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Management of Non-alcoholic Fatty Liver Disease from Primary Care: Prevention and Intervention through Nutrition and Physical Exercise

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A special issue of Nutrients (ISSN 2072-6643). This special issue belongs to the section "Clinical Nutrition".

Deadline for manuscript submissions: closed (20 July 2022) | Viewed by 35013

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Dr. Pere Torán-Monserrat

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Unitat de Suport a la Recerca Metropolitana Nord, Fundació Institut Universitari per a la recerca a l'Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), 08303 Mataró, Spain
Interests: primary care medicine; clinical epidemiology; cohort studies; evidence-based medicine; clinical medicine; portfolio theory; diabetes; health; hypertension; preventive medicine
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Dear Colleagues,

In recent years, as a result of the increasing prevalence of overweight and obesity, non-alcoholic fatty liver disease (NAFLD) has become an emerging disease in the general population. In fact, in Western countries, NAFLD has become the most common liver disease in both adult and paediatric populations. This pathology is closely related to metabolic syndrome (MS). Therefore, it is an important risk factor for the development of other comorbidities such as pre-diabetes, diabetes, insulin resistance, dyslipidaemia and cardiovascular diseases. Moreover, the presence of NAFLD together with any of these comorbidities is associated with increased cardiovascular and liver morbidity and mortality, including its progression to cirrhosis and hepatocarcinoma. However, we do not have sufficient data on the impact of NAFLD in the general population, or the consequences it may have in the future.

Since obesity and NAFLD are very prevalent in our environment, they tend to be underestimated; however, they are potentially serious pathologies due to their association with multiple cardiovascular risk factors. Obesity at an early age is mostly related to cultural level, family socioeconomic status and, especially, to the lifestyle changes that have occurred in the last few years (e.g., the consumption of unhealthy foods and sedentary habits). As a result, NAFLD leads to an increase in the overall burden of disease, a considerable expenditure of health resources and an increase in long-term mortality.

Primary care is the most appropriate setting for any early detection technique as well as any intervention aimed at weight loss through nutrition and physical exercise. Framing this as a challenge for preventive practices will give us the opportunity to avoid the development of the advanced stages of the disease as well as its multiple associated comorbidities and complications.

Considering all that, in this Special Issue of Nutrients entitled "Management of Non-Alcoholic Fatty Liver Disease from Primary Care" we encourage researchers to submit articles that examine strategies for the early detection of NAFLD, its risk factors and interventions aimed at weight loss through physical exercise and especially nutrition.

Prof. Dr. Pere Torán-Monserrat
Guest Editor

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Keywords

NAFLD
metabolic syndrome
chronic liver disease
fibrosis
steatosis
primary care
nutrition
nutritional intervention
weight loss
prevention

Published Papers (9 papers)

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Research

14 pages, 322 KiB

Open AccessArticle

Intrahepatic Fat Content and COVID-19 Lockdown in Adults with NAFLD and Metabolic Syndrome

by Sofía Montemayor, Catalina M. Mascaró, Lucía Ugarriza, Miguel Casares, Cristina Gómez, J. Alfredo Martínez, Josep A. Tur and Cristina Bouzas

Nutrients 2022, 14(17), 3462; https://0-doi-org.brum.beds.ac.uk/10.3390/nu14173462 - 24 Aug 2022

