The effects of total energy expenditure from all levels of physical activity vs. physical activity energy expenditure from moderate-to-vigorous activity on visceral fat and insulin sensitivity in obese Type 2 diabetic women. Dietary fat and carbohydrates differentially alter insulin sensitivity during caloric restriction. Non-invasive assessment of hepatic steatosis: prospective comparison of the accuracy of imaging examinations. Magnetic resonance spectroscopy to measure hepatic triglyceride content: prevalence of hepatic steatosis in the general population. Effects of moderate weight loss and orlistat on insulin resistance, regional adiposity, and fatty acids in type 2 diabetes. Effect of a 12-Month Intensive Lifestyle Intervention on Hepatic Steatosis in Adults With Type 2 Diabetes Reversal of nonalcoholic hepatic steatosis, hepatic insulin resistance, and hyperglycemia by moderate weight reduction in patients with type 2 diabetes. A modified Mediterranean diet is associated with the greatest reduction in alanine aminotransferase levels in obese type 2 diabetes patients: results of a quasi-randomised controlled trial Therapeutic effects of restricted diet and exercise in obese patients with fatty liver. Effect of exercise and dietary modification on serum aminotransferase levels in patients with nonalcoholic steatohepatitis. Correlation of paired liver biopsies in morbidly obese patients with suspected nonalcoholic fatty liver disease Independent effects of physical activity in patients with nonalcoholic fatty liver disease. Randomized controlled trial testing the effects of weight loss on nonalcoholic steatohepatitis. The Effect of a Low-Carbohydrate, Ketogenic Diet on Nonalcoholic Fatty Liver Disease: A Pilot Study
AIMS We examined the effects of physical activity with or without dietary restriction for 3 months on regional fat and insulin sensitivity and compared the effect of total energy expenditure from all levels of physical activity with that of physical activity energy expenditure from moderate-to-vigorous exercise in obese women with Type 2 diabetes . METHODS In this r and omized , controlled trial , we assessed change of body weight , abdominal visceral fat area , subcutaneous fat area and insulin sensitivity , expressed as K(ITT ) , and monitored total energy expenditure and physical activity energy expenditure using an accelerometer during a 12-week intervention in four groups : control , diet , exercise and diet plus exercise . RESULTS The mean body mass index was 28.0 + /- 2.7 kg/m(2 ) and the mean duration of diabetes was 8 + /- 6 years . Both the diet and diet plus exercise groups showed significant body weight loss compared with the control group ( P < 0.05 ) . However , the visceral fat area was reduced only in the diet and exercise group ( P = 0.017 ) and the subcutaneous fat area was reduced only in the diet group ( P = 0.009 ) . Mean energy intake was an independent determinant of the change in subcutaneous fat area ( P = 0.020 ) and mean total anergy expenditure was an independent determinant of visceral fat area ( P = 0.002 ) . Insulin sensitivity K(ITT ) was associated with physical activity energy expenditure ( P = 0.006 ) , energy intake ( P = 0.047 ) and the change in fructosamine level ( P = 0.016 ) but not with changes in body weight , subcutaneous fat area , visceral fat area or adipokine level . CONCLUSIONS Exercise had an additive effect to dietary restriction on visceral fat reduction . Visceral fat area was associated with total energy expenditure , but insulin sensitivity was associated with physical activity energy expenditure BACKGROUND & AIMS We determined the effects of acute and chronic calorie restriction with either a low-fat , high-carbohydrate ( HC ) diet or a low-carbohydrate ( LC ) diet on hepatic and skeletal muscle insulin sensitivity . METHODS Twenty-two obese subjects ( body mass index , 36.5 + /- 0.8 kg/m2 ) were r and omized to an HC ( > 180 g/day ) or LC ( < 50 g/day ) energy-deficit diet . A euglycemic-hyperinsulinemic clamp , muscle biopsy specimens , and magnetic resonance spectroscopy were used to determine insulin action , cellular insulin signaling , and intrahepatic triglyceride ( IHTG ) content before , after 48 hours , and after approximately 11 weeks ( 7 % weight loss ) of diet therapy . RESULTS At 48 hours , IHTG content decreased more in the LC than the HC diet group ( 29.6 % + /- 4.8 % vs 8.9 % + /- 1.4 % ; P < .05 ) but was similar in both groups after 7 % weight loss ( LC diet , 38.0 % + /- 4.5 % ; HC diet , 44.5 % + /- 13.5 % ) . Basal glucose production rate decreased more in the LC than the HC diet group at 48 hours ( 23.4 % + /- 2.2 % vs 7.2 % + /- 1.4 % ; P < .05 ) and after 7 % weight loss ( 20.0 % + /- 2.4 % vs 7.9 % + /- 1.2 % ; P < .05 ) . Insulin-mediated glucose uptake did not change at 48 hours but increased similarly in both groups after 7 % weight loss ( 48.4 % + /- 14.3 % ; P < .05 ) . In both groups , insulin-stimulated phosphorylation of c-Jun-N-terminal kinase decreased by 29 % + /- 13 % and phosphorylation of Akt and insulin receptor substrate 1 increased by 35 % + /- 9 % and 36 % + /- 9 % , respectively , after 7 % weight loss ( all P < .05 ) . CONCLUSIONS Moderate calorie restriction causes temporal changes in liver and skeletal muscle metabolism ; 48 hours of calorie restriction affects the liver ( IHTG content , hepatic insulin sensitivity , and glucose production ) , whereas moderate weight loss affects muscle ( insulin-mediated glucose uptake and insulin signaling ) BACKGROUND & AIMS Despite increasing use of various imaging examinations for non-invasive assessment of hepatic steatosis ( HS ) , their relative accuracy is unknown . The objective of this study is to prospect ively compare the accuracy of computed tomography ( CT ) , dual gradient echo magnetic resonance imaging ( DGE-MRI ) , proton magnetic resonance spectroscopy ( (1)H-MRS ) , and ultrasonography ( US ) for the diagnosis and quantitative estimation of HS . METHODS A total of 161 consecutive potential living liver donors underwent US ( performed by two independent radiologists , US1 and US2 ) , CT , DGE-MRI , (1)H-MRS , and liver biopsy on the same day . Using the histologic degree of HS as the reference st and ard , we compared the diagnostic performance of US1 , US2 , CT , DGE-MRI , and (1)H-MRS for diagnosing HS > or= 5 % and HS > or= 30 % and compared the accuracy of CT , DGE-MRI , and (1)H-MRS in the quantitative estimation of HS . RESULTS  DGE-MRI and (1)H-MRS  significantly outperformed CT and US for the diagnosis of HS5 % .  DGE-MRI  showed a tendency of higher accuracy than the other examinations for diagnosing HS > or= 30 % . The cross-vali date d sensitivity and specificity of DGE-MRI  at the optimal cut-off were 76.7 % and 87.1 % , respectively , for diagnosing HS > or= 5 % and 90.9 % and 94 % , respectively , for diagnosing HS > or= 30 % . The cross-vali date d Bl and -Altman 95 % limits of agreement between the estimated degree of HS on imaging examinations and the histologic degree of HS , were the narrowest with DGE-MRI , yielding -12.7 % to 12.7 % . CONCLUSIONS Among CT , DGE-MRI , (1)H-MRS , and US , DGE-MRI is the most accurate method for the diagnosis and quantitative estimation of HS . Therefore , DGE-MRI may be the preferred imaging examination for the non-invasive assessment of HS Despite the increasing prevalence of nonalcoholic fatty liver disease ( NAFLD ) , the criteria used to diagnose the disorder remain poorly defined . Localized proton magnetic resonance spectroscopy ( MRS ) accurately measures hepatic triglyceride content ( HTGC ) but has been used only in small research studies . Here , MRS was used to analyze the distribution of HTGC in 2,349 participants from the Dallas Heart Study ( DHS ) . The reproducibility of the procedure was vali date d by showing that duplicate HTGC measurements were high correlated ( r = 0.99 , P < 0.001 ) and that the coefficient of variation between measurements was low ( 8.5 % ) . Intake of a high-fat meal did not significantly affect the measurements , and values were similar when measurements were made from the right and left hepatic lobes . To determine the " upper limit of normal " for HTGC , the distribution of HTGC was examined in the 345 subjects from the DHS who had no identifiable risk factors for hepatic steatosis ( nonobese , nondiabetic subjects with minimal alcohol consumption , normal liver function tests , and no known liver disease ) . The 95th percentile of HTGC in these subjects was 5.56 % , which corresponds to a hepatic triglyceride level of 55.6 mg/g . With this value as a cutoff , the prevalence of hepatic steatosis in Dallas County was estimated to be 33.6 % . Thus MRS provides a sensitive , quantitative , noninvasive method to measure HTGC and , when applied to a large urban US population , revealed a strikingly