Effect of Short Term Intensive Lifestyle Intervention on Hepatic Steatosis Indexes in Adults with Obesity and/or Type 2 Diabetes

Gender differences in adherence and retention in Mediterranean diet interventions with a weight-loss outcome: A systematic review and meta-analysis

BACKGROUND

The Mediterranean diet has been shown to be effective in improving health outcomes and for weight loss. Adherence and retention in dietary interventions are critical to ensure the benefits of the exposure. No studies to date have assessed the role of gender in understanding participants who remain engaged and adhere to Mediterranean diet interventions.

AIMS

This study aimed to explore gender differences in recruitment, adherence, and retention for Mediterranean diet interventions and whether these were associated with differences in weight-loss outcomes.

METHODS

A systematic search was completed in EMBASE, Medline, Cochrane, and clinicaltrials.gov from inception to March 2023. A meta-analysis of studies reporting retention by gender was completed using odds ratios comparing female to male dropout numbers. A second meta-analysis was completed for adherence comparing standardized mean difference of Mediterranean diet scores stratified by gender. Newcastle Ottawa score was used to assess risk of bias.

RESULTS

A total of 70 articles were included in the systematic review with six articles included in the adherence meta-analysis and nine in the dropout meta-analysis. No statistically significant difference was shown for adherence or retention by gender. Weight-loss outcomes were inconsistent.

CONCLUSIONS

The results of the study suggest a higher adherence and lower dropout for women although these results were not statistically significant. Future studies of Mediterranean diet interventions should include adherence, retention, and weight-loss data stratified by gender to allow further investigation of this relationship.

Fatty liver index (FLI): more than a marker of hepatic steatosis

Fatty liver index (FLI) was developed as a simple and accurate marker of hepatic steatosis. FLI is derived from an algorithm based on body mass index, waist circumference, and levels of triglycerides and gamma-glutamyltransferase, and it is widely used in clinical and epidemiological studies as a screening tool for discriminating between healthy and nonalcoholic fatty liver disease (NAFLD) subjects. However, a systematic review of the literature regarding FLI revealed that this index has more extensive relationships with biochemical and physiological parameters. FLI is associated with key parameters of lipid, protein and carbohydrate metabolism, hormones, vitamins and markers of inflammation, or oxidative stress. FLI can be a predictor or risk factor for a number of metabolic and nonmetabolic diseases and mortality. FLI is also used as an indicator for determining the effects of health-related prevention interventions, medications, and toxic substances on humans. Although in most cases, the exact mechanisms underlying these associations have not been fully elucidated, they are most often assumed to be mediated by insulin resistance, inflammation, and oxidative stress. Thus, FLI may be a promising marker of metabolic health due to its multiple associations with parameters of physiological and pathological processes. In this context, the present review summarizes the data from currently available literature on the associations between FLI and biochemical variables and physiological functions. We believe that this review will be of interest to researchers working in this area and can provide new perspectives and directions for future studies on FLI.

Metabolic Dysfunction-Associated Steatotic Liver Disease and Metabolic Dysfunction-Associated Steatohepatitis: The Patient and Physician Perspective

Diagnosing and managing metabolic dysfunction-associated steatotic liver disease (MASLD) remains a major challenge in primary care due to lack of agreement on diagnostic tools, difficulty in identifying symptoms and determining their cause, absence of approved pharmacological treatments, and limited awareness of the disease. However, prompt diagnosis and management are critical to preventing MASLD from progressing to more severe forms of liver disease. This highlights the need to raise awareness and improve understanding of MASLD among both patients and physicians. The patient perspective is invaluable to advancing our knowledge of this disease and how to manage it, as their perspectives have led to the growing recognition that patients experience subtle symptoms and that patient-reported outcomes should be incorporated into drug development. This review and expert opinion examine MASLD and metabolic dysfunction-associated steatohepatitis from the patient and physician perspective from pre-diagnosis to diagnosis and early care, through to progression to advanced liver damage. Specifically, the paper dives into the issues patients and physicians experience, and, in turn, what is required to improve diagnosis and management, including tips and tools to empower patients and physicians dealing with MASLD.

