Differential Diagnosis
such as hepatitis C.
Hepatic Steatosis
RULE IN
EPIDEMIOLOGY
21% (mild-severe hepatic steatosis) in the
lean population (body mass index <25
kg/m2)31 and 27% in non - obese population
(body mass index <30 kg/m2)
RISK FACTORS
● Obesity
● High - fat diet
● High alcohol intake
● Diabetes mellitus
CLINICAL FEATURES
● Hepatomegaly
● Mild elevation of serum bilirubin
● Mild elevation of alkaline
phosphatase
● Severe hepatic dysfunction is
unusual
Alcoholic Liver Disease
RULE IN
EPIDEMIOLOGY
● Starts with steatosis and progresses
to fibrosis and ultimately cirrhosis in
approximately 20% to 25% of
patients who drink heavily over
many years.
● Chronic alcohol use of
approximately 20 to 50 g/day for
women or 60 to 80 g/day for men
increases the risk for alcoholic
cirrhosis.
RISK FACTORS
● Overweight or obese.
● Female – women appear to be more
vulnerable than men to the harmful
effects of alcohol.
● Having a pre-existing liver condition,
● Genetics – alcohol dependence and
problems processing alcohol often
run in families.
RULE OUT
CLINICAL FEATURES
CLINICAL FEATURES ● Losing muscle tone (atrophy)
● BMI: 26 - Overweight ● Bruising easily
● Total cholesterol: 259 mg/dL - ● Loss of appetite and weight loss
Increased ● Yellowing of the skin and eyes
● Triglycerides: 175 mg/dL - (jaundice)
Increased
● LDL: 200 mg/dL -
● Fluid build-up and swelling of the
legs (edema) and abdomen (ascites)
Increased
● Fasting Blood Sugar: 98 mg/dL - ● Bleeding in your mouth (mouth
within the normal range bleeds) or vomiting blood
● Patchy red skin on the palms of your
Ultrasound of the whole abdomen: hands (erythema)
Hepatic steatosis, Grade 1 with mild ● Confusion, memory loss, poor
hepatomegaly with craniocaudal concentration, and mental fog
measurement of 16.7 cm
RISK FACTORS
Takes in alcoholic beverages occasionally,
cannot even finish 2 bottles of beer.
Non alcoholic steatohepatitis
RULE IN RULE OUT
EPIDEMIOLOGY
● About 2-3% of the general CLINICAL FEATURES
population is estimated to have non-
RULE OUT alcoholic steatohepatitis (NASH), Total cholesterol: 259 mg/dL - Increased
which may progress to liver cirrhosis Triglycerides: 175 mg/dL - Increased
CLINICAL FEATURES and hepatocarcinoma BMI: 26 - Overweight
● Flat abdomen ● The prevalence of NASH among
● Liver span noted 15 cm on the right NAFLD patients who underwent a
midclavicular line random liver biopsy was 6.67%.
● No tenderness on abdominal
palpation RISK FACTORS No tenderness on abdominal palpation
● No edema on extremities ● High cholesterol Ultrasound of the whole abdomen:
● Full pulses ● High levels of triglycerides in the Hepatic steatosis, Grade 1 with mild
blood hepatomegaly with craniocaudal
RISK FACTORS measurement of 16.7 cm
● Metabolic syndrome
● Non-cigarette smoker
● Takes in alcoholic beverages
● Obesity, particularly when fat is
concentrated in the abdomen
occasionally, cannot even finish 2
bottles of beer ● Polycystic ovary syndrome
Elevated ALT
● Sleep apnea
Normal AST
● Type 2 diabetes
● Underactive thyroid (hypothyroidism)
● Underactive pituitary gland
 (hypopituitarism)
● Non specific symptoms:
○ Fatigue
○ Complain on right - sided
abdominal discomfort with
metabolic syndrome
CLINICAL FEATURES
Abdominal obesity
- Men: waist circumference >40 inches
- Women: waist circumference >35 inches
Serum AST & ALT are elevated

● Fasting glucose ≥110 and < 126

mg/dL
● Blood pressure ≥130/80 mm Hg
● Triglycerides ≥150 mg/dL
● HDL cholesterol: Men <40 mg/dL;
women <50 mg/dL
III. ETIOLOGY & PATHOPHYSIOLOGY insulin actions. Obese adipose depots also produce excessive soluble factors (adipokines)
that inhibit tissue insulin sensitivity.

