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      A global action agenda for turning the tide on fatty liver disease

      research-article
      1 , 2 , 3 , , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 9 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 3 , 31 , 1 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 1 , 45 , 46 , 47 , 48 , 49
      Hepatology (Baltimore, Md.)
      Lippincott Williams & Wilkins

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          Abstract

          Background and Aims:

          Fatty liver disease is a major public health threat due to its very high prevalence and related morbidity and mortality. Focused and dedicated interventions are urgently needed to target disease prevention, treatment, and care.

          Approach and Results:

          We developed an aligned, prioritized action agenda for the global fatty liver disease community of practice. Following a Delphi methodology over 2 rounds, a large panel (R1 n = 344, R2 n = 288) reviewed the action priorities using Qualtrics XM, indicating agreement using a 4-point Likert-scale and providing written feedback. Priorities were revised between rounds, and in R2, panelists also ranked the priorities within 6 domains: epidemiology, treatment and care, models of care, education and awareness, patient and community perspectives, and leadership and public health policy. The consensus fatty liver disease action agenda encompasses 29 priorities. In R2, the mean percentage of “agree” responses was 82.4%, with all individual priorities having at least a super-majority of agreement (> 66.7% “agree”). The highest-ranked action priorities included collaboration between liver specialists and primary care doctors on early diagnosis, action to address the needs of people living with multiple morbidities, and the incorporation of fatty liver disease into relevant non-communicable disease strategies and guidance.

          Conclusions:

          This consensus-driven multidisciplinary fatty liver disease action agenda developed by care providers, clinical researchers, and public health and policy experts provides a path to reduce the prevalence of fatty liver disease and improve health outcomes. To implement this agenda, concerted efforts will be needed at the global, regional, and national levels.

          Abstract

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          Most cited references50

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          Progression of NAFLD to diabetes mellitus, cardiovascular disease or cirrhosis.

          NAFLD is a spectrum of progressive liver disease that encompasses simple steatosis, NASH, fibrosis and, ultimately, cirrhosis. NAFLD is recognized as the hepatic component of the metabolic syndrome, as these conditions have insulin resistance as a common pathophysiological mechanism. Therefore, NAFLD is strongly associated with type 2 diabetes mellitus and abdominal obesity. As lifestyles have become increasingly sedentary and dietary patterns have changed, the worldwide prevalence of NAFLD has increased dramatically and is projected to be the principal aetiology for liver transplantation within the next decade. Importantly, a growing body of clinical and epidemiological evidence suggests that NAFLD is associated not only with liver-related morbidity and mortality, but also with an increased risk of developing both cardiovascular disease and type 2 diabetes mellitus. This article reviews the evidence that suggests NAFLD is a multisystem disease and the factors that might determine interindividual variation in the development and progression of its major hepatic and extrahepatic manifestations (principally type 2 diabetes mellitus and cardiovascular disease).
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            Treatment of NAFLD with diet, physical activity and exercise.

            Lifestyle intervention can be useful across all the spectrum of NAFLD patients. Losing weight decreases cardiovascular / diabetes risk and also regresses liver disease. Weight reductions of ≥ 10% are required for inducing near universal NASH resolution or fibrosis improvement by at least one stage. However, modest weight losses (>5%) also produce important benefits on NAS and its components. In addition, to improve the success of this intervention we need to explore, beyond total calories and type of weight loss diet, the role of micro and macronutrients, evidence-based benefits of physical activity and exercise and finally supporting these modifications through established behaviour change models and techniques. The Mediterranean diet can reduce liver fat even without weight loss and is the most recommended dietary pattern in NAFLD. The Mediterranean diet is characterized by reduced carbohydrates intake, especially sugars and refined carbohydrates (40% of the calories vs. 50-60% in a typical low fat diet), and increased monounsaturated and omega-3 fatty acids intake (40% of the calories as fat vs. up-to 30% in a typical low fat diet). Both TV sitting (a reliable marker of overall sedentary behaviour) and physical activity are associated with cardio-metabolic health, NAFLD and overall mortality. A 'triple hit behavioural phenotype' of 1) sedentary behaviour, 2) low physical activity, and 3) poor diet have been defined. Clinical evidence strongly supports the role of lifestyle modification as a primary therapy for the management of NAFLD and NASH, and this should be accompanied by the implementation of strategies to avoid relapse and weight regain.
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              The need for a complex systems model of evidence for public health

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                Author and article information

