Dietary Treatment of Non Alcoholic Fatty Liver Disease: A Case Study

In this case study, we explore the goals of an NAFLD Patient, and the dietary changes required to achieve these goals, including Food Lists and Sample Menu.

PATIENT PROFILE

MALE , 52 years

Height:                                    175cm

Weight:                                    95kg

Body fat percentage:              30%

Inactive / sedentary

Diagnosis:           Non alcoholic fatty liver disease

Type 2 Diabetes

Hypercholesterolaemia (fasting total cholesterol: 7.4mmol/l)

Medical Treatment:               Metformin b.d.

Statin

TREATMENT GOALS

  1. WEIGHT

Obesity

  • Obesity, combined with host factors such as diet, sedentary lifestyle, and genetic predisposition, has been directly associated with increases in the prevalence of insulin resistance, type 2 diabetes, metabolic syndrome, and NAFLD among adults. Estimates suggest that about 80% of adults who are class 1 or 2 obese and 90% who are class 3 obese have NAFLD, with 36% having the more aggressive form of fatty liver, NASH.
  • Obesity itself is a chronic inflammatory condition resulting from the failure of normal homeostatic regulation of energy intake, storage, and utilization. With obesity, particularly central obesity, there’s an expansion of visceral adipose tissue. Weight loss can change the activity of adipose tissue and reverse many negative consequences of the condition, including NAFLD, as can dietary macronutrient content.
  • Energy balance is a major factor in liver fat accumulation. NAFLD can be a precursor to developing the metabolic syndrome or a “hepatic manifestation” of insulin resistance. Although the liver isn’t meant to store fat, caloric excess coupled with and unmatched caloric expenditure can result in fat accumulation in this organ.
  • NASH patients have been shown to have higher energy intake compared with healthy controls. Overfeeding studies have clearly shown that an increased intake of fat, glucose, or fructose can increase liver fat in young, healthy individuals.
  • In addition, several mechanisms may play a role in the pathogenesis of NAFLD, including insulin resistance, oxidative stress, and cytokine toxicity. These factors likely are present in those with severe obesity and NAFLD and at a significantly increased prevalence than in their normal-weight counterparts.
  • An increasing number of patients with NAFLD have been described as having a normal BMI, although these individuals tend to have central adiposity and insulin resistance.16,17 Clinical and epidemiologic studies suggest a direct association between hepatic fat content and visceral adiposity.

Weight Reduction

The minimal amount of weight loss for improving NASH hasn’t been determined. Long-term dietary intervention studies are limited; however, evidence suggests that weight loss is effective for improving liver disease related to NAFLD, as it positively influences insulin sensitivity, hypertension, and dyslipidemia.

Data from a small study have shown that a 9% weight loss significantly improves steatosis and marginally improves inflammation but doesn’t affect fibrosis. In the same study, subjects with NASH who lost 5% of their body weight experienced improvements related to insulin sensitivity and hepatic steatosis compared with those who lost less than 5% of their body weight. However, only in subjects who achieved at least a 9% weight reduction were there significant improvements in inflammation, ballooning (a form of liver cell death), and steatosis.

One study demonstrated that a decrease of about 200 kcal/day and a weight loss of about 3.5 kg improved liver histology and enzymes in NASH patients. In older adults who were obese, a 10% weight loss over six months resulted in a 45% reduction in liver fat.

A randomized controlled trial involving patients with biopsy-proven NASH involved a combination of diet, exercise, and behavior modification.66 Participants who achieved the study weight loss goal of 7% or more experienced significant improvements in steatosis, inflammation, and ballooning injury. Weight loss also has been shown to prevent the progression of fibrosis in NASH.

Several recent studies using a variety of interventions, either diet alone or in combination with different exercise prescriptions, have consistently reported reduction in liver fat ranging from 20% to 81% (average of 40%). The degree of hepatic fat reduction was proportional to the intensity of the lifestyle intervention and generally required a weight loss of 5% to 10%. Aiming for a weight loss of 7%, as proposed by the international societies on the basis of an extensive body of literature, appears to be a reasonable recommendation in overweight and class obese patients

  1. TYPE 2 DIABETES

Dietary treatment to control NAFLD will assist in treatment of Type 2 Diabetes.

