What is the treatment for fatty liver disease?

Treatment for Fatty Liver Disease

The primary treatment for fatty liver disease is lifestyle modification, with a target weight loss of 7-10% to improve liver histology, resolve non-alcoholic steatohepatitis (NASH), and improve fibrosis. 1

Lifestyle Modifications

Weight Loss Goals

• 5% weight loss: Improves hepatic steatosis 1
• 7% weight loss: Improves NAFLD Activity Score 1
• ≥10% weight loss: Induces near-universal NASH resolution and fibrosis improvement 1, 2

Dietary Recommendations

1. Mediterranean diet pattern:

   • Emphasize vegetables, fruits, whole grains, legumes
   • Use olive oil as principal source of fat
   • Include moderate consumption of fish and shellfish
   • Limit red meat and processed meats 1
   • Can reduce liver fat even without weight loss 2

2. Caloric restriction:

   • Men: 1,500-1,800 kcal/day
   • Women: 1,200-1,500 kcal/day
   • Target approximately 500 kcal/day reduction from baseline 1
   • Progressive weight loss of less than 1 kg/week to avoid worsening portal inflammation 1

3. Specific dietary guidance:

   • Reduce simple carbohydrates and fructose
   • Avoid sugar-sweetened beverages 1
   • Increase monounsaturated and omega-3 fatty acid intake 2

Physical Activity

• At least moderate-intensity exercise (brisk walking, swimming, dancing)
• Duration: >30 minutes
• Frequency: >3 times per week 1
• Reduces sedentary behavior which is associated with NAFLD progression 2

Pharmacological Treatments

For Patients with Biopsy-Proven NASH and Fibrosis:

1. For non-diabetic NASH patients without cirrhosis:

   • Vitamin E (800 IU/day) - improves steatosis, inflammation, and ballooning 1

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

   • Pioglitazone (30 mg/day) - improves all histological features except fibrosis 1

3. For NAFLD patients with diabetes:

   • GLP-1 receptor agonists (particularly Semaglutide) - improves cardiometabolic profile and reverses steatosis 1
     • Semaglutide: Titrate to 1 mg weekly
     • Liraglutide: Titrate to standard therapeutic dose
   • SGLT2 Inhibitors - improve glucose control and cardiometabolic profile 1

Medications NOT Recommended:

• Metformin - no significant effect on liver histology 1
• Silymarin - insufficient evidence for significant histological improvement 1

Monitoring and Risk Stratification

Risk Assessment Tools:

1. FIB-4 Index:

   • Low Risk: <1.3
   • Indeterminate Risk: 1.3-2.67
   • High Risk: >2.67

2. FibroScan:

   • Low Risk: <8 kPa
   • Indeterminate Risk: 8-12 kPa
   • High Risk: >12 kPa 1

Monitoring Schedule:

• Low-risk patients: Reassess using non-invasive tests after 3 years
• Higher-risk patients: More frequent monitoring and possible referral to specialist care 1

Special Considerations

• Complete alcohol restriction is recommended, as even low alcohol intake doubles the risk of adverse liver outcomes 1
• Cardiovascular risk management is crucial due to the strong association between NAFLD and cardiovascular disease 1
• Optimal diabetes management is essential for patients with both conditions 1
• Nutritional consultation is strongly recommended, especially for patients with sarcopenia 1
• Bariatric surgery may be considered for obese patients with NAFLD/NASH if otherwise indicated 1, 3

Treatment Effectiveness

• Combined diet and exercise interventions are superior to either intervention alone in improving liver enzymes and insulin resistance 4
• Exercise alone improves quality of life, cardiorespiratory fitness, and weight 4
• Lifestyle changes through cognitive-behavioral treatment can achieve the desired 7-10% weight loss 3
• Bariatric surgery can achieve NASH resolution in 80% of subjects at 1-year follow-up 3

Common Pitfalls to Avoid

1. Focusing only on weight loss without addressing dietary quality - Mediterranean diet components are beneficial even without weight loss 2
2. Rapid weight loss - Can worsen portal inflammation; aim for <1 kg/week 1
3. Neglecting physical activity - Exercise is essential even without significant weight loss 4
4. Overlooking cardiovascular risk - NAFLD patients have increased cardiovascular risk requiring attention 1
5. Relying on medications alone - Lifestyle modification remains the cornerstone of treatment 1, 5