April 28, 2015
Weight Loss Reduces Features of Nonalcoholic Steatohepatitis
Gastroenterology
TAKE-HOME MESSAGE
- In this study, 293 patients with nonalcoholic steatohepatitis (NASH) were encouraged to make lifestyle changes over 1 year to reduce their weight. After 52 weeks, liver biopsies revealed that steatohepatitis had resolved in 25%, reductions in non-alcoholic fatty liver disease activity scores were seen in 47%, and 19% showed regression of fibrosis. The degree of weight loss was shown to be independently associated with histological improvements, with patients who lost >10% of their body weight showing the biggest changes.
- Lifestyle changes inducing weight loss cause significant improvements in the histologic features of NASH, with the highest rates of improvement seen in individuals who achieved a weight loss of >10% of baseline body weight.
Primary Care
Written by Eric Kallwitz MD
An overweight patient comes to clinic for a follow-up visit. He has diabetes mellitus, hypertension, and increasingly elevated lipids. Before starting a statin, a liver function panel is ordered and elevated aminotransferases are noted. A subsequent serologic evaluation for causes of elevated aminotransferases and an ultrasound reveal non–alcoholic fatty liver disease (NAFLD). This clinical situation should sound alarmingly common, with roughly one-third of the US population having hepatic steatosis and 5% having non–alcoholic steatohepatitis (NASH). NASH is the more aggressive presentation of NAFLD, and is more likely to result in cirrhosis and complications of end-stage liver disease.
The issue now becomes how to best manage patients with NAFLD and NASH. An extensive list of pharmaceutical interventions were evaluated in trials with the common finding being that medication alone is ineffective. One example is vitamin E, which was found to have equivocal benefits with other literature suggesting it is not entirely benign. Other agents, such as obeticholic acid, are undergoing clinical trials and are not approved by the Food and Drug Administration. The one treatment continually found to be effective is weight loss.
Most providers assuredly have been frustrated with failed attempts at having patients achieve medical weight loss. However, data can drive these discussions to better ends. The highlighted paper in Gastroenterology addresses this issue in a well-designed fashion. In this study, 261 patients underwent paired liver biopsies after lifestyle intervention. The lifestyle intervention included a low-fat, hypocaloric diet, the recommendation to walk at least 200 minutes per week, and behavioral sessions every 8 weeks to promote adherence. The primary outcome was histologic resolution of NASH without worsening of fibrosis. Few patients actually increased physical activity, and only 30% had significant weight loss. The main finding was that patients who had more than 5% weight loss had higher rates of resolution of NASH (58%). In the group of patients who lost more than 10% of their weight, 90% had resolution of NASH and 81% had an improvement in fibrosis.
A primary care physician can take apply data from this study to his or her practice. First, the ideal goal should be 10% weight loss over a year-long period. For example, a recommendation to a 250-pound patient would be an easy-to-calculate 2 pounds per month. Second, at minimum, a referral to a dietician is needed. Even in the setting of a tertiary care hospital conducting research, most participants failed to increase physical activity. This finding emphasizes the need for help in finding an appropriate hypocaloric diet. Finally, reinforcement is key. Participants were seen every other month in this study. A short follow-up visit could result in extra motivation or the identification and correction of a continuing poor lifestyle habit.
Hopefully these data can be used to decrease frustration and improve patient outcomes.