title: Physical activity support or weight loss counseling for nonalcoholic fatty liver disease?
abstract: OBJECTIVE
  To determine the clinical effectiveness of intense psychological support to physical activity (PA) in nonalcoholic fatty liver disease (NAFLD), compared with cognitive-behavioral treatment (CBT).
  
  
  METHODS
  Twenty-two NAFLD cases received support to exercise, tailored to their motivational needs (PA group). The effects on body weight, physical fitness [6-min walk test, VO2max and the PA-rating (PA-R) questionnaire] and body fat (fatty liver indices and visceral adiposity index) were compared with data obtained in 44 NAFLD subjects enrolled in a CBT program for weight loss, after adjustment for propensity score, calculated on baseline data. Measurements were performed at baseline, at 4-mo and one-year follow-up. Changes in anthropometric, biochemical and PA parameters were tested by repeated measurement ANOVA. Outcome results were tested by logistic regression analysis.
  
  
  RESULTS
  At the end of the intensive program, BMI was less significantly reduced in the PA group (-1.09 ± 1.68 kg/m(2) vs -2.04 ± 1.42 kg/m(2) in the CBT group, P = 0.019) and the difference was maintained at 1-year follow-up (-0.73 ± 1.63 vs -1.95 ± 1.88, P = 0.012) (ANOVA, P = 0.005). PA-R was similar at baseline, when only 14% of cases in PA and 36% in CBT (P = 0.120) recorded values ≥ 3. At 4 mo, a PA-R ≥ 3 was registered in 91% of PA and 46% of CBT, respectively (P < 0.001) and PA-R ≥ 5 (up to 3 h/wk of moderate-to-heavy intensity physical activity) was registered in 41% of PA and only 9% of CBT group (P < 0.007). The 6-min walk test increased by 139 ± 26 m in PA and by only 43 ± 38 m in CBT (P < 0.001) and VO2max by 8.2 ± 3.8 mL/kg per minute and 3.3 ± 2.7 mL/kg per minute, respectively (P < 0.002). After adjustment for propensity, weight loss > 7% was significantly associated with CBT group at one year (OR = 6.21; 95%CI: 1.23-31.30), whereas PA-R > 3 was associated with PA group (10.31; 2.02-52.63). Liver enzymes decreased to values within normal limits in 36% of PA cases and 61% of CBT (P < 0.070). Estimated liver fat (Kotronen index) fell below the fatty liver threshold in 36% of PA and 34% and CBT cases at one-year (not different). Also the fatty liver index and the visceral adiposity index improved to a similar extent.
  
