ABSTRACT
Background: The coronavirus disease 2019 (COVID-19) pandemic has been detrimental to those with chronic diseases, even those without infection. Management of non-alcoholic fatty liver disease (NAFLD) centers on weight management and optimization of metabolic risk factors, requiring a multi-disciplinary approach. Periods of quarantine and inactivity therefore pose limitations on lifestyle modifications and potentially impact both liver-related and health-related quality of life (HRQOL) outcomes. This study aims to identify the effects of the COVID-19 pandemic and alterations in healthcare access on patients with NAFLD. Methods: This study utilized a prospectively enrolled cohort of patients with NAFLD seen at the Innovative Center for Health and Nutrition in Gastroenterology (ICHANGE), a multidisciplinary clinic which targets treatment of obesity and related diseases in New York. Patients included had a comprehensive initial evaluation during the pre-pandemic period within six months of the first COVID-19 case at our institution (October 1, 2019 to March 3, 2020) and had follow-up with repeat laboratory data. Studied outcomes included changes in alanine aminotransferase (ALT), aspartate aminotransferase (AST), metabolic markers (hemoglobin A1c and lipids), weight and body composition. 16 patients had follow-up HRQOL data measured by the Chronic Liver Disease Questionnaire (CLDQ) and Short-Form 26 (SF-36) Health Survey. Secondary analysis compared those with at least three provider visits to those with fewer to evaluate for impact of medical care during this period. Analysis was performed using the Wilcoxon signed-rank test and the Mann-Whitney U test. This study was approved by the Institutional Review Board of Weill Cornell Medicine. Results: Of the 29 patients included patients, the mean age was 52 years and pre-pandemic body mass index 33.54 kg/m2 (Table 1). Overall, there was no significant change in weight during this period (p= 0.07), though skeletal muscle and truncal fat mass both decreased (p=0.02). Hemoglobin A1c and AST decreased upon follow-up (p=0.002 and p=0.04, respectively), though there was no significant change in ALT or lipids. There was an increase in both CLDQ and SF-36 total and composite activity and emotional scores though not to a significant degree, and was irrespective of the number of provider visits (Table 2). Conclusion: This cohort of motivated patients with NAFLD following within a resource abundant multidisciplinary clinic showed mild improvement in select biomarkers and body composition, though there was no significant improvement in the remainder of objective measures to the degree expected, which may have been limited by the COVID-19 pandemic. Though not significant in this cohort, the overall trend in improvement in HRQOL highlights the importance of ongoing targeted care within this at-risk group. (Table presented.)
ABSTRACT
Background: Modest weight loss (5-7%) remains the goldstandard of treatment for nonalcoholic fatty liver disease (NAFLD), though patients rarely achieve this independently The YMCA's Diabetes Prevention Program (DPP) is a nationwide structured lifestyle intervention program that has demonstrated weight loss within this range The goal of this study is to determine if the DPP can be repurposed to induce weight loss, decrease liver enzymes, and improve hepatic steatosis in NAFLD Methods: Eligible patients had NAFLD (defined by Fibroscan controlled attenuation parameter (CAP) score >238dB/m) and elevated liver enzymes (ALT>25U/L in females, >33U/L in males) without competing etiologies for liver disease Patients with cirrhosis were excluded A retrospective cohort that received standard of care recommendations was analyzed for change in ALT Two sequential prospective cohorts of 20 patients were enrolled in the experimental YMCA DPP Classroom sessions occurred weekly for 16 weeks, bi-weekly for 4 weeks, and then monthly for 48 weeks total Primary endpoints included change in BMI, ALT, and Fibroscan score. Completers were defined as those attending at least 9 of the first 16 weekly sessions. Changes in variables were analyzed using paired t-test End of study data was not completed for cohort 2 due to COVID19 and therefore aggregate data is presented for week 16 and end of study data (week 48) is presented for only cohort 1 Results: A total of 20 patients from both cohorts were completers 16% were female (n=12) 16 patients had interim study data and were included in the week 16 analysis All but one patient lost weight Baseline mean BMI was 34 3 and decreased to 33 6 by week 16 (p=0 02) Baseline mean ALT was 91 8U/L and decreased to 55 1U/L by week 16 (p=0 005) Mean Fibroscan fibrosis score improved from 6.7kPa to 5.5kPa and CAP score improved from 321dB/m to 291dB/m by week 16 (p=0 008 and p=0 12, respectively) 9 patients from cohort 1 were included in the week 48 analysis Mean BMI was 35 4 at baseline and decreased to 33 6 by week 48 (p=0 002) Mean ALT was 85 0U/L at baseline decreased to 41 6U/L (p=0 01) Mean Fibroscan score improved from 6 9kPa to 5 9kPa (p=0 07) Other metabolic parameters also trended towards significant improvement at week 16 and 48 (Table 1). The retrospective cohort (N=31) had a mean baseline ALT of 69U/L with no significant change at 6-month follow-up (mean ALT 60U/L, p=0 24) Conclusion: Standard of care lifestyle recommendations are ineffective in inducing weight loss and improvement in ALT in NAFLD The YMCA DPP repurposed to treat NAFLD resulted in statistically significant improvements in BMI and ALT in patients with NAFLD Fibroscan scores and other metabolic parameters also improved, though the sample size is likely too small to see a statistically significant improvement The existing infrastructure established by the YMCA throughout the U S could emerge as a leading treatment option for NAFLD patients.