is a single-arm experimental design, conducted between November 2009 and May 2016 on 430 women affected by BC. Weight, BMI, and PA were assessed at baseline, at 12 months, and at the end of the study. Survival curves were estimated among normal, overweight, and obese patients. Results: Mean BMI decreased from baseline to the end of the study was equal to 2.9% (p = 0.065) in overweight patients and 3.3% in obese patients (p = 0.048). Mean PA increase from baseline to the end of the study was equal to 125% (p < 0.001) in normal patients, 200% (p < 0.001) in overweight patients and 100% (p < 0.001) in obese patients. After 70 months of follow-up, the 5-year overall survival (OS) rate was 96%, 96%, and 93%, respectively in normal, obese, and overweight patients. Overweight patients had significantly worse OS than normal ones (HR = 3.69, 95%CI = 1.82–4.53 p = 0.027) whereas no statistically significant differences were seen between obese and normal patients (HR 2.45, 95%CI = 0.68–8.78, p = 0.169). Conclusions: A lifestyle intervention can lead to clinically meaningful weight loss and increase PA in patients with BC. These results could contribute to improving the OS in obese patients compared to overweight ones.

Anthropometric Measurements and Lifestyle Characteristics of Individuals with Non-alcoholic Fatty Liver Disease

Background

Non-alcoholic fatty liver disease (NAFLD) is a common liver disorder caused by the deposition of lipids and fats in the hepatocytes, in individuals who consume little or no alcohol, which eventually progresses to cirrhosis and carcinoma. Apart from the known risk factors like obesity, metabolic syndrome (MS), and lack of physical activity (PA), diet also plays a major role in the development of NAFLD. A high body mass index (BMI) and waist circumference (WC) have positive associations with NAFLD. The aim of this study was to find the prevalence of risk factors of hepatic steatosis in NAFLD population and to raise public awareness about the condition.

Method

We conducted a cross-sectional study from October to December 2019 with a sample size of 98 subjects determined by using a confidence interval (CI) of 99.9%. Patients presenting to Essa Laboratory, Karachi for abdominal ultrasound (US) were scanned for fatty changes in the liver, after obtaining consent, and were then assessed for risk factors by administering a 20-item questionnaire along with registering their BMI and WC measurement. The collected data was analyzed using the Statistical Package for Social Sciences (SPSS), version 22 (IBM, Armonk, NY). The independent sample t-test was applied for the exploration of variables and a p-value <0.05 was considered significant.

Result

Our study included 96 participants, of which 49 (51%) were male and 47 (49%) female. Mean BMI in females was slightly greater (30.58) than in males (27.98), whereas WC (in inches) was almost equal in males (40.796) and females (40.383). Among the people that had any comorbidities (n = 60, 62.5%), hypertension (HTN) was the most common one (n = 37, 38.5%) followed by diabetes mellitus (DM) type 2 (n = 26, 27.1%). A significant majority (n = 63, 65.5%) never consumed any fruits or vegetables in their meal nor did they perform any sort of physical exercise (n = 46, 47.9%).

Conclusion

Obesity (high BMI), lack of PA, lower consumption of fruits and vegetables along with a carbohydrate- and fat-rich diet play a vital role in the development of hepatic steatosis. Moreover, HTN and DM, as components of MS, exhibit a significant association with NAFLD. Screening and counseling sessions should be considered for individuals with these anthropometric measurements and lifestyle characteristics.

Current treatment options for nonalcoholic fatty liver disease

PURPOSE OF REVIEW

Nonalcoholic fatty liver disease (NAFLD) is the leading cause of liver disease in the United States and is strongly associated to the metabolic syndrome. In this review, we will discuss the evidence behind the current recommendations on lifestyle modifications and available treatment options for NAFLD.

RECENT FINDINGS

The unrelenting rise in obesity and diabetes epidemic has led to a large healthcare burden from NAFLD and it is projected to continue to grow over the next two decades. Lifestyle modification that leads to weight loss is effective at treating NAFLD, but these modifications require a multidisciplinary approach for success in the real world. Multiple pharmacologic treatment options have been studied with promising results, but none have been approved for treatment in the United States. Clinical trials are on-going to study further pharmacologic treatment alternatives.

SUMMARY

NAFLD is the most common chronic liver disease in United States, and an independent risk factor for mortality. Implementation of lifestyle modifications through a multidisciplinary approach and careful selection of patients for pharmacologic interventions will be essential for successful management of NAFLD.