  
  CONCLUSIONS
  Intensive psychological counseling for PA produces hepatic effects not different from standard CBT, improving physical fitness and liver fat independent of weight loss. Strategies promoting exercise are worth and effective in motivated patients, particularly in lean NAFLD patients where large weight loss cannot be systematically pursued.
authors.affiliation: Luca Montesi, Chiara Caselli, Elena Centis, Chiara Nuccitelli, Simona Moscatiello, Alessandro Suppini, Giulio Marchesini, Unit of Metabolic Diseases and Clinical Dietetics, "Alma Mater Studiorum" University, S. Orsola-Malpighi Hospital, I-40138 Bologna, Italy.
authors.forename: Luca
authors.initials: L
authors.lastname: Montesi
authors.affiliation: Luca Montesi, Chiara Caselli, Elena Centis, Chiara Nuccitelli, Simona Moscatiello, Alessandro Suppini, Giulio Marchesini, Unit of Metabolic Diseases and Clinical Dietetics, "Alma Mater Studiorum" University, S. Orsola-Malpighi Hospital, I-40138 Bologna, Italy.
authors.forename: Chiara
authors.initials: C
authors.lastname: Caselli
authors.affiliation: Luca Montesi, Chiara Caselli, Elena Centis, Chiara Nuccitelli, Simona Moscatiello, Alessandro Suppini, Giulio Marchesini, Unit of Metabolic Diseases and Clinical Dietetics, "Alma Mater Studiorum" University, S. Orsola-Malpighi Hospital, I-40138 Bologna, Italy.
authors.forename: Elena
authors.initials: E
authors.lastname: Centis
authors.affiliation: Luca Montesi, Chiara Caselli, Elena Centis, Chiara Nuccitelli, Simona Moscatiello, Alessandro Suppini, Giulio Marchesini, Unit of Metabolic Diseases and Clinical Dietetics, "Alma Mater Studiorum" University, S. Orsola-Malpighi Hospital, I-40138 Bologna, Italy.
authors.forename: Chiara
authors.initials: C
authors.lastname: Nuccitelli
authors.affiliation: Luca Montesi, Chiara Caselli, Elena Centis, Chiara Nuccitelli, Simona Moscatiello, Alessandro Suppini, Giulio Marchesini, Unit of Metabolic Diseases and Clinical Dietetics, "Alma Mater Studiorum" University, S. Orsola-Malpighi Hospital, I-40138 Bologna, Italy.
authors.forename: Simona
authors.initials: S
authors.lastname: Moscatiello
authors.affiliation: Luca Montesi, Chiara Caselli, Elena Centis, Chiara Nuccitelli, Simona Moscatiello, Alessandro Suppini, Giulio Marchesini, Unit of Metabolic Diseases and Clinical Dietetics, "Alma Mater Studiorum" University, S. Orsola-Malpighi Hospital, I-40138 Bologna, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Suppini
authors.affiliation: Luca Montesi, Chiara Caselli, Elena Centis, Chiara Nuccitelli, Simona Moscatiello, Alessandro Suppini, Giulio Marchesini, Unit of Metabolic Diseases and Clinical Dietetics, "Alma Mater Studiorum" University, S. Orsola-Malpighi Hospital, I-40138 Bologna, Italy.
authors.forename: Giulio
authors.initials: G
authors.lastname: Marchesini
mesh_terms: D050154:Adiposity; D000328:Adult; D000886:Anthropometry; D031204:Caloric Restriction; D015928:Cognitive Behavioral Therapy; D003376:Counseling; D005080:Exercise Test; D005081:Exercise Therapy / Q000379:methods*; D005260:Female; D015438:Health Behavior; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008297:Male; D008875:Middle Aged; D009042:Motivation; D009043:Motor Activity; D065626:Non-alcoholic Fatty Liver Disease / Q000175:diagnosis / Q000503:physiopathology / Q000523:psychology / Q000628:therapy*; D009765:Obesity / Q000175:diagnosis / Q000503:physiopathology / Q000523:psychology / Q000628:therapy*; D010809:Physical Fitness; D057216:Propensity Score; D012307:Risk Factors; D040242:Risk Reduction Behavior; D011795:Surveys and Questionnaires; D013997:Time Factors; D016896:Treatment Outcome; D015431:Weight Loss
keywords: Behavior treatment; Liver enzymes; Nonalcoholic fatty liver disease; Physical activity; Physical fitness; Weight loss liver fat
references.citation: Lipids Health Dis. 2011 Oct 19;10:183
references.pmid: 22011564
references.citation: Diabetes Care. 2010 Apr;33(4):920-2
references.pmid: 20067971
references.citation: JAMA. 2010 Oct 27;304(16):1795-802
references.pmid: 20935337
references.citation: Intern Emerg Med. 2013 Dec;8(8):655-66
references.pmid: 23657989
references.citation: World J Hepatol. 2012 Jul 27;4(7):209-17
references.pmid: 22855696
references.citation: Obesity (Silver Spring). 2008 Jun;16(6):1355-62
references.pmid: 18421281
references.citation: N Engl J Med. 2011 Mar 31;364(13):1218-29
references.pmid: 21449785
references.citation: Hepatology. 2010 Jan;51(1):121-9
references.pmid: 19827166
references.citation: World J Gastroenterol. 2013 Jan 7;19(1):57-64
references.pmid: 23326163
references.citation: Semin Liver Dis. 2012 Feb;32(1):65-79
references.pmid: 22418889
references.citation: J Hepatol. 2010 Aug;53(2):372-84
references.pmid: 20494470
references.citation: Stat Med. 2007 Jan 15;26(1):20-36
references.pmid: 17072897
references.citation: Clin Gastroenterol Hepatol. 2013 Sep;11(9):1201-4
references.pmid: 23353640
references.citation: J Hepatol. 2013 Apr;58(4):771-7
references.pmid: 23201248
references.citation: Ann Intern Med. 2002 Jul 2;137(1):1-10
references.pmid: 12093239
references.citation: Obesity (Silver Spring). 2010 Feb;18(2):384-90
references.pmid: 19696755
references.citation: Gastroenterology. 2009 Sep;137(3):865-72
references.pmid: 19524579
references.citation: J Obes. 2011;2011:348293
references.pmid: 21052533
references.citation: Med Sci Sports Exerc. 1990 Dec;22(6):863-70
references.pmid: 2287267
references.citation: World J Gastroenterol. 2011 Aug 7;17(29):3377-89
references.pmid: 21876630
references.citation: Diabetes Care. 2011 Jul;34(7):1481-6
references.pmid: 21593294
references.citation: Arch Intern Med. 2005 Nov 14;165(20):2362-9
references.pmid: 16287765
references.citation: Hepatology. 2008 Feb;47(2):746-54
references.pmid: 18098321
references.citation: Obesity (Silver Spring). 2008 Oct;16(10):2281-8
references.pmid: 18719669
references.citation: J Clin Endocrinol Metab. 2005 Jun;90(6):3191-6
references.pmid: 15769987
references.citation: Hepatology. 2003 Apr;37(4):917-23
references.pmid: 12668987
references.citation: Gastroenterology. 2012 Jun;142(7):1592-609
references.pmid: 22656328
references.citation: Obesity (Silver Spring). 2011 Apr;19(4):763-70
references.pmid: 20966900
references.citation: N Engl J Med. 2002 Feb 7;346(6):393-403
references.pmid: 11832527
references.citation: BMC Gastroenterol. 2006 Nov 02;6:33
references.pmid: 17081293
references.citation: J Hepatol. 2012 Jul;57(1):157-66
references.pmid: 22414768
references.citation: Ann Oncol. 2013 Oct;24(10):2506-2514
references.pmid: 23793035
references.citation: Gut. 2008 Jun;57(6):807-13
references.pmid: 18270241
references.citation: Diabetologia. 1985 Jul;28(7):412-9
references.pmid: 3899825
references.citation: Medicine (Baltimore). 2012 Nov;91(6):319-327
references.pmid: 23117851
references.citation: Gut. 2011 Sep;60(9):1278-83
references.pmid: 21708823
references.citation: J Chronic Dis. 1985;38(6):517-24
references.pmid: 4008592
references.citation: Hepatology. 2009 Jul;50(1):68-76
references.pmid: 19444870