Weight Loss Contract for Patients with NASH/Fatty Liver

I understand that I am by calculated BMI, Body Mass Index (Website MedCalc)

Overweight: _____ BMI 25-29.9
Obese: _______ BMI 30-34.9
Morbidly Obese: ______ BMI 35-39.9

I understand that I am at high risk of dying from: liver failure, many types of cancer including liver cancer,
heart disease, kidney failure or stroke: ____________ (initials)
I am committed to a stringent long-term goal of attaining a healthy weight: _______________________
(initials) BMI 24 for Caucasians/other ethnic groups, BMI 23 for Asians
I hereby am committed to a weight loss program that works: _________ (initials)
1) Nutrition consult now, treat high cholesterol if present, treat diabetes if present
2) Keep a log book within a paper folder or using this online website:
http://www.myfooddiary.com/
a. daily weights
b. daily calorie counts
In addition: document your activity
c. 3 hours of exercise per week
i. heart rate over 100 for 3 hours
ii. learn to take heart rate or obtain and use a heart rate monitor
3) Initiate an immediate 40 % calorie restriction
4) 5 small meals per day
a. Use tea cup saucers for all meals, no second servings
b. High protein
c. Moderate carbohydrate
d. Low fat
e. Mediterranean/Vegetarian diet preferred
5) No liquids from plastic bottles, use only glass/metal storage containers (see information on bis-
Phenols (see website: “Nova”, keyword “epigenetics”)
6) No alcohol
7) Utilize “Hungry is healthy” motto
8) Coffee is recommended up to 3-5 cups per day provided that this no sleep effect and is liver
protective
9) If you have NASH/fatty liver: Natural vitamin E is recommended at 800IU per day, discuss this
dosing with your provider
10) Statins are safe for the treatment of high cholesterol and recommended if you meet treatment
guidelines
11) Probiotics 50 Billion Level is/are recommended if you have NASH/fatty liver and Prebiotics
IsoThrive https://isothrive.com/ 5mL daily
12) Fiber supplements: 2 times per day with meals
13) Sign and date this weight contract and mail to your provider
14) Post the weight loss contract in your:
a. Bedroom
b. Bathroom
c. Kitchen

______________ ___________________ ____________________

Name Signature Date