Non-alcoholic steatohepatitis 

20% of patients with NASH will develop cirrhosis

strongly associated with 

• Obesity
• Dyslipidemia
• type 2 diabetes
• metabolic syndrome

    Risk Factors

• Obesity
  • NASH occurs in 66% of all obese patients (BMI>30) over age 50 years old
  • Occurs in 90% of patients at BMI>39
• Hyperglycemia (75% of NASH patients)
  • Metabolic Syndrome
  • Type II Diabetes Mellitus (33-66% will develop NAFLD)
  • Polycystic Ovary Syndrome
• Hyperlipidemia (especially Hypertriglyceridemia)
  • More than half of those with Hyperlipidemia will develop NAFLD
  • High Triglyceride to HDL ratio is associated with up to 78% Prevalence of NAFLD
• Rapid weight loss
  • Starvation
  • Gastric Bypass
• Genetic Associations
  • Patatin-Like Phospholipase Domain-Containing Protein 3 (PNPLA3)
  • Associated with 2 fold increased risk of NAFLD with hepatic fibrosis
• Refeeding Syndrome
• Total Parenteral Nutrition
• Older age (Prevalence increases with age)
• Hispanic descent
• More common in women
• Obstructive Sleep Apnea
• Hypothyroidism
• HIV Infection

Management

• Lifestyle modification is the mainstay of treatment
• Weight Management:
  • Weight Loss:
    • Aim for a gradual weight loss of 7-10% of body weight over 6-12 months.
    • Significant improvement in liver histology can occur with sustained weight loss.
    • Weight loss of 7-10% can improve liver histology in NASH patients (Musso, G., et al., Hepatology, 2010).
  • Dietary Changes:
    • Follow a balanced, calorie-restricted diet (e.g., Mediterranean diet, low-fat diet).
    • Reduce intake of saturated fats, trans fats, and refined sugars.
    • Increase consumption of fruits, vegetables, whole grains, and lean proteins.
    • Mediterranean diet associated with reduced liver fat (Zelber-Sagi, S., et al., J Hepatol, 2008).
• Physical Activity:
  • Exercise:
    • Engage in at least 150-300 minutes of moderate-intensity aerobic activity per week (e.g., brisk walking, cycling).
    • Include muscle-strengthening activities on two or more days per week.
    • Exercise can reduce liver fat, even without significant weight loss.
• Lifestyle Modifications:
  • Avoid Alcohol: Completely avoid alcohol to prevent additional liver damage.
  • Smoking Cessation: Stop smoking to reduce overall health risks and support liver health.
• Diabetes Management:
  • Glycemic Control:
    • Maintain optimal blood glucose levels if diabetic.
    • Regular monitoring and adjustment of diabetes medications as needed.
• Cardiovascular Health:
  • Manage Hypertension and Lipids:
    • Control blood pressure and cholesterol levels through diet, exercise, and medications if prescribed.
    • Reduce overall cardiovascular risk factors.
• Regular Monitoring:
  • Follow-Up:
    • Regular follow-up with healthcare provider to monitor liver function tests, liver imaging, and overall health.
    • Assess for progression of liver disease and any new symptoms.
• Education and Support:
  • Patient Education:
    • Understand the condition, its implications, and the importance of lifestyle modifications.
  • Support Groups:
    • Join support groups for motivation and shared experiences.