Exercising the hepatobiliary-gut axis. The impact of physical activity performance

BACKGROUND

Physical inactivity puts the populations at risk of several health problems, while regular physical activity brings beneficial effects on cardiovascular disease, mortality and other health outcomes, including obesity, glycaemic control and insulin resistance. The hepatobiliary tract is greatly involved in several metabolic aspects which include digestion and absorption of nutrients in concert with intestinal motility, bile acid secretion and flow across the enterohepatic circulation and intestinal microbiota. Several metabolic abnormalities, including nonalcoholic fatty liver as well as cholesterol cholelithiasis, represent two conditions explained by changes of the aforementioned pathways.

MATERIALS AND METHODS

This review defines different training modalities and discusses the effects of physical activity in two metabolic disorders, that is nonalcoholic fatty liver disease (NAFLD) and cholelithiasis. Emphasis is given to pathogenic mechanisms involving intestinal bile acids, microbiota and inflammatory status.

RESULTS

A full definition of physical activity includes the knowledge of aerobic and endurance exercise, metabolic equivalent tasks, duration, frequency and intensity, beneficial and harmful effects. Physical activity influences the hepatobiliary-gut axis at different levels and brings benefits to fat distribution, liver fat and gallbladder disease while interacting with bile acids as signalling molecules, intestinal microbiota and inflammatory changes in the body.

CONCLUSIONS

Several beneficial effects of physical activity are anticipated on metabolic disorders linking liver steatosis, gallstone disease, gut motility, enterohepatic circulation of signalling bile acids in relation to intestinal microbiota and inflammatory changes.

Non-alcoholic fatty liver disease and associated dietary and lifestyle risk factors

Nonalcoholic fatty liver disease (NAFLD) has emerged as the most common chronic liver disease worldwide with a reported prevalence ranging 20-30% depending on the studied populations. The high prevalence of NAFLD is probably due to the contemporary epidemics of obesity, unhealthy dietary pattern, and sedentary lifestyle. NAFLD patients are at increased risk of cardiovascular and liver related mortality. The cornerstone of any treatment regimen for patients with NAFLD is lifestyle modification focused on weight loss, exercise, and improving insulin sensitivity. The purpose of this review is to outline the effect of diet and lifestyle factors on developing NAFLD.

Relationship between Diet and Non-alcoholic Fatty Liver Disease: A Review Article

BACKGROUND

Diet plays a key role in the development of non-alcoholic fatty liver disease (NAFLD). The aim of this study was to review systematically observational studies available regarding the relationship between food intakes and NAFLD.

METHODS

We searched Scopus, PubMed, and Cochrane Library databases to identify English observational studies on food groups, dietary patterns, and NAFLD. Cross-sectional, case-control and cohort studies were selected and then duplication, topic, type of study, study population, variables examined and quality of data reporting of the articles were evaluated.

RESULTS

We identified 2128 studies in the initial search, of which 33 were reviewed in full text and 7 articles were included in this systematic review. Intakes of red meat, fats, and sweets were high whereas consumption of whole grains, fruits and vegetables were less in NAFLD patients. Moreover, there was a positive association between the Western dietary pattern and the risk of NAFLD, while adherence to the Mediterranean diet was significantly associated with the severity of hepatic steatosis.

CONCLUSION

Generally, different food group intakes and dietary patterns are associated with the progression of NAFLD and its risk factors. Because of the many limitations of available studies reviewed on this topic, more prospective studies are suggested.

Effect of a counseling-supported treatment with the Mediterranean diet and physical activity on the severity of the non-alcoholic fatty liver disease

AIM

To determine the clinical effectiveness of nutritional counseling on reduction of non-alcoholic fatty liver disease (NAFLD) severity, weight loss, metabolic and anthropometric indexes and liver enzymes.

METHODS

Forty-six adults with NAFLD received a 6-mo clinical and a dietary intervention (based on Mediterranean diet) carried out respectively by a gastroenterologist and a nutritionist with counseling license. The counseling process consisted of monthly meeting (about 45 min each). The effect of the treatment was evaluated monitoring liver enzymes, metabolic parameters, cardiovascular risk indexes, NAFLD severity [assessed by ultrasound (US)] and related indexes. All parameters were assessed at baseline. Biochemistry was also assessed at mid- and end-interventions and US was repeated at end-intervention.

