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Serbis A, Polyzos SA, Paschou SA, Siomou E, Kiortsis DN. Diet, exercise, and supplements: what is their role in the management of the metabolic dysfunction-associated steatotic liver disease in children? Endocrine 2024; 85:988-1006. [PMID: 38519764 DOI: 10.1007/s12020-024-03783-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 03/13/2024] [Indexed: 03/25/2024]
Abstract
Metabolic dysfunction-associated steatotic liver disease (MASLD), previously known as nonalcoholic fatty liver disease (NAFLD), is the main cause of chronic liver disease in children and adolescents. Indeed, epidemiological studies have shown that MASLD affects up to 40% of children with obesity. Despite the recent approval of medications that target weight loss in adolescents that could have benefits on pediatric MASLD, lifestyle interventions, such as diet and exercise, remain the mainstay of our therapeutic approach. More specifically, studies on diet alone have focused on the possible role of carbohydrate or fat restriction, albeit without a definite answer on the best approach. Weight loss after dietary intervention in children with obesity and MASLD has a beneficial effect, regardless of the diet used. In relation to the role of exercise in MASLD reversal, indirect evidence comes from studies showing that a sedentary lifestyle leading to poor fitness, and low muscle mass is associated with MASLD. However, research on the direct effect of exercise on MASLD in children is scarce. A combination of diet and exercise seems to be beneficial with several studies showing improvement in surrogate markers of MASLD, such as serum alanine aminotransferase and hepatic fat fraction, the latter evaluated with imaging studies. Several dietary supplements, such as vitamin E, probiotics, and omega-3 fatty acid supplements have also been studied in children and adolescents with MASLD, but with equivocal results. This review aims to critically present available data on the effects of lifestyle interventions, including diet, exercise, and dietary supplements, on pediatric MASLD, thus suggesting a frame for future research that could enhance our knowledge on pediatric MASLD management and optimize clinicians' approach to this vexing medical condition.
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Affiliation(s)
- Anastasios Serbis
- Department of Pediatrics, School of Medicine, University of Ioannina, Ioannina, Greece.
| | - Stergios A Polyzos
- First Laboratory of Pharmacology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stavroula A Paschou
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Ekaterini Siomou
- Department of Pediatrics, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Dimitrios N Kiortsis
- Laboratory of Physiology, Medical School, University of Ioannina, Ioannina, Greece
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Yodoshi T, Orkin S, Trout AT, Catalina Arce-Clachar A, Bramlage K, Liu C, Fei L, Dillman JR, Xanthakos SA, Mouzaki M. Non-Invasive Approaches to Estimate Liver Steatosis and Stiffness in Children With Non-Alcoholic Fatty Liver Disease. J Pediatr Gastroenterol Nutr 2022; 74:495-502. [PMID: 34908012 PMCID: PMC9673005 DOI: 10.1097/mpg.0000000000003371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To develop pediatric-specific models that predict liver stiffness and hepatic steatosis in non-alcoholic fatty liver disease (NAFLD), based on clinical and laboratory data. METHODS Children with NAFLD, who had undergone magnetic resonance imaging with proton density fat fraction (MRI-PDFF) for steatosis quantification and/or magnetic resonance elastography (MRE) for liver stiffness assessment were included. We used data from patients imaged between April 2009 to July 2018 to develop a predictive model for fat fraction and stiffness. We validated the performance of the models using data from a second cohort, imaged between 2018 and 2019. RESULTS The first cohort (n = 344) consisted of predominantly non-Hispanic (80%), male (67%) adolescents. MRE data were available for 343 children, while PDFF data were available for 130. In multivariable regression, ethnicity, insulin levels, platelet count, and aspartate aminotransferase independently predicted liver stiffness and these variables were used to develop the predictive model. Similarly, sex, ethnicity, alanine aminotransferase, and triglycerides levels independently predicted liver PDFF and were used in the PDFF model. The AUC of the optimal cutoff for the model that predicted a stiffness of >2.71 kPa was 0.70 and for the model that predicted PDFF >5% was 0.78. The validation group (n = 110) had similar characteristics. The correlation coefficient of the model with the measured liver stiffness was 0.30 and with the measured liver PDFF was 0.26. CONCLUSIONS Pediatric-specific models perform poorly at predicting exact liver stiffness and steatosis; however, in the absence of magnetic resonance imaging can be used to predict the presence of significant steatosis (>5%) and/or significant stiffness (>2.71). Thus, imaging remains an invaluable adjunct to laboratory investigations in determining disease severity.
