In the JournalsPerspective

Stress, environment key barriers to Mediterranean diet uptake for NAFLD

Barriers to initiating a Mediterranean diet — shown to improve liver health in patients with nonalcoholic fatty liver disease — included an obesogenic environment, life stressors, and demand for convenience, according to a study published in Clinical Gastroenterology and Liver Disease.

“Poor understanding about NAFLD appeared to influence the priority placed on following dietary advice,” Laura Haigh from the Liver Research Group at Newcastle University in the United Kingdom, and colleagues wrote. “NAFLD causality and the strength of these associations produced responses that incorporated physiological drivers, lifestyle behaviors and genetic predisposition.”

The study comprised 19 patients with NAFLD, 16 of whom had biopsy-proven nonalcoholic steatohepatitis. Patients underwent dietary intervention for 12 weeks and reported perceived barriers and facilitators to adopting a Mediterranean diet.

Mediterranean diet adoption increased from moderate to high levels during the study (P = .006). At 12 weeks, 79% of patients achieved a mean 2.4 kg bodyweight reduction compared with baseline (P = .001) and 72% of patients with improved diet uptake had increased HDL cholesterol (P = .009).

From patient responses, Haigh and colleagues found that poor diet and excess weight were often viewed as causal with regional cultural identity as influential. In contrast, the relationship between diet and disease and the impact of excess weight was questioned by some patients with the absence of alcohol in disease development stressed among responses.

Although patients generally recognized that high-quality dietary patterns improve life expectancy and health outcomes, many reported a sense of helplessness in changing dietary habits and increasing their “food skills.”

Participants were less likely to engage in changing diet if they “interpreted their habitual diet as either low or high Mediterranean,” the researchers wrote. Those who placed a high value on potential health benefits and expected to enjoy the available food options were more likely to adopt the Mediterranean diet.

Key barriers included stressful experiences, ambivalence, high responsiveness to “food cheats” and rewards, and feasibility of consuming a Mediterranean diet through different seasons with an emphasis on pervasive obesogenic environments and societal pressure to consume.

“The unhealthy selections available in institutions, workplaces and supermarkets negatively impacted diet maintenance,” Haigh and colleagues wrote. “Work patterns and dietary habits were problematic for appetite regulation and food routines. In contrast, easy access to budget supermarkets, good transport links and having family diet supporters were regarded positively.”

Diet modification occurred more frequently with personalized approaches that combined nutrition education and counseling skills, with face-to-face contacts combined with an online program, and through group counseling. In contrast, telephone contacts appeared to be the least helpful.

“Acceptance of NAFLD as a disease and nutritional care engagement is impacted by patients understanding of their condition,” Haigh and colleagues wrote. “Poor health service utilization may be in part attributed to lack of symptoms, and viewing long-term diseases and their outcomes as inevitable. Therefore, clinicians should stress that NAFLD is treatable and even reversible if diet improvements are sustained.” – by Talitha Bennett

Disclosure: The authors report no relevant financial disclosures.

Barriers to initiating a Mediterranean diet — shown to improve liver health in patients with nonalcoholic fatty liver disease — included an obesogenic environment, life stressors, and demand for convenience, according to a study published in Clinical Gastroenterology and Liver Disease.

“Poor understanding about NAFLD appeared to influence the priority placed on following dietary advice,” Laura Haigh from the Liver Research Group at Newcastle University in the United Kingdom, and colleagues wrote. “NAFLD causality and the strength of these associations produced responses that incorporated physiological drivers, lifestyle behaviors and genetic predisposition.”

The study comprised 19 patients with NAFLD, 16 of whom had biopsy-proven nonalcoholic steatohepatitis. Patients underwent dietary intervention for 12 weeks and reported perceived barriers and facilitators to adopting a Mediterranean diet.

Mediterranean diet adoption increased from moderate to high levels during the study (P = .006). At 12 weeks, 79% of patients achieved a mean 2.4 kg bodyweight reduction compared with baseline (P = .001) and 72% of patients with improved diet uptake had increased HDL cholesterol (P = .009).

From patient responses, Haigh and colleagues found that poor diet and excess weight were often viewed as causal with regional cultural identity as influential. In contrast, the relationship between diet and disease and the impact of excess weight was questioned by some patients with the absence of alcohol in disease development stressed among responses.

Although patients generally recognized that high-quality dietary patterns improve life expectancy and health outcomes, many reported a sense of helplessness in changing dietary habits and increasing their “food skills.”

Participants were less likely to engage in changing diet if they “interpreted their habitual diet as either low or high Mediterranean,” the researchers wrote. Those who placed a high value on potential health benefits and expected to enjoy the available food options were more likely to adopt the Mediterranean diet.

Key barriers included stressful experiences, ambivalence, high responsiveness to “food cheats” and rewards, and feasibility of consuming a Mediterranean diet through different seasons with an emphasis on pervasive obesogenic environments and societal pressure to consume.

“The unhealthy selections available in institutions, workplaces and supermarkets negatively impacted diet maintenance,” Haigh and colleagues wrote. “Work patterns and dietary habits were problematic for appetite regulation and food routines. In contrast, easy access to budget supermarkets, good transport links and having family diet supporters were regarded positively.”

Diet modification occurred more frequently with personalized approaches that combined nutrition education and counseling skills, with face-to-face contacts combined with an online program, and through group counseling. In contrast, telephone contacts appeared to be the least helpful.

“Acceptance of NAFLD as a disease and nutritional care engagement is impacted by patients understanding of their condition,” Haigh and colleagues wrote. “Poor health service utilization may be in part attributed to lack of symptoms, and viewing long-term diseases and their outcomes as inevitable. Therefore, clinicians should stress that NAFLD is treatable and even reversible if diet improvements are sustained.” – by Talitha Bennett

Disclosure: The authors report no relevant financial disclosures.

    Perspective
    Jasmohan S. Bajaj

    Jasmohan S. Bajaj

    It is always difficult to initiate and importantly sustain health behaviors regardless of the field. This is important in other areas of chronic liver disease such as sodium restriction and alcohol abstinence. The challenges faced by the patients vis-à-vis the Mediterranean diet in Haigh et al. illustrate that personalized and multi-disciplinary input from health care providers is needed for success of nonmedical, chronic disease management based on behavior alterations.

    • Jasmohan S. Bajaj, MD
    • Division of Gastroenterology, Hepatology and Nutrition
      Virginia Commonwealth University and McGuire VA Medical Center

    Disclosures: Bajaj reports no relevant financial disclosures.