Background and aims: Nonalcoholic fatty liver disease (NAFLD) is now recognized as part of the metabolic syndrome, and is specifically related to obesity and insulin resistance. Lifestyle modification is advocated for the treatment of NAFLD, but few studies have evaluated its impact on liver histology. The purpose of this study was to investigate which, if any, specific diet and exercise recommendations are associated with histopathologic changes. Methods: A total of 56 participants were randomly assigned to 1 of 4 lifestyle modification subgroups for 6 months: standard care, low-fat diet and moderate exercise, moderate-fat/lowprocessed-carbohydrate diet and moderate exercise, or moderate exercise only. All subjects had biopsy-proven NAFLD, to include nonalcoholic steatohepatitis (NASH), and received a repeat 6-month biopsy to detect histopathologic changes. Other measures included blood assay of liver enzymes (aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase), fasting glucose, serum insulin, lipid panel, body weight, dietary intake, fat mass, and fitness level. Results: Among the 41 participants who completed the study (88% with NASH), a significant change was found in pre-to post-NAFLD activity score in the group as a whole (p < 0.001) with no difference detected between subgroups (p = 0.31). Our results confirm that lifestyle modification is effective in improving NAFLD and NASH. Conclusions: Regardless of intervention group, lifestyle modification improved liver histology, as verified by repeat biopsy, after a 6-month intervention. This study reinforces the importance of lifestyle modification as the primary treatment strategy for patients with NAFLD.

In this 2-phase randomized controlled study, we examined whether consuming a higher-protein (HP) diet would attenuate fat-free mass (FFM) loss during energy deficit (ED) at high altitude (HA) in 17 healthy males (mean 6 SD: 23 6 6 yr; 82 6 14 kg). During phase 1 at sea level (SL, 55 m), participants consumed a eucaloric diet providing standard protein (SP; 1.0 g protein/kg,) for 21 d. During phase 2, participants resided at HA (4300 m) for 22 d and were randomly assigned to either an SP or HP (2.0 g protein/kg) diet designed to elicit a 40% ED. Body composition, substrate oxidation, and postabsorptive whole-body protein kinetics were measured. Participants were weight stable during SL and lost 7.9 6 1.9 kg (P < 0.01) during HA, regardless of dietary protein intake. Decrements in wholebody FFM (3.6 6 2.4 kg) and fat mass (3.6 6 1.3 kg) were not different between SP and HP. HP oxidized 0.95 6 0.32 g protein/kg per day more than SP and whole-body net protein balance was more negative for HP than for SP (P < 0.01). Based on changes in body energy stores, the overall ED was 70% (21849 6 511 kcal/d, no group differences). Consuming an HP diet did not protect FFM during severe ED at HA.-Berryman, C. E., Young, A. J., Karl, J. P., Kenefick, R. W., Margolis, L. M., Cole, R. E., Carbone, J. W., Lieberman, H. R., Kim, I.-Y., Ferrando, A. A., Pasiakos, S. M. Severe negative energy balance during 21 d at high altitude decreases fat-free mass regardless of dietary protein intake: a randomized controlled trial. FASEB J. 32, 894-905 (2018 For lowlanders sojourning at high altitude (HA .1500 m), maintaining energy balance can be challenging because of an increase in resting metabolic rate (RMR) (1, 2) and a decrease in appetite (3) caused by physiologic adaptations to hypoxia. The effects of hypoxia on energy balance are frequently compounded by limited access to food and high physical activity levels while at HA. Negative energy balance usually develops at HA and typically leads to weight loss (4). Barnholt et al. (4) showed that individuals sustaining a 40% energy deficit (ED) for 21 d at HA lost more body weight than individuals adhering to the same controlled diet and physical activity at sea level (SL). Furthermore, some studies (5-8) have observed .50% of total body mass (TBM) loss as fat-free mass (FFM) during prolonged ED at HA, which is greater than the 25-35% typically observed at SL (9-11), suggesting protein turnover kinetics and substrate utilization during weight loss at HA may differ from that at SL.At SL, protein intake above the Recommended Dietary Allowance (RDA, 0.8 g protein/kg per day) limits FFM loss during moderate negative energy balance (;40% ED) in healthy, normal weight adults (12)(13)(14). We have shown that consuming a diet containing 1.6 or 2.4 g protein/kg per day (2 and 3 times the RDA, respectively) for 21 d, within the context of a 40% ED, attenuates FFM loss as a percentage of TBM loss (30 6 7 and 36 6 5%, respectively) compared to an isocaloric diet containing 0.8 g protein/kg per d...

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As demands on health care providers continue to rise, finding innovative ways to manage the patient load while providing quality health care is increasingly important. SMA health outcomes were equivalent to individual counseling outcomes, while increasing the provider's productivity by treating 6 to 8 people with prediabetes in 90 minutes compared to 1 patient in 60 minutes.