2. Dietary Factors – Patient M’s diet is rich in carbohydrate and saturated fat
ETIOLOGY

The etiology of non-alcoholic fatty liver disease (NAFLD) is multifactorial. It is thought to result
from a combination of genetic, environmental, and metabolic factors that lead to fat
accumulation in the liver. The main etiological factors of NAFLD are:
1. Insulin resistance: Insulin resistance is a condition where the body's cells become less
responsive to insulin, resulting in high levels of insulin in the blood. This condition is
commonly associated with obesity and metabolic syndrome, and is a major risk factor for
NAFLD.
PATHOPHYSIOLOGY
The key histologic feature of NAFLD is the accumulation of fats in the hepatocytes. This results
when hepatocyte mechanisms for triglyceride synthesis (lipid uptake and de novo lipogenesis)
overwhelm mechanisms for triglyceride disposal (degradative metabolism and lipoprotein
export) leading to accumulation of fat within hepatocytes.

2. Overweight/Obesity: Overweight and Obesity are strongly associated with NAFLD, and
are one of the most common risk factors for the disease. It is thought that the excess fat
in the body can lead to fat accumulation in the liver.

3. Metabolic syndrome: Metabolic syndrome is a cluster of conditions that includes high

blood pressure, high blood sugar, high cholesterol, and abdominal obesity. It is strongly
associated with NAFLD, and many people with NAFLD also have metabolic syndrome.

4. Dietary factors: A high intake of fructose, glucose and saturated fats has been linked to
the development of NAFLD.

5. Genetics: Certain genetic mutations have been associated with an increased risk of
NAFLD.

6. Medications: Some medications, such as corticosteroids, tamoxifen, and antiretroviral

therapy for HIV, have been linked to the development of NAFLD.

