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The Burden Of NASH

The burden of non-alcoholic fatty liver disease (NAFLD) continues to increase at an alarming rate. The prevalence of disease equals the prevalence of metabolic syndrome (nearly 30% of the adult population), and NASH-cirrhosis represents the second cause for entering the waiting list for liver transplantation, with/without associated primary liver cancer.

Lifestyle changes are the cornerstone of prevention and treatment; several studies have suggested that weight loss is associated with a reduced risk of NASH progression to more advanced stages but there is also evidence of fibrosis regression whenever weight loss exceeds 7-10% body weight. Strategies for promoting weight loss are well known: counselling for lifestyle changes, including healthy diet and habitual physical activity, are definitely effective, and all guidelines, including the more recent guidelines shared by the Liver, Diabetes and Obesity associations include intensive counselling programs as first-line therapy.

How can liver units provide lifestyle programs to the high number of cases who need treatment? Intensive programs require frequent attendance as outpatients to busy liver units, and the availability of multidisciplinary teams, including dietitians, psychologists, lifestyle trainers, rarely present among the hospital personnel. Are patients ready to accept the intensive education and close monitoring necessary to lose weight and maintain weight loss? Frequent hospital attendance results in high direct and indirect costs in young, free living individuals with job and time constraints.

We need to develop new strategies to help patients improve their lifestyle. The possibility to expand educational approaches via the internet might help address the needs of a larger community, reducing attendance to busy liver units and sparing patients’ and physicians’ time. There is preliminary evidence that this strategy might be pursued, following a face-to-face approach carried out using the techniques dictated by motivational interviewing.

The results have been recently published in the Journal of Hepatology: the effects of an internet-based intervention carried out in 278 NAFLD patients where compared with the standard, group based treatment, carried out in 438 cases. The interventions produced a similar weight loss, accompanied by similar reduction in calorie intake and an increase in habitual physical activity. The hepatic effects of treatment were tested by surrogate markers: liver enzyme levels were reduced in both groups, and there was evidence of reduced liver fat (Fat Liver Index) and fibrosis (NAFLD fibrosis score and FIB-4).

Until drugs to treat NASH become available, weight loss remains the sole strategy to address the disease from its deep roots, and any attempt should be made to help patients improve and maintain healthy lifestyles. Information and Communication Technology may help promote lifestyle changes in NAFLD, especially in younger patients who are actively engaged in job activities that limit their attendance to hospital.


Giulio Marchesini is Professor of Diabetes at the University of Bologna. He will present “A web-based intervention to support lifestyle changes in NAFLD” at the Global NASH Congress.


The Global NASH Congress will take place in London, February 25th-26th. Download the agenda now to see what topics will be covered.

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