high prevalence of hepatic steatosis OBJECTIVE Moderate weight loss is recommended for overweight and obese patients with type 2 diabetes , and conjunctive use of weight loss medication has been advocated . The current study examined weight loss-dependent and -independent effects of the intestinal lipase inhibitor orlistat at 6 months of treatment , using behavioral intervention ( Int ) combined with r and omized , double-blinded , placebo (P)-controlled treatment with orlistat ( O ) . RESEARCH DESIGN AND METHODS Metabolic control , insulin sensitivity ( IS ) , regional fat distribution , and fat content in liver and muscle were measured in 39 volunteers with type 2 diabetes in whom all antidiabetic medication was withdrawn 1 month preceding r and omization .  Weight loss was equivalent in the Int+O and Int+P groups , respectively ( -10.3 + /- 1.3 vs. -8.9 + /- 1.1 % ) , and there were identical decreases in visceral adipose tissue ( VAT ) , fat mass ( FM ) , thigh adiposity , and hepatic steatosis . RESULTS Weight loss result ed in substantial improvement ( P < 0.001 ) in HbA(1c ) ( -1.6 + /- 0.3 vs. -1.0 + /- 0.4 % ; NS between groups ) . IS improved significantly more with orlistat ( Delta2.2 + /- 0.4 vs. Delta1.2 + /- 0.4 mg . min(-1 ) . kg(-1 ) fat-free mass [ FFM ] ; P < 0.05 ) , and plasma free fatty acid ( FFA ) levels were strongly correlated with IS ( r = 0.56 ; P < 0.001 ) . Orlistat caused greater reductions in fasting plasma FFA ( Delta-154 + /- 22 vs. Delta-51 + /- 33 micro mol/l ; P < 0.05 ) , insulin-suppressed FFA ( Delta-119 + /- 23 vs. Delta-87 + /- 34 micro mol/l ; P < 0.05 ) , and fasting plasma glucose ( FPG ; -62 + /- 9 vs. -32 + /- 8 mg/dl ; P = 0.02 ) . Changes in HbA(1c ) were correlated with DeltaIS ( r = -0.41 ; P < 0.01 ) but not with weight loss per se . CONCLUSIONS At equivalent weight loss , conjunctive use of orlistat result ed in greater improvement in FFA levels and IS OBJECTIVE Weight loss through lifestyle changes is recommended for nonalcoholic fatty liver disease ( NAFLD ) . However , its efficacy in patients with type 2 diabetes is unproven . RESEARCH DESIGN AND METHODS Look AHEAD ( Action for Health in Diabetes ) is a 16-center clinical trial with 5,145 overweight or obese adults with type 2 diabetes , who were r and omly assigned to an intensive lifestyle intervention ( ILI )  to induce a minimum weight loss of 7 % or a control group who received diabetes support and education ( DSE ) . In the Fatty Liver Ancillary Study , 96 participants completed proton magnetic resonance spectroscopy to quantify hepatic steatosis and tests to exclude other causes of liver disease at baseline and 12 months . We defined steatosis > 5.5 % as NAFLD . RESULTS Participants were 49 % women and 68 % white . The mean age was 61 years , mean BMI was 35 kg/m2 , mean steatosis was 8.0 % , and mean aspartate aminotransferase ( AST ) and alanine aminotransferase ( ALT ) were 20.5 and 24.2 units/l , respectively . After 12 months , participants assigned to ILI ( n = 46 ) lost more weight ( −8.5 vs. −0.05 % ; P < 0.01 ) than those assigned to DSE and had a greater decline in steatosis ( −50.8 vs. −22.8 % ; P = 0.04 ) and in A1C ( −0.7 vs. −0.2 % ; P = 0.04 ) . There were no significant 12-month changes in AST or ALT levels . At 12 months , 26 % of DSE participants and 3 % ( 1 of 31 ) of ILI participants without NAFLD at baseline developed NAFLD ( P < 0.05 ) . CONCLUSIONS A 12-month intensive lifestyle intervention in patients with type 2 diabetes  reduces steatosis and incident NAFLD To examine the mechanism by which moderate weight reduction improves basal and insulin-stimulated rates of glucose metabolism in patients with type 2 diabetes , we used (1)H magnetic resonance spectroscopy to assess intrahepatic lipid ( IHL ) and intramyocellular lipid ( IMCL ) content in conjunction with hyperinsulinemic-euglycemic clamps using [6,6-(2)H(2)]glucose to assess rates of glucose production and insulin-stimulated peripheral glucose uptake . Eight obese patients with type 2 diabetes were studied before and after weight stabilization on a moderately hypocaloric very-low-fat diet ( 3 % ) . The diabetic patients were markedly insulin resistant in both liver and muscle compared with the lean control subjects . These changes were associated with marked increases in IHL ( 12.2 + /- 3.4 vs. 0.6 + /- 0.1 % ; P = 0.02 ) and IMCL ( 2.0 + /- 0.3 vs. 1.2 + /- 0.1 % ; P = 0.02 ) compared