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

AIM:To determine the clinical effectiveness of intense psychological support to physical activity(PA)in nonalcoholic fatty liver disease(NAFLD),compared with cognitive-behavioral treatment(CBT).METHODS:Twenty-two NAFLD cases received support to exercise,tailored to their motivational needs(PA group).The effects on body weight,physical fitness[6-min walk test,VO2max and the PA-rating(PA-R)questionnaire]and body fat(fatty liver indices and visceral adiposity index)were compared with data obtained in 44 NAFLD subjects enrolled in a CBT program for weight loss,after adjustment for propensity score,calculated on baseline data.Measurements were performed at baseline,at 4-mo and one-year follow-up.Changes in anthropometric,biochemical and PA parameters were tested by repeated measurement ANOVA.Outcome results were tested by logistic regression analysis.RESULTS:At the end of the intensive program,BMI was less significantly reduced in the PA group(-1.09±1.68 kg/m2 vs-2.04±1.42 kg/m2 in the CBT group,P=0.019)and the difference was maintained at 1-year follow-up(-0.73±1.63 vs-1.95±1.88,P=0.012)(ANOVA,P=0.005).PA-R was similar at baseline,when only 14%of cases in PA and 36%in CBT(P=0.120)recorded values≥3.At 4 mo,a PA-R≥3 was registered in 91%of PA and 46%of CBT,respectively(P<0.001)and PA-R≥5(up to 3 h/wk of moderate-toheavy intensity physical activity)was registered in 41%of PA and only 9%of CBT group(P<0.007).The6-min walk test increased by 139±26 m in PA and by only 43±38 m in CBT(P<0.001)and VO2max by8.2±3.8 mL/kg per minute and 3.3±2.7 mL/kg per minute,respectively(P<0.002).After adjustment for propensity,weight loss>7%was significantly associated with CBT group at one year(OR=6.21;95%CI:1.23-31.30),whereas PA-R>3 was associated with PA group(10.31;2.02-52.63).Liver enzymes decreased to values within normal limits in 36%of PA cases and61%of CBT(P<0.070).Estimated liver fat(Kotronen index)fell below the fatty liver threshold in 36%of PA and 34%and CBT cases at one-year(not different).Also the fatty liver index and the visceral adiposity index improved to a similar extent.CONCLUSION:Intensive psychological counseling for PA produces hepatic effects not different from standard CBT,improving physical fitness and liver fat independent of weight loss.Strategies promoting exercise are worth and effective in motivated patients,particularly in lean NAFLD patients where large weight loss cannot be systematically pursued.

Body composition changes after transjugular intrahepatic portosystemic shunt in patients with cirrhosis

AIM:To investigate the effect of transjugular intra-hepatic porto-systemic shunt (TIPS) on malnutrition in portal hypertensive cirrhotic patients.METHODS: Twenty-one patients with liver cirrhosis and clinical indications for TIPS insertion were investigated before and 1, 4, 12, 52 wk after TIPS. For each patient we assayed body composition parameters [dry lean mass, fat mass, total body water (TBW)], routine liver and kidney function tests, and free fatty acids (FFA). Glucose and insulin were measured for the calculation of the homeostasis model assessment insulin resistance (HOMA-IR); liver function was measured by the galactose elimination capacity (GEC); the severity of liver disease was graded by model for end-stage liver disease (MELD).RESULTS: Porto-systemic gradient decreased after TIPS (6.0±2.1 mmHg vs 15.8±4.8 mmHg, P<0.001). Patients were divided in two groups according to initial body mass index. After TIPS, normal weight patients had an increase in dry lean mass (from 10.9±5.9 kg to 12.7±5.6 kg, P=0.031) and TBW (from 34.5±7.6 L to 40.2±10.8 L,P=0.007), as well as insulin (from 88.9±49.2 pmol/L to 164.7±107.0 pmol/L,P=0.009) and HOMA-IR (from 3.36%±2.18% to 6.18%±4.82%,P=0.023). In overweight patients only FFA increased significantly (from 0.59±0.24 mmol/L to 0.93±0.34 mmol/L, P=0.023).CONCLUSION: TIPS procedure is effective in lowering portal pressure in patients with portal hypertension and improves body composition without significant changes in metabolic parameters.

Diabetes in migrants and ethnic minorities in a changingWorld

On a worldwide scale, the total number of migrants exceeds 200 million and is not expected to reduce, fuelled by the economic crisis, terrorism and wars, generating increasing clinical and administrative problems to National Health Systems. Chronic non-communicable diseases(NCD), and specifically diabetes, are on the front-line, due to the high number of cases at risk, duration and cost of diseases, and availability of effective measures of prevention and treatment. We reviewed the documents of International Agencies on migration and performed a Pub Med search of existing literature, focusing on the differences in the prevalence of diabetes between migrants and native people, the prevalence of NCD in migrants vs rates in the countries of origin, diabetes convergence, risk of diabetes progression and standard of care in migrants. Even in universalistic healthcare systems, differences in socioeconomic status and barriers generated by the present culture of biomedicine make high-risk ethnic minorities under-treated and not protected against inequalities. Underutilization of drugs and primary care services in specific ethnic groups are far from being money-saving, and might produce higher hospitalization rates due to disease progression and complications. Efforts should be made to favor screening and treatment programs, to adapt education programs to specific cultures, and to develop community partnerships.

Diabetes and NAFLD:a high-risk cohort with definite therapeutic potential

Despite the fact that non-alcoholic fatty liver disease(NAFLD)and its severe clinical forms[non-alcoholic steatohepatitis(NASH)and NASH-cirrhosis]are highly prevalent in the general population,there are no licensed drugs for NAFLD,and lifestyle intervention remains the only treatment accepted by international guidelines.This is despite massive investments in research by pharmaceutical companies.In the presence of type 2 diabetes,novel anti-diabetic drugs offer an opportunity to reduce the burden of NAFLD,by adequate control of glucose and lipid metabolism,also reducing the risk of NASH progression,advanced fibrosis,and finally hepatocellular carcinoma.We extensively reviewed the literature,based either on registration studies,ad hoc randomized studies or real-world data,to define the effectiveness of anti-diabetic drugs in the treatment of NAFLD and prevention of hepatocellular carcinoma(HCC).Metformin provides the best evidence for decreased risk of HCC,pioglitazone was associated with decreased progression to fibrosis,glucagon-like peptide-1 receptor agonists offer a possible opportunity to reduce NAFLD progression coupled with a definite protection for cardiovascular outcomes,and sodium-glucose cotransporter-2 inhibitors are likely to reduce lipid burden,simultaneously reducing the risk of progressive renal and heart failure.For the latter two drug classes,the effects on NAFLD might largely explained by decreased body weight,in keeping with the beneficial effects of intensive lifestyle intervention.