Physical activity support or weight loss counseling for nonalcoholic fatty liver disease?

AIM: To determine the clinical effectiveness of intense psychological support to physical activity (PA) in nonalcoholic fatty liver disease (NAFLD), compared with cognitive-behavioral treatment (CBT). METHODS: Twenty-two NAFLD cases received support to exercise, tailored to their motivational needs (PA group). The effects on body weight, physical fitness [6-min walk test, VO2max and the PA-rating (PA-R) questionnaire] and body fat (fatty liver indices and visceral adiposity index) were compared with data obtained in 44 NAFLD subjects enrolled in a CBT program for weight loss, after adjustment for propensity score, calculated on baseline data. Measurements were performed at baseline, at 4-mo and one-year follow-up. Changes in anthropometric, biochemical and PA parameters were tested by repeated measurement ANOVA. Outcome results were tested by logistic regression analysis. RESULTS: At the end of the intensive program, BMI was less significantly reduced in the PA group (-1.09 ± 1.68 kg/m(2) vs -2.04 ± 1.42 kg/m(2) in the CBT group, P = 0.019) and the difference was maintained at 1-year follow-up (-0.73 ± 1.63 vs -1.95 ± 1.88, P = 0.012) (ANOVA, P = 0.005). PA-R was similar at baseline, when only 14% of cases in PA and 36% in CBT (P = 0.120) recorded values ≥ 3. At 4 mo, a PA-R ≥ 3 was registered in 91% of PA and 46% of CBT, respectively (P < 0.001) and PA-R ≥ 5 (up to 3 h/wk of moderate-to-heavy intensity physical activity) was registered in 41% of PA and only 9% of CBT group (P < 0.007). The 6-min walk test increased by 139 ± 26 m in PA and by only 43 ± 38 m in CBT (P < 0.001) and VO2max by 8.2 ± 3.8 mL/kg per minute and 3.3 ± 2.7 mL/kg per minute, respectively (P < 0.002). After adjustment for propensity, weight loss > 7% was significantly associated with CBT group at one year (OR = 6.21; 95%CI: 1.23-31.30), whereas PA-R > 3 was associated with PA group (10.31; 2.02-52.63). Liver enzymes decreased to values within normal limits in 36% of PA cases and 61% of CBT (P < 0.070). Estimated liver fat (Kotronen index) fell below the fatty liver threshold in 36% of PA and 34% and CBT cases at one-year (not different). Also the fatty liver index and the visceral adiposity index improved to a similar extent. CONCLUSION: Intensive psychological counseling for PA produces hepatic effects not different from standard CBT, improving physical fitness and liver fat independent of weight loss. Strategies promoting exercise are worth and effective in motivated patients, particularly in lean NAFLD patients where large weight loss cannot be systematically pursued.

The role of lifestyle change in the prevention and treatment of NAFLD.

Healthy habits in terms of food intake and physical activity are first-line approach to prevention and treatment of nonalcoholic fatty liver disease, but difficulties arise in turning attempts into practice. Independently of the specific role of individual nutrients, not universally proven, overweight, obesity and diabetes are the specific conditions most frequently associated with hepatic fat accumulation. Accordingly, weight loss is mandatory in the majority of patients; this can be achieved by dietary restriction, but is rarely maintained in the long-term. Physical activity programs, both aerobic and resistance exercise may improve cardiorespiratory fitness, reduce the multiple conditions associated with the metabolic syndrome and help weight loss maintenance. However, motivating sedentary individuals to move is difficult and is favored by structured programs carried out along the lines of cognitive-behavior therapy. The role of behavior therapy is now supported by pilot studies, observational studies and finally by a randomized controlled study with histological outcomes. In the future, behavior interventions might be supported by important technological advances, such as smart phone technology and webbased platforms to facilitate interactive engagement amongst patients and with their health care providers. Lifestyle programs must also incorporate methods of overcoming barriers to accessing health service, engaging with workplace health programs and linking with community attempts to improve public health.

Validation of a novel, objective measure of occupational sitting.

OBJECTIVE: To test the validity of a sitting pad (SP) to measure desk based sitting time and transitions, against camera derived direct observation; and to compare the data with those from inclinometers in the ActivPAL(3) (AP) and ActiGraph GT3X+ (AG). METHODS: Australian employees (n=13; 9 women; mean age 30 ± 6.5 years) were provided with a SP, AG and AP in 2011. A camera recorded chair based transitions during a prescribed and a free living protocol. Mean sitting time and transitions were calculated for each device and intra-class correlations (ICCs) and mean differences between (a) the SP and the camera and (b) the AP, AG and camera, were compared. RESULTS: During the prescribed protocol, the smallest mean differences compared with the camera were for the SP; sitting time 0.30 ± 0.21 minutes, transitions -0.46 ± 0.78. During free living, both the SP and AP (set to record events greater than 3 seconds) showed excellent levels of agreement with the camera for sitting time (0.999 and 0.990 respectively) and transitions (0.997 and 0.928 respectively). Agreement between the camera and the AG was poor for both sitting time and transitions (0.257 and 0.033 respectively). CONCLUSIONS: The SP is a highly accurate measure of desk based sitting time and transitions and provides novel measurement and intervention opportunities for research into occupational sitting.

