
 nonalcoholic fatty liver disease ( nafl ) is a term applied to the accumulation of fat in the liver in the absence of alcohol consumption .
nafl refers to a wide spectrum of liver damage ranging from simple steatosis to non - alcoholic steatohepatitis ( nash ) to advanced fibrosis and finally , cirrhosis . 
 

the clinical significance of nafl is derived mostly from its high prevalence in the general population and in its possible progression to liver failure . 
 

obesity , type 2 diabetes mellitus and hyperlipidemia are the major risk factors associated with nafl .
a bulk of evidence suggests that insulin resistance plays a major role in the pathogenesis of nafl and nash . 
 

however with meticulous questioning , more than half would mention fatigue , right upper quadrant pain and occasional discomfort , although the significance of these symptoms is uncertainmost cases initially come to medical attention by the incidental finding of increased liver echogenicity during ultrasonography performed for other reasons
. 
 
 ultrasonography could be used as a non - invasive predictor of liver histology in both moderate and severe steatosis , and advanced fibrosis with acceptable sensitivity and specificity . 
 

nevertheless , gradual and sustained weight reduction and exercise are most frequently recommended for overweight nafl patients . 
 

weight reduction can not only improve symptoms , but also the risk of progression of nafl to cirrhosis . 
 
 in the present study
we compare the effect of a weight reduction diet on liver ultrasonographic findings in overweight nafl patients .
to our knowledge , only one study has thus far researched weight reduction in nafl adults . 


 from july 2003 to december 2005 all patients incidentally found to have fatty liver by ultrasonography who referred to radiology and gastroenterology clinics were included . 
 

fasting blood sugar ( fbs ) , and liver transaminase were checked for all patients .
waist circumference was measured using a measuring tap placed in a horizontal plane around the abdomen at the level of the iliac creast . 
 

patients with body mass index ( bmi ) above 25 and of the ages 16 to 60 were included in the study .
patients not consenting to the study or not able to refer for regular follow - up were also excluded . 
 

the degree of steatosis was graded by ultrasonography from 0 to 3 according to table 2 .
the diet contained 50 percent carbohydrates , 30 percent fat and 20 percent protein given in three meals with a deficit of 500 calories planned to ideally reduce weight by 2 kg per month .
patients were followed monthly by a nutritionist . 
 
 at the end of month three ,
anthropometric and ultrasonographic measures before and after dieting were compared using student s paired t - test by spss version 14 . 
 

the study protocol was approved by the institutional review board and ethics committee of the digestive disease research center ( ddrc ) of tehran university of medical sciences ( tums ) . 


 in this study , 23 patients ( 13 females , 10 males ) were enrolled .
the decrease in weight , bmi , waist circumference and hip circumference were statistically significant .
the ultrasonographic grade decreased in all patients ; eight had a two grade reduction and 15 patients reduced one grade ( table 4 ) . 
 

the decrease in ultrasonographic grade had a significant correlation with decrease in weight and bmi , but not with changes in waist and hip circumferences ( table 5 ) . 
 

the amount of decrease in weight and bmi was significantly greater in patients whose ultrasonographic grades improved by two scores when compared to patients who only had a one score improvement . 
 

men had a significantly greater weight loss ( p<0.01 ) , but changes in ultrasonographic grade , bmi , waist circumference and hip circumference were not significantly different among the two sexes . 


 the treatment of nafl is controversial and even the necessity of treatment is doubted when there is no indication of liver damage . even in nash , where liver damage is well documented ,
there is no universally accepted treatment . when treatment is instituted , evaluation of treatment response is usually through transaminase levels or liver histology . 
 

in nafl patients , where the transaminase levels are normal to begin with , histology is the only guide to treatment .
but liver biopsy is a fairly invasive procedure and is difficult to justify in subjects with normal liver transaminase levels where the prognosis is generally considered to be very good . in such cases
another non - invasive method , such as ultrasonography , could be a good substitute . 
 

in this study we observed a significant improvement in ultrasonographic features of nafl by a low calorie diet .
unfortunately , we did not have histologic confirmation but we believe it is safe to assume that improvement in histology parallels improvement in ultrasonography . 
 

ultrasonography has an acceptable sensitivity and specificity in evaluating liver steatosis and provides a non - invasive predictor of liver histology and degree of steatosis in nafl patients . 
 

based on the current study , we suggest ultrasonography as a guide to weight loss . 
 
 we also observed that patients with a higher initial ultrasonographic grade had greater improvement .
it can be concluded that more severe cases will respond better to weight loss . 
 
 in our study ,
the diet was designed with a modest calorie deficit aiming at a maximum weight loss of 2 kg per month .
the gradual weight loss is important as rapid and severe weight loss , starvation , or even total parenteral nutrition , could result in or perpetuate fatty liver disease 3 - 5 .
although slightly more rapid weight loss might also be safe , a modest diet would result in better patient compliance . 
 
 as mentioned above , the necessity of treatment for non - complicated nafl with no indication of liver injury is in doubt . but considering the safety and other obvious benefits of gradual weight loss , we believe it should be offered to all overweight cases of nafl .
we conclude that weight loss is effective in improving the ultrasonographinc grade of steatosis and ultrasonography may be used as a non - invasive indicator of improvement of liver steatosis in patients with nafl during weight reduction . 

 
 background 
 non - alcoholic fatty liver ( nafl ) includes a spectrum of diseases ranging from simple hepatic steatosis to nonalcoholic steatohepatitis ( nash ) and cirrhosis . 
 nafl is typically seen in association with obesity , diabetes and hypertriglyceridaemia . in order to seek the role of diet therapy in treatment of nafl 
 , we compared the ultrasonographic findings of patients with fatty liver disease before and after standard diet therapy . 
 
 methods 

 twenty - three overweight or obese subjects with incidental fatty liver discovered during ultrasonography were included . 
 subjects underwent 3 months of diet therapy , and anthropometric data including weight , height , bmi , waist circumference , and hip circumference were measured . 
 ultrasonographic findings were graded from 0 to 3 . 
 changes in ultrasonographic findings and anthropometric data were studied . 

 
 results 

 after three months of dieting , the ultrasonographic grade of all patients decreased by one or two grades . 
 fifteen patients decreased one grade while 8 others decreased by 2 grades . 
 we observed a significant correlation between the decrease in ultrasonographic grade and the decrease in weight and bmi . 

 
 conclusion 

 our study indicates that standard diet therapy could be used as an effective treatment for nafl patients . 
 
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONFLICT OF INTEREST