RESULTS

The percentage of patients with steatosis grade equal or higher than 2 was reduced from 93% to 48% and steatosis regressed in 9 patients (20%). At the end of the treatment the end-point concerning the weight (i.e., a 7% weight reduction or achievement/maintenance of normal weight) was accomplished by 25 out of 46 patients (i.e., 54.3%). As far as the liver enzymes is concerned, all three liver enzymes significantly decrease during the treatment the normalization was particularly evident for the ALT enzyme (altered values reduced from 67% down to 11%). Several parameters, i.e., BMI, waist circumference, waist-to-hip ratio, AST, ALT, GGT, HDL, serum glucose, Tot-Chol/HDL, LDL/HDL, TG/HDL, AIP, HOMA, FLI, Kotronen index, VAI, NAFLD liver fat score and LAP, showed a significant improvement (P < 0.01) between baseline and end-treatment.

CONCLUSION

Outcomes of this study further strengthen the hypothesis that MedDiet and more active lifestyle can be considered a safe therapeutic approach for reducing risk and severity of NAFLD and related disease states. The proposed approach may be proposed as a valid and recommended approach for improving the clinical profile of NAFLD patients.

Supervised vs. self-selected physical activity for individuals with diabetes and obesity: the Lifestyle Gym program

The effectiveness of different programs of physical activity outside randomized studies is difficult to determine. We carried out an audit in two different units where either a supervised physical activity (PA) program or a self-selected PA program was in use in individuals with type 2 diabetes or obesity. The supervised PA cohort (n = 101) received progressive gym training (120 min, twice a week for 13 weeks) by a dedicated team, with nutritional counseling during resting periods. The self-selected PA cohort (n = 69) was enrolled in a 13-week cognitive-behavioral program (120 min/week, in groups of 12-15 individuals), chaired by an expert team. Body weight and physical fitness (6-min walk test) were measured at baseline and after 6 and 12 months. Outcome measures were attrition, weight loss ≥10 % initial body weight, 10 % increase in 6-min walk test; their association with a PA program was tested by logistic regression analysis. Attrition rate was lower in the supervised PA group (28 vs. 45 % than in the self-selected cohort, P = 0.023). After adjustment for confounders, the supervised PA program was associated with a lower risk of attrition at 1 year (odds ratio 0.45; 95 % confidence interval, 0.21-0.98) at logistic regression analysis. Body weight similarly decreased in both groups (more rapidly in the supervised PA cohort); also physical fitness improved in a similar way, and no differences in achieved targets of body weight (supervised, 31 %; self-selected, 18 %; P = 0.118) or fitness (supervised, 62 %; self-selected, 49 %; P = 0.312) were demonstrated. Different PA programs produce very similar health benefits, but an initially supervised program has lower attrition rates, which might translate into better outcomes in the long term.

Non-alcoholic fatty liver disease and risk of cardiovascular disease

Non-alcoholic fatty liver disease (NAFLD) has become the leading cause of chronic liver diseases worldwide, causing considerable liver-related mortality and morbidity. During the past decade, it has also become increasingly evident that NAFLD is a multisystem disease that affects many extra-hepatic organ systems, including the heart and the vascular system. In this updated clinical review, we discuss the rapidly expanding body of clinical and epidemiological evidence that supports a strong association of NAFLD with cardiovascular diseases (CVDs) and other functional and structural myocardial abnormalities. We also discuss some recently published data that correlate NAFLD due to specific genetic polymorphisms with the risk of CVDs. Finally, we briefly examine the assessment tools for estimating the global CVD risk in patients with NAFLD as well as the conventional and the more innovative pharmacological approaches for the treatment of CVD risk in this group of patients.

Diet, weight loss, and liver health in nonalcoholic fatty liver disease: Pathophysiology, evidence, and practice

Fatty liver accumulation results from an imbalance between lipid deposition and removal, driven by the hepatic synthesis of triglycerides and de novo lipogenesis. The habitual diet plays a relevant role in the pathogenesis of nonalcoholic fatty liver disease (NAFLD), and both risky (e.g., fructose) and protective foods (Mediterranean diet) have been described, but the contribution of excess calories remains pivotal. Accordingly, weight loss is the most effective way to promote liver fat removal. Several controlled studies have confirmed that an intense approach to lifestyle changes, carried on along the lines of cognitive-behavior treatment, is able to attain the desired 7%-10% weight loss, associated with reduced liver fat, nonalcoholic steatohepatitis (NASH) remission, and also reduction of fibrosis. Even larger effects are reported after bariatric surgery-induced weight loss in NAFLD, where 80% of subjects achieve NASH resolution at 1-year follow-up. These results provide solid data to evaluate the safety and effectiveness of the pharmacological treatment of NASH. The battle against metabolic diseases, largely fueled by increased liver fat, needs a comprehensive approach to be successful in an obesiogenic environment. In this review, we will discuss the role of hepatic lipid metabolism, genetic background, diet, and physical activity on fatty liver. They are the basis for a lifestyle approach to NAFLD treatment. (Hepatology 2016;63:2032-2043).

