What are the management recommendations for patients with fatty liver disease (FLD)?

Management Recommendations for Fatty Liver Disease

Lifestyle modifications are the cornerstone of treatment for all patients with fatty liver disease, focusing on weight loss of 7-10% through caloric restriction and regular physical activity.1, 2

Assessment and Diagnosis

• Perform comprehensive metabolic and serological screening to confirm NAFLD diagnosis and exclude co-existing liver diseases 1
• Assess fibrosis severity using sequential non-invasive tests (e.g., FIB-4 followed by ELF, transient elastography, or ARFI) 1
• Conduct a medicines review to identify and potentially discontinue medications that may worsen steatosis (e.g., corticosteroids, amiodarone, methotrexate, tamoxifen) 1, 2
• Evaluate dietary habits and physical activity levels to guide lifestyle modification recommendations 1

Lifestyle Modifications

Weight Loss

• Target gradual weight loss of 7-10% of total body weight 1, 2, 3
  • Weight loss of >5% reduces intrahepatic fat content and inflammation 1, 4
  • Weight loss of >10% can induce near-universal NASH resolution and fibrosis improvement 3, 4
• Aim for progressive weight loss of less than 1 kg/week to avoid complications from rapid weight loss 1, 2

Dietary Recommendations

• Follow a Mediterranean diet pattern, characterized by: 1, 2, 3, 5
  • Reduced carbohydrate intake (40% of calories vs. 50-60% in typical low-fat diets)
  • Increased monounsaturated and omega-3 fatty acid intake (40% of calories as fat)
  • High consumption of vegetables, fruits, legumes, nuts, seeds, and whole grains
• Limit excess fructose consumption and avoid processed foods and beverages with added fructose 1
• Replace saturated fats with polyunsaturated (especially omega-3) and monounsaturated fats 1, 2
• Reduce daily caloric intake by 500-1000 kcal to achieve gradual weight loss 2, 6

Physical Activity

• Engage in at least 150-300 minutes of moderate-intensity aerobic exercise per week 2, 7
• Include resistance training as a complement to aerobic exercise 2, 7
• Even minimal physical activity below recommended thresholds can provide benefits for NAFLD 7, 5
• Combined exercise and dietary intervention is superior to either intervention alone in improving liver enzymes and insulin resistance 4

Management of Comorbidities

• Treat hypertension according to established guidelines 1
• Manage dyslipidemia with statins in patients at increased cardiovascular risk (T2DM and/or QRISK-3 >10%) 1
  • Statins are safe in NAFLD patients and may confer protection against liver-related histological endpoints 1
• Optimize diabetes management, as diabetes increases the risk of HCC and liver-related complications 1
• Recommend smoking cessation and alcohol abstinence to reduce HCC risk 1

Monitoring and Follow-up

• Patients with NAFLD who have significant-advanced fibrosis or cirrhosis should be managed in secondary care 1
• For patients with cirrhosis, implement: 1, 2
  • HCC surveillance with right upper quadrant ultrasound every 6 months
  • Screening for esophageal varices
  • Referral to transplant center when appropriate
• Regularly reassess fibrosis using non-invasive tests every 1-3 years to monitor treatment response or disease progression 1

Common Pitfalls and Considerations

• Avoid rapid weight loss (>1 kg/week) as it may worsen liver disease 1, 2
• Recognize that even modest physical activity below recommended thresholds can improve liver health 7
• Focus on sustainable lifestyle changes that can be maintained long-term 2, 6
• Consider liver biopsy only when it would provide additional useful diagnostic or prognostic information 1, 2