Cited by 2 | Viewed by 1886

Abstract

Background: COVID-19 lockdowns had a significant impact on people’s health, triggering levels of anxiety, perceived stress, and changes in food and nutritional status. Objectives: To assess the changes in dietary habits, metabolic syndrome (MetS) and liver parameters before and after the COVID-19 lockdown according to changes in intrahepatic fat content in adults with non-alcoholic fatty liver disease (NAFLD) and MetS. Design: Pre- and post-lockdown observation of the COVID-19 lockdown on fifty-nine 40–60-year-old participants with MetS and NAFLD, in a parallel group, randomised experiment intended to treat NAFLD. Methods: Anthropometrics, liver and MetS biochemical parameters, intrahepatic fat content by abdominal magnetic resonance imaging, and dietary assessment using a validated 148-item Food Frequency Questionnaire were collected pre-COVID-19 lockdown and post-lockdown. Results: COVID-19 lockdown led to negative changes in the liver of patients with NAFLD and MetS, with weight gain and increases in glycemia, ALT and intrahepatic fat content post lockdown. Participants with worsened liver status had low consumption of fibre, cheese, nuts and coffee, and high consumption of sweets and pastries. Participants who improved liver status ameliorated ALT values, waist circumference, and intrahepatic fat content, assessed by magnetic resonance imaging post-lockdown. Conclusions: The maintenance of healthy lifestyle habits is vital, especially for populations with NAFLD and MetS, to reduce unhealthy lifestyle patterns displayed during lockdown. Full article

(This article belongs to the Special Issue Management of Non-alcoholic Fatty Liver Disease from Primary Care: Prevention and Intervention through Nutrition and Physical Exercise)

13 pages, 1722 KiB

Open AccessArticle

Metabolic Score for Insulin Resistance Is Inversely Related to Incident Advanced Liver Fibrosis in Patients with Non-Alcoholic Fatty Liver Disease

by Jun-Hyuk Lee, Yu-Jin Kwon, Kyongmin Park, Hye Sun Lee, Hoon-Ki Park, Jee Hye Han and Sang Bong Ahn

Nutrients 2022, 14(15), 3039; https://0-doi-org.brum.beds.ac.uk/10.3390/nu14153039 - 24 Jul 2022

Cited by 13 | Viewed by 2163

Abstract

We determined the relationships between metabolic score for IR (METS-IR), triglyceride-glucose (TyG) index, and homeostatic model assessment for IR (HOMA-IR) and incident advanced liver fibrosis (ALF) and assessed the abilities of the three IR indicators to predict ALF in patients with non-alcoholic fatty liver disease (NAFLD) in adults with NAFLD who were aged 40–69 years old. Among 2218 participants with NAFLD at baseline, the areas under the receiver operating characteristic curve for predicting ALF of the METS-IR was 0.744 (0.679–0.810), significantly higher than that of TyG index (0.644 (0.569–0.720)) or that of HOMA-IR (0.633 (0.556–0.710)). Among 1368 patients with NAFLD and without ALF at baseline, 260 (19.0%) patients with NAFLD progressed to ALF during the 16-year follow-up period. Multivariable Cox proportional hazard regression analysis revealed that the adjusted hazard ratio (95% confidence interval) for incident ALF in the highest tertiles of METS-IR, TyG index, and HOMA-IR compared with the lowest tertile of each IR indicator were 0.5 (0.36–0.91), 0.7 (0.49–1.00), and 1.01 (0.71–1.42), respectively. METS-IR was inversely associated with ALF in patients with NAFLD, which cautiously suggests that the risk of ALF may need to be evaluated when metabolic parameters improve in individuals with NAFLD. Full article

(This article belongs to the Special Issue Management of Non-alcoholic Fatty Liver Disease from Primary Care: Prevention and Intervention through Nutrition and Physical Exercise)

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12 pages, 909 KiB

Open AccessArticle

Cutoff Points of Waist Circumference for Predicting Incident Non-Alcoholic Fatty Liver Disease in Middle-Aged and Older Korean Adults

by Jun-Hyuk Lee, Soyoung Jeon, Hye Sun Lee and Yu-Jin Kwon

Nutrients 2022, 14(14), 2994; https://0-doi-org.brum.beds.ac.uk/10.3390/nu14142994 - 21 Jul 2022