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Affiliation(s)
- Toshifumi Yodoshi
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Clinical Research and Quality Management, University of the Ryukyus Graduate School of Medicine, Okinawa Chubu Hospital, Okinawa, Japan
- Department of Pediatrics, Okinawa Chubu Hospital, Okinawa, Japan
| | - Sarah Orkin
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Andrew T. Trout
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Ana Catalina Arce-Clachar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Kristin Bramlage
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Chunyan Liu
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Lin Fei
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Jonathan R. Dillman
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Stavra A. Xanthakos
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Marialena Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
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Brecelj J, Orel R. Non-Alcoholic Fatty Liver Disease in Children. ACTA ACUST UNITED AC 2021; 57:medicina57070719. [PMID: 34357000 PMCID: PMC8304730 DOI: 10.3390/medicina57070719] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/12/2021] [Accepted: 07/14/2021] [Indexed: 12/15/2022]
Abstract
Background and Objectives: The prevalence of pediatric non-alcoholic fatty liver disease is increasing. A lot of new data are published regularly. Materials and Methods: Original clinical studies, review articles, and guidelines in children were searched for and the most relevant included in this review. Results: A total of 138 retrieved papers were classified into pathogenesis, epidemiology, diagnosis, and treatment. Pathogenesis is currently explained with the “multi hit hypothesis”, with complex interactions of genetic and environmental factors which trigger inflammation in steatotic liver. The prevalence is rising. A diagnosis can be made with laboratory tests, imaging, and liver biopsy after the exclusion of other causes of liver steatosis. The mainstay of treatment is lifestyle modification consisting of dietary intervention and increased physical activity. The progression to liver cirrhosis can occur even in children. Conclusions: Non-alcoholic fatty liver disease in children is a part of a metabolic syndrome in the majority of patients. Due to its complex etiology and high prevalence, multidisciplinary teams, together with public health professionals, should be involved in its treatment.
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Affiliation(s)
- Jernej Brecelj
- Department of Gastroenterology, Hepatology and Nutrition, University Children’s Hospital Ljubljana, Bohoriceva 20, SI-1000 Ljubljana, Slovenia;
- Department of Paediatrics, Faculty of Medicine, University of Ljubljana, Bohoriceva 20, SI-1000 Ljubljana, Slovenia
- Correspondence: ; Tel.: +386-1-5229-276
| | - Rok Orel
- Department of Gastroenterology, Hepatology and Nutrition, University Children’s Hospital Ljubljana, Bohoriceva 20, SI-1000 Ljubljana, Slovenia;
- Department of Paediatrics, Faculty of Medicine, University of Ljubljana, Bohoriceva 20, SI-1000 Ljubljana, Slovenia
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Draijer LG, Haggenburg S, Benninga MA, Chegary M, Koot BGP. Survey on screening for paediatric non-alcoholic fatty liver disease in clinical practice in Dutch hospitals. Acta Paediatr 2020; 109:2388-2393. [PMID: 32271954 PMCID: PMC7687083 DOI: 10.1111/apa.15294] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 02/26/2020] [Accepted: 03/31/2020] [Indexed: 12/20/2022]
Abstract
AIM Non-alcoholic fatty liver disease (NAFLD) is a highly prevalent liver disease that affects 34% of children with obesity. Besides the liver-related morbidity, NAFLD also increases the risk of cardiometabolic diseases at adult age. Diverse screening recommendations exist on paediatric NAFLD. The aim of this study was to assess screening practices among paediatricians managing children with obesity in the Netherlands. METHODS Between 2016 and 2017, an Internet-based survey was sent to all 167 members of the endocrinology section of the Dutch Paediatricians Society, that includes all paediatricians involved in obesity care. Descriptive statistics (frequencies) were used to analyse responses. RESULTS In total, 42/167 (25%) of the invited paediatricians responded. Thirty-six of 42 respondents (86%) screen for NAFLD. One-third of those do not follow any guideline. Most respondents use ALT as screening tool, with thresholds varying between 21-80 IU/L. The majority (29/36) indicate they lack guidance on screening and follow-up. CONCLUSION In this study sample of Dutch paediatricians, screening for paediatric NAFLD is widely, albeit not universally, performed and in a highly variable way. This underlines the need come to a uniform and comprehensive screening strategy and raise awareness about NAFLD among physicians treating children with obesity.
