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Fatty liver disease at epidemic proportions

The world-wide incidence of non-alcoholic fatty liver disease (NAFLD) — characterized by fat accumulation greater than five percent of the liver’s weight — is estimated to be between 8 to 45%, with Europe and North America weighing in at 25-34%, Asia at 15-20%, and the Middle East and South America with the highest rate of occurrence.

NAFLD can present in various configurations, such as non-alcoholic steatohepatitis (NASH), with advanced thickening and scarring of the liver’s connective tissue — fibrosis — associated with injury, cirrhosis, and hepatocellular carcinoma, a primary malignancy of the liver, which occurs predominantly in patients with underlying chronic liver disease and cirrhosis.

NAFLD is not due to excess alcohol consumption, autoimmune dysregulation, infection, or other such liver diseases. It’s primarily the result of an “unforced error” — an unhealthy lifestyle, characterized by a large waist circumference, greater than 40 inches in a man and 35 in a woman, especially after the age of 40.

Louisiana, with its high rate of obesity and type 2 diabetes, is prime territory for NAFLD development and its associated risk to cardiovascular disease – without affecting positive lifestyle change in its population.

Researchers in Pamplona, Spain, writing — Impact of Nutritional Changes on Nonalcoholic Fatty Liver Disease — in the March issue of the online journal Nutrients, searched for original articles and reviews published between January 2000 and December 2018, focusing on NAFLD dietary treatment.

They comment that, “diet and exercise interventions remain as the first line of therapy, aiming mainly at controlling body weight and cardio-metabolic risk factors related to metabolic syndrome. In the early stages of NAFLD, a healthy diet and weight loss of at least 7% might be sufficient.”

Metabolic syndrome is a cluster of events, such as high, “bad,” LDL cholesterol, pre-hypertension and diabetes, high waist measurements, and low, “good” HDL cholesterol.

The Spaniards also report that, “in more advanced stages, high genetic risk or, in the presence of diabetes, intensified lifestyle intervention reinforced by pharmacological treatment might be necessary, though there is still no registered drug for the treatment of NAFLD.”

Weight reduction – even at modest levels, through a Mediterranean-style (MED) eating plan and exercise, improves insulin sensitivity, which reduces the storage of fat in and around the muscles and liver.

The Spanish researchers cite a 2003 study of NASH individuals who had, “a significantly higher saturated fat intake and a smaller amount of polyunsaturated fatty acid (PUFAs), fiber, vitamin C and vitamin E consumption.”

Monounsaturated fatty acids (MUFA), key components of the MED diet, found in olive oil, avocados, and nuts, have anti-inflammatory and anti-oxidant properties that decrease the risk of cardiovascular disease and metabolic syndrome associated with NAFLD.

The review of the research concluded, “while there is still controversy in some studies, it is prudent to recommend moderate MUFAs consumption (20 g/day).”

Polyunsaturated fatty acids (PUFA) have two essential components, omega-3 and omega-6 fatty acids.

Omega-3 PUFA — found in seafood like, mackerel, trout, salmon, herring, tuna, haddock, cod, crustaceans, shellfish, and in certain vegetable oils (flaxseed oil), with lower amounts, in eggs and meat — include eicosapentaenoic acid (EA), docosahexaenoic acid (DHA), and docosapentaenoic acid (DPA). Omega-3 fatty acids control the liver’s lipid composition and increase anti-inflammatory mediators, which improve insulin sensitivity.

Omega-6’s are found in vegetable oils (canola and cottonseed), cereal grains and nuts. Increased amounts of linoleic acid,the main dietary omega-6 PUFAs, are related to a higher incidence of inflammatory and thrombotic events, including cardiovascular disease, cancer, inflammatory and autoimmune diseases.

The researchers concluded that, “lifestyle modifications towards a healthy diet and habitual physical activity are desirable in NAFLD. A 7–10% weight loss and its sustainability is the goal in NAFLD patients. Reduced calorie intake, improved macronutrient composition, and increased physical activity may act independently to stop disease progression.”

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