NAFLD incidence and remission: Only a matter of weight gain and weight loss?

The prevalence of non-alcoholic fatty liver disease (NAFLD) in the community is probably rising, driven by the epidemics of obesity and diabetes. A provocative study on obesity prevalence in the U.S. suggested that, given the trend observed between 1970 and 2004, all American adults would become overweight or obese by 2048, with differences between genders and ethnic ancestry [1]. Similar data exist for the prevalence of type 2 diabetes, which is now well above a 10% prevalence rate in several countries, with an estimated total of 382 million cases throughout the world and a prospective rise to 592 million cases in the next 25 years [2]. From the early description of NAFLD, we know that the disease is intimately connected with obesity, diabetes and the metabolic syndrome, therefore it is not surprising that NAFLD is among the top three causes of liver transplantation. Considering the rapid advances in antiviral therapy, it is expected to become the most common indication in the near future. A correct identification of incident cases may help to determine additional risk factors and program therapeutic interventions. Only a few studies have been available so far on fatty liver or NAFLD incidence (Table 1). The usual method to diagnose NAFLD has been ultrasonography, sometimes coupled with raised liver enzymes [3–10]. We all know that this method is crude, imprecise, highly insensitive and operator-dependent and cannot provide quantitative data. Overall, data are remarkably different in relation to study population, age, gender and comorbidities (in particular, to the presence/absence of obesity and the method of ascertainment). In the present issue of the Journal, Wong et al. present their analysis of NAFLD incidence based on paired proton-magnetic resonance spectroscopy (MRS) in a community-based Hong-Kong cohort, where also the parameters of metabolic syndrome were recorded [11]. In 565 cases without evidence of NAFLD at baseline (intrahepatic triglyceride (IHTG) content 5%) was set at 3.4% per year, after exclusion of two cases with excessive alcohol intake, with 20% of new cases in the range of moderate-severe steatosis and only one patient with liver stiffness indicative of advanced fibrosis. The presence of metabolic syndrome at baseline was the strongest predictor of incident steatosis, which was also associated with incident obesity, incident metabolic syndrome, and no remission of impaired glucose tolerance

Evidence-Based Medicine and the Problem of Healthy Volunteers

Healthy controls are subjects without the disease being studied but may have other conditions indirectly affecting outcome. In the present epidemics of obesity a few subjects with undiagnosed nonalcoholic fatty liver disease enter clinical studies as controls, producing biased results. Stricter selection criteria should be considered to prevent this risk

The Role of Medications for the Management of Patients with NAFLD

The article is intended to provide an overview of the strengths and limits of controlled trials of pharmacological treatment of NAFLD. No drug has so far been approved, although validated on histological outcomes. Several new drugs are under scrutiny, acting with different mechanisms along the chain of events from fatty liver to fibrosis, cirrhosis and hepatocellular carcinoma. We need to know which drug, if any, should be preferred for a tailored intervention in individual patients, according to age, comorbidities and disease severity, and if treatment should be continued lifelong, to prevent disease progression and long-term occurrence of cirrhosis

Psychological Profile and Quality of Life of Morbid Obese Patients Attending a Cognitive Behavioural Program

The results show that 27% of cases had a BES score ≥ 17, indicative of possible binge eating, and 13% had a BES ≥ 27, largely indicative of binge eating, with a higher prevalence in females. The BDI score was above normal in 30% of males and 45% of females, and 13% of females were in the range of moderate-severe depression. BES and BDI were significantly correlated with each other. Orwell-97 was much higher in females, and similarly the generic PGWB was indicative of a poorer HRQL in females. PGWB was positively associated with age, without any effect of BMI. The association with age was maintained in female, not in males. Both the Orwell-97 and the PGWB were associated with both BES and BDI in both genders. Psychological distress is common and largely variable in patients attending CBT for morbid obesity. This data should be considered for individual treatment protocols, and should be compared with similar series of patients enrolled for bariatric surger

Physical activity for the prevention and treatment of metabolic disorders

Metabolic syndrome and its various features 10 (obesity, hypertension, dyslipidemia, diabetes, and nonal- 11 coholic fatty liver disease) are increasing worldwide and 12 constitute a severe risk for the sustainability of the present 13 universal Italian health care system. Lifestyle interventions 14 should be the first therapeutic strategy to prevent/treat 15 metabolic diseases, far before pharmacologic treatment. 16 The role of diet and weight loss has been fully ascertained, 17 whereas the role of physical activity is frequently over- 18 looked both by physicians and by patients. Physical activity 19 has favorable effects on all components of the metabolic 20 syndrome and on the resulting cardiovascular risk, the 21 cornerstone in the development of cardiometabolic dis- 22 eases. The quantity and the frequency of physical activity 23 necessary to produce beneficial effects has not been defined 24 as yet, but brisk walking is considered particularly appro- 25 priate, as it can be practiced by a large number of indi- 26 viduals, without any additional cost, and has a low rate of 27 injury. The effects of exercise and leisure time physical 28 activity extend from prevention to treatment of the various 29 components of the metabolic syndrome, as well as to mood 30 and quality of life. Any effort should be done to favor adherence to protocols of physical activity in the 31 community