                Contributors
                Journal
                Hepatology
                Hepatology
                HEP
                Hepatology (Baltimore, Md.)
                Lippincott Williams & Wilkins (Hagerstown, MD )
                0270-9139
                1527-3350
                February 2024
                4 August 2023
                : 79
                : 2
                : 502-523
                Affiliations
                [1 ]Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
                [2 ]Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
                [3 ]CUNY Graduate School of Public Health and Health Policy (CUNY SPH), New York, New York, USA
                [4 ]European Association for the Study of the Liver (EASL), Geneva, Switzerland
                [5 ]Independent consultant, Nottingham, UK
                [6 ]Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
                [7 ]Department of Medicine, Division of Gastroenterology, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada
                [8 ]Department of Epidemiology and Biostatistics, Schulich School of Medicine, Western University, London, Ontario, Canada
                [9 ]Department of Gastroenterology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
                [10 ]Aix Marseille Univ, Inserm, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l’Information Médicale, ISSPAM, Marseille, France
                [11 ]Houston Methodist Hospital, Houston Research Institute, Houston, Texas, USA
                [12 ]Barts Liver Centre, Blizard Institute, Queen Mary University of London, London, UK
                [13 ]Fatty Liver Program, Arizona Liver Health, Phoenix, Arizona, USA
                [14 ]King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
                [15 ]Translational & Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
                [16 ]Liver Unit, Hospital Clínic, University of Barcelona, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
                [17 ]Department of Medicine II, Division of Hepatology, Leipzig University Medical Center, Leipzig, Germany
                [18 ]Division of Hepatology, University of Dundee, Dundee, Scotland, UK
                [19 ]Multivisceral Transplant Unit-Gastroenterology, Department of Surgery, Oncology and Gastroenterology at the Padua University Hospital, Padua, Italy
                [20 ]Department of Hepatology and Transplant, Hospital Médica Sur, Mexico City, Mexico
                [21 ]Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
                [22 ]Asociación Latinoamericana para el Estudio del Hígado (ALEH), Santiago, Chile
                [23 ]Clinica Universitária de Gastrenterologia, Laboratório de Nutrição, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
                [24 ]Department of Medicine, Division of Endocrinology, Diabetes & Metabolism, University of Florida, Gainesville, Florida, USA
                [25 ]Greek Patients Association, Athens, Greece
                [26 ]Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
                [27 ]Department of Gastroenterology and Hepatology, Antwerp University Hospital, Edegem, Belgium
                [28 ]InflaMed Centre of Excellence, Laboratory for Experimental Medicine and Paediatrics, Translational Sciences in Inflammation and Immunology, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
                [29 ]Institute of Clinical Physiology, National Research Council, Pisa, Italy
                [30 ]Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
                [31 ]CUNY Center for Systems and Community Design and NYU-CUNY Prevention Research Center, New York, New York, USA
                [32 ]Kautz 5 gUG, Köln, Germany
                [33 ]Independent researcher, Ponte de Lima, Portugal
                [34 ]Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
                [35 ]National Institute for Health Research Birmingham Biomedical Research Centre at University Hospitals Birmingham NHS Foundation Trust and the University of Birmingham, Birmingham, UK
                [36 ]Department of Medicine, University of Chicago, Chicago, Illinois, USA
                [37 ]Department of Community Health and Social Sciences, CUNY Graduate School of Public Health and Health Policy, New York, New York, USA
                [38 ]Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
                [39 ]Hepatology and Clinical Research Units, Hospital Universitario Austral, Buenos Aires, Argentina
                [40 ]Department of Medicine, Division of Hepatology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
                [41 ]Gastrointestinal and Liver Disease Division, University of Southern California, Los Angeles, California, USA
                [42 ]UCL Institute for Liver and Digestive Health, Royal Free Hospital, London, UK
                [43 ]Precision Medicine, Biological Resource Center, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
                [44 ]Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
                [45 ]School of Public Health, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
                [46 ]Department of Gastroenterology, Tel Aviv Medical Centre, Tel Aviv, Israel
                [47 ]Metabolic Liver Research Program, I. Department of Medicine, University Medical Centre Mainz, Mainz, Germany
                [48 ]The Chinese University of Hong Kong, Hong Kong, China
                [49 ]Center for Liver Disease, Inova, Falls Church, Virginia, USA
                Author notes
                Correspondence Jeffrey V. Lazarus, CUNY Graduate School of Public Health and Health Policy (CUNY SPH), New York, NY, USA. Email: Jeffrey.Lazarus@ 123456sph.cuny.edu
                Author information
                https://orcid.org/0000-0001-9618-2299
                https://orcid.org/0000-0002-8022-4279
                https://orcid.org/0000-0002-8393-8410
                https://orcid.org/0000-0002-8561-396X
                https://orcid.org/0000-0002-6794-4837
                https://orcid.org/0000-0003-2127-2040
                https://orcid.org/0000-0002-3891-5914
                https://orcid.org/0000-0001-9872-2391
                https://orcid.org/0000-0003-2017-3526
                https://orcid.org/0000-0002-9518-0088
                https://orcid.org/0000-0002-1119-7799
                https://orcid.org/0000-0003-0003-6241
                https://orcid.org/0000-0001-8368-1478
                https://orcid.org/0000-0002-8791-191X
                https://orcid.org/0000-0001-7511-5396
                https://orcid.org/0000-0002-8537-8744
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                https://orcid.org/0000-0001-5544-5187
                https://orcid.org/0000-0002-6238-3938
                https://orcid.org/0009-0004-7245-9184
                https://orcid.org/0000-0002-9598-4932
                https://orcid.org/0000-0001-6085-3652
                https://orcid.org/0000-0002-4832-9564
                https://orcid.org/0000-0002-0544-5610
                https://orcid.org/0000-0003-3199-301X
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                https://orcid.org/0000-0001-5069-2461
                https://orcid.org/0000-0001-8909-0345
                https://orcid.org/0000-0002-7332-735X
                https://orcid.org/0000-0002-4224-4703
                https://orcid.org/0000-0003-2215-9410
                https://orcid.org/0000-0001-9313-577X
                Article
                HEP-23-0851 00021
                10.1097/HEP.0000000000000545
                10789386
                37540183
                5f74b08a-4f5c-4d0f-84eb-39388fed96dc
                Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.

                This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0/

                History
                : 11 May 2023
                : 23 June 2023
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                Gastroenterology & Hepatology
                Gastroenterology & Hepatology

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