Education

1. “especially when liver enzyme levels are elevated without other causes.” which liver enzymes, specifically?

2. ADD info about intrahepatic triglyceride (IHTG) content either here or in the Medical Treatment section – i.e. what does it tell us? why might it be tested and/or monitored?

Diagnosis

● Diagnostic criteria

○ Non-alcoholic fatty liver disease (NAFLD) is suspected in patients with obesity, metabolic syndrome, or type 2 diabetes mellitus, especially when liver enzyme levels are elevated without other causes.3

○ MRIs and controlled attenuation parameter (CAP) which is an ultrasound technique, are non-invasive techniques that can measure liver fat with CAP values above 288 dB/m suggesting significant liver fat accumulation.3

○ Liver biopsy not only confirms NAFLD but also differentiates simple steatosis from non-alcoholic steatohepatitis (NASH) by identifying inflammation and fibrosis.4

● Biochemical markers

○ Gamma-glutamyl transferase (GGT): elevated GGT can support the diagnosis in the presence of other abnormalities (normal range 9-48 U/L), elevated levels above 48 U/L are found in patients with NAFLD.3

○ C-reactive protein (CRP): higher CRP levels indicating inflammation are usually found in patients with NAFLD (normal: < 3 mg/L; elevated >3 mg/L).4

○ Fasting insulin and homeostatic model assessment of insulin resistance (HOMA-IR): elevated fasting insulin levels and HOMA-IR levels of (>2.5) suggest insulin resistance, a key factor in NAFLD development.2

3. Remember your topic is NAFLD, so any mention of ESLD should be brief

Medical Treatments

● Medications

○ Obeticholic acid (OCA): is under investigation for NASH treatment which is an farnesoid X receptor agonist and may lower liver fibrosis and inflammation.3

○ Metformin: while mainly used for diabetes some clinical trials indicate that it may enhance insulin levels as well as decrease fat in the liver.3

○ Statins: not a direct therapy for NAFLD, statins have been shown to be beneficial for cardiovascular disease and are recommended for dyslipidemia treatment.4

● Emerging therapies

○ FXR agonists: This drug is in trials for their ability to delay liver fibrosis and inflammation in NASH patients.4

○ Anti-fibrotic agents: are able to help reduce the progression of fibrous tissue in the body.2

● Procedures and other interventions

○ Liver transplant: for patients with end stage liver disease (ESLD) related to NAFLD liver transplant may be necessary but eligibility depends on age and presence of coexisting conditions.2

○ Weight loss programs: clinically supervised weight reduction training.3

4. need to have 
quantified/specific intake recs for CHO, protein, and vitE (refer to Newberry article) 

5. What about coffee? fructose? 

Nutrition & Lifestyle

● Nutrition recommendations

○ Energy: recommended to set a target of 500-1,000 kcals per day.3

● Macronutrients

○ Carbohydrates: avoid intake of simple sugars and consume carbohydrates from sources of whole grain foods.2

○ Protein: should come from plant sources such as beans and nuts.4

● Micronutrients

○ Vitamin D: low levels of vitamin D are usually seen in NAFLD, some findings suggest that

supplementation may help with fat in the liver (RDA 600-800 IU).4

○ Magnesium: intakes can be associated with insulin resistance and NAFLD (RDA 310-420 mg/d).2

● Recommended foods

○ Leafy greens (magnesium and fiber).5

○ Walnuts (omega-3).3

○ Chickpeas (plant protein).4

● Foods to avoid

○ Fried foods (saturated fat).3

○ Processed snacks (trans fat and high sugar).

● Nutrient content per 100g

○ Leafy greens: magnesium 79 mg, fiber 3g, vitamin k 250 mcg.2

○ Walnuts: omega-3 fatty acids 2.5g, protein 15g, fiber 7g.3

○ Chickpeas: protein 19g, fiber 17g, carbohydrates 61g.4

○ Fried foods: saturated fat 15g, trans fat 0.5g, sodium 500mg and over.3

○ Processed snacks: sugar 25g, trans fat 1g.4

● Lifestyle recommendations

○ Exercise: high intensity interval training and aerobic exercises.2

○ Weight loss: 5-7% of body fat reduction.3

○ Alcohol abstinence

○ Smoking abstinence

1.
file:///C:/Users/user/Downloads/Rinella%202023%20AASLD%20Practice%20Guidance%20on%20the%20clinical%20assessment%20and%20management%20of%20NAFLD%20(1).pdf

2.
file:///C:/Users/user/Downloads/Newberry%202023%20-%20Dietary%20and%20nutrition%20considerations%20in%20caring%20for%20patients%20with%20NAFLD%20(1).pdf

3.
file:///C:/Users/user/Downloads/Ezpeleta%202023%20Effect%20of%20alternate%20day%20fasting%20combined%20with%20aerobic%20exercise%20on%20NAFLD%20(4).pdf

4. Li H, Wang X, Ye M, et al. Does a High Intake of Green Leafy Vegetables Protect from NAFLD? Evidence from a Large Population Study. Nutr Metab Cardiovasc Dis. 2021;31(6): 1691-1701. doi: 10.1016/j.numecd.2021.01.009