Cited by 8 | Viewed by 1883

Abstract

This study aimed to determine the optimal cutoff value of waist circumference (WC) for predicting incident NAFLD. In this community-based prospective cohort study, we analyzed data from 5400 participants without NAFLD at baseline aged 40–69 years. NAFLD was defined as a NAFLD-liver fat score >−0.640. A Cox proportional hazards regression model was used to estimate the hazard ratio (HR) and 95% confidence interval (CI) for an association between body composition and NAFLD incidence. The predictive power of each body composition indicator was assessed by Harrell’s concordance index for Cox models. During a mean follow-up period of 12 years, there were 2366 new-onset NAFLD events. Compared with men with WC < 81 cm, the adjusted HR (95% CI) for incident NAFLD in those with WC ≥ 81 cm was 2.44 (2.23–2.67). Compared with women with WC < 78.5 cm, the adjusted HR (95% CI) for incident NAFLD in those with WC ≥ 78.5 cm was 2.54 (2.25–2.87). WC was the most significant risk factor for predicting incident NAFLD among body composition indicators in middle-aged and older Korean adults. The optimal WC cutoff point for predicting incident NALFD was 81 cm in men and 78.5 cm in women, which might assist in the early detection and prevention of NAFLD. Full article

(This article belongs to the Special Issue Management of Non-alcoholic Fatty Liver Disease from Primary Care: Prevention and Intervention through Nutrition and Physical Exercise)

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13 pages, 318 KiB

Open AccessFeature PaperArticle

Impact of Physical Activity Differences Due to COVID-19 Pandemic Lockdown on Non-Alcoholic Fatty Liver Parameters in Adults with Metabolic Syndrome

by Catalina M. Mascaró, Cristina Bouzas, Sofía Montemayor, Silvia García, David Mateos, Miguel Casares, Cristina Gómez, Lucía Ugarriza, Pere-Antoni Borràs, J. Alfredo Martínez and Josep A. Tur

Nutrients 2022, 14(12), 2370; https://0-doi-org.brum.beds.ac.uk/10.3390/nu14122370 - 08 Jun 2022

Cited by 5 | Viewed by 2297

Abstract

Background: A Mediterranean lifestyle with a Mediterranean diet and regular physical activity (PA) improves metabolic syndrome (MetS) characteristics and non-alcoholic fatty liver disease (NAFLD). The COVID-19 pandemic stopped healthy habits and increased NAFLD progression. Objectives: To assess how PA differences due to COVID-19 lockdown affected NAFLD parameters in adults with MetS. Design: Longitudinal 2-year analysis of data obtained between COVID-19 pre- and post-lockdown in a parallel-group randomized trial (n = 57, aged 40–60 years old, with MetS and NAFLD). Methods: NAFLD status and related parameters were assessed by magnetic resonance imaging (MRI), blood collection analysis and related indexes. PA and fitness status were assessed by an Alpha-Fit test battery, accelerometers, validated Minnesota questionnaire and functional fitness score. During lockdown, study personnel telephoned patients to motivate them. Participants were grouped according to PA levels. Results: The low PA group improved its fitness score tests (0.2) after lockdown more than the medium PA group, and it decreased its sedentary activity (−48.7 min/day), increased light (20.9 min/day) and moderate (32.3 min/day) PA intensities and improved sleep efficiency (0.6%) in comparison with the medium and high PA groups. The high PA group increased its steps per day more than the other groups. The low PA group was the only group that decreased its gamma glutamyl transferase (GGT) levels (−17.0 U/L). All groups increased their fatty liver index (FLI) after lockdown, but the medium PA group increased its FLI more than the low PA group. Participants in the high PA group decreased their HDL-cholesterol levels more than participants in the medium PA group (−0.4 mg/dL). Conclusions: Stopping regular PA together with an unhealthy lifestyle leads to a worsening of MetS and NAFLD. COVID-19 lockdown induced a decrease in PA in more active people, but inactive people increased their PA levels. Motivation seemed to be very important during lockdown. Full article

(This article belongs to the Special Issue Management of Non-alcoholic Fatty Liver Disease from Primary Care: Prevention and Intervention through Nutrition and Physical Exercise)

