Stopping NASH in its tracks: Lifestyle Intervention Key from Day 1
In this guest editorial, Joel E. Lavine, MD, PhD, chief of pediatric gastroenterology, hepatology, and nutrition at the Columbia College of Physicians and Surgeons , discusses the future of treating nonalcoholic fatty liver disease and its progressive form, nonalcoholic steatohepatitis, as these epidemics accompany with increasing obesity prevalence. He explains that even with upcoming therapeutics and noninvasive screening methods, appropriate diet and exercise are vital to avoiding and treating these diseases.
For this year’s International NASH Day, I want to address the best tool we have currently to prevent and treat nonalcoholic fatty liver disease and nonalcoholic steatohepatitis: lifestyle intervention. NASH is a little-known or recognized problem among the general population, who may not realize that it is a comorbidity associated with many of the other abundant problems we’re seeing these days including obesity, diabetes, hypertension and dyslipidemia. While we wait on emerging therapies to treat NASH along with these associated problems, we need to ensure that our patients are aware of the importance of eating properly so that caloric intake aligns with expenditure, and diet composition provides essential nutrients.
In the present absence of FDA-approved therapeutics for NAFLD and NASH, it has been difficult to screen even with noninvasive methods for fatty liver on a broad scale for several reasons. For one, while imaging with MRI-based technologies is relatively easy to reproduce simply and accurately, these technologies are relatively expensive, and it can be difficult to locate institutions that perform magnetic resonance elastography. Ultrasound-based technologies are more widely available and can assess fat and liver stiffness, but remain primarily in the domain of hepatologists and lack sufficient validation to monitor response to impending therapies.
Secondly, most patients with NAFLD and NASH also have obesity and will receive the same advice for being overweight: keep to a proper diet with healthy, nutritious food and exercise most days, whether it be moderate or more intense.
Looking ahead, it is likely that Ocaliva (obeticholic acid, Intercept Pharmaceuticals) will be the first to receive FDA approval for NASH, based on completed phase 2b and interim phase 3 data that have shown significant reductions in fibrosis with no worsening of NASH. While this will greatly benefit many patients who have already developed NASH-related fibrosis, we must also focus on prevention of fatty liver, especially among the most vulnerable group who are identified at a young age.
Pediatric NAFLD and NASH are found most commonly among Native American and Hispanic children, especially boys, and young adults can also present with fatty liver disease. While this can be construed to be an acute outcome of lifestyle and alcohol intake, these liver problems may have started unrecognized at a much younger age.
When faced with a parent who says their child is a picky eater who demands specific foods that are generally carbohydrate-loaded, processed, packaged or canned and refuses vegetables, fruits or lean meats, I start out with one question: “Who’s the boss?” Those in charge of shopping and meal preparation need to take responsibility for their children’s diets.
Similarly, parents and guardians can take steps to ensure their children maintain a healthy balance of physical activity. Screen-time from smart phones, computers or television can interfere with sufficient exercise. Ensuring that screen time is limited while encouraging even informal exercise, such as sports or dance, can make a healthy lifestyle enjoyable.
What might be considered a problem for the family can also be considered a family opportunity for all to eat better and get moving. Just like any other part of the day — taking a shower or making a meal — you have to schedule time for physical activity. This doesn’t have to be going to the gym; find things that can be maintained and enjoyed for decades.
For physicians: this is a matter of identifying obstacles, helping your patient identify their motivations and health goals, and design obtainable, agreed-upon steps that build a foundation for success so that your patient feels like a champion.
The earlier you start to address this, the better. NAFLD and NASH require frequent visits and information about the consequences of not adhering to a better lifestyle. We need to spread the word and ensure our patients know that this is a life-threatening problem for many of them, but they are at the helm.
Disclosure: Lavine reports no relevant financial disclosures.