Stages of psychological change among patients with non-alcoholic fatty liver disease in China: a national cross-sectional study

OBJECTIVES

Non-alcoholic fatty liver disease (NAFLD) is becoming the leading cause of chronic liver disease worldwide. However, treatment of NAFLD is potentially influenced by psychological conditions. Using the simplified version of the University of Rhode Island Change Assessment (URICA-SV) scale, this study aimed to evaluate the stage of psychological change as a prerequisite to refining implementation strategies for psychological change.

DESIGN

A multicentre cross-sectional survey.

SETTING

Ninety hospitals in China.

PARTICIPANTS

5181 patients with NAFLD were included in this study.

OUTCOME MEASURES

All patients completed the URICA-SV questionnaire and were assigned to one of the three stages of change (precontemplation, contemplation or action) according to their readiness scores. A stepwise multivariate logistic regression analysis was used to identify independent factors associated with the stage of psychological change.

RESULTS

A total of 4832 (93.3%) patients were included in the precontemplation stage and only 349 (6.7%) considered making a change or preparing to make one. There were significant differences in gender (Cohen's d=0.039, p=0.005), age (Cohen's d=-0.327, p<0.001), waist circumference (Cohen's d=0.143, p=0.003), alanine transaminase (Cohen's d=0.347, p=0.001), triglyceride (Cohen's d=0.351, p=0.002), body mass index (BMI; Cohen's d=0.056, p<0.001), proportion of hyperlipidaemia (Cohen's d=0.068, p<0.001) and cardiovascular disease (Cohen's d=0.032, p=0.029), therapeutic regimen (Cohen's d=0.136, p<0.001), and Chronic Liver Disease Questionnaire-Non-Alcoholic Fatty Liver Disease overall score (Cohen's d=-0.420, p<0.001) between patients with NAFLD in the precontemplation stage and those in the contemplation/action stage. Logistic regression identified BMI (HR 0.659, 95% CI 0.469 to 0.928, p=0.017), cardiovascular disease (HR 2.161, 95% CI 1.089 to 4.287, p=0.027) and triglyceride (HR 0.751, 95% CI 0.591 to 0.955, p=0.020) as independent factors predicting psychological change.

CONCLUSIONS

The results demonstrated that very few patients with NAFLD presented psychological condition in the stage of action. Psychological condition was found to be significantly related to BMI, cardiovascular disease and triglyceride factors. Integrated diversity considerations for evaluating psychological change are necessary.

Fatty liver index relationship with biomarkers and lifestyle: result from RaNCD cohort study

BACKGROUND

Lifestyle intervention can effectively treat patients with non-alcoholic fatty liver disease (NAFLD). The present study aimed to investigate the association between lifestyle factors with fatty liver index (FLI) in Iranian adults.

METHODS

This study enrolled 7114 subjects from the Ravansar Non-Communicable Diseases (RaNCD) cohort study in western Iran. To compute the FLI score, anthropometric measures, and a few non-invasive liver status indicators were used. Binary logistic regression models examined the association between FLI score and lifestyle.

RESULTS

Participants with FLI < 60 had a lower daily energy intake compared to those with FLI ≥ 60 (2740.29 vs. 2840.33 kcal/day, P = < 0.001). The risk of NAFLD in males with high socioeconomic status (SES) was 72% higher than in those with low SES (OR: 1.72; 95% CIs 1.42-2.08). An adjusted logistic regression model showed a significantly negative association between high physical activity and fatty liver index in both men and women. (OR: 0.44, p-value < 0.001 and OR: 0.54, p-value < 0.001, respectively). The odds of NAFLD in female participants with depression were 71% higher than in non-depressed participants (OR: 1.71, 95% CI: 1.06-2.64). Dyslipidemia and high visceral fat area (VFA) were also associated with a significant increase in the risk of NAFLD (P < 0.05).

CONCLUSION

In our study, we found that good SES, high VFA, and dyslipidemia were associated with an increased risk of NAFLD. Conversely, high physical activity reduces the risk of NAFLD. Therefore, lifestyle modification may help improve liver function.

Obesity-Induced Hepatic Steatosis Is Partly Mediated by Visceral Fat Accumulation in Subjects with Overweight/Obesity: A Cross-Sectional Study

INTRODUCTION

We explored whether visceral fat accumulation mediates the development of hepatic steatosis in individuals living with overweight and obesity.

