NAFLD and food issues

a couple of articles from the ny times. one today, one last year.

today's was on the increasing incidence of non-alcoholic fatty liver disease (NAFLD), which is increasingly becoming a significant cause of liver failure and transplantation, ironically as we move forward in eliminating hepatitis C as the major cause til now. the article (http://well.blogs.nytimes.com/2014/06/13/threat-grows-from-liver-illness-tied-to-obesity/?hp) notes that:

    -- NAFLD has increased dramatically of late (eg now in 10% of children and 20% of adults)

    --2-3% of the US population have nonalcoholic steatohepatitis (NASH, the progressive form leading to cirrhosis)

    --nationwide liver transplant increased from 1% due to NASH in 2001 to 10% in 2009 (and projected to be leading cause for transplants by 2020).  

    --NAFLD particularly common in Latinos, partly because they tend to have a genetic variant (PNPLA3), leading the liver to produce and store more triglycerides.  eg, liver dz is found in 50% of obese Latino children, and 25% of liver transplants in los angeles are because of NASH

    --lots of comments in the article on lots of drugs-in-process, with relatively understated comments about lifestyle change, but will add on older blog from last year on effectiveness of wt loss and exercise. and, in this regard (as also per recent blog) the low glycemic index diet has particular value

and, speaking of food, last year's article (http://www.nytimes.com/2013/05/26/opinion/sunday/breeding-the-nutrition-out-of-our-food.html?pagewanted=1&hp) reviewed the rather distressing fact that the foods we currently grow have much less nutritional quality (fewer phytonutrients) than even in the recent past. wild dandelions of old had 7 times the phytonutrients than spinach (one of our better vegetables). purple potatoes from peru have 28x the anthocyanins (which may help fight cancer) than russet potatoes. why are the foods less beneficial? the author postulates that part of the issue is taste (some of the most beneficial phytonutrients are bitter, sour or astringent). and farmers over time tended to plant foods that have less fiber, more sugar/starch/oil, which were more palatale and provided fast calories for our strenuous lifestyle. eg, sweet corn is derived from a wild bushy plant with short spikes of grain instead of ears, with the kernals encased in dense shells, but had 10x the amount of protein of current corn. there have been natural genetic variations since then, but a major change took place over the past 50 years do to agricultural engineering, with supersweet corn (the predominant variety available in supermarkets) which are pretty devoid of nutritional value.

blog from october 2013:

non-alcoholic fatty liver disease is the most common cause of abnormal liver chemistries throughout the world, with purported incidence of 15-40% (16% in the recent NHANES3 data), often associated with obesity, metabolic syndrome, diabetes, dyslipidemia. we certainly see more NAFLD in patients with increased ALT than hepatitis C at the health center, which is also quite common. recent article found that weight loss was associated with reversal of NAFLD (see NAFLD wt loss j hepatol 2013 in dropbox, or http://dx.doi.org/10.1016/j.jhep.2013.04.013#sthash.DTEHzjif.dpuf). in brief:

    --154 pts with NAFLD in community-based study in Hong Kong identified by increased ALT (median 43) and negative viral serologies/ANA, randomized to diet (dietician-led individual education weekly x 4 months, then monthly for 8 months, focusing on exercise and reducing calorie intake) vs control, assessing intrahepatic triglyceride content (IHTG) by proton-magnetic resonance spectroscopy at start and end of study (following ALT levels is a less reliable indicator of NAFLD activity). primary outcome was remission of NAFLD, as evidenced by IHTG <5% (average initial IHTG was 12%, overall a group with pretty mild NAFLD). average BMI = 25. 

    --results: NAFLD remitted in 64% of patients in intervention group vs 20% of controls. body weight dec 5.6 vs 0.6 kg, but of those who lost >10% of body weight, 97% had remission of NAFLD. 41% of those with wt loss of 3-5% also achieved remission. of parameters assessed, only weight reduction significantly correlated with NAFLD remission. intervention group also had decreased in ALT and LDL-cholesterol


so, NAFLD is very common, recent studies have suggested that the long-term outcome is pretty much the same as with hepatitis C infection in terms of progression to cirrhosis/hepatoma, but in this community-based study there was significant remission with aggressive weight loss. one caveat is that though it seems that IHTG is a more reliable indicator of NAFLD than ALT, it does not reveal important histologic data (eg necroinflammation) which can only be assessed by biopsy and seems to be more associated with adverse hepatic outcomes. this study was done in hong kong, so although the average BMI was not so high compared to our standards,