From the Guidelines
The first-line management of fatty liver disease should focus on lifestyle modifications, including a weight loss of 7-10% of body weight, achieved through a combination of caloric restriction and regular exercise, as well as a Mediterranean diet pattern, emphasizing fruits, vegetables, whole grains, lean proteins, and healthy fats. This approach is supported by the most recent and highest quality study, which recommends lifestyle modification using diet and exercise to achieve weight loss as beneficial for all patients with nonalcoholic fatty liver disease (NAFLD) 1. Key components of this approach include:
- Weight loss of 5% of total body weight to decrease hepatic steatosis, 7% to lead to nonalcoholic steatohepatitis resolution, and 10% for fibrosis regression or stability 1
- A hypocaloric diet targeting 1200–1500 kcal/d or a reduction of 500–1000 kcal/d from baseline 1
- A Mediterranean diet, minimizing saturated fatty acid intake, and limiting or eliminating consumption of commercially produced fructose 1
- Regular physical activity, with a target of 150–300 minutes of moderate-intensity or 75–150 minutes of vigorous-intensity aerobic exercise per week 1
- Optimal management of comorbidities like diabetes, hypertension, and dyslipidemia, with medications like pioglitazone or GLP-1 receptor agonists potentially offering dual benefits for patients with both diabetes and fatty liver 1
- Consideration of vitamin E (800 IU daily) for non-diabetic patients with biopsy-proven non-alcoholic steatohepatitis 1. These interventions work by reducing insulin resistance, decreasing inflammation, and limiting fat accumulation in the liver, thereby preventing progression to more severe liver disease including fibrosis, cirrhosis, and liver failure.
From the Research
First Line Management of Fatty Liver
The first line management of fatty liver, also known as non-alcoholic fatty liver disease (NAFLD), involves lifestyle modifications and weight loss.
- Weight loss is considered the cornerstone in the treatment of obesity-related liver diseases 2
- Dietary modifications and exercise are established first-line treatments for NAFLD 3
Pharmacological Approaches
Several pharmacological approaches have been studied for the management of NAFLD, including:
- Pioglitazone and vitamin E, which have provided consistent benefits on liver histology and are recommended by European and American guidelines 4, 3
- Statins, which have been shown to produce clinically meaningful results in patients with NAFLD or NASH 4, 5
- Metformin and polyunsaturated fatty acids, which have been used in clinical practice off-label and have provided benefits on hepatic biochemical and diabetes-related markers, although data on liver histology are scarce 4, 6
- Silymarin, which has been shown to improve liver aminotransferases in patients with NAFLD after 3 months of treatment 6
Treatment Recommendations
Based on the available evidence, the following treatment recommendations can be made: