Is there a relationship between anxiety/stress and non-alcoholic fatty liver disease (NAFLD)?

From the Guidelines

Anxiety and stress management should be considered a crucial part of non-alcoholic fatty liver disease (NAFLD) treatment, as chronic stress can exacerbate the condition by increasing cortisol levels, promoting fat accumulation in the liver, and contributing to insulin resistance. Effective stress management techniques include regular physical activity, such as aiming for 150 minutes of moderate exercise weekly 1, mindfulness meditation, and cognitive behavioral therapy. For those with significant anxiety, medications like SSRIs may be beneficial, though these should be prescribed by a healthcare provider who can monitor liver function 1.

Key Recommendations

• Lifestyle modifications, including a Mediterranean diet, weight loss of 7-10% if overweight, limiting processed foods, and avoiding alcohol, remain the cornerstone of NAFLD management 1.
• Regular physical activity, such as 150 minutes of moderate exercise weekly, can help improve insulin sensitivity and reduce liver fat 1.
• Mindfulness meditation and cognitive behavioral therapy can be effective stress management techniques for patients with NAFLD 1.
• Addressing sleep quality is also important, as poor sleep can exacerbate both stress and metabolic dysfunction 1.

Considerations for Management

• The American Gastroenterological Association (AGA) recommends a clinical care pathway for the risk stratification and management of patients with NAFLD, which includes lifestyle modifications, weight loss, and management of cardiovascular risk factors 1.
• Patients with NAFLD should be encouraged to restrict alcohol consumption to reduce liver-related events 1.
• Glucagon-like peptide 1 receptor agonists (GLP-1RAs) and sodium-glucose co-transporter-2 (SGLT2) inhibitors may be beneficial for patients with type 2 diabetes and NAFLD, as they can improve insulin sensitivity and reduce liver fat 1.

From the Research

Relationship Between Anxiety/Stress and Non-Alcoholic Fatty Liver Disease

• Non-alcoholic fatty liver disease (NAFLD) is a liver condition that is increasing worldwide and is expected to become the number one cause of cirrhosis and hepatocellular carcinoma in the next 5 years 2.
• There is a positive association between metabolic syndrome and certain mental health problems, such as depression, anxiety, and chronic stress, which are often observed in patients with NAFLD 3.
• Higher perceived stress is independently associated with an increased prevalence of NAFLD, supporting a possible relationship between perceived stress and NAFLD 4.

Mechanisms and Associations

• The identification of links between NAFLD and mental health comorbidity, such as depression, anxiety, and stress, is worthy of further investigation, as this can inform more targeted interventions for patients with NAFLD 3.
• Psychological stress may have adverse metabolic effects and induce unhealthy behaviors, which can contribute to the development of NAFLD 4.
• The association between perceived stress and NAFLD was observed in all subgroups analyzed, although the association was stronger in men compared to women, and in obese compared to non-obese individuals 4.

Management and Treatment

• Lifestyle changes, including daily exercise and diet, are effective in the treatment of NAFLD, and combined exercise with diet seems to elicit greater reductions in liver enzymes and HOMA-IR than diet or exercise alone 2.
• Weight loss, dietary modification, and the treatment of underlying metabolic syndrome remain the mainstays of therapy once the diagnosis is established, with promising results but are difficult to maintain 5.
• Patients with NAFLD should develop a full understanding of the disease in order to enable them to take an active role in their disease management, and a patient guideline has been developed to support patients in making informed decisions 6.