Cognitive‐Behavioral Treatment of Nonalcoholic Fatty Liver Disease: A Propensity Score‐Adjusted Observational Study

Abstract

The effectiveness of cognitive‐behavior treatment (CBT) in nonalcoholic fatty liver disease (NAFLD), largely related to overweight/obesity and considered the hepatic expression of the metabolic syndrome (MS), has so far been tested in very limited samples. In a tertiary referral center, consecutively observed NAFLD subjects were offered a CBT program aimed at weight loss and increased physical activity, based on 13 group sessions; 68 cases entered the treatment protocol, those who refused (n = 82) were given recommendations for diet and physical activity. Treatment goals (weight loss ≥7% initial body weight, normalization of liver enzymes, and improved parameters of MS) were tested by logistic regression at 6 months (all cases) and at 2 years, both on intention‐to‐treat and in completers (Diet, 78; CBT, 65). The results were adjusted for the propensity score of attending the CBT program, based on civil, anthropometric and clinical variables. At baseline the CBT group had a larger prevalence of obesity and more severe insulin resistance (homeostasis model assessment (HOMA)). At follow‐up, CBT was associated with a higher probability of weight loss and normal liver enzymes (6‐month: odds ratio (OR), 2.56; 95% confidence interval (CI), 1.15–5.69; 2‐year intention‐to‐treat: OR, 3.57, 95% CI, 1.59–8.00), after adjustment for propensity and changes in body weight. A similar trend was observed in the outcome goals of insulin resistance and the score of MS, which were both reduced. In conclusion, subjects with NAFLD participating in a CBT program significantly improve their general and liver parameters. The beneficial effects are largely maintained at 2‐year follow‐up, in keeping with the lifestyle‐related pathogenesis of disease.

A standard ballroom and Latin dance program to improve fitness and adherence to physical activity in individuals with type 2 diabetes and in obesity

“…The modest but significant reduction of liver enzymes is likely to reflect decreased hepatic triglyceride accumulation [30], as commonly observed in nonalcoholic fatty liver disease entering specific activity programs, also independent of weight loss [31,32]. It should be viewed in the context of the chronic liver disease associated with obesity and diabetes, where intense behavioral treatment [33], also leading to improved glucose control, reduced insulin levels and improved insulin sensitivity [34], is expected to stop liver disease progression [33,35]. …”

Diet, weight loss, and liver health in nonalcoholic fatty liver disease: Pathophysiology, evidence, and practice

“…Several studies have tested the effectiveness of lifestyle modifications in NAFLD (Table 4) (58)(59)(60)(61)(62)(63)(64)(65)(66)(67)(68)(69)(70)(71)(72)(73) ; only a few are based on solid behavioral strategies, not simply on intensive counseling for healthy diet and habitual physical activity. Overall, 7%-10% weight loss is achieved in the majority of cases, accompanied by a remarkable normalization of liver enzymes and a systematic reduction of liver fat, measured by either surrogate algorithms or USG or MRI.…”

An internet-based approach for lifestyle changes in patients with NAFLD: Two-year effects on weight loss and surrogate markers

“…Their effectiveness in promoting weight loss has been demonstrated on long-term follow-up. 7 Programs of cognitive-behavioral therapy have also been applied in NAFLD; 8 weight loss through healthy and restrictive diet, coupled with habitual physical activity, has been reported to reduce NAFLD progression in small pilot trials, [9][10][11] and a large prospective intervention study confirmed that weight loss is associated with histologic improvement on repeated liver biopsy. 12 Unfortunately, these programs require dedicated teams and support, which are rarely found in liver units.…”