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19 pages, 2168 KiB

Open AccessArticle

Effect of Dietary and Lifestyle Interventions on the Amelioration of NAFLD in Patients with Metabolic Syndrome: The FLIPAN Study

by Sofía Montemayor, Cristina Bouzas, Catalina M. Mascaró, Miguel Casares, Isabel Llompart, Itziar Abete, Escarlata Angullo-Martinez, María Ángeles Zulet, J. Alfredo Martínez and Josep A. Tur

Nutrients 2022, 14(11), 2223; https://0-doi-org.brum.beds.ac.uk/10.3390/nu14112223 - 26 May 2022

Cited by 22 | Viewed by 3841

Abstract

Background: Adults with fatty liver present unusual glycaemia and lipid metabolism; as a result, non-alcoholic fatty liver disease (NAFLD) is now considered as part of the metabolic syndrome (MetS). Objective: To assess the 6- and 12-month effects of customized hypocaloric dietary and enhanced physical activity intervention on intrahepatic fat contents and progression of NAFLD, in patients with MetS. Design: Cross-sectional study in 155 participants (40–60 years old) from Balearic Islands and Navarra (Spain) with a diagnosis of NAFLD and MetS, and BMI (body mass index) between 27 and 40 kg/m²; patients were randomized in a 1:1:1 ratio to either Conventional Diet, Mediterranean diet (MD)–high meal frequency, and MD–physical activity groups. Methods: Dietary intake was assessed using a validated food frequency questionnaire. Adherence to Mediterranean diet, anthropometrics, physical activity, and biochemical parameters (fasting glucose, glycated hemoglobin, bilirubin, aspartate aminotransferase, alanine aminotransferase—ALT–, gamma-glutamyl transferase, uric acid, urea, creatinine, albumin, total cholesterol, high-density lipoprotein cholesterol—HDL-cholesterol–, and triglycerides) were also assessed. Results: Subjects with NAFLD and MetS had reduced intrahepatic fat contents, and liver stiffness, despite the intervention the participants went through. All participants ameliorated BMI, insulin, Hb1Ac, diastolic blood pressure, HDL-cholesterol, and ALT, and improved consumption of total energy, fish, and legumes. Participants in the MD–HMF group improved waist circumference. Conclusions: Customized hypocaloric dietary and enhanced physical activity interventions may be useful to ameliorate NAFLD. Full article

(This article belongs to the Special Issue Management of Non-alcoholic Fatty Liver Disease from Primary Care: Prevention and Intervention through Nutrition and Physical Exercise)

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11 pages, 525 KiB

Open AccessArticle

Effect of a Six-Month Lifestyle Intervention on the Physical Activity and Fitness Status of Adults with NAFLD and Metabolic Syndrome

by Catalina M. Mascaró, Cristina Bouzas, Sofia Montemayor, Miguel Casares, Isabel Llompart, Lucía Ugarriza, Pere-Antoni Borràs, J. Alfredo Martínez and Josep A. Tur

Nutrients 2022, 14(9), 1813; https://0-doi-org.brum.beds.ac.uk/10.3390/nu14091813 - 26 Apr 2022

Cited by 17 | Viewed by 4074

Abstract

(1) Background: Physical inactivity has been linked to NAFLD, and exercise has been reported as useful to reduce intrahepatic fat content in NAFLD. (2) Objectives: To assess the physical activity (PA) and fitness status after a six-month lifestyle intervention (diet and PA) in adults with NAFLD and metabolic syndrome (MetS). (3) Design: Prospective cohort analysis of data obtained between baseline and six-year parallel-group randomized trial (n = 155, aged 40–60 years old, with MetS and NAFLD). Participants were randomized into three nutritional and PA intervention groups: Conventional diet (CD); MedDiet-high meal frequency (MD-HMF); MedDiet-physical activity (MD-PA). (4) Methods: PA and fitness status were assessed using a validated Minnesota questionnaire, ALPHA-FIT test battery, accelerometers, and functional fitness score. Information related to age, gender, education level, marital status, socioeconomic status, smoking habit, and alcohol consumption were also obtained. (5) Results: The CD group had higher improvement in standing handgrip than the MD-HMF group. The MD-PA group did more modified push-up repetitions than the CD group. The MD-PA and CD groups showed higher sitting handgrip than the MD-HMF group. The MD-HMF group showed the highest decrease in aerobic capacity. The MD-PA group showed lower light intensity PA/day than the CD and MD-HMF groups. The MD-PA group showed higher moderate intensity PA than the CD and MD-HMF groups. The CD group reported more METs per day than the MD-HMF group. (6) Conclusions: Lifestyle six-month intervention with diet and regular PA improved functional fitness in middle-aged patients with NAFLD and MetS. Aerobic capacity improved in patients who followed a Mediterranean diet and regular training sessions at six months. Full article

