What is the treatment for fatty liver disease?

Treatment for Fatty Liver Disease

The cornerstone of fatty liver disease treatment is lifestyle modification, specifically targeting weight loss of 5-7% to decrease hepatic steatosis, and 7-10% weight loss to improve hepatic inflammation and potentially fibrosis. 1

Lifestyle Modifications

Diet

• Mediterranean diet pattern is strongly recommended as the diet of choice for NAFLD 1, 2:
  • Rich in vegetables, fruits, whole grains, legumes
  • Olive oil as principal source of fat
  • Moderate consumption of fish and shellfish
  • Limited red meat and processed meats
• Caloric restriction:
  • Target 1,500-1,800 kcal/day for men and 1,200-1,500 kcal/day for women 1
  • Reduction of approximately 500 kcal/day from baseline
  • Progressive weight loss of less than 1 kg/week to avoid worsening portal inflammation 1
• Specific dietary recommendations:
  • Reduce simple carbohydrates and fructose 1
  • Avoid sugar-sweetened beverages 1, 3
  • Reduce carbohydrate intake to about 40% of calories (vs. 50-60% in typical low-fat diets) 1
  • Increase monounsaturated and omega-3 fatty acid intake 1

Physical Activity

• At least moderate-intensity exercise (e.g., brisk walking, swimming, dancing) 1
• Duration: >30 minutes
• Frequency: >3 times per week
• Both aerobic and resistance training are beneficial 4
• Vigorous activity (≥6 METs) is required for improvement in NASH and fibrosis 3

Pharmacological Interventions

For patients with biopsy-proven NASH and fibrosis, pharmacological treatments may be considered 3:

1. For NASH patients with diabetes:

   • GLP-1 receptor agonists (particularly semaglutide and liraglutide) 1
   • SGLT2 inhibitors 1

2. For non-diabetic NASH patients without cirrhosis:

   • Vitamin E (800 IU/day) 1

3. For NASH patients with or without diabetes (without cirrhosis):

   • Pioglitazone (30 mg/day) 1

Treatment Approach Based on Patient Profile

For Obese Patients with NAFLD

• Target weight loss of 7-10% through diet and exercise 3, 1
• Consider bariatric surgery if otherwise indicated 1

For Lean Patients with NAFLD

• More modest weight loss goal of 3-5% is beneficial 3
• Focus on exercise and diet modification even without significant weight loss 3
• Particularly emphasize avoiding fructose and sugar-sweetened drinks 3

Monitoring and Risk Stratification

• Assess fibrosis risk using non-invasive tests like FIB-4 or FibroScan 1
• Risk stratification:
  • Low risk: FIB-4 <1.3 or FibroScan <8 kPa
  • Intermediate risk: FIB-4 1.3-2.67 or FibroScan 8-12 kPa
  • High risk: FIB-4 >2.67 or FibroScan >12 kPa
• Monitor low-risk patients every 3 years; higher-risk patients require more frequent monitoring 1

Important Considerations

• Complete alcohol restriction is recommended for all NAFLD patients 1
• Nutritional consultation is strongly recommended, especially for patients with sarcopenia 1
• Address cardiovascular risk factors, as NAFLD has a strong association with cardiovascular disease 1
• For patients with diabetes, optimize diabetes management 1

Common Pitfalls to Avoid

1. Focusing only on liver enzymes: Normal liver enzymes do not exclude significant liver disease
2. Rapid weight loss: Can worsen portal inflammation; aim for gradual weight loss
3. Neglecting cardiovascular risk: NAFLD patients have increased cardiovascular risk requiring attention
4. Underestimating the importance of lifestyle changes: Even modest improvements in diet and physical activity can have significant benefits for liver health 5, 6
5. Overlooking lean NAFLD: These patients also benefit from lifestyle modifications, though with more modest weight loss goals 3