METHODS

This cross-sectional study enrolled 769 outpatients with overweight and obesity aged 18-65 years. The controlled attenuation parameter (CAP) was used to quantify the degree of hepatic steatosis. Visceral fat accumulation, represented by the visceral fat area (VFA), was measured using magnetic resonance imaging. The associations of body mass index (BMI), VFA, and CAP with each other were assessed by univariate analysis, multivariate linear regression, and mediation analysis, respectively.

RESULTS

Compared with women, male subjects had higher BMI, VFA, and CAP levels. In both sex, CAP was positively correlated with BMI and VFA by the univariate analysis. After adjusting for demographic and serum characteristics, the linear correlation coefficients between BMI and CAP were 1.738 (95% confidence interval (CI): 1.100, 2.377), 1.524 (95% CI: 0.798, 2.249), and 2.650 (95% CI: 1.292, 4.009) in all subjects, females, and males, respectively, while those between VFA and CAP were 0.190 (95% CI: 0.133, 0.247), 0.184 (95% CI: 0.117, 0.252), and 0.194 (95% CI: 0.086, 0.301). Mediation analysis showed that visceral fat accumulation contributed to 51.37%, 53.85%, and 26.51% of obesity-induced hepatic steatosis in the total, female, and male subjects, respectively.

CONCLUSION

Visceral fat accumulation partially mediates obesity-induced hepatic steatosis in individuals with overweight and obesity, especially in women. More focus on visceral fat reduction is needed in individuals with obesity.

Impact of BMI, Physical Activity, and Sitting Time Levels on Health-Related Outcomes in a Group of Overweight and Obese Adults with and without Type 2 Diabetes

Physical activity level and sedentary behaviors affect health status in people with obesity and type 2 diabetes (DM2); their assessment is mandatory to properly prescribe exercise programs. From January 2011 to February 2014, 293 overweight/obese adults (165 women and 128 men, mean age of 51.9 ± 9.5 years and 54.6 ± 8.3 years, respectively), with and without DM2, participated in a three-month intensive exercise program. Before starting, participants were allocated into three subgroups (overweight, body mass index or BMI = 25-29.9; class 1 of obesity, BMI = 30-34.4; or class 2 (or superior) of obesity, BMI > 35). The international physical activity questionnaire (IPAQ-it) was used to evaluate participants' baseline sitting time (SIT) and physical activity level (PAL). Stratified multiple analyses were performed using four subgroups of SIT level according to Ekelund et al., 2016 (low, 8 h/day of SIT) and three subgroups for PAL (high, moderate, and low). Health-related measures such as anthropometric variables, body composition, hematic parameters, blood pressure values, and functional capacities were studied at the beginning and at the end of the training period. An overall improvement of PAL was observed in the entire sample following the three-month intensive exercise program together with a general improvement in several health-related measures. The BMI group factor influenced the VO₂ max variations, leg press values, triglycerides, and anthropometric variables, while the SIT group factor impacted the sitting time, VO₂ max, glycemic profile, and fat mass. In this study, baseline PAL and SIT did not seem to influence the effects of an exercise intervention. The characteristics of our educational program, which also included a physical exercise protocol, allowed us to obtain positive results.

The Visceral Adiposity Index in Non-Alcoholic Fatty Liver Disease and Liver Fibrosis-Systematic Review and Meta-Analysis

(1) Background: In order to avoid a liver biopsy in non-alcoholic fatty liver disease (NAFLD), several noninvasive biomarkers have been studied lately. Therefore, we aimed to evaluate the visceral adiposity index (VAI) in NAFLD and liver fibrosis, in addition to its accuracy in predicting NAFLD and NASH. (2) Methods: We searched PubMed, Embase, Scopus, and Cochrane Library, identifying observational studies assessing the VAI in NAFLD and liver fibrosis. QUADAS-2 was used to evaluate the quality of included studies. The principal summary outcomes were mean difference (MD) and area under the curve (AUC). (3) Results: A total of 24 studies were included in our review. VAI levels were significantly increased in NAFLD (biopsy-proven and ultrasound-diagnosed), simple steatosis vs. controls, and severe steatosis vs. simple steatosis. However, no significant MD was found according to sex, liver fibrosis severity, simple vs. moderate and moderate vs. severe steatosis, pediatric NAFLD, and NASH patients. The VAI predicted NAFLD (AUC 0.767) and NASH (AUC 0.732). (4) Conclusions: The VAI has a predictive value in diagnosing NAFLD and NASH, with significantly increased values in adult NAFLD patients, simple steatosis compared to controls, and severe steatosis compared to simple steatosis.