with the control subjects . A weight loss of only approximately 8 kg result ed in normalization of fasting plasma glucose concentrations ( 8.8 + /- 0.5 vs. 6.4 + /- 0.3 mmol/l ; P < 0.0005 ) , rates of basal glucose production ( 193 + /- 7 vs. 153 + /- 10 mg/min ; P < 0.0005 ) , and the percentage suppression of hepatic glucose production during the clamp ( 29 + /- 22 vs. 99 + /- 3 % ; P = 0.003 ) . These improvements in basal and insulin-stimulated hepatic glucose metabolism were associated with an 81 + /- 4 % reduction in IHL ( P = 0.0009 ) but no significant change in insulin-stimulated peripheral glucose uptake or IMCL ( 2.0 + /- 0.3 vs. 1.9 + /- 0.3 % ; P = 0.21 ) . In conclusion , these data support the hypothesis that moderate weight loss normalizes fasting hyperglycemia in patients with poorly controlled type 2 diabetes by mobilizing a relatively small pool of IHL , which reverses hepatic insulin resistance and normalizes rates of basal glucose production , independent of any changes in insulin-stimulated peripheral glucose metabolism Abstract Aim The aim of the study was to compare the effect of different dietary interventions on alanine aminotransferase ( ALT ) in obese patients with diabetes . Methods A post hoc analysis of an open label , parallel design , quasi-r and omised ( allocation by alternation ) , controlled trial , conducted in Israel . Obese patients with diabetes ( n = 259 ) , treated in the community , were central ly allocated to one of three diets : ( 1 ) the 2003 recommended American Diabetes Association diet ( ADA ) : 50–55 % carbohydrate , 30 % fat and 20 % protein , n = 85 ; ( 2 ) a low glycaemic index ( LGI ) diet : 50–55 % LGI carbohydrate , 30 % fat , 15–20 % protein , n = 89 ; or ( 3 ) a modified Mediterranean diet ( MMD ) : 35 % LGI carbohydrate , 45 % fat that was high in monounsaturated fat , 15–20 % protein , n = 85 . ALT was measured at 6 and 12 months . Results ALT levels decreased in all arms ; however , the MMD was associated with the lowest ALT levels at month 6 ( n = 201 : ADA n = 64 , LGI n = 73 , MMD n = 64 ) and month 12 of follow-up ( n = 179 ) . At 12 months mean ALT levels were 19.8 ± 1.4 U/l in the ADA diet arm ( n = 54 ) , 18.0 ± 1.5 U/l in the LGI diet arm ( n = 64 ) and 14.4 ± 1.7 in the MMD arm ( n = 61 , p < 0.001 ) . Evidence for an effect of diet on ALT levels persisted when controlling for post-r and omisation changes in waist to hip ratio , BMI , homeostasis model assessment ( HOMA ) or triacylglycerol . Conclusions A Mediterranean diet may have a beneficial effect on liver steatosis in obese patients with diabetes . Results of trials assessing the effect of dietary composition on clinical outcomes should be awaited before a decisive conclusion can be reached . In addition to clinical outcomes , such studies should address the issue of primary prevention of steatosis in high-risk and healthy individuals . Trial registration : Clinical Trials.gov NCT00520182 Funding : This study was supported by a grant from Tnuva Research Institute , Rehovot , Israel BACKGROUND / AIMS The incidence of obese patients with fatty liver has recently increased in Japan as well as in the United States and Europe . Fatty liver may occasionally progress to liver cirrhosis . In this study , we have compared the effects of restricted diet and exercise versus no treatment in obese patients with fatty liver . METHODS Twenty-five obese patients with fatty liver were divided into treated and control groups . Fifteen obese patients followed a program of restricted diet ( ideal weight x 25 Cal x kg(-1 ) ) and exercise ( walking or jogging ) for a trial period of 3 months . No changes in diet or lifestyle were made by the other 10 patients during the same trial period . Blood biochemical tests and liver histology were compared in all patients before and after the trial . RESULTS In the treated group , weight , blood biochemical data such as aminotransferase , albumin , cholinesterase , total cholesterol and fasting blood glucose values , and steatosis were significantly decreased after the trial . In the control group , there were no significant differences in the clinical and histological findings before and after the trial . CONCLUSIONS These results indicate that restricted diet and exercise therapy , such as walking and jogging , are useful means of improving blood biochemical data and histological findings in liver tissues related to fatty liver