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You may not realise it, because neither do they – but many of your overweight clients may have non-alcoholic fatty liver disease, writes Maitreyi Raman.

Nonalcoholic Fatty Liver Disease (NAFLD) is the leading cause of liver disease in the developed world. In fact, if the prevalence of overweight clinical status and obesity persist at current rates, NAFLD will become the leading cause of liver cirrhosis in the next decade.

This is very concerning, as the vast majority of people with NAFLD don’t have any symptoms until some liver damage has transpired. NAFLD is often suspected upon routine completion of blood work suggested by an individual’s GP. Elevated liver enzymes can prompt the doctor to refer patients to a gastroenterologist or hepatologist for further assessment and management. The specialist will generally ask the patient to complete a specialised set of lab testing to test for and rule out standard causes for liver diseases that may either co-exist with, or mimic, NAFLD. Additionally, as NAFLD historically has been a diagnosis of exclusion, negative liver panel testing also help to confirm the diagnosis of NAFLD, especially in the context of appropriate risk factors.

Risk factors

Major risk factors for NAFLD include overweight status, obesity, type 2 diabetes (DM), central obesity (waist circumference), high blood pressure, elevated cholesterol and/or triglycerides. As excess alcohol consumption can also lead to fatty liver disease that looks identical to NAFLD, alcohol consumption must be documented and quantified. In general, consumption of more than two standard alcoholic drinks per day for men and more than one standard alcoholic drink for women (in the context of abnormal liver enzymes) would be more consistent with alcohol-related fatty liver disease, so a diagnosis of NAFLD cannot be provided in the setting of excess alcohol consumption.


Once the diagnosis of NAFLD has been suspected following confirmation of appropriate risk factors, abnormal liver enzymes and exclusion of alcohol as a contributing factor, an ultrasound of the liver will usually be recommended to establish fat content, and rule out cirrhosis. The gold standard for establishing the diagnosis of NAFLD is a liver biopsy, which is invasive and associated with the possibility of complications such as bleeding and or perforation of major organs. For these reasons, a liver biopsy is generally recommended when there is diagnostic uncertainty or to prognosticate liver severity, as there are few existing tools that can provide us with information surrounding the severity of liver disease apart from biopsy. A test called the fibroscan is becoming increasingly popular to assess the stiffness of the liver, which can establish early scarring or fibrosis of the liver, however, it is not yet widely available, and is associated with some limitations in patients with NAFLD.

You probably train clients with NAFLD

Many of your clients who are overweight, obese, or have obesity related conditions such as type 2 diabetes, high blood pressure and/or high cholesterol would have NAFLD. The vast majority of people will not know this. Standard treatment is targeted toward lifestyle modification, with the aim of achieving 10 per cent weight loss over a six-month period. Of course, achievable, gradual and sustainable fat loss that can be incorporated into daily living is the goal, as opposed to the damaging fad diets that many clients will have attempted in the past.

As in all instances of clients seeking to achieve fat loss, this goal should be achieved through a combination of healthy eating and physical activity. Generally the recommendation is a focus on sensible portion sizes and reduced intake of sugar and refined carbohydrates, along with increased vegetable intake and lean protein choices. Saturated fats should be minimised, and fatty fish such as salmon and tuna choices encouraged.

Exercise is critical in the successful management of NAFLD. As you will be aware, there are two major distributions of fat in the body. The first, subcutaneous fat, is the fat that you can pinch under your skin. This type of fat is not metabolically active and therefore not critical to the progression of NAFLD. However, the second type – visceral fat – is the internal fat that resides around the organs within the body. This type of fat predisposes to inflammation, and also progression of NAFLD towards scarring and cirrhosis. Exercise (both aerobic and resistance) is critical to improving the visceral fat. Interestingly, exercise, independent of weight loss, is sufficient to induce an improvement in NAFLD. However, many patients with NAFLD get discouraged with exercise strategies if they do not lead to weight loss. It is valuable therefore to reinforce this fact to clients.

Questions to ask your clients regarding possible NAFLD:

  1. What is your current weight and have you had a change in your weight over the past 5-10 years? Weight increases over time in the context of current obesity is a big risk factor for NAFLD
  2. Have you been diagnosed with NAFLD? What suggestions have you been provided with to manage your condition?
  3. Have you tried to lose weight before? What strategies have you tried and what outcomes have you achieved? Many patients with NAFLD have tried multiple approaches to weight loss but have not had success, often due to lofty unrealistic goals, or socioeconomic factors precluding prioritising commitment to this area of health.
  4. Have you been diagnosed with diabetes, high blood pressure and/or high cholesterol? How are these being treated? Have you seen your doctor to ensure that your blood sugars, blood pressure and cholesterol are being treated and monitored appropriately? It is important that these risk factors for NAFLD be treated appropriately to optimise therapy for NAFLD.

NAFLD is a very common silent disease. It is associated with the same risk factor profile that leads toward heart disease and heart attacks. Cleaner eating and regular structured exercise sessions are the keys to success in its treatment.

Maitreyi Raman, MD, MSc, FRCPC, is the author of Healing Fatty Liver Disease (Exisle Publishing, 2014). She is a gastroenterologist and physician nutritionist and the medical director of the Southern Alberta Home Enteral and Parenteral Program.

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