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Affiliation(s)
- Laura G. Draijer
- Department of Paediatric Gastroenterology and Nutrition Amsterdam University Medical Centers Location Academic Medical Center Emma Children’s Hospital Amsterdam The Netherlands
- Amsterdam Reproduction & Development Research Institute Amsterdam University Medical Centers Academic Medical Center/Emma Children’s Hospital Amsterdam The Netherlands
| | - Sabine Haggenburg
- Department of Paediatric Gastroenterology and Nutrition Amsterdam University Medical Centers Location Academic Medical Center Emma Children’s Hospital Amsterdam The Netherlands
| | - Marc A. Benninga
- Department of Paediatric Gastroenterology and Nutrition Amsterdam University Medical Centers Location Academic Medical Center Emma Children’s Hospital Amsterdam The Netherlands
| | - Malika Chegary
- Department of Paediatrics OLVG hospital Amsterdam The Netherlands
| | - Bart G. P. Koot
- Department of Paediatric Gastroenterology and Nutrition Amsterdam University Medical Centers Location Academic Medical Center Emma Children’s Hospital Amsterdam The Netherlands
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Ribeiro A, Igual-Perez MJ, Santos Silva E, Sokal EM. Childhood Fructoholism and Fructoholic Liver Disease. Hepatol Commun 2019; 3:44-51. [PMID: 30619993 PMCID: PMC6312651 DOI: 10.1002/hep4.1291] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 11/06/2018] [Indexed: 12/17/2022] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) is an emerging entity, becoming the most prevalent pediatric chronic liver disease. Its broad spectrum of histological findings, comorbidities, and complications, including cirrhosis and liver failure, can occur in childhood, emphasizing the severity of pediatric NAFLD. Current lifestyle and diet modifications have been linked to the increasing prevalence of NAFLD, including the rise of fructose consumption, a monosaccharide present in foods that contain added sugar, such as sugar‐sweetened beverages. Excessive fructose consumption is believed to cause addiction like alcohol and other drugs. As such, the new term “fructoholism” refers to the consumption of a substance (fructose) that can cause psychological and physical damage and become a major public health concern, highlighting the seriousness of the excessive consumption of fructose in the pediatric age. Hepatic fructose metabolization leads to hepatic steatosis and progression to fibrosis through mechanisms comparable to alcoholic liver disease, hence the term “fructoholic liver disease.” Conclusion: The importance of implementing reliable global strategies, such as education campaigns to promote healthy diet, increasing taxes on foods that contain added sugars, subsidies to promote accessibility to fruit and vegetables, and strict food industry regulation to reduce sugar intake in children and adolescents, cannot be overemphasized.
