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Relation
Abenavoli L, Greco M, Milic N, et al. Effect of Mediterranean diet and antioxidant formulation in nonalcoholic fatty liver disease: a randomized trial.Nutrients. 2017;9(870).
Draft
Randomized, prospective 6-month study with 3 cohorts (A, B, C): nutritional intervention alone (A); dietary intervention with antioxidant supplementation (B); and control without treatment (C).
Participant
Fifty Caucasians, overweight (BMI>25 kg/m2) Men and women with nonalcoholic fatty liver disease (NAFLD) were recruited from an outpatient gastroenterology clinic in Italy; NAFLD diagnosis was based on Hamaguchi ultrasound scoring. Patients with hepatitis B, hepatitis C, heart disease, kidney disease, autoimmune disease, recreational drug use, insulin treatment, excessive alcohol consumption, and exposure to environmental toxins related to liver steatosis were excluded from the study.
intervention
Group A (n=20) followed a low-calorie Mediterranean diet (1,400-1,600 kcal/day), while Group B (n=20) followed a low-calorie Mediterranean diet supplemented with antioxidants. Macronutrients in the Mediterranean diet intervention groups were divided as follows: 50% to 60% carbohydrates; 15% to 20% protein, with approximately 50% of protein sources coming from vegetables; less than 30% monounsaturated and polyunsaturated fats with less than 10% saturated fatty acids; less than 300 mg of cholesterol per day; and 25 to 30 grams per day of fiber. Group B received 2 pills daily of bilirel antioxidant supplement consisting of artichoke, milk thistle, L-methionine, fumitory and L-glutathione.
Group C (n = 10) did not change their lifestyle or existing pharmacological (medication) regimen.
Study parameters assessed
Anthropometric parameters, blood pressure, lipid profile, homeostatic model assessment of insulin resistance (HOMA-IR), transaminases (serum levels of alanine aminotransferase, aspartate aminotransferase and gamma-glutamyl transpeptidase) and liver fibrosis were assessed at baseline and after 6 months of the intervention. Liver fibrosis was assessed using transient elastography, and a fatty liver index was used to predict the likelihood of steatosis.
Key insights
After 6 months of treatment, group A showed a significant weight reduction compared to group C (control) (-6% vs. -0.5%,P=0.0001), BMI (–7.5% vs. –0.45%,P=0.0001), triglycerides (–32.16 vs. +2.8%,P=0.001), total cholesterol (-14.8% vs. +9.3%,P=0.0001), triglyceride glucose index (–3.3% vs. +1%,P=0.020), fatty liver index (-19% vs. +4.7%,P=0.017) and transient elastography (–21% vs. +8.7%,P=0.001). Similar significant reductions were observed in the Group B cohort compared to the control group. Compared to Group A, Group B had significant reductions in HOMA-IR (-43% vs. +6.2%,P=0.0001), insulin (–38% vs. +10%,P=0.0001) and fasting glucose (-11% vs. -3.5%,P=0.016). These results demonstrate that a Mediterranean diet significantly reduces anthropometric parameters and lipid parameters and improves transient elastography in patients with NAFLD. Adding antioxidants may have the additional benefit of improving insulin-related biomarkers.
Practice implications
Many observational studies have shown that patients with NAFLD have a dietary pattern that is generally high in calories, high in saturated fat, low in polyunsaturated fats, and low in antioxidants, with excessive carbohydrate intake from simple sugars1-5and a significant amount of calories from soft drinks, including sodas and juices.6
Physicians caring for these patients should be aware of their dietary habits and ultimately encourage a transition to a Mediterranean diet or a diet that reduces simple carbohydrates and saturated fats and promotes a higher intake of fruits and vegetables. Patients should also be encouraged to eliminate high fructose corn syrup – fructose is not metabolized in the same rate-limiting manner as glucose, so it directly promotes fat deposition in the liver.7
When obese patients are able to lose approximately 7% to 10% of their body weight, the steatosis begins to resolve.8-12In one study, steatosis disappeared in 90% of NAFLD patients who lost more than 10% body weight.13Ultimately, hepatic steatosis begins to improve as patients are able to exercise and change their diet.
Nonalcoholic fatty liver disease is insidious because most patients are asymptomatic and serum transaminases can be misleading.
Many specialists predict that in the next 15 to 20 years the main reason for orthotropic liver transplantation will be fatty liver disease, which will displace hepatitis C and alcoholism.14It is currently estimated that 20% to 30% of simple steatosis progresses to NASH, the inflammatory stage of NAFLD, and 7% to 25% of NASH progresses to cirrhosis.fifteenNo one has identified a single mechanism that triggers the progression from simple steatosis to NAFLD; however, several studies show that NAFLD occurs more frequently in patients with metabolic syndrome and its subgroups.16-19
Nonalcoholic fatty liver disease is insidious because most patients are asymptomatic and serum transaminases can be misleading. Our approach for patients with NAFLD should include early detection along with appropriate nutritional and lifestyle recommendations, such as: B. the Mediterranean diet paired with exercise.