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for males as 2 drinks/day and for females as 1 drink/ day) and 0 for alcohol consumption above or below
these values. Thus the MDS ranges from 0 (lowest adherence) to 9 (highest adherence). It is important
to note that in large population studies, individuals who follow a Mediterranean diet are also more likely
to engage in vigorous physical activity, have lower overall calorie intake, and are less likely to be current
smokers or perform heavy activities at work [14].
In a recent cross sectional study of people with NAFLD, adherence to a Mediterranean dietary pattern
was associated with less severe IR and liver disease [15]. There was an inverse correlation between
Mediterranean diet score and steatosis, fibrosis and liver stiffness. Those with NASH had significantly
lower adherence to the Mediterranean dietary pattern compared to those with fatty liver alone [15].The
Mediterranean diet has clear anti-inflammatory and anti-oxidant effects that could partly explain the
protective effects against NASH.
In a prospective randomized cross over intervention study, 12 participants consumed a Mediterranean
diet or a control diet (low fat, high carbohydrate) for 6 weeks [16]. They were permitted to drink up to
two standard alcoholic drinks per day on up to 5 days per week.The Mediterranean diet did not result in
weight loss but did result in a 39% relative reduction in steatosis, with significantly greater improvements
in IR and fasting insulin than the control diet.This is a small study, but provides promising evidence that
manipulations of dietary composition, in the absence of weight loss, may yield important therapeutic
benefits.
Sugar sweetened beverages. There are plausible hypotheses for how fructose may contribute to the
severity of NAFLD. Cross-sectional associations between fructose consumed in sweetened beverages
and liver fibrosis have been described [17] and consuming soft drinks daily for 6 months can increase
liver fat by 140% in healthy people [18], but a casual relationship with NASH remains unclear and
is complicated by the independent contribution of obesity and overall energy intake. High fructose
consumption in obese adolescents increases the likelihood of developing NAFLD, while this relationship
is not seen in lean adolescents with similarly high fructose intake [19].
Sleep duration and quality. Monitoring and assessing sleep behaviors may be an important component
of lifestyle intervention for people with NAFLD.There is mounting evidence that poor sleep quality and
short sleep duration is associated with metabolic disturbances, such as IR, inflammation and obesity
[20]. Cross-sectional population data has identified that short sleep duration (≤5 hours per night) and
poor sleep quality (self-assessed by questionnaire) is associated with a greater risk for NAFLD compared
to people who regularly sleep >7 hours per night or who report good quality sleep, respectively [21].
The presence of more severe sleep dysfunction, such as obstructive sleep apnoea syndrome (OSAS) has
been associated with an increased prevalence of NAFLD. In people with NAFLD, co-morbid OSAS
is associated with a two-fold greater risk for more severe disease such as NASH and advanced fibrosis,
independent of age, gender and obesity [22].There is limited data on the therapeutic potential of OSAS
treatment for improving features of NASH, however, general inquiry about symptoms of OSAS and
administering quick sleep questionnaires (e.g. Epworth Sleepiness Scale) when discussing lifestyle
behaviours may be warranted [20].
Lifestyle intervention and cancer
One of the most worrying recent trends in patients with NAFLD is the increasing number of patients
being seen with HCC, including HCC developing in non-cirrhotic patients with NAFLD. Obesity has
been shown to be a risk factor for developing a range of cancers and may impact on HCC recurrence
or progression. Thus a new dimension of lifestyle intervention in NAFLD relates to advice regarding
HCC. Various organizations have issued dietary and physical activity guidelines for cancer survivors
but all point to the lack of data after curative cancer therapies and are deemed consensus statements to
inform clinical practice rather than evidence based guidelines [23-25]. The guidelines for weight loss in
overweight or obese cancer survivors (based mainly on studies of breast and prostate cancer) are broad,
with recommendations to achieve and maintain a healthy weight, increase plant based foods, and reduce
The International Liver Congress™ 2015 • Vienna, Austria • April 22–23, 2015 89
these values. Thus the MDS ranges from 0 (lowest adherence) to 9 (highest adherence). It is important
to note that in large population studies, individuals who follow a Mediterranean diet are also more likely
to engage in vigorous physical activity, have lower overall calorie intake, and are less likely to be current
smokers or perform heavy activities at work [14].