(This article belongs to the Special Issue Management of Non-alcoholic Fatty Liver Disease from Primary Care: Prevention and Intervention through Nutrition and Physical Exercise)

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12 pages, 309 KiB

Open AccessArticle

Association between Stages of Hepatic Steatosis and Physical Activity Performance in Adults with Metabolic Syndrome: A Cross-Sectional Analysis in FLIPAN Study

by Catalina M. Mascaró, Cristina Bouzas, Sofía Montemayor, Miguel Casares, Cristina Gómez, Lucía Ugarriza, Pere-Antoni Borràs, J. Alfredo Martínez and Josep A. Tur

Nutrients 2022, 14(9), 1790; https://0-doi-org.brum.beds.ac.uk/10.3390/nu14091790 - 24 Apr 2022

Cited by 2 | Viewed by 2023

Abstract

Background: Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease. The best treatment now is a healthy lifestyle with a Mediterranean diet and physical activity (PA). Objective: To assess the association between stages of hepatic steatosis and physical activity performance in adults with metabolic syndrome. Design: Cross-sectional study in 155 participants (40–60 years old) with MetS, a diagnosis of NAFLD by magnetic resonance imaging and BMI (body mass index) between 27 and 40 kg/m². Methods: Stages of hepatic steatosis were assessed and defined according to the percentage of intrahepatic fat contents: stage 0 ≤ 6.4% (control group); stage 1 = 6.4–17.4%; stage 2 ≥ 17.4%. Fitness was assessed through ALPHA-FIT test battery for adults, aerobic capacity by Chester-step test and PA by accelerometry and Minnesota questionnaire. Results: Participants without NAFLD reported more years of education and major socioeconomic status than participants with NAFLD. A higher percentage of people in the most advanced stage of NAFLD were no smokers and no alcohol consumers. They also had higher stages of steatosis, lower sitting handgrip, standing handgrip, Chester step test values, sleep efficiency, and energy expenditure, and higher intensity of light and moderate physical activity, and self-reported physical activity. Conclusions: NAFLD patients showed lower fitness status, aerobic capacity, sleep efficiency and energy expenditure than non-NAFLD participants. Full article

(This article belongs to the Special Issue Management of Non-alcoholic Fatty Liver Disease from Primary Care: Prevention and Intervention through Nutrition and Physical Exercise)

16 pages, 2009 KiB

Open AccessArticle

A Low Glycemic Index Mediterranean Diet Combined with Aerobic Physical Activity Rearranges the Gut Microbiota Signature in NAFLD Patients

by Francesco Maria Calabrese, Vittoria Disciglio, Isabella Franco, Paolo Sorino, Caterina Bonfiglio, Antonella Bianco, Angelo Campanella, Tamara Lippolis, Pasqua Letizia Pesole, Maurizio Polignano, Mirco Vacca, Giusy Rita Caponio, Gianluigi Giannelli, Maria De Angelis and Alberto Ruben Osella

Nutrients 2022, 14(9), 1773; https://0-doi-org.brum.beds.ac.uk/10.3390/nu14091773 - 23 Apr 2022

