Original Article
Hepatology
Intensive Lifestyle Management Improves Steatosis and Fibrosis in Pediatric Nonalcoholic Fatty Liver Disease

https://doi.org/10.1016/j.cgh.2021.11.039Get rights and content

Background & Aims

Childhood obesity, with associated comorbidities such as nonalcoholic fatty liver disease (NAFLD), is an increasing global health problem. Although lifestyle management is the mainstay of treatment, its efficacy on liver fibrosis has not yet been established.

Methods

Children and adolescents admitted for severe obesity at a tertiary center (Zeepreventorium, De Haan, Belgium) were enrolled in this prospective study. Intensive lifestyle therapy encompassed caloric restriction, physical activity, education on a healthy lifestyle, and psychosocial support. At baseline, 6 months, and 12 months, liver ultrasound and transient elastography with controlled attenuation parameter were performed to assess liver steatosis and fibrosis.

Results

A total of 204 patients (median age, 14.0 y; body mass index Z-score, +2.8) were evaluated at admission. NAFLD on ultrasound was present in 71.1%, whereas 68.6% had controlled attenuation parameter values of 248 dB/m or greater. A total of 32.8% of patients had at least F2 fibrosis, including 10.3% with transient elastography of 9 kPa or greater. After 6 months, the median body weight loss was 16.0% in the 167 patients evaluated. Fibrosis improved in 75.0% (P < .001). Baseline severity of liver fibrosis and steatosis were predictors of fibrosis resolution. Seventy-nine patients had reached the 1-year time point. The improvements were sustained because fibrosis regressed at least 1 stage in all patients with baseline fibrosis. Fasting serum alanine aminotransferase and homeostasis model assessment of insulin resistance decreased significantly over the 1-year period (P < .001).

Conclusions

NAFLD and associated fibrosis are highly prevalent in children and adolescents with severe obesity. An intensive multidisciplinary lifestyle management program that causes significant weight loss not only improves liver steatosis, but also fibrosis.

Section snippets

Patients and Methods

Part of the methods are described in the Supplementary Methods section.

Baseline Characteristics

Of the 229 patients screened for participation in this study, 204 could be included with adequate baseline data (Figure 1). The clinical and biochemical characteristics are summarized in Table 1. The median age was 14 years (interquartile range, 12–16), 104 (51.0%) were female, and the median BMI was 36.0 kg/m2, corresponding to a BMI Z-score of +2.76. Liver steatosis on ultrasound was present in 71.1% of patients, which was severe in 20.1%, whereas in 68.6% the CAP was suggestive of steatosis.

Discussion

In this prospective study in children and adolescents with severe obesity, an intensive lifestyle program improved liver fibrosis in 75.0% of patients with baseline fibrosis after 6 months of treatment. These changes were maintained and consolidated over the 1-year period, and coincided with significant weight loss and improvements in liver steatosis, aminotransferase levels, and insulin resistance.

Lifestyle management is the cornerstone of treatment for pediatric NAFLD, yet its efficacy on

CRediT Authorship Contributions

Sander Lefere, MD (Conceptualization: Equal; Data curation: Lead; Formal analysis: Lead; Funding acquisition: Supporting; Project administration: Equal; Writing – original draft: Lead)

Ellen Dupont (Data curation: Supporting; Methodology: Equal)

Ann De Guchtenaere (Methodology: Equal; Resources: Supporting)

Stephanie Van Biervliet (Resources: Supporting; Writing – review & editing: Supporting)

Saskia Vande Velde (Resources: Supporting; Writing – review & editing: Supporting)

Xavier Verhelst

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    • Conflicts of interest The authors disclose no conflicts.

    Funding This project was supported by a grant from Ghent University Hospital (FIKO19-TYPE2-006 [A.G.]), and by the Research Foundation–Flanders grants 12R0321N (S.L.) and 1805718N and 1801721N (A.G. and H.V.V.). These funding agencies were not involved in the study design, analysis, or reporting.

    Data Sharing Statement Deidentified patient data that underlie the results reported in this article, together with the study protocol, will be shared with researchers who provide a methodologically sound proposal. To gain access to the data, proposals should be sent to [email protected] or [email protected].

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    Authors share co-senior authorship.

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