BACKGROUND Nonalcoholic steatohepatitis ( NASH ) is commonly associated with overweight and insulin resistance . Aerobic exercise is known to reduce insulin resistance . We studied the effect of regular aerobic exercise on serum aminotransferase levels in patients with NASH . METHODS Sixty-five ( mean age 38.7+/-9.5 years ; 46 [ 78 % ] males ) out of 94 patients diagnosed with NASH participated in the study . Each patient was advised regular aerobic exercise for 30 min duration per day , and trained to achieve a heart rate of 60 - 70 % of his/her maximal heart rate for at least 5 days a week . In addition , those with a high body mass index ( BMI ) were advised a moderately energy-restricted diet . Patients were followed up monthly for at least 3 months by BMI , waist-hip ratio ( WHR ) , waist circumference ( WC ) , aspartate aminotransferase ( AST ) and alanine aminotransferase ( ALT ) . RESULTS Forty-three ( 72.8 % ) patients had a high BMI .  Central obesity ( WHR > or=0.90 cm in men and > or=0.85 cm in women ) was present in 58 ( 98.3 % ) patients and metabolic syndrome in 12 ( 20.3 % ) patients . In the 44 patients who complied regularly with the exercise program , serum ALT normalized in 20 ( 45 % ; P<0.05 ) , and mean AST and ALT values declined from 70.5 and 104.0 - 41.5 ( P<0.001 ) and 63.2 ( P<0.001 ) , respectively . Overweight patients lost a mean 3.1 kg ( range 0 - 13 kg ) weight and showed a decline in BMI ( 28.7 vs 27.5 ; P<0.001 ) and WC ( 99.4 cm vs 96.1 cm ; P=0.001 ) . Serum ALT did not normalize in any of the 15 patients who failed to comply with the exercise program ; their pre- and post-AST ( 82.8 and 81.2 , respectively ) and ALT ( 98.0 and 96.1 , respectively ) levels , BMI ( 27.5 and 27.6 , respectively ) and WHR ( 0.99 cm and 0.99 cm , respectively ) did not show any significant change at 3 months , and also for an extended mean follow-up period of 5.3 months . CONCLUSION Moderate intensity aerobic exercise helps in normalizing ALT levels in patients with NASH In the absence of surrogate markers , the evaluation of suspected nonalcoholic fatty liver disease ( NAFLD ) is highly dependent on histological examination . The extent of sampling variability affecting the reliability of a single liver biopsy in patients with suspected NAFLD is poorly characterized . This prospect i ve study aim ed to correlate precise histological findings in paired biopsies — right and left lobe — in the diagnosis of NAFLD in morbidly obese subjects undergoing bariatric surgery  employing both Brunt and Matteoni classifications and the NAFLD Activity Score ( NAS ) . We also aim ed to determine whether the composite histopathological findings of the two biopsies would improve diagnostic accuracy . Consecutive subjects had an intraoperative biopsy from both right and left lobes , evaluated and scored in a blinded manner . Intraobserver agreement was also assessed . Kappa coefficients of agreement were calculated . Forty‐one subjects had acceptable biopsies . Agreement for steatosis was excellent and moderate for fibrosis . Concordance was only fair for most features of necroinflammation . Intraobserver agreement was only moderate for lobular inflammation . Excellent agreement was seen for the diagnosis of NASH using Brunt criteria and good agreement when using Matteoni and NAS scoring systems . Composite biopsy data particularly improved identification of hepatocyte ballooning . The diagnostic accuracy also improved substantially when composite features were compared with single‐sided biopsy features , especially for the Matteoni and NAS scoring systems . In conclusion , significant sampling variability occurs in NAFLD , particularly for features of necroinflammation . This should be factored into the design of clinical trials and studies of the natural history of the disease . ( HEPATOLOGY 2006;44:874–880 . UNLABELLED Nonalcoholic fatty liver disease , characterized by elevated liver enzymes , central obesity , and insulin resistance , is becoming increasingly prevalent . The effects of changes in physical activity on the metabolic profile of this group have not been reported . We assessed at 3 months the impact of a behavior change-based lifestyle intervention on physical activity  and the effects of this change on the metabolic profile of people with fatty liver disease . In all , 141 participants with nonalcoholic fatty liver disease were prospect ively enrolled into either a low- or