Effective Treatment of Nonalcoholic Fatty Liver Disease Using a Community-Based Weight Management Program

Introduction

Obesity-related gastrointestinal disorders including nonalcoholic fatty liver disease (NAFLD) and gastroesophageal reflux disease (GERD) are more frequent and usually present earlier than type 2 diabetes mellitus (T2DM) and cardiovascular disorders. This provides an opportunity for the gastroenterologist to intervene early with an effective weight-loss therapy. We evaluated the outcomes of a multifaceted, community-based gastroenterologist-supervised weight management program compared with patient-directed weight-loss efforts after physician advice. The program is aimed at achieving a 10% total body weight (TBW) loss at three months, a known determinant for NAFLD regression.

Methods

This is a retrospective pre- and post-intervention study of NAFLD patients, who participated in a medically supervised weight management program in the period between May 2017 and May 2019. The program is comprised of a very-low-calorie (800 kcal/day) meal replacement diet, a recommended medical fitness program, and weekly behavioral support groups. Patients are followed on monthly basis and slowly transitioned to a whole food plant-based or Mediterranean diet after three months of participation. Patients’ weight trends driven by self-directed efforts to lose weight after physician advice were collected based on historical data up to two years prior to program participation. The primary outcome was defined as percentage TBW loss at three months under medical supervision (post-intervention) compared with patient-directed weight-loss efforts (pre-intervention). The secondary outcomes included percentage TBW loss in relation to behavioral support group attendance and improvement in GERD and T2DM disease status after program participation. Linear mixed and linear regression models were used to assess for a statistically significant difference in percentage TBW loss. Statistical significance was defined as p < 0.05.

Results

A total of 114 NAFLD patients (mean age 55 years, mean BMI 39 kg/m², 77 females, and 37 males) completed at least three months of follow-up and were included in the study. Of those, 89 patients had a documented three-month office visit. At three months, 65% of patients had lost at least 10% of their TBW. Percentage TBW loss under medical supervision was noted to be significantly higher and occurred at a faster rate over three months when compared with patient-directed efforts after physician advice (p < 0.001). Patients who attended the behavioral support groups ≥ 50% of the time had a 3% higher TBW loss at three months compared with patients who attended <50% of the time (p = 0.006). Approximately, 52% of patients with GERD and 38% of patients with T2DM had symptoms improvement and/or medication reduction at their three-month follow-up visit.

Conclusion

A multifaceted, community-based, gastroenterologist supervised weight management program is effective in achieving a clinically significant TBW loss of at least 10% within three months of participation. This weight loss was greater and occurred at a faster rate when compared with patient-directed efforts. Additionally, improvement in GERD and T2DM disease status was noted in 52% and 38% of patients with these conditions, respectively. Further community-based studies of a larger scale are needed to determine the sustainability of this weight loss over one year.

The performance of noninvasive indexes of adults in identification of nonalcoholic fatty liver disease in children

BACKGROUND

The aim of this study is to evaluate the performance of three existing prediction scores which are applicable to adults for identifying nonalcoholic fatty liver disease (NAFLD) in Chinese children.

METHODS

We used data from routine check-up based medical records of 1845 children to validate the performance of three existing scoring systems including the hepatic steatosis index (HSI), Zhejiang University index (ZJU index), and triglyceride-glucose index (TyG index) in detection of NAFLD in children. Propensity score matching was applied to adjust for potential confounding effects in both training and validation cohorts. The area under the curve (AUC) of the receiver operating characteristic curve analysis was utilized to assess the performance of the three scoring systems.

RESULTS

Children with NAFLD had higher scores of HSI, ZJU index, and TyG index when compared with the control group (children without NAFLD). Elevated HSI, ZJU index, and TyG index scores were significantly associated with the presence of pediatric NAFLD since adjusted odds ratio and 95% CI with per interquartile range elevation of the HSI, ZJU index, and TyG index were 32.81 (20.48, 52.55), 26.31 (16.97, 40.79), and 1.83 (1.57, 2.13), respectively. In terms of discrimination of NAFLD in children, the AUC of the HSI, ZJU index, and TyG index depending on the validation cohort were 0.964, 0.960, and 0.769, respectively.

