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Younossi ZM, Paik JM, Golabi P, Younossi Y, Henry L, Nader F. The impact of fatigue on mortality of patients with non-alcoholic fatty liver disease: Data from National Health and nutrition examination survey 2005-2010 and 2017-2018. Liver Int 2022; 42:2646-2661. [PMID: 36161464 DOI: 10.1111/liv.15437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 08/31/2022] [Accepted: 09/23/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Fatigue among patients with NAFLD may negatively impact their health-related quality of life and clinical outcomes (mortality). We determined fatigue prevalence and its association with all-cause mortality among patients with NAFLD. DESIGN NHANES 2005-2010 and 2017-2018 data were used with linked mortality data. NAFLD was defined by fatty liver index for NHANES 2005-2010 and by transient elastography for NHANES 2017-2018. Fatigue was assessed by Patient Health Questionnaire. RESULTS NHANES 2005-2010 cohort (n = 5429, mean age 47.1 years, 49.7% male, 69.9% white), 37.6% had NAFLD. Compared to non-NAFLD controls, fatigue was more common in NAFLD (8.35% vs 6.0%, p = .002). Among NHANES 2017-2018 cohort (n = 3830, mean age 48.3 years, 48.6% male, 62.3% white), 36.9% had NAFLD. Compared to non-NAFLD controls, fatigue was more common among NAFLD (8.7% vs 6.2%). NAFLD had more sleep disturbance (34.0% vs 26.7%), cardiovascular disease (CVD) (10.7% vs. 6.3%), significant hepatic fibrosis (liver stiffness>8.0 kPa, 17.9% vs 3.5%) and advanced hepatic fibrosis (>13.1 kPa, 5.4% vs 0.9%; all p < .003). The presence of depression (OR: 11.52, 95% CI: 4.45-29.80, p < .0001), CVD (OR: 3.41, 95% CI: 1.02-11.34, p = .0462) and sleep disturbance (OR: 2.00, 95% CI: 1.00-3.98, p = .0491) was independently associated with fatigue; good sleep quality (OR: 0.58, 95% CI: 0.35-0.96, p = .0366) had an inverse association. By multivariable Cox model, NAFLD adults with fatigue experienced 2.3-fold higher mortality than NAFLD without fatigue (HR: 2.31, 95% CI: 1.37-3.89, p = .002). CONCLUSIONS Fatigue among those with NAFLD is associated with increased risk for mortality and is mainly driven by depression, sleep disturbance and CVD. These findings have important clinical implications.
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Affiliation(s)
- Zobair M Younossi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, Virginia, USA.,Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, Virginia, USA.,Inova Medicine, Inova Health System, Falls Church, Virginia, USA
| | - James M Paik
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, Virginia, USA.,Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, Virginia, USA.,Inova Medicine, Inova Health System, Falls Church, Virginia, USA
| | - Pegah Golabi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, Virginia, USA.,Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, Virginia, USA.,Inova Medicine, Inova Health System, Falls Church, Virginia, USA
| | - Youssef Younossi
- Center for Outcomes Research in Liver Diseases, Washington, District of Columbia, USA
| | - Linda Henry
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, Virginia, USA.,Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, Virginia, USA.,Inova Medicine, Inova Health System, Falls Church, Virginia, USA.,Center for Outcomes Research in Liver Diseases, Washington, District of Columbia, USA
| | - Fatema Nader
- Center for Outcomes Research in Liver Diseases, Washington, District of Columbia, USA
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Weinstein AA, De Avila L, Kannan S, Paik JM, Golabi P, Gerber LH, Younossi ZM. Interrelationship between physical activity and depression in nonalcoholic fatty liver disease. World J Hepatol 2022; 14:612-622. [PMID: 35582293 PMCID: PMC9055201 DOI: 10.4254/wjh.v14.i3.612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/21/2021] [Accepted: 02/20/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Nonalcoholic fatty liver disease (NAFLD) is associated with a sedentary lifestyle and depressive symptoms. It is also well established that physical inactivity and depressive symptoms are related. However, an investigation of the interaction between all of these factors in NAFLD has not been previously conducted.
AIM To investigate the interrelationship between physical inactivity and depressive symptoms in individuals with NAFLD.
METHODS Data from the Rancho Bernardo Study of Healthy Aging were utilized. 589 individuals were included in the analyses (43.1% male; 95.8% non-Hispanic white; aged 60.0 ± 7.0 years). NAFLD was defined by using the hepatic steatosis index, depression using the Beck Depression Inventory, and physical activity by self-report of number of times per week of strenuous activity. Multivariable generalized linear regression models with Gamma distribution were performed to investigate the proposed relationship.
