Fatty Liver Disease Management
Primary Treatment: Achieve 7-10% Weight Loss Through Lifestyle Modification
All patients with fatty liver disease require lifestyle modification targeting 7-10% weight loss through caloric restriction and regular physical activity, which improves liver histology, reduces inflammation, and can reverse fibrosis. 1, 2
Weight Loss Targets and Timeline
- 3-5% weight loss improves steatosis alone 1, 2
- 5-7% weight loss decreases intrahepatic fat content and inflammation 1
- 7-10% weight loss is required for fibrosis regression and improves fibrosis in 45% of patients 1, 2
- Weight loss must be gradual at 500-1000g per week maximum, as rapid weight loss worsens liver disease 2
Caloric Deficit Protocol
- Create a 500-1000 kcal/day deficit, typically 1,200-1,500 kcal/day for women and 1,500-1,800 kcal/day for men 2
Risk Stratification Determines Treatment Intensity
Initial Assessment
- Calculate FIB-4 score and obtain liver stiffness measurement to determine treatment intensity 1
- FIB-4 >2.67 indicates high risk for advanced fibrosis and mandates hepatology referral 3
- Liver stiffness >12.0 kPa by transient elastography indicates clinically significant fibrosis requiring multidisciplinary management 3
Risk-Based Monitoring
- Low-risk patients (FIB-4 <1.3, liver stiffness <8.0 kPa) focus exclusively on lifestyle modifications with annual monitoring 1
- Intermediate/high-risk patients (FIB-4 >1.3, liver stiffness >8.0 kPa) undergo aggressive lifestyle intervention plus pharmacotherapy consideration, with monitoring every 6 months 1, 3
Dietary Intervention: Mediterranean Diet Pattern
Adopt a Mediterranean diet pattern as the primary dietary approach, which reduces liver fat even without weight loss. 1, 2
Core Dietary Components
- Daily consumption of vegetables, fruits, whole grains, legumes, nuts, fish, and olive oil as primary fat source 1, 2
- Replace saturated fats with monounsaturated and polyunsaturated fats, especially omega-3 fatty acids 4, 2
Foods to Strictly Limit or Eliminate
- Eliminate fructose-containing beverages and processed foods 4, 2
- Strictly limit simple sugars, red meat, processed meats, and ultra-processed foods 1, 3
- Avoid excess alcohol consumption 4
Exercise Prescription: 150-300 Minutes Weekly
Target a minimum of 150-300 minutes of moderate-intensity aerobic exercise weekly, or 75-150 minutes of vigorous-intensity exercise weekly. 1, 2, 3
Exercise Modalities
- Add resistance training as a complement to aerobic exercise, particularly beneficial for patients with poor cardiorespiratory fitness 1, 3
- Both aerobic exercise and resistance training effectively reduce liver fat, with vigorous exercise carrying greater benefit than moderate exercise for NASH and fibrosis 2
- Combined exercise with diet elicits greater reductions in ALT, AST, and HOMA-IR than diet or exercise alone 5
Pharmacological Management
Cardiovascular Risk Reduction
Use statins for dyslipidemia in all NAFLD patients, which are safe in fatty liver disease and associated with a 37% reduction in hepatocellular carcinoma risk and 46% reduction in hepatic decompensation. 1, 2, 3
Diabetes Management
- Use GLP-1 receptor agonists for diabetes, which improve steatosis and may reverse steatohepatitis 1, 2
- Liraglutide achieves 39% NASH resolution vs 9% placebo, and semaglutide achieves 59% NASH resolution vs 17% placebo 3
- Avoid sulfonylureas and insulin as they may increase HCC risk 2
Limited Role for NASH-Specific Agents
- Pioglitazone and vitamin E improve steatohepatitis in nondiabetic patients with biopsy-proven NASH; however, long-term efficacy and safety with both agents are lacking 4
Bariatric Surgery for Severe Obesity
Consider bariatric surgery for patients with severe obesity who meet national eligibility criteria, as it resolves NASH in 85% of patients at 1 year post-surgery and improves steatosis, steatohepatitis, and fibrosis. 2
Hepatocellular Carcinoma Surveillance
Perform abdominal ultrasound every 6 months for HCC screening in patients with advanced fibrosis (F3) or cirrhosis. 1, 3
- Consider CT or MRI in overweight/obese patients where ultrasound quality is limited 3
- Thrombocytopenia or liver stiffness ≥20 kPa requires esophageal varices screening 3
Critical Pitfall: Cardiovascular Disease Drives Mortality
Cardiovascular disease is the main driver of morbidity and mortality in NAFLD patients before cirrhosis develops, emphasizing the need to address all metabolic risk factors aggressively. 2, 3