moderate-intensity lifestyle intervention or to a control group . Physical activity  was assessed using a vali date d reporting tool and  physical fitness  was measured using the YMCA protocol on a cycle ergometer . Individualized counseling to increase physical activity  was provided . Overall , 96 % of participants attended the 3-month follow-up assessment . Participants in the moderate- and low-intensity intervention groups were 9 times more likely to increase physical activity by an hour or more per week compared to controls . Patients increasing or maintaining their reported physical activity to > or = 150 minutes/week , and those who increased their objective levels of fitness , had the greatest improvements in liver enzymes and other metabolic indices compared to those who were least active . This effect was independent of weight loss and was corroborated by an objective measure of fitness . There was no dose-response effect on liver enzymes with incremental increases in physical activity above 60 minutes/week . CONCLUSION Lifestyle counseling interventions are effective in improving physical activity behavior . Maintaining or increasing physical activity provides health benefits for patients with fatty liver , independent of changes in weight UNLABELLED Nonalcoholic steatohepatitis ( NASH ) is a chronic progressive liver disease that is strongly associated with obesity . Currently , there is no approved therapy for NASH . Weight reduction is typically recommended , but efficacy data are lacking . We performed a r and omized controlled trial to examine the effects of lifestyle intervention using a combination of diet , exercise , and behavior modification , with a goal of 7 % to 10 % weight reduction , on clinical parameters of NASH . The primary outcome measure was the change in NASH histological activity score ( NAS ) after 48 weeks of intervention . Thirty-one overweight or obese individuals ( body mass index [ BMI ] , 25 - 40 kg/m(2 ) ) with biopsy-proven NASH were r and omized in a 2:1 ratio to receive intensive lifestyle intervention ( LS ) or structured education ( control ) . After 48 weeks of intervention , participants assigned to LS  lost an average of 9.3 % of their weight versus 0.2 % in the control group ( P = 0.003 ) . A higher proportion of participants in the LS group had a reduction of NAS of at least 3 points or had posttreatment NAS of 2 or less as compared with the control group ( 72 % versus 30 % , P = 0.03 ) . NAS improved significantly in the LS group ( from 4.4 to 2.0 ) in comparison with the control group ( from 4.9 to 3.5 ) ( P = 0.05 ) . Percent weight reduction correlated significantly with improvement in NAS ( r = 0.497 , P = 0.007 ) . Participants who achieved the study weight loss goal ( > or=7 % ) , compared with those who lost less than 7 % , had significant improvements in steatosis ( -1.36 versus -0.41 , P < 0.001 ) , lobular inflammation ( -0.82 versus -0.24 , P = 0.03 ) , ballooning injury ( -1.27 versus -0.53 , P = 0.03 ) and NAS ( -3.45 versus -1.18 , P < 0.001 ) . CONCLUSION Weight reduction achieved through lifestyle intervention leads to improvements in liver histology in NASH Nonalcoholic fatty liver disease is an increasingly common condition that may progress to hepatic cirrhosis . This pilot study evaluated the effects of a low-carbohydrate , ketogenic diet on obesity-associated fatty liver disease .  Five patients with a mean body mass index of 36.4 kg/m2 and biopsy evidence of fatty liver disease were instructed to follow the diet ( < 20 g/d of carbohydrate ) with nutritional supplementation for 6 months . Patients returned for group meetings biweekly for 3 months , then monthly for the second 3 months . The mean weight change was −12.8 kg ( range 0 to −25.9 kg ) . Four of 5 posttreatment liver biopsies showed histologic improvements in steatosis ( P=.02 ) inflammatory grade ( P=.02 ) , and fibrosis ( P=.07 ) . Six months of a low-carbohydrate , ketogenic diet led to significant weight loss and histologic improvement of fatty liver disease . Further research is into this approach is warranted
Non-alcoholic fatty liver disease is a serious and growing clinical problem .
Despite lifestyle modification , i.e. diet and physical activity , being the recommended therapy , there are currently no systematic evaluations of its efficacy .
This review applies a systematic approach to evaluating lifestyle modifications studied to date .