A position statement on NAFLD/NASH based on the EASL 2009 special conference

Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are increasingly relevant public health issues owing to their close association with the worldwide epidemics of diabetes and obesity. NAFLD/NASH is one of the most common chronic liver diseases and increases the 5-year direct and indirect health care costs by an estimated 26% [1]. Although evidencebased clinical practice guidelines for this condition are badly needed, currently not enough evidence is available to formulate guidelines in an unbiased, responsible, and unequivocal way. This position statement summarizes the proceedings of the 2009 EASL Special Conference on NAFLD/NASH and proposes expert opinion for different aspects of the clinical care of these patients

Cognitive-Behavioral Strategies to Increase the Adherence to Exercise in the Management of Obesity

Physical activity plays a major role in the development and management of obesity. High levels of physical activity provide an advantage in maintaining energy balance at a healthy weight, but the amount of exercise needed to produce weight loss and weight loss maintenance may be difficult to achieve in obese subjects. Barriers to physical activity may hardly be overcome in individual cases, and group support may make the difference. The key role of cognitive processes in the failure/success of weight management suggests that new cognitive procedures and strategies should be included in the traditional behavioral treatment of obesity, in order to help patients build a mindset of long-term weight control. We reviewed the role of physical activity in the management of obesity, and the principal cognitive-behavioral strategies to increase adherence to exercise. Also in this area, we need to move from the traditional prescriptive approach towards a multidisciplinary intervention

Stress Hyperglycemia and Complications Following Traumatic Injuries in Individuals With/Without Diabetes: The Case of Orthopedic Surgery

Purpose: Hyperglycemia in trauma patients may stem from metabolic response to stress, both in the presence and the absence of underlying diabetes. We aimed to test the association of stress hyperglycemia with risks of adverse events subjects undergoing orthopedic surgery. Patients and Methods: In a prospective observational study, we enrolled 202 consecutive patients with hyperglycemia at hospital admission for trauma injuries requiring orthopedic surgery. Based on history, diabetes was present in 183, and 13 more were defined as unknown diabetes on the basis of HbA1c ≥48mmol/mol. Stress hyperglycemia was defined in subjects with/without diabetes by a stress hyperglycemia ratio (SHR) >1.14, calculated as admission glucose/average glucose, estimated from glycosylated hemoglobin. Logistic regression analysis was used to calculate the risk of post-surgery adverse events associated with different states of hyperglycemia, after correction for demographic and clinical confounders. Results: Stress hyperglycemia was diagnosed, either as superimposed to diabetes (54/196 cases, 27.6%) as well as in the 6 cases without diabetes. At least one complication was recorded in 68 cases (33.7%), the most common being systemic infection (22.8% of cases). In the total cohort, stress hyperglycemia, irrespective of the presence of diabetes, increased the risk of adverse events (any events, odds ratio [OR], 4.43; 95% confidence interval [CI], 2.11–9.30), cardiovascular events (OR, 7.09; 95% CI, 2.47–19.91), systemic infections (OR, 4.21; 95% CI, 1.97–9.03) and other adverse events (OR, 6.30; 95% CI, 1.41–28.03), after adjustment for confounders; hospital stay was much longer. The same was true when the analysis was limited to the diabetes cohort or by comparing pure stress hyperglycemia vs diabetes without stress hyperglycemia. Conclusion: The study highlights the importance of stress hyperglycemia for adverse events in the setting of orthopedic surgery following trauma injuries. This condition requires stricter management, considering the much longer length of hospital stay and higher costs

Lifestyle modification in the management of the metabolic syndrome: achievements and challenges

Lifestyle modification based on behavior therapy is the most important and effective strategy to manage the metabolic syndrome. Modern lifestyle modification therapy combines specific recommendations on diet and exercise with behavioral and cognitive strategies. The intervention may be delivered face-to-face or in groups, or in groups combined with individual sessions. The main challenge of treatment is helping patients maintain healthy behavior changes in the long term. In the last few years, several strategies have been evaluated to improve the long-term effect of lifestyle modification. Promising results have been achieved by combining lifestyle modification with pharmacotherapy, using meals replacement, setting higher physical activity goals, and long-term care. The key role of cognitive processes in the success/failure of weight loss and maintenance suggests that new cognitive procedures and strategies should be included in the traditional lifestyle modification interventions, in order to help patients build a mind-set favoring long-term lifestyle changes. These new strategies raise optimistic expectations for an effective treatment of metabolic syndrome with lifestyle modifications, provided public health programs to change the environment where patients live support them