The case presented that Patient M has a rich carbohydrate diet (rice, pasta, bread), processed
snacks and chips, and it is also noted he has no limitations on his soda consumption. Highly
processed food is often rich in fructose and saccharose – especially soda. Sodas contain high
amounts of aspartame and caramel colorant. Aspartame is a peptide ester which is sweeter than
saccharose. The intake of processed food high in aspartame causes weight gain and increases
the risk of diabetes mellitus development. Fructose intensifies lipogenesis and triglyceride
synthesis. As for processed snacks and chips, which are food high in monosodium glutamate
(MSG). MSG intake contributes to the rise in free fatty acids and triglyceride serum concentrations. Increased energy intake, particularly with a Western diet rich in sucrose, high-fructose corn syrup,
Exposition to MSG causes deterioration in β-oxidation of fatty acids. and saturated fat, leads to NAFLD and increased ectopic lipid deposition in skeletal muscle.
Increases in intramyocellular lipid content, stimulates SREBP1c, which, in turn, promotes
However, going back to the case, Patient M has normal fasting blood sugar of 98 mg/dL. increased expression of key hepatic enzymes that regulate DNL, resulting in increased VLDL
production, hypertriglyceridemia, and NAFLD. Increased rates of lipolysis and increased fatty acid
The etiologic factors that most likely caused Patient M’s NAFLD are: delivery to the liver, which promotes increased fatty acid esterification into hepatic triglycerides.
Triglyceride rich lipoproteins (TRLs) are cleared from the circulation by peripheral lipoprotein
1. Overweight – with a BMI of 25.8, Patient M is overweight.
lipase (Lpl) activity. Endogenous Lpl inhibitors (e.g. ApoC3, ANGPTL3/8 complex, and ANGPTL4)
Overweight/Obesity stimulates hepatocyte triglyceride accumulation by altering the
attenuate peripheral triglyceride clearance, increasing hepatic triglyceride uptake from TRLs (e.g.
intestinal microbiota to enhance both energy harvest from dietary sources and intestinal
chylomicron remnants).
permeability. Reduced intestinal barrier function increases hepatic exposure to gut-
derived products, which stimulate liver cells to generate inflammatory mediators that inhibit
METABOLISMS INVOLVED
Glucose Metabolism
Glycolysis
The breakdown of glucose occurs in several stages, each of which involves different enzymes.
Here is a brief overview of the major enzymes involved in glucose metabolism:
1. Hexokinase: This enzyme catalyzes the conversion of glucose to glucose-6-phosphate,
the first step in glucose metabolism. This reaction requires the input of ATP, which is
hydrolyzed to ADP.
2. Phosphoglucose isomerase: This enzyme catalyzes the conversion of glucose-6-
phosphate to fructose-6-phosphate. This reaction is an isomerization, meaning that the
molecule is rearranged without any change in its molecular formula.
3. Phosphofructokinase: This enzyme catalyzes the conversion of fructose-6-phosphate to
fructose-1,6-bisphosphate, a key regulatory step in glucose metabolism. This reaction also
requires the input of ATP.
4. Aldolase: This enzyme cleaves fructose-1,6-bisphosphate into two three-carbon
molecules: dihydroxyacetone phosphate and glyceraldehyde-3-phosphate.
5. Triose phosphate isomerase: This enzyme catalyzes the isomerization of
dihydroxyacetone phosphate into glyceraldehyde-3-phosphate, which is an important
intermediate in the subsequent steps of glucose metabolism.
6. Glyceraldehyde-3-phosphate dehydrogenase: This enzyme catalyzes the oxidation of
glyceraldehyde-3-phosphate to 1,3-bisphosphoglycerate, producing NADH in the process.
7. Phosphoglycerate kinase: This enzyme catalyzes the transfer of a phosphate group from
1,3-bisphosphoglycerate to ADP, producing ATP and 3-phosphoglycerate.
8. Phosphoglycerate mutase: This enzyme catalyzes the isomerization of 3-
phosphoglycerate to 2-phosphoglycerate.
9. Enolase: This enzyme catalyzes the conversion of 2-phosphoglycerate to
phosphoenolpyruvate, a reaction that involves the elimination of a molecule of water.
10. Pyruvate kinase: This enzyme catalyzes the transfer of a phosphate group from
phosphoenolpyruvate to ADP, producing ATP and pyruvate, the final product of glycolysis.
Next is the conversion of pyruvate to acetyl CoA. This process is catalyzed by a multi-enzyme
complex called the pyruvate dehydrogenase complex (PDC), which consists of three enzymes.
The PDC requires several coenzymes and cofactors to function properly, including thiamine
pyrophosphate, lipoic acid, CoA, FAD, and NAD+. Conversion of pyruvate to acetyl CoA is as
follows:
1. First, pyruvate enters the mitochondrial matrix and is oxidatively decarboxylated by the
enzyme pyruvate dehydrogenase (PDH), which requires the coenzyme thiamine
pyrophosphate (TPP). This step produces a molecule of CO2 and a two-carbon molecule
called an acetyl group.
2. The acetyl group then combines with the enzyme-bound lipoamide domain of the
dihydrolipoyl transacetylase (DLAT) enzyme to form acetyl-lipoamide. The DLAT enzyme
also requires lipoic acid as a cofactor.
3. The acetyl group is then transferred from acetyl-lipoamide to CoA-SH by the same DLAT
enzyme, producing acetyl CoA and regenerating the enzyme-bound lipoamide.
4. The dihydrolipoyl dehydrogenase (DLD) enzyme, which contains FAD as a cofactor, then
oxidizes the reduced lipoamide to regenerate the oxidized form of the DLAT enzyme,
allowing it to undergo another cycle of acetyl-CoA formation.
Kreb's Cycle
Acetyl CoA will then enter the Kreb’s cycle
1. Acetyl CoA enters the Krebs cycle by combining with oxaloacetate, a four-carbon molecule,
to form citrate. This reaction is catalyzed by the enzyme citrate synthase.
2. Citrate is then isomerized to isocitrate by the enzyme aconitase.
3. Isocitrate is then oxidized by isocitrate dehydrogenase, releasing a molecule of CO2 and
producing a molecule of NADH.
4. The resulting molecule, alpha-ketoglutarate, is then oxidized by alpha-ketoglutarate
dehydrogenase, releasing a molecule of CO2 and producing a molecule of NADH.
5. The resulting molecule, succinyl-CoA, is then produced when the enzyme succinyl-CoA
synthetase cleaves off a molecule of CoA, forming a high-energy bond with a molecule of
GDP, producing GTP as a byproduct.
6. Succinyl-CoA is then oxidized by succinate dehydrogenase, producing a molecule of
FADH2.
7. The resulting molecule, fumarate, is then produced when the enzyme fumarase catalyzes
the hydration of the double bond in succinate.
8. Fumarate is then oxidized by the enzyme, malate dehydrogenase, producing a molecule
of NADH and regenerating oxaloacetate, which can combine with another molecule of
acetyl CoA to continue the cycle.

