Weight Management in Nonalcoholic Steatohepatitis

Nonalcoholic steatohepatitis (NASH) is one of the most common chronic liver diseases. The cause of NASH is not completely understood and currently there is no effective treatment for this disease. An effective approach to treatment is needed since without treatment this disease may progress to fibrosis and cirrhosis. Obesity is one of the most important risk factors for NASH and weight reduction is generally recommended as an initial step in its management. However, there has never been a randomized controlled trial evaluating the efficacy of weight reduction as a treatment for NASH. Data from uncontrolled trials using poorly defined primary outcome measures and patient populations and nonstandardized weight loss interventions suggest that modest weight loss may improve liver histology. The objective of this project is to conduct a pilot study in preparation for a randomized controlled trial of weight reduction in the management of NASH. In this study, 30 overweight or obese individuals with biopsy-proven NASH will be enrolled. Twenty patients will be randomized to receive 48 weeks of intensive weight management using a combination of diet, exercise and behavior modification with a goal of 7-10% weight reduction. This weight loss program is similar to programs used successfully in other overweight populations and to the intensive lifestyle program of the Diabetes Prevention Program and Look AHEAD. The other 10 patients will be randomized to a control group where they will receive standard medical care and general counseling on healthy eating and exercise. At the end of the 48-week study, patients will have a repeat liver biopsy that will be compared to their baseline biopsy. The pilot study will establish the feasibility of recruiting and retaining, producing sustained weight loss and performing repeat liver biopsies in this population. Based on the outcomes of this preliminary trial, this program will be further refined and readied for a larger-scale clinical trial.

Inclusion criteria

• Evidence of chronic steatohepatitis on liver biopsy.
• Elevated alanine or aspartate aminotransferase values (ALT > 41 or AST > 34) within 3 months of enrollment
• Absence of another form of liver disease
• Body mass index between 25-50 kg/m2.
• At least 18 years of age
• Absence of significant alcohol consumption (more than one standard drink per day).
• Able to walk 2 blocks or a quarter of a mile without stopping
• Willing to complete a two-week run-in period with successful completion of self-monitoring records.

Exclusion criteria

• < 18 years of age
• Significant alcohol consumption (> 1 standard drink per day)
• Contraindications to obtaining a liver biopsy
• Unable to walk 2 blocks or a quarter of a mile without stopping
• Currently pregnant or pregnant in the previous six months
• Currently engaged in an active weight-loss program or taking weight-loss medication
• Report conditions that, in the judgment of the investigators, render potential participants unlikely to follow the protocol for 12 months, including illness likely to be terminal within 2 years, plans to move, substance abuse, or other significant psychiatric problems