Cited by 26 | Viewed by 13534

Abstract

Non-alcoholic fatty liver disease (NAFLD) is the most common liver disease, and its prevalence worldwide is increasing. Several studies support the pathophysiological role of the gut–liver axis, where specific signal pathways are finely tuned by intestinal microbiota both in the onset and progression of NAFLD. In the present study, we investigate the impact of different lifestyle interventions on the gut microbiota composition in 109 NAFLD patients randomly allocated to six lifestyle intervention groups: Low Glycemic Index Mediterranean Diet (LGIMD), aerobic activity program (ATFIS_1), combined activity program (ATFIS_2), LGIMD plus ATFIS_1 or ATFIS2 and Control Diet based on CREA-AN (INRAN). The relative abundances of microbial taxa at all taxonomic levels were explored in all the intervention groups and used to cluster samples based on a statistical approach, relying both on the discriminant analysis of principal components (DAPCs) and on a linear regression model. Our analyses reveal important differences when physical activity and the Mediterranean diet are merged as treatment and allow us to identify the most statistically significant taxa linked with liver protection. These findings agree with the decreased ‘controlled attenuation parameter’ (CAP) detected in the LGIMD-ATFIS_1 group, measured using FibroScan^®. In conclusion, our study demonstrates the synergistic effect of lifestyle interventions (diet and/or physical activity programs) on the gut microbiota composition in NAFLD patients. Full article

(This article belongs to the Special Issue Management of Non-alcoholic Fatty Liver Disease from Primary Care: Prevention and Intervention through Nutrition and Physical Exercise)

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12 pages, 480 KiB

Open AccessArticle

Association between Physical Activity and Non-Alcoholic Fatty Liver Disease in Adults with Metabolic Syndrome: The FLIPAN Study

by Catalina M. Mascaró, Cristina Bouzas, Sofia Montemayor, Miguel Casares, Cristina Gómez, Lucía Ugarriza, Pere-Antoni Borràs, José Alfredo Martínez and Josep A. Tur

Nutrients 2022, 14(5), 1063; https://0-doi-org.brum.beds.ac.uk/10.3390/nu14051063 - 03 Mar 2022

Cited by 3 | Viewed by 2313

Abstract

Background: A lifestyle with regular PA (physical activity) and Mediterranean diet has benefits on NAFLD (non-alcoholic fatty liver disease) and MetS (metabolic syndrome). Objectives: To assess the association between physical activity and NAFLD in adults with MetS. Design: Cross-sectional study in 155 participants (40–60 years old) from Balearic Islands and Navarra (Spain) with diagnosis of NAFLD and MetS, and BMI (body mass index) between 27 and 40 Kg/m². Methods: PA level was categorized into two groups according to weekly METs (metabolic equivalents of tasks). PA was assessed using a validated Minnesota questionnaire and accelerometers. MetS parameters were assessed by blood collection analysis and NAFLD by abdominal MRI (magnetic resonance imaging). Results: Participants with high PA showed more energy expenditure and expended more calories than ingested (−143.9 Kcal/day; p < 0.001). PA was a risk factor for AST (aspartate aminotransferase) (adjusted OR: 7.26; 95% CI: 1.79–29.40) and a protective factor for ALT (alanine aminotransferase) (adjusted OR: 0.24; 95% CI: 0.12–0.48), GGT (gamma-glutamyl transferase) (adjusted OR: 0.52; 95% CI: 0.29–0.94) and IFC-NMR (intrahepatic fat content by nuclear magnetic resonance) (adjusted OR: 0.26; 95% CI: 0.12–0.56) when sociodemographic confounders were considered. Conclusions: NAFLD patients with high PA showed more positive relationship on MetS parameters and liver profile (ALT, GGT, IFC-NMR) than subjects with low PA, but not for AST. Difference between calories ingested and expended influenced this relationship. Full article

(This article belongs to the Special Issue Management of Non-alcoholic Fatty Liver Disease from Primary Care: Prevention and Intervention through Nutrition and Physical Exercise)

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