In our case, having a high carbohydrate diet means that there is excess molecules in Krebs
especially the molecule citrate. Under normal conditions, the amount of citrate produced in the
citric acid cycle is relatively constant and tightly regulated. However, in certain situations such as
high carbohydrate diets or insulin resistance, there may be an increase in the production of citrate
in the mitochondria, which can lead to an increase in citrate transport out of the mitochondria.
Conversion of acetyl CoA to malonyl CoA
The next step is the conversion of acetyl CoA to malonyl CoA as it is an important step in fatty
acid biosynthesis. This process is catalyzed by the enzyme acetyl-CoA carboxylase (ACC), which
consists of several subunits and is regulated by various factors including hormones, substrates,
and allosteric regulators.
The conversion of acetyl CoA to malonyl CoA involves the following steps:
1. Acetyl CoA is first carboxylated by ACC using bicarbonate and ATP to form an unstable
intermediate, carbamoyl phosphate.
2. The carbamoyl phosphate is then converted into carboxybiotin by the biotin carboxylase
subunit of ACC.
3. The carboxybiotin is then transferred to a biotin-carrier protein (BCP) subunit of ACC.
4. The carboxyl group is finally transferred to acetyl CoA, forming malonyl CoA. This step is
catalyzed by the carboxyltransferase subunit of ACC.
The conversion of acetyl CoA to malonyl CoA is the first step in fatty acid biosynthesis and is
important for regulating energy metabolism. Malonyl CoA acts as a regulator of fatty acid
metabolism, inhibiting the transport of fatty acids into the mitochondria for beta-oxidation and
promoting the synthesis of fatty acids in the cytosol.
Fructose Metabolism
Fructose metabolism involves several steps, which are catalyzed by specific enzymes. The major
steps in fructose metabolism are as follows:
1. Fructose is phosphorylated by fructokinase to fructose-1-phosphate (F1P).
2. F1P is cleaved by aldolase B to form dihydroxyacetone phosphate (DHAP) and
glyceraldehyde.
3. DHAP is isomerized to glyceraldehyde-3-phosphate (G3P) by triosephosphate isomerase.
4. G3P enters the glycolytic pathway, where it can be further metabolized to pyruvate.
 LIPID TRANSPORT

INCREASE OF CHOLESTEROL DUE TO INTAKE OF SATURATED FATS

Increase of TAG due to Cholesterol stimulating the production of LDL and VLDL apolipoprotein,
and decreasing HDL

High cholesterol levels can lead to an increase in the accumulation of triglycerides (TAG) in the
liver through several mechanisms. One of the main mechanisms is that high levels of cholesterol
can lead to the formation of fatty deposits in the liver, which can interfere with the normal
metabolism of lipids, including TAG.

In addition, high levels of cholesterol can also lead to an increase in the production of very low-
density lipoprotein (VLDL) particles in the liver. VLDL particles are responsible for transporting
triglycerides from the liver to other tissues in the body. When there is an excess of VLDL particles,
the liver can become overwhelmed and some of the triglycerides may be stored in the liver as
fatty deposits.

High cholesterol levels can also affect the transport of low-density lipoprotein (LDL) particles,
which are often referred to as "bad" cholesterol. LDL particles are responsible for transporting
cholesterol from the liver to other tissues in the body. When there is an excess of LDL particles,
They can become oxidized, leading to inflammation and the formation of fatty deposits in the
arteries.

Cholesterol can have a significant impact on apolipoproteins, which are proteins that are bound
to lipids, including cholesterol, within lipoprotein particles.

