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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

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