RESULTS About 40% of the sample had evidence of NAFLD, 9.3% had evidence of depression, and 29% were physically inactive. Individuals with NAFLD and depression were more likely to be physically inactive (60.7%) compared to individuals with neither NAFLD nor depression (22.9%), individuals with depression without NAFLD (37.0%), and individuals with NAFLD without depression (33.3%). After accounting for various comorbidities (i.e., age, sex, diabetes, hypertension, obesity), individuals with NAFLD and higher levels of physical activity were at a decreased odds of having depressive symptoms [16.1% reduction (95% confidence interval: -25.6 to -5.4%), P = 0.004], which was not observed in those without NAFLD.
CONCLUSION Individuals with NAFLD have high levels of physical inactivity, particularly those with depressive symptoms. Because this group is at high risk for poor outcomes, practitioners should screen for the coexistence of depressive symptoms and NAFLD. This group should receive appropriate interventions aimed at increasing both participation and levels of intensity of physical activity.
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Affiliation(s)
- Ali A Weinstein
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA 22042, United States
- Global and Community Health, George Mason University, Fairfax, VA 22030, United States
| | - Leyla De Avila
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA 22042, United States
| | - Saisruthi Kannan
- Global and Community Health, George Mason University, Fairfax, VA 22030, United States
| | - James M Paik
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA 22042, United States
| | - Pegah Golabi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA 22042, United States
| | - Lynn H Gerber
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA 22042, United States
- Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA 22042, United States
| | - Zobair M Younossi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA 22042, United States
- Center for Liver Disease, Department of Medicine, Inova Fairfax Medical Campus, Falls Church, VA 22042, United States
- Inova Medicine, Inova Health System, Falls Church, VA 22042, United States
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Funuyet-Salas J, Martín-Rodríguez A, Pérez-San-Gregorio MÁ, Romero-Gómez M. Influence of Psychological Biomarkers on Therapeutic Adherence by Patients with Non-Alcoholic Fatty Liver Disease: A Moderated Mediation Model. J Clin Med 2021; 10:2208. [PMID: 34065216 PMCID: PMC8161151 DOI: 10.3390/jcm10102208] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 05/17/2021] [Accepted: 05/18/2021] [Indexed: 01/14/2023] Open
Abstract
Our aim was to analyze whether depressive symptoms mediated the association between physical quality of life (QoL) and adherence to physical activity in patients with non-alcoholic fatty liver disease (NAFLD), as well as the association between social support and adherence to diet. We also examined whether self-efficacy exerted a moderating role in these associations. QoL (SF-12), social support (MSPSS), depressive symptoms (HADS), self-efficacy (GSE), physical activity (IPAQ) and diet (MEDAS) were evaluated in 413 biopsy-proven NAFLD patients. Mediation and moderated mediation models were conducted using the SPSS PROCESS v3.5 macro. Results showed that depressive symptoms mediated the relationship between physical QoL and adherence to physical activity (indirect effect = 6.248, CI = 1.917-10.727), as well as the relationship between social support and adherence to diet (indirect effect = 0.148, CI = 0.035-0.275). Self-efficacy also moderated the indirect effects of QoL and social support on therapeutic adherence through depressive symptoms. Specifically, the higher self-efficacy was, the lower the negative impact on the NAFLD patient's mental health. In conclusion, self-efficacy is defined as a protective factor for therapeutic adherence by NAFLD patients with a psychosocial risk profile. Self-efficacy should, therefore, be a main psychological target in future multidisciplinary NAFLD approaches.
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Affiliation(s)
- Jesús Funuyet-Salas
- Department of Personality, Assessment and Psychological Treatment, Faculty of Psychology, University of Seville, 41018 Seville, Spain; (A.M.-R.); (M.Á.P.-S.-G.)
| | - Agustín Martín-Rodríguez
- Department of Personality, Assessment and Psychological Treatment, Faculty of Psychology, University of Seville, 41018 Seville, Spain; (A.M.-R.); (M.Á.P.-S.-G.)
| | - María Ángeles Pérez-San-Gregorio
- Department of Personality, Assessment and Psychological Treatment, Faculty of Psychology, University of Seville, 41018 Seville, Spain; (A.M.-R.); (M.Á.P.-S.-G.)