Apolipoproteins play a key role in the metabolism and transport of lipids in the body. They help to
stabilize and regulate the formation, secretion, and uptake of lipoprotein particles, including VLDL,
LDL, and HDL.

In particular, cholesterol can affect apolipoprotein B (apoB), which is the primary apolipoprotein
found in LDL and VLDL particles. ApoB plays a key role in the transport of cholesterol and other
lipids to peripheral tissues, including the arterial wall, where it can contribute to the development
of atherosclerosis. OVERVIEW OF TAG METABOLISM
High levels of cholesterol can lead to an increase in the production of VLDL particles in the liver,
which are rich in apoB. This can lead to an increase in the number of LDL particles, which are
also rich in apoB, as VLDL particles are converted to LDL particles in the blood.

In addition, cholesterol can also affect apolipoprotein A-I (apoA-I), which is the primary
apolipoprotein found in HDL particles. ApoA-I plays a key role in the reverse cholesterol transport
pathway, which involves the transport of excess cholesterol from peripheral tissues back to the
liver for excretion. High levels of cholesterol can lead to a decrease in the production of HDL
particles and a decrease in apoA-I levels, which can impair the reverse cholesterol transport
pathway and contribute to the development of atherosclerosis.

TRIACYLGLYCEROL METABOLISM

In our body, triacylglycerols are essential for long-term energy storage as well as for insulation
and protection. Triacylglycerols can be ingested directly or synthesized from extra dietary
protein or carbohydrates.

Triacylglycerols from our diet are transported through the bloodstream in form of chylomicrons.
When a chylomicron encounters the enzyme lipoprotein lipase, the triacylglycerols are broken
down by hydrolysis into fatty acids and glycerol. These products then pass through capillary
walls to be used for energy by cells or stored in adipose tissue as fat deposits. Liver cells
combine the remaining chylomicron remnants with proteins, forming lipoproteins that transport
cholesterol in the blood.

When energy is not sufficient, lipases in adipose tissues or fat cells are activated to hydrolyze
stored triacylglycerols into fatty acids and glycerol and release them into the bloodstream. Once
the fatty acids reach the muscles or the liver they are used to generate acetyl-CoA and
eventually ATP. The hydrolysis of triacylglycerols produce fatty acids, which are used for energy
and glycerol. The glycerol can be recycled to regenerate triacylglycerol or it can enter glycolysis
(to produce more energy) or gluconeogenesis (to make new glucose in the body) in the form
dihydroxyacetone phosphate (DHAP).
 OXIDATIVE STRESS

Triglyceride is not hepatotoxic. However, its precursors (e.g., fatty acids and diacylglycerols) and
metabolic by-products (e.g., reactive oxygen species) may damage hepatocytes, leading to
hepatocyte lipotoxicity.

Living organisms produce reactive oxygen species (ROS) on account of regular cellular
metabolism and extrinsic effects. ROS are extremely reactive chemicals that are able to damage
and change the functioning of cell components such as carbohydrates, nucleic acids, lipids, and
proteins. Oxidative stress (OS) refers to a shift in the equilibrium of oxidants and antioxidants in
favor of oxidants. The redox state regulation is crucial for cell survival, activation, proliferation,
and organ function. NAFLD is strongly associated with the presence of oxidative stress.