Does the use of standing 'hot' desks change sedentary work time in an open plan office?

OBJECTIVE: This study assessed the use of standing 'hot' desks in an open plan office and their impact on sedentary work time. METHOD: Australian employees (n=11; 46.9 [9.8] years; BMI 25.9 [3.5 kg/m(2)]) wore an armband accelerometer for two consecutive working weeks (November-December 2010). In the second week, employees were encouraged to use a pod of four standing 'hot' desks to stand and work as often as possible. Desk use was recorded using time logs. The percentages of daily work time spent in sedentary (<1.6 METs), light (1.6-3.0 METs) and moderate+ (>3 METs) intensity categories were calculated for each week, relative to the total daily time at work. Paired sample t tests were used to compare weekly differences. RESULTS: Employees spent 8:09 ± 0:31h/day at work and 'hot' desk use ranged from zero to 9:35 h for the week. There were no significant changes in mean time spent in sedentary (difference of -0.1%), light (difference of 0.8%) and moderate+ (-0.7%) intensity categories. However, individual changes in sedentary work time ranged from -5.9 to 6.4%. CONCLUSIONS: Volitional use of standing 'hot' desks varied and while individual changes were apparent, desk use did not alter overall sedentary work time in this sample.

Cognitive-behavioral treatment of nonalcoholic Fatty liver disease: a propensity score-adjusted observational study.

The effectiveness of cognitive-behavior treatment (CBT) in nonalcoholic fatty liver disease (NAFLD), largely related to overweight/obesity and considered the hepatic expression of the metabolic syndrome (MS), has so far been tested in very limited samples. In a tertiary referral center, consecutively observed NAFLD subjects were offered a CBT program aimed at weight loss and increased physical activity, based on 13 group sessions; 68 cases entered the treatment protocol, those who refused (n = 82) were given recommendations for diet and physical activity. Treatment goals (weight loss ≥7% initial body weight, normalization of liver enzymes, and improved parameters of MS) were tested by logistic regression at 6 months (all cases) and at 2 years, both on intention-to-treat and in completers (Diet, 78; CBT, 65). The results were adjusted for the propensity score of attending the CBT program, based on civil, anthropometric and clinical variables. At baseline the CBT group had a larger prevalence of obesity and more severe insulin resistance (homeostasis model assessment (HOMA)). At follow-up, CBT was associated with a higher probability of weight loss and normal liver enzymes (6-month: odds ratio (OR), 2.56; 95% confidence interval (CI), 1.15-5.69; 2-year intention-to-treat: OR, 3.57, 95% CI, 1.59-8.00), after adjustment for propensity and changes in body weight. A similar trend was observed in the outcome goals of insulin resistance and the score of MS, which were both reduced. In conclusion, subjects with NAFLD participating in a CBT program significantly improve their general and liver parameters. The beneficial effects are largely maintained at 2-year follow-up, in keeping with the lifestyle-related pathogenesis of disease.

Behavior therapy for nonalcoholic fatty liver disease: The need for a multidisciplinary approach.

Nonalcoholic fatty liver disease (NAFLD) is systematically associated with insulin resistance and the metabolic syndrome, where behavior therapy remains the primary treatment, simultaneously addressing all the clinical and biochemical defects. However, very few studies have tested the effectiveness of intensive behavior therapy in NAFLD, aimed at lifestyle modifications to produce stable weight loss by reduced calorie intake and increased physical activity. Searching the literature for studies testing weight loss and lifestyle modifications for the treatment of NAFLD, only 14 reports were traced where the entry assessment satisfied well-defined criteria. The final effectiveness was based on hard histological outcomes in 5 cases. All but 1 were pilot, uncontrolled studies or limited case series, and in general the details of treatment were scanty. In only 3 cases treatment was carried out along the guidelines of behavior treatment to reduce excess nutrition and increase exercise; in these cases, a remarkable effect on weight loss and an improvement in liver histology were reported. The principles of behavior therapy are presented in detail, to help physicians change their prescriptive attitude into a more empowerment-based approach. A brief section is also included on the practical aspects and public policies to be implemented at societal level to obtain the maximum effects in lifestyle changes. There is a need for multidisciplinary teams including dietitians, psychologists, and physical activity supervisors caring for patients with NAFLD. Alternatively, general practitioners and physicians working in gastrointestinal units should limit their intervention to engage patients with NAFLD before referral to specialized teams set up for the treatment of diabetes and obesity.