| | - Manuel Romero-Gómez
- UCM Digestive Diseases and Ciberehd, Virgen del Rocío University Hospital, Institute of Biomedicine of Seville, University of Seville, 41013 Seville, Spain;
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Machado MV. Aerobic Exercise in the Management of Metabolic Dysfunction Associated Fatty Liver Disease. Diabetes Metab Syndr Obes 2021; 14:3627-3645. [PMID: 34408459 PMCID: PMC8364841 DOI: 10.2147/dmso.s304357] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/29/2021] [Indexed: 12/17/2022] Open
Abstract
Sedentarism is the pandemic of modern times. It is associated with several medical conditions including obesity, type 2 diabetes mellitus, cardiovascular diseases and also liver disease, particularly metabolic dysfunction associated fatty liver disease (MAFLD). In an era when MAFLD is the most prevalent chronic liver disease worldwide, whilst no pharmacological therapy has been approved for it, exercise has proved to be effective in improving liver steatosis. Interestingly, exercise decreases liver fat even in the absence of weight loss. The challenge for the clinician is to motivate the obese patient with MAFLD, and associated co-morbidities, who has crystallized a sedentary behavior, at times when every need is at the distance of a click on the Internet, and the entire world can be visited behind a screen. In this review, the aggregate evidence on the mechanisms and effects of exercise in the management of MAFLD is summarized, with simple recommendations for everyday clinical practice.
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Affiliation(s)
- Mariana Verdelho Machado
- Serviço de Gastrenterologia, Hospital de Vila Franca de Xira, Vila Franca de Xira, Portugal
- Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
- Correspondence: Mariana Verdelho Machado Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, Lisboa, 1649-035, PortugalTel +35 1912620306 Email
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Gerber L. 2020 Sidney licht lecture: Metabolic syndrome and obesity negatively impact function. THE JOURNAL OF THE INTERNATIONAL SOCIETY OF PHYSICAL AND REHABILITATION MEDICINE 2021. [DOI: 10.4103/jisprm.jisprm_28_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Gerber LH, Weinstein AA, Mehta R, Younossi ZM. Importance of fatigue and its measurement in chronic liver disease. World J Gastroenterol 2019; 25:3669-3683. [PMID: 31391765 PMCID: PMC6676553 DOI: 10.3748/wjg.v25.i28.3669] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 06/12/2019] [Accepted: 06/23/2019] [Indexed: 02/06/2023] Open
Abstract
The mechanisms of fatigue in the group of people with non-alcoholic fatty liver disease and non-alcoholic steatohepatitis are protean. The liver is central in the pathogenesis of fatigue because it uniquely regulates much of the storage, release and production of substrate for energy generation. It is exquisitely sensitive to the feedback controlling the uptake and release of these energy generation substrates. Metabolic contributors to fatigue, beginning with the uptake of substrate from the gut, the passage through the portal system to hepatic storage and release of energy to target organs (muscle and brain) are central to understanding fatigue in patients with chronic liver disease. Inflammation either causing or resulting from chronic liver disease contributes to fatigue, although inflammation has not been demonstrated to be causal. It is this unique combination of factors, the nexus of metabolic abnormality and the inflammatory burden of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis that creates pathways to different types of fatigue. Many use the terms central and peripheral fatigue. Central fatigue is characterized by a lack of self-motivation and can manifest both in physical and mental activities. Peripheral fatigue is classically manifested by neuromuscular dysfunction and muscle weakness. Therefore, the distinction is often seen as a difference between intention (central fatigue) versus ability (peripheral fatigue). New approaches to measuring fatigue include the use of objective measures as well as patient reported outcomes. These measures have improved the precision with which we are able to describe fatigue. The measures of fatigue severity and its impact on usual daily routines in this population have also been improved, and they are more generally accepted as reliable and sensitive. Several approaches to evaluating fatigue and developing endpoints for treatment have relied of biosignatures associated with fatigue. These have been used singly or in combination and include: physical performance measures, cognitive performance measures, mood/behavioral measures, brain imaging and serological measures. Treatment with non-pharmacological agents have been shown to be effective in symptom reduction, whereas pharmacological agents have not been shown effective.