When oxidative stress is elevated, as occurs in NAFLD, lipid peroxidation would subsequently
arise and lead to lipid hydroperoxide production. Those lipid hydroperoxides, together with
increased cytokines produced by Kupffer cells and hepatocytes, can cause direct damage to liver
cell membranes, enhance intrahepatic inflammation, and induce fibrosis in the liver. Changes in
intracellular redox status and oxidative changes in proteins are the two main mechanisms of
action in current ROS signaling theories. Thiol redox systems, primarily glutathione and
thioredoxin, mitigate intracellular oxidative stress by decreasing H2O2 and lipid hydroperoxides in
the first mechanism.
IV. TREATMENT & MANAGEMENT
At present there are no pharmacologic therapy for NAFLD. However, NAFLD may be reversible
and can be managed accordingly with the following:
1. Diet and Exercise
2. Supplementation of Vitamins (Vitamin E, Glutathione, Phospholipids+Choline, Selenium)
Diet & Exercise
Diet
Lifestyle alteration, including dietary recommendations, plays an important role in the treatment
of nonalcoholic fatty liver disease (NAFLD). A well composed, restrictive diet tailored to personal
demands enables weight loss and improvement in the clinical picture of NAFLD. The diet should
be low in calories and rich in unsaturated fatty acids and natural antioxidants (vitamins A and C).
According to the nutritional recommendations for patients with NAFLD, carbohydrates should
comprise 40–50% of total dietary energy. It is advisable to increase the amount of complex
carbohydrates rich in dietary fiber. A substantial role in the etiology of NAFLD is played by
excessive intake of fructose caused by the high consumption of nonalcoholic beverages.
Fructose intake causes the development of fatty liver through stimulation of de
novo lipogenesis. Ingestion of simple carbohydrates should not exceed 10% of total energy
intake.
Weight loss
Weight loss is advisable for overweight (body mass index (BMI): 25–30 kg/m2) and obese (BMI
> 30 kg/m2) patients. It is recommended to avoid very low-calorie diets (388 kcal/day) which can
cause the activation of overall inflammation and a rise in serum bilirubin levels.
Saturated Fatty Acids
Saturated fatty acids (SFAs) stimulate oxidative stress in mitochondria and contributes to the
damage of hepatocytes. A high ratio of saturated to unsaturated fatty acids in subjects with
NAFLD increases the susceptibility of hepatocytes to endotoxin action and induces progression
of simple steatosis towards nonalcoholic steatohepatitis (NASH). Exposure of hepatocytes to
stearic and palmitic acids causes their apoptosis through activation of caspase 3 and stimulation
of DNA fragmentation.
Trans Fatty Acids
Trans fatty acids occur naturally in dairy products. They are synthesized by bacterial microbiota
in the gastrointestinal tract of ruminants. Trans fatty acids can also be made commercially
during the production of margarine. They are formed during the hydrogenation of plant oils.
Conjugated linoleic acid (isomer cis-9 trans-11) contained in dairy products does not negatively
influence the human organism. On the other hand, trans fatty acids contained in hydrogenated
margarine exhibit the opposite effect. The intake of conjugated linoleic acid (isomer trans-10 cis-
12) in the form of hydrogenated margarine promotes proinflammatory action, intensifies
endothelium dysfunction and predisposes towards lipid profile disturbances.
Monounsaturated Fatty Acids
Ingestion of monounsaturated fatty acids (MUFAs) lowers the risk of development of
cardiovascular disease and contributes to the improvement of lipid profile. Food products rich in
MUFAs include olive oil, rapeseed oil, sunflower, soy, nuts and avocado. Replacement of
dietary saturated fatty acids by monounsaturated fatty acids in a diet causes amelioration of
serum glucose level and blood pressure.
A diet rich in MUFAs increases the level of HDL-cholesterol and decreases the level of total
cholesterol in subjects with diabetes. Monounsaturated fatty acids inhibit oxidation of LDL-
cholesterol and decrease the serum level of triglycerides by activation of peroxisome
proliferator-activated receptor α (PPARα).
Unrefined, extra virgin olive oil contains a number of bioactive constituents with antioxidative
properties. A diet enriched with olive oil ameliorates endothelial function and inhibits TNF-α
production.

Polyunsaturated fats
Polyunsaturated fatty acids, including docosahexaenoic acid (DHA) and eicosapentaenoicacid
(EPA), positively affect the course of NAFLD. Food products rich in EPA and DHA include sea
fish, green leafy vegetables, rapeseed oil and flax seeds. Consumption of fish oil decreases de
novo lipogenesis, increases glucose uptake in fat tissue and reduces visceral fat.
The intake of omega-3 fatty acids inhibits activation of Kupffer cells and output of
proinflammatory cytokines.
Effects of Polyunsaturated fats as part of the diet:
1. Decrease in triglycerides, free fatty acids, glucose and insulin serum level
2. Decrease in very low-density lipoprotein (VLDL) secretion and inhibition of hepatic
lipogenesis
3. Increase in utilization and storage of glucose in skeