Diet-Related Improvement Of Non-Alcoholic Steatohepatitis

Abstract

Non-alcoholic fatty liver disease (NAFLD) refers to a wide pathological spectrum ranging from simple steatosis to steatohepatitis (NASH) with or without variable degrees of fibrosis. It represents an increasing health problem since it leads to the development of cirrhosis and liver cancer. In Western countries NAFLD/NASH-associated cirrhosis is becoming one of the most frequent indications for liver transplantation. Thus it is important to recognize and identify patients at risk of progression of NAFLD and implement therapeutic interventions. The goal is to prevent or reverse the liver inflammation and finally prevent detrimental consequences of advanced NASH. NAFLD is more commonly encountered in obese and patients with diabetes. The key pathogenic trigger is insulin resistance, which through simple steatosis leads to steatohepatitis. The later is the strongest predictor of fibrosis progression in NAFLD. The management of NAFLD/NASH is challenging as there is lack of an effective therapy and no approved pharmacological agent for the treatment of NASH. The results from clinical studies point to dietary intervention as the cornerstone of the therapy. We present a case where improvement of NASH was achieved solely by lifestyle modification. A 37 year old male patient with elevated transaminases was referred to our clinic for evaluation. After initial assessment with detalied history, compre - hensive laboratory analyses and abdominal ultrasound, a liver biopsy was performed and he was diagnosed with NASH. His initial body mass index (BMI) was 28.9 kg/m2, the homeostasis model assessment-insulin resistance (HOMA-IR) was 5.6. Presence of hypercholesterolemia and hyperferritinemia was also noted. He was advised to commence a low calorie diet accompanied with physical activity. Additionaly he was prescribed hepatoprotective (silymarin) therapy, vitamin D and C supplementation and lipid lowering agents. In the following year the transaminase activity and insulin resistance were maintened despite pharmacological treatment but the patient reported that he hasn’t been paying attention to his calorie in - take and has been practicing only mild physical activity. Upon re-evaluation, he was advised to initiate metformin therapy, but he refused, so a dedicated nutritional counseling was performed emphisizing the risks of ongoing liver inflammation and ensuing liver damage. The patient started with calorie restrictive diet, low impact aerobic exercise (pool swimming) and continiued only with vitamin D supplementation. After 3 months he achieved a reduction of 10% of his initial body weight. Control blood analyses showed normalisation of the transaminase activity, as well as a decrease in HOMA-IR value. The BMI was 25.7 kg/m2, his lipid profile improved and ferritin levels also decresed. He was advised to continue with his lifestyle modification and was scheduled for 3 months interval monitoring as to sustain his compliance. The results achieved with dieting and physical activity presented in this case strongly support the role of lifestyle modification as primary therapy for the management of NAFLD/NASH. But there is a reasonable possibility of relapses, so dietary intervention accompanied with strategies to avoid relapse and weight regain should be implemented.