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Affiliation(s)
- Andreia Ribeiro
- Service de Gastroentérologie et Hépatologie Pédiatrique Cliniques Universitaires Saint-Luc, Université Catholique de Louvain Brussels Belgium
| | - Maria-Jose Igual-Perez
- Service de Gastroentérologie et Hépatologie Pédiatrique Cliniques Universitaires Saint-Luc, Université Catholique de Louvain Brussels Belgium
| | - Ermelinda Santos Silva
- Pediatric Gastroenterology and Hepatology Department Centro Materno-Infantil do Norte, Centro Hospitalar Universitário do Porto Porto Portugal
| | - Etienne M Sokal
- Service de Gastroentérologie et Hépatologie Pédiatrique Cliniques Universitaires Saint-Luc, Université Catholique de Louvain Brussels Belgium
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Serum Immunoglobulin A Levels Do Not Correlate With Liver Disease Severity in Pediatric Nonalcoholic Fatty Liver Disease. J Pediatr Gastroenterol Nutr 2018; 67:631-634. [PMID: 30363043 PMCID: PMC6447283 DOI: 10.1097/mpg.0000000000002104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Serum immunoglobulin A (IgA) is a biomarker of liver disease severity in adult nonalcoholic fatty liver disease (NAFLD). The objective of this study was to assess whether this is true in pediatric NAFLD. This was a retrospective study of children followed in the Steatohepatitis Center of a tertiary care center (2010-2017). Serum IgA levels, histology and biochemical markers of hepatocellular injury and metabolic dysregulation were collected. Of the 600 children with available serum IgA levels (mean age 14 ± 3 years, 62% boys, 80% non-Hispanic), IgA was elevated in 4%. The group with elevated IgA levels was younger and had a greater representation of Hispanic ethnicity compared with those with normal or low IgA. Body mass index and aminotransferases were not different between the groups. Histology was available for 170 children and was not different in those with elevated, normal and low IgA. In contrast to adults, serum IgA is not a biomarker of liver disease severity in pediatric NAFLD.
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Mouzaki M, Trout AT, Arce-Clachar AC, Bramlage K, Kuhnell P, Dillman JR, Xanthakos S. Assessment of Nonalcoholic Fatty Liver Disease Progression in Children Using Magnetic Resonance Imaging. J Pediatr 2018; 201:86-92. [PMID: 30041934 PMCID: PMC6429948 DOI: 10.1016/j.jpeds.2018.05.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 04/16/2018] [Accepted: 05/15/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To assess liver disease progression using paired magnetic resonance imaging (MRI) measurements of liver fat fraction (FF) and stiffness. STUDY DESIGN Retrospective cohort study including patients with nonalcoholic fatty liver disease who had undergone repeat MRI studies. Descriptive statistics were used, as well as Pearson or Spearman correlation when appropriate. Mixed model analyses were used to determine relationships between liver FF/stiffness and predictor variables. RESULTS Sixty-five patients (80% non-Hispanic, mean age 14 ± 3 years) were included. Time from first to last MRI was 27 ± 14 months. Over time, body mass index z score remained stable, and there were no significant differences in mean serum aminotransferases, insulin, glucose, triglycerides, low-density lipoprotein, and high-density lipoprotein (HDL) levels. However, the proportion of patients with alanine aminotransferase (ALT) < 50 U/L increased. MRI FF and stiffness decreased in 29% and 20% of patients, respectively, and increased in 25% and 22% of patients, respectively. There was a weak positive correlation between FF change and ALT change (r = 0.41, P = .053) and a moderate negative correlation between change in FF and change in serum HDL levels (r = -0.58, P = .004). After adjusting for HDL, increase in serum insulin was the only variable predictive of increase in FF (P = .061). There was no correlation between change in liver stiffness and change in ALT (r = .02, P = .910). CONCLUSIONS MRI-determined hepatic FF and stiffness improved in a minority of patients overtime. ALT levels were not reflective of the change in FF or stiffness. MRI-based imaging is complementary in the assessment of NAFLD progression.
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Affiliation(s)
- Marialena Mouzaki
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH.
| | - Andrew T Trout
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Ana Catalina Arce-Clachar
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kristin Bramlage
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Pierce Kuhnell
- Department of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jonathan R Dillman
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Stavra Xanthakos
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
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