In a recent cross sectional study of people with NAFLD, adherence to a Mediterranean dietary pattern
was associated with less severe IR and liver disease [15]. There was an inverse correlation between
Mediterranean diet score and steatosis, fibrosis and liver stiffness. Those with NASH had significantly
lower adherence to the Mediterranean dietary pattern compared to those with fatty liver alone [15].The
Mediterranean diet has clear anti-inflammatory and anti-oxidant effects that could partly explain the
protective effects against NASH.
In a prospective randomized cross over intervention study, 12 participants consumed a Mediterranean
diet or a control diet (low fat, high carbohydrate) for 6 weeks [16]. They were permitted to drink up to
two standard alcoholic drinks per day on up to 5 days per week.The Mediterranean diet did not result in
weight loss but did result in a 39% relative reduction in steatosis, with significantly greater improvements
in IR and fasting insulin than the control diet.This is a small study, but provides promising evidence that
manipulations of dietary composition, in the absence of weight loss, may yield important therapeutic
benefits.
Sugar sweetened beverages. There are plausible hypotheses for how fructose may contribute to the
severity of NAFLD. Cross-sectional associations between fructose consumed in sweetened beverages
and liver fibrosis have been described [17] and consuming soft drinks daily for 6 months can increase
liver fat by 140% in healthy people [18], but a casual relationship with NASH remains unclear and
is complicated by the independent contribution of obesity and overall energy intake. High fructose
consumption in obese adolescents increases the likelihood of developing NAFLD, while this relationship
is not seen in lean adolescents with similarly high fructose intake [19].
Sleep duration and quality. Monitoring and assessing sleep behaviors may be an important component
of lifestyle intervention for people with NAFLD.There is mounting evidence that poor sleep quality and
short sleep duration is associated with metabolic disturbances, such as IR, inflammation and obesity
[20]. Cross-sectional population data has identified that short sleep duration (≤5 hours per night) and
poor sleep quality (self-assessed by questionnaire) is associated with a greater risk for NAFLD compared
to people who regularly sleep >7 hours per night or who report good quality sleep, respectively [21].
The presence of more severe sleep dysfunction, such as obstructive sleep apnoea syndrome (OSAS) has
been associated with an increased prevalence of NAFLD. In people with NAFLD, co-morbid OSAS
is associated with a two-fold greater risk for more severe disease such as NASH and advanced fibrosis,
independent of age, gender and obesity [22].There is limited data on the therapeutic potential of OSAS
treatment for improving features of NASH, however, general inquiry about symptoms of OSAS and
administering quick sleep questionnaires (e.g. Epworth Sleepiness Scale) when discussing lifestyle
behaviours may be warranted [20].
Lifestyle intervention and cancer
One of the most worrying recent trends in patients with NAFLD is the increasing number of patients
being seen with HCC, including HCC developing in non-cirrhotic patients with NAFLD. Obesity has
been shown to be a risk factor for developing a range of cancers and may impact on HCC recurrence
or progression. Thus a new dimension of lifestyle intervention in NAFLD relates to advice regarding
HCC. Various organizations have issued dietary and physical activity guidelines for cancer survivors
but all point to the lack of data after curative cancer therapies and are deemed consensus statements to
inform clinical practice rather than evidence based guidelines [23-25]. The guidelines for weight loss in
overweight or obese cancer survivors (based mainly on studies of breast and prostate cancer) are broad,
with recommendations to achieve and maintain a healthy weight, increase plant based foods, and reduce
The International Liver Congress™ 2015 • Vienna, Austria • April 22–23, 2015 89