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Affiliation(s)
- Lynn H Gerber
- Department of Medicine, Beatty Center for Liver and Obesity Research, Inova Health System, Falls Church, VA 22042, United States
| | - Ali A Weinstein
- Center for the Study of Chronic Illness and Disability, George Mason University, Fairfax, VA 22030, United States
| | - Rohini Mehta
- Beatty Center for Liver and Obesity Research, Inova Health System, Falls Church, VA 22042, United States
| | - Zobair M Younossi
- Department of Medicine, Beatty Center for Liver and Obesity Research, Inova Health System, Falls Church, VA 22042, United States
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Brea Á, Pintó X, Ascaso JF, Blasco M, Díaz Á, González-Santos P, Hernández-Mijares A, Mantilla T, Millán J, Pedro-Botet J. Enfermedad del hígado graso no alcohólico, asociación con la enfermedad cardiovascular y tratamiento (II). Tratamiento de la enfermedad del hígado graso no alcohólico. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS 2017; 29:185-200. [DOI: 10.1016/j.arteri.2016.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 06/28/2016] [Indexed: 12/12/2022]
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Portal Hypertension Complications Are Frequently the First Presentation of NAFLD in Patients Undergoing Liver Transplantation Evaluation. Dig Dis Sci 2016; 61:2102-7. [PMID: 26993824 DOI: 10.1007/s10620-016-4124-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 03/06/2016] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Nonalcoholic fatty liver disease (NAFLD) is likely to replace Hepatitis C as the leading cause of cirrhosis resulting in liver transplantation (LT) within a few years. Unfortunately, due to the lack of established guidelines for the screening of NAFLD in high-risk populations, many patients present with portal hypertension complications as their first manifestation of NAFLD require a LT evaluation. We aimed to investigate what proportion of patients who underwent LT for NAFLD-cirrhosis had knowledge of their liver disease prior to presenting with portal hypertension complications and to identify differences in clinical parameters between those with and without knowledge of preexisting NAFLD. METHODS Consecutive patients who underwent LT for NAFLD-cirrhosis at a tertiary referral center were included in the study. Demographic and clinical data at the time of the first LT evaluation visit were collected, and patient knowledge of previous NAFLD was documented. Ascites, variceal bleeding, hepatic encephalopathy, and thrombocytopenia leading to diagnosis of underlying cirrhosis were considered as the presenting symptoms of portal hypertension. A p < 0.05 was considered statistically significant. RESULTS A total of 124 subjects who received LT for NAFLD-cirrhosis were included, 58 % (n = 72) were male. At the time of the first LT evaluation visit, 60 % had diabetes, the mean body mass index was 33.2 [28.6, 37.6] kg/m(2), and the mean Model for End-Stage Liver Disease (MELD) score was 14.0 [11.0, 19.0]. More importantly, 85/124 patients (68.5 %) had no knowledge of preexisting NAFLD prior to presentation with symptoms of portal hypertension. The presenting symptoms were new-onset ascites in 61 %, hepatic encephalopathy in 25 %, variceal bleeding in 18 %, thrombocytopenia in 9 %, and other in 9 % (non-exclusive). Patients with no prior knowledge of NAFLD were less likely to have a diagnosis of hypercholesterolemia (30 vs. 50 %, p = 0.035) and had a trend toward having higher MELD scores at the time of the first LT evaluation visit (15 vs. 13.5, p = 0.05) and presenting with encephalopathy (25 vs. 10 %, p = 0.06) compared to those with previous knowledge of NAFLD diagnosis. CONCLUSION The majority of patients undergoing liver transplant evaluation for NAFLD-cirrhosis are not aware of underlying NAFLD until they present with features of portal hypertension. New guidelines should consider screening for NAFLD in certain high-risk groups as more effective treatments for NAFLD are emerging.
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Effect of Weight Loss, Diet, Exercise, and Bariatric Surgery on Nonalcoholic Fatty Liver Disease. Clin Liver Dis 2016; 20:339-50. [PMID: 27063273 DOI: 10.1016/j.cld.2015.10.008] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is the hepatic manifestation of the metabolic syndrome. NAFLD is the most common liver disease in developed countries. Weight reduction of 3% to 5% is associated with improved steatosis; reductions of 5% to 7% are necessary for decreased inflammation; with 7% to 10%, individuals may experience NAFLD/NASH remission and regression of fibrosis. No specific dietary intervention has proven beneficial beyond calorie restriction. Physical activity without weight loss seems to decrease hepatic steatosis. Bariatric surgery is associated with decreased cardiovascular risk and improved overall mortality in addition to reduction in hepatic steatosis, inflammation, and fibrosis.
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Abstract
Nonalcoholic fatty liver disease (NAFLD) is the most common cause of abnormal serum aminotransferase levels in both developed and developing countries. Patients with nonalcoholic steatohepatitis (NASH), a subset of NAFLD, are at risk for progressive liver disease and in need of effective treatment options. A practical approach may be pursued by identifying patients with NAFLD with the highest likelihood for histologic evidence of NASH. Despite decades of clinical trials, no single treatment can be recommended to all patients with NASH. Importantly, there is no evidence that pioglitazone or vitamin E improves fibrosis. Bariatric surgeries may improve hepatic histology in morbidly obese patients with NASH, although randomized clinical trials are lacking. Currently, NASH is the second leading etiology of liver disease among adults awaiting liver transplantation in the United States. The primary and secondary prevention of NAFLD may require aggressive strategies for managing obesity, diabetes, and metabolic syndrome.
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Affiliation(s)
- Aijaz Ahmed
- Division of Gastroenterology and Hepatology, Liver Transplant Program, Stanford University School of Medicine, Stanford, California
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Alameda Health System, Highland Hospital Campus, Oakland, California
| | - Stephen A Harrison
- Division of Gastroenterology, San Antonio Military Medical Center, Fort Sam Houston, Texas.
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