Type 2 Diabetes in Non-Alcoholic Fatty Liver Disease and Hepatitis C Virus Infection--Liver: The "Musketeer" in the Spotlight

The pathogenesis of type 2 diabetes (T2D) involves chronic hyperinsulinemia due to systemic and hepatic insulin resistance (IR), which if uncorrected, will lead to progressive pancreatic beta cell failure in predisposed individuals. Non-alcoholic fatty liver disease (NAFLD) encompasses a spectrum of fatty (simple steatosis and steatohepatitis) and non-fatty liver changes (NASH-cirrhosis with or without hepatocellular carcinoma (HCC)) that are commonly observed among individuals with multiple metabolic derangements, notably including visceral obesity, IR and T2D. Hepatitis C virus (HCV) infection is also often associated with both hepatic steatosis and features of a specific HCV-associated dysmetabolic syndrome. In recent years, the key role of the steatotic liver in the development of IR and T2D has been increasingly recognized. Thus, in this comprehensive review we summarize the rapidly expanding body of evidence that links T2D with NAFLD and HCV infection. For each of these two liver diseases with systemic manifestations, we discuss the epidemiological burden, the pathophysiologic mechanisms and the clinical implications. To date, substantial evidence suggests that NAFLD and HCV play a key role in T2D development and that the interaction of T2D with liver disease may result in a "vicious circle", eventually leading to an increased risk of all-cause mortality and liver-related and cardiovascular complications. Preliminary evidence also suggests that improvement of NAFLD is associated with a decreased incidence of T2D. Similarly, the prevention of T2D following HCV eradication in the era of direct-acting antiviral agents is a biologically plausible result. However, additional studies are required for further clarification of mechanisms involved.

Role of diet on non-alcoholic fatty liver disease: An updated narrative review

The purpose of this article review is to update what is known about the role of diet on non-alcoholic fatty liver disease (NAFLD). NAFLD is the most common cause of chronic liver disease in the developed world and is considered to be a spectrum, ranging from fatty infiltration of the liver alone (steatosis), which may lead to fatty infiltration with inflammation known as non alcoholic steatohepatitis While the majority of individuals with risk factors like obesity and insulin resistance have steatosis, only few people may develop steatohepatitis. Current treatment relies on weight loss and exercise, although various insulin-sensitizing medications appear promising. Weight loss alone by dietary changes has been shown to lead to histological improvement in fatty liver making nutrition therapy to become a cornerstone of treatment for NAFLD. Supplementation of vitamin E, C and omega 3 fatty acids are under consideration with some conflicting data. Moreover, research has been showed that saturated fat, trans-fatty acid, carbohydrate, and simple sugars (fructose and sucrose) may play significant role in the intrahepatic fat accumulation. However, true associations with specific nutrients yet to be clarified.

A standard ballroom and Latin dance program to improve fitness and adherence to physical activity in individuals with type 2 diabetes and in obesity

OBJECTIVE

To test the effectiveness of a dance program to improve fitness and adherence to physical activity in subjects with type 2 diabetes and obesity.

RESEARCH DESIGN AND METHODS

Following a motivational interviewing session, 100 subjects with diabetes and/or obesity were enrolled either in a dance program (DP, n = 42) or in a self-selected physical activity program (SSP, n = 58), according to their preferences. Outcome measures were reduced BMI/waist circumference, improved metabolic control in type 2 diabetes (-0.3% reduction of HbA1c) and improved fitness (activity expenditure >10 MET-hour/week; 10% increase in 6-min walk test (6MWT)). Target achievement was tested at 3 and 6 months, after adjustment for baseline data (propensity score).

RESULTS

Attrition was lower in DP. Both programs significantly decreased body weight (on average, -2.6 kg; P < 0.001) and waist circumference (DP, -3.2 cm; SSP, -2.2; P < 0.01) at 3 months, and the results were maintained at 6 months. In DP, the activity-related energy expenditure averaged 13.5 ± 1.8 MET-hour/week in the first three months and 14.1 ± 3.0 in the second three-month period. In SSP, activity energy expenditure was higher but highly variable in the first three-month period (16.5 ± 13.9 MET-hour/week), and decreased in the following three months (14.2 ± 12.3; P vs. first period < 0.001). At three months, no differences in target achievement were observed between groups. After six months the odds to attain the MET, 6MWT and A1c targets were all significantly associated with DP.

CONCLUSION

Dance may be an effective strategy to implement physical activity in motivated subjects with type 2 diabetes or obesity (Clinical trial reg. no.NCT02021890, clinicaltrials.gov).