Multidisciplinary lifestyle intervention is associated with improvements in liver damage and in surrogate scores of NAFLD and liver fibrosis in morbidly obese patients

Monika Bischoff, Sebastian Zimny, Sebastian Feiner, Johannes Sauter, Svenja Sydor, Gerald Denk, Jutta M Nagel, Gert Bischoff, Christian Rust, Simon Hohenester, Monika Bischoff, Sebastian Zimny, Sebastian Feiner, Johannes Sauter, Svenja Sydor, Gerald Denk, Jutta M Nagel, Gert Bischoff, Christian Rust, Simon Hohenester

Abstract

Purpose: Non-alcoholic fatty liver disease (NAFLD) is the hepatic manifestation of the metabolic syndrome. Particularly morbidly obese patients are at risk of developing progressive liver disease. Nutritional and lifestyle intervention is recommended as the standard of care in NAFLD. However, there is a striking lack of evidence to support the efficacy of lifestyle intervention to treat NAFLD in morbidly obese patients. Here, we aimed to assess the impact of lifestyle intervention on NAFLD in the morbidly obese in a real-world setting.

Methods: 136 obese patients were included in an industry-independent, multiprofessional lifestyle intervention program with a lead-in phase of 12 weeks of formula diet and a total of 48 weeks intensive counselling. Body weight and markers of the metabolic syndrome were analyzed. Presence of NAFLD was screened for by use of non-invasive markers of fatty liver, non-alcoholic steatohepatitis and liver fibrosis.

Results: Weight loss goals (i.e. > 5% or > 10% of initial body weight, respectively, depending on baseline BMI) were achieved in 89.7% of subjects in the intention-to-treat analysis and 93.9% in the per-protocol analysis. This was associated with a pronounced improvement in serum ALT values. The percentage of subjects who fulfilled non-invasive criteria for fatty liver dropped from 95.2 to 54.8%. Risk of NASH improved and the number of patients at risk of liver fibrosis declined by 54.1%.

Conclusion: Lifestyle intervention was associated with a marked improvement of serum ALT and an improvement of surrogate scores indicative of NAFLD and, importantly, advanced fibrosis, in a real-world cohort of morbidly obese patients.

Keywords: Lifestyle intervention; Liver fibrosis; Morbid obesity; NAFLD.

Conflict of interest statement

Monika Bischoff, Jutta M. Nagel, Gert Bischoff and Christian Rust are employees of the public hospital offering lifestyle intervention programs. The authors report no further financial or non-financial interests.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Body weight and glycemic status improve with lifestyle intervention. A total of 136 obese subjects were included in the lifestyle intervention program. 114 (84%) participants could be included in the per protocol analysis. A BMI is given over time for males (blue) and females (red) showing marked and sustained weight loss. ***p < 0.001 vs. W0, $p < 0.001 vs. W15, ANOVA, Bonferroni-adjusted post-hoc analysis. B Glycemic status was followed over time. Subjects on antidiabetic medication or fasting plasma glucose levels ≥ 126 mg/dL were considered diabetic (red), while subjects with fasting plasma glucose levels 100–125 mg/dL were defined as subjects with impaired fasting glucose (IFG). As a result of lifestyle intervention, glycemic status of patients markedly improved. **p < 0.01, McNemar test
Fig. 2
Fig. 2
Liver damage and risk of fatty liver improve with lifestyle intervention A total of 136 obese subjects were included in the lifestyle intervention program. 114 (84%) subjects could be included in the per protocol analysis. A Serum ALT values over time are given for female (red) and male (blue) participants, respectively. Dotted lines mark the gender-specific upper limits of normal (ULN) at 19U/L (females) and 30U/L (males). *p < 0.05, **p < 0.01 vs. W0, ANOVA, Bonferroni-adjusted post-hoc analysis. B The percentage of subjects with elevated (red) or normal ALT values (green) before and after lifestyle intervention is given, accounting for gender-specific ULN. **p < 0.01, ***p < 0.001, McNemar test. C γGT values are given over time. *p < 0.05 vs. W0, ANOVA, Bonferroni-adjusted post-hoc analysis. D Fatty liver was assessed by calculation of FLI. Subjects in which fatty liver was excluded are depicted in green, subjects with indeterminate values are shown in yellow and those with definite fatty liver are shown in red. Weight loss during lifestyle intervention was associated with a marked decrease in the proportion of patients with fatty liver. ***p < 0.001, Chi-squared test
Fig. 3
Fig. 3
Serum M30 values and risk of liver fibrosis improve with weight loss during lifestyle intervention. A As a surrogate for NASH, patients were classified per M30 values with a cut-off set at 200U/L. Weight loss led to a decrease in participants with M30 values > 200U/L. ##p < 0.01, McNemar. B NFS was calculated and participants in whom liver fibrosis could be excluded are depicted in green, participants with indeterminate values are shown in yellow and those with definite fibrosis are shown in red. Weight loss during lifestyle intervention was associated with a marked decrease in the proportion of subjects at risk for liver fibrosis. **p < 0.01, Chi-squared test

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