CONCLUSIONS

The HSI and ZJU index could be appropriate noninvasive biomarkers in distinguishing NAFLD in children from their controls with satisfied accuracy, which would emphasize the clinical and public health policy relevance of pediatric NAFLD. Our findings need to be confirmed by additional longitudinal studies.

Influence of Psychological Biomarkers on Therapeutic Adherence by Patients with Non-Alcoholic Fatty Liver Disease: A Moderated Mediation Model

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.

Joint Effect of Hepatic Steatosis and Alanine Aminotransferase Within the Normal Range on Incident Ischemic Heart Disease: A Prospective Study in Koreans

Purpose

Hepatic steatosis has been associated with some cardiovascular risks. Increased alanine aminotransferase (ALT) was suggested to be linked to endothelial dysfunction. We prospectively investigated the joint effect of hepatic steatosis and elevated ALT within the normal range on incident ischemic heart disease (IHD) risk as an extrahepatic complication.

Patients and Methods

We assessed 16,541 participants without diabetes using data from a health risk assessment study (HERAS) and Korean Health Insurance Review and Assessment (HIRA) data. We defined elevated ALT within the normal range as 30-40 IU/L in men and 23-40 IU/L in women, according to previous Korean epidemiological data. We prospectively assessed hazard ratios (HRs) with 95% confidence intervals (CIs) for IHD using multivariate Cox proportional hazards regression models over a 50-month period after the baseline survey.

Results

During the follow-up period, 368 (2.2%) participants developed IHD. Compared to the group with no hepatic steatosis and controlled ALT, the HRs for IHD were 1.68 (95% CI, 1.16-2.42) in the group with hepatic steatosis and elevated ALT after adjusting for confounding variables.

Conclusion

Hepatic steatosis and elevated ALT levels within the normal range may jointly affect the development of IHD among nondiabetic adults. This indicates that lifestyle advice and vascular health management should be recommended among individuals with hepatic steatosis and elevated ALT, even if it falls within the normal range.

Mediterranean Diet for the Prevention of Gestational Diabetes in the Covid-19 Era: Implications of Il-6 In Diabesity

The aim of this review is to highlight the influence of the Mediterranean Diet (MedDiet) on Gestational Diabetes Mellitus (GDM) and Gestational Weight Gain (GWG) during the COVID-19 pandemic era and the specific role of interleukin (IL)-6 in diabesity. It is known that diabetes, high body mass index, high glycated hemoglobin and raised serum IL-6 levels are predictive of poor outcomes in coronavirus disease 2019 (COVID-19). The immunopathological mechanisms of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection include rising levels of several cytokines and in particular IL-6. The latter is associated with hyperglycemia and insulin resistance and could be useful for predicting the development of GDM. Rich in omega-3 polyunsaturated fatty acids, vitamins, and minerals, MedDiet improves the immune system and could modulate IL-6, C reactive protein and Nuclear Factor (NF)-κB. Moreover, polyphenols could modulate microbiota composition, inhibit the NF-κB pathway, lower IL-6, and upregulate antioxidant enzymes. Finally, adhering to the MedDiet prior to and during pregnancy could have a protective effect, reducing GWG and the risk of GDM, as well as improving the immune response to viral infections such as COVID-19.

Cold Press Pomegranate Seed Oil Attenuates Dietary-Obesity Induced Hepatic Steatosis and Fibrosis through Antioxidant and Mitochondrial Pathways in Obese Mice

Aim: Obesity is associated with metabolic syndrome, hypertension, dyslipidemia, nonalcoholic fatty liver disease (NAFLD), and type 2 diabetes. In this study, we investigated whether the dietary supplementation of pomegranate seed oil (PSO) exerted a protective effect on liver lipid uptake, fibrosis, and mitochondrial function in a mouse model of obesity and insulin resistance. Method: In this in vivo study, eight-week-old C57BL/6J male mice were fed with a high fat diet (HFD) for 24 weeks and then were divided into three groups as follows: group (1) Lean; group (n = 6) (2) HF diet; group (n = 6) (3) HF diet treated with PSO (40 mL/kg food) (n = 6) for eight additional weeks starting at 24 weeks. Physiological parameters, lipid droplet accumulation, inflammatory biomarkers, antioxidant biomarkers, mitochondrial biogenesis, insulin sensitivity, and hepatic fibrosis were determined to examine whether PSO intervention prevents obesity-associated metabolic syndrome. Results: The PSO group displayed an increase in oxygen consumption, as well as a decrease in fasting glucose and blood pressure (p < 0.05) when compared to the HFD-fed mice group. PSO increased both the activity and expression of hepatic HO-1, downregulated inflammatory adipokines, and decreased hepatic fibrosis. PSO increased the levels of thermogenic genes, mitochondrial signaling, and lipid metabolism through increases in Mfn2, OPA-1, PRDM 16, and PGC1α. Furthermore, PSO upregulated obesity-mediated hepatic insulin receptor phosphorylation Tyr-⁹⁷², p-IRB tyr¹¹⁴⁶, and pAMPK, thereby decreasing insulin resistance. Conclusions: These results indicated that PSO decreased obesity-mediated insulin resistance and the progression of hepatic fibrosis through an improved liver signaling, as manifested by increased insulin receptor phosphorylation and thermogenic genes. Furthermore, our findings indicate a potential therapeutic role for PSO in the prevention of obesity-associated NAFLD, NASH, and other metabolic disorders.

A Mixed Methods Evaluation of a Randomized Control Trial to Evaluate the Effectiveness of the Pure Prairie Living Program in Type 2 Diabetes Participants

The primary objective of this randomized control trial was to evaluate the effectiveness of the Pure Prairie Living Program (PPLP) in a primary care setting. Adults with type 2 diabetes were randomized into intervention (PPLP, n = 25) and wait-listed controls (CON, n = 24). The PPLP group participated in education sessions. The intervention yielded no significant within-group changes in HbA1c at three-month (-0.04 (-0.27 to 0.17) and -0.15 (-0.38 to 0.08)) or six-month (-0.09 (-0.41 to 0.22) and 0.06 (-0.26 to 0.38)) follow ups in either CON or PPLP groups, respectively. Dietary adherence scores improved in the PPLP group (p < 0.05) at three and six months but were not different in the between-group comparison. No changes in diabetes self-efficacy scores were detected. In the qualitative analysis, participants described the program as clear and easy to understand. Knowledge acquired influenced their everyday decision making but participants faced barriers that prevented them from fully applying what they learned. Healthcare professionals enjoyed delivering the program but described the "back-stage" workload as detrimental. In conclusion, while some positive effects of the PPLP intervention were observed, they were not comparable to those previously attained by our group in an academic setting or to what the guidelines recommend, which reflects the challenge of translating lifestyle intervention to real-world settings.

Managing NAFLD in Type 2 Diabetes: The Effect of Lifestyle Interventions, a Narrative Review

The prevalence of non-alcoholic fatty liver disease (NAFLD) and type 2 diabetes (T2D) is increasing. As a strong association between these two diseases exist, it is unsurprising that the number of patients with coexisting NAFLD and T2D is also increasing. These patients display a deleterious metabolic profile (e.g. hypertriglyceridemia), and increased mortality rates relative to those with only NAFLD or T2D in isolation; therefore, effective treatment strategies are required. Here we review the available intervention studies that have investigated the effects of changes in lifestyle (diet and exercise/physical activity) on NAFLD in patients with both NAFLD and T2D. On the basis of the available evidence, it appears that the addition of any kind of exercise (i.e. resistance, aerobic, or high-intensity intermittent exercise) is beneficial for patients with both NAFLD and T2D. These effects appear to occur independently of changes in body weight. Hypocaloric diets leading to weight loss are also effective in improving metabolic parameters in patients with both NAFLD and T2D, with data indicating that ~ 7–10% weight loss is required in order to observe beneficial effects. It is unclear if multidisciplinary interventions incorporating changes in both diet and physical activity levels are a more effective treatment strategy in this population than diet or exercise interventions in isolation. In conclusion, it is clear that lifestyle interventions are an effective treatment strategy in patients with both NAFLD and T2D, although further research is required to optimise these interventions and determine their scalability.