Liver disease of metabolic origin, associated with obesity, is now recognized as the most prevalent liver disease in Western countries. Strategies are needed to approach obesity-associated liver disease by behavior programs, motivating people to adopt a healthier lifestyle. Such programs should be coupled with public policies at a societal level to obtain the maximum effects in lifestyle changes.

Highlights Job/time constraints limit the engagement of patients with NAFLD in counseling programs. Web-and group-based programs promote similar calorie/physical activity changes. Surrogate markers indicate reduced fat in the liver and no changes in hepatic fibrosis. Web counseling results in clinically significant weight loss in motivated patients. Structured web-based program is as effective as groupcounseling in selected patients with NAFLD.

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Non-alcoholic fatty liver disease (NAFLD) is a clinical/biochemical condition associated with the metabolic syndrome. As the disease stems from excess calorie intake and lack of physical activity, the correction of unhealthy lifestyles is the background of any prevention and treatment strategy; drugs should remain a second-line treatment. Several studies have shown that weight loss and physical activity, the cornerstones of a healthy lifestyle, have a specific therapeutic role in NAFLD, preventing disease progression and reducing the burden of disease. Prescriptive diets have a limited long-term efficacy; after a short period, most patients resume their old habits and weight regain is the rule. Physical activity, usually in combination with diet, but also independent of weight loss, improves liver enzymes and reduces liver fat, with uncertain results on hepatic necroinflammation; however, making patients increase their physical activity is very difficult. Only a behavioral approach may give patients the practical instruments to achieve their eating and exercise goals, incorporate them into lifestyle, and maintain the results for a long period, thereby possibly guaranteeing long-term durability of change. Cognitive-behavior treatment should be provided to patients at risk of advanced liver disease, and this action should be coupled with prevention strategies at the population level. Only a synergistic approach and a global societal response might be effective in reducing the burden of advanced liver disease and premature death due to NAFLD/NASH (non-alcoholic steatohepatitis).

OBJECTIVE:To measure the effects of cognitive -behavioural therapy on health-related quality of life (HRQL) in obese patients, in relation to binge eating disorder. DESIGN: Longitudinal, clinical intervention study consisting of structured sessions of cognitive -behavioural therapy, preceded by sessions chaired by a psychologist in subjects with binge eating. SUBJECTS: Two groups of obese patients (92 treated by cognitive -behavioural therapy (77 females); 76 untreated controls (67 female), selected from the waiting list (control group)). Of 92 treated patients, 46 had a binge eating disorder at psychometric testing and structured clinical interview. MEASUREMENTS: Health-related quality of life by means of Short-Form 36 questionnaire at baseline and after 3 -5 months. RESULTS: Cognitive -behavioural treatment produced an average weight loss of 9.4 AE 7.5 kg, corresponding to a BMI reduction of 3.48 AE 2.70 kg=m 2 . No changes were observed in the control group. All scales of HRQL improved in treated subjects (by 5 -19%). In obese subjects with binge eating weight loss was lower in comparison to non-bingers (7.7 AE 8.1 vs 11.1 AE 6.6; P ¼ 0.034). However, the improvement in HRQL was on average larger, and significantly so for Role Limitation -Physical (P ¼ 0.006), Role Limitation -Emotional (P ¼ 0.002), Vitality (P ¼ 0.003), Mental Health (P ¼ 0.032) and Social Functioning (P ¼ 0.034). Bodily Pain was the sole scale whose changes paralleled changes in body weight. CONCLUSIONS: The positive effects of cognitive -behavioural therapy, mainly in subjects with binge eating, largely outweigh the effects on body weight, resulting in a significant change in self-perceived health status.