  1. HYPERLIPIDAEMIA

Lipid lowering therapy, including dietary intervention will improve overall outcomes.

  1. INACTIVITY

  • Patients with NAFLD generally engage in less than one-half the amount of exercise performed by age- and sex-matched controls, and in one study, less than 20% met current recommendations for physical activity (at least 150 minutes of moderate-intensity physical activity per week).
    In a large-scale study of 349 individuals, the NAFLD group engaged in less reported leisure time physical activity, including total, aerobic, and resistance, although only the association with resistance physical activity remained significant when adjusted for BMI.
  • In a small study of 37 NAFLD patients, there was a lower level of cardiorespiratory fitness among patients with higher NAFLD activity scores and NASH.
  • Decreased physical activity correlates with intrahepatic fat, decreased insulin sensitivity, and increased abdominal fat. Sedentary time alone is associated with metabolic status. The amount of time patients were sedentary predicted higher levels of fasting insulin, independent of the amount of time spent engaging in moderate- or vigorous-intensity activity. This highlights the importance of reducing sedentary time to improve metabolic health, possibly in addition to the benefits associated with a physically active lifestyle.

Nutritional Guidelines for NAFLD/NASH

 

Weight loss10% of initial body weight over six months
Maintenance of weight loss
Bariatric surgery when individuals qualify
Goal: achieve 86kg in 6 months; and reduce body fat to <24%
Calorie intake1,200 to 1,500 daily
*Energy deficit of 500 kcal/day based on Mifflin-St Jeor formula
Plan: 6700kJ (1608kCal) per day
Total fat≤ 35% of total calories33% TE as fat
Monounsaturated fatty acids15% to 25% of total calories20% TE
Polyunsaturated fatty acids5% to 10% of total calories
Omega-3 fatty acids
7% TE
Saturated fatty acids7% to 10% of total calories7% TE
Carbohydrate50% of total calories
> 50% carbohydrate sources from whole grains
Avoid high-fructose corn syrup
Added sugars < 10% of total calories
USE LOW GI CARBOHYDRATE SOURCES*
45% TE
Education on Low GI
Protein15% of total calories
Lean and vegetable protein, INCLUDING SOYA
20%
Education on inclusion of soya
AntioxidantsNone
Physical activity≥ 150 minutes/week at moderate intensity or ≥ 75 minutes/week at vigorous intensity
Cardiovascular exercise five times weekly
Resistance training two or more times weekly
Decrease time spent sedentary
Encourage to achieve a more active lifestyle

Sample Menu

MEALFOOD GROUPPORTIONSDAY 1DAY 2
BREAKFASTSTARCH
Low GI
250g Soya Life PorridgeSoya Life Instant Meal Replacement Drink
DAIRY
Low Fat
11 cup (250ml) low fat milk 1 cup (250ml) low fat milk / yoghurt
MIDMORNINGSTARCH
Low GI
1Soya Life Instant Meal Replacement Drink2 Ryvita
PROTEIN lean11 cup low fat milk Hummus
LUNCHSTARCH low GI22 slices low GI bread1 large seed roll
PROTEIN lean22 slices lean cold meat60g grilled chicken breast
VEG AFree: use lots!Lettuce, tomatoSalad
FAT12tsp lite marg½ avocado
15H30FRUIT21 large apple1 cup strawberries
SUPPERSTARCH low GI1½ cup brown rice2 baby potatoes
PROTEIN lean3
Palm-size
120g cooked chicken breast2 large portions extra Light fish
VEG AFree: use lots!Cauliflower , broccoliSalad, Gem squash
VEG B1½ cup carrots½ cup peas

DIET

No specific medications are approved for treating NAFLD. The current standard of care for treating patients with NAFLD focuses on lifestyle interventions, particularly diet and exercise. Sustained weight loss is the most effective treatment and should be the foundation of any treatment plan.

In summary, soya used in daily diets for those with NAFLD and NASH, can bring about favourable benefits, and result in the risk of further complications associated with NAFLD being significantly minimised.

Soya Life Porridge and/or Soya Life Instant Meal Replacement Drinks should be used as an important daily addition in diets to treat NAFLD and NASH.

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