Just Read: EASL–EASD–EASO Clinical Practice Guidelines (and the health threat and confusion around) the management of non-alcoholic fatty liver disease

Association for the Study of the Liver E, Association for the Study of Diabetes E, Association for the Study of Obesity E. EASO Clinical Practice Guidelines for the management of non-alcoholic fatty liver disease. 2016; http://linkinghub.elsevier.com/retrieve/pii/S0168827815007345

I know these are from 2016 which is a century ago in this field, I wanted to start somewhere.

A Growing Epidemic

I was introduced to the threat of Non-Alcoholic Fatty Liver Disease (NAFLD) not too long ago (at Low Carb San Diego actually), and the medical profession, not too long before that. As Nicolai Worm related, there were just 6 (six) pubmed references to NAFLD in the year 2000.

NAFLD is the most common liver disorder in Western countries, affecting 17–46% of adults, with differences according to the diagnostic method, age, sex and ethnicity [4]. NAFLD is also present in 7% of normal-weight (lean) persons [5], more frequently in females, at a younger age and with normal liver enzymes.

It travels with diabetes/insulin resistance

NAFLD is tightly associated with IR not only in the liver, but also in muscle and adipose tissues [44], and also with the MetS, defined as the cluster of any three of the following five features associated with IR: impaired fasting glucose (IFG) or T2DM, hypertriglyceridaemia, low high-density lipoprotein (HDL)- cholesterol (gender-adjusted), increased waist circumference (ethnicity adjusted) and high blood pressure [45].

There’s no identified drug treatment, only lifestyle changes have been shown to be effective

No drug has currently been tested in phaseI II trials and is approved for NASH by regulatory agencies. Therefore, no specific therapy can be firmly recommended and any drug treatment would be off-label.

Concerns

Confusion about what lifestyle/diet changes work best

Both of these approaches are included:

  • Low-to-moderate fat and moderate-to-high carbohydrate intake
  • Low-carbohydrate ketogenic diets or high-protein

I’m aware there are newer studies that try to tease this apart, I will post on those next.

Confusion around the importance

My (family medicine) specialty journal recently covered the topic of elevated liver tests, and in my opinion gave a confusing look at the importance of NAFLD

Nonalcoholic fatty liver is generally benign and treated successfully with lifestyle modificationOh RC, Hustead TR, Memorial Health H, Syed Ali KM, Pantsari MW. Mildly Elevated Liver Transaminase Levels: Causes and Evaluation. 2017 [cited 2018 Feb 19];96(11). Available from: www.aafp.org/afp

Later on in the article the association with diabetes is discussed.

Connection to the just published DIETFITS study, is the low fat diet a precursor to NAFLD?

In reviewing the well done DIETFITS study (see my post: Just Read: DIETFITS and Effect of Low-Fat vs Low-Carbohydrate Diet, real food is better, is the low fat diet worse for metabolic health? ), I found from doing calculations of lipid levels that the TG/HDL ratios improved in the low carbohydrate group, got worse in the low fat group. This is not discussed in the paper, just the fact that the lipid changes are significant. If this is the case and happens after just one year in a relatively healthy co-hort (about 1/3 with metabolic syndrome), does the low-fat diet then become diabetogenic?

I ended up going to the supplemental data to review lipid and metabolic health changes. I plotted those in the attached images, click on any to see full size.

I’m putting this here to note what a new phenomenon this is and the challenge of understanding how to manage it that exists. A few more posts coming before #LCB18.

1. Association for the Study of the Liver E, Association for the Study of Diabetes E, Association for the Study of Obesity E. EASO Clinical Practice Guidelines for the management of non-alcoholic fatty liver disease. 2016; http://linkinghub.elsevier.com/retrieve/pii/S0168827815007345
2. Oh RC, Hustead TR, Memorial Health H, Syed Ali KM, Pantsari MW. Mildly Elevated Liver Transaminase Levels: Causes and Evaluation. 2017 [cited 2018 Feb 19];96(11). Available from: www.aafp.org/afp
3. Gardner CD, Trepanowski JF, Del Gobbo LC, Hauser ME, Rigdon J, Ioannidis JPA, et al. Effect of Low-Fat vs Low-Carbohydrate Diet on 12-Month Weight Loss in Overweight Adults and the Association With Genotype Pattern or Insulin Secretion. JAMA [Internet]. 2018 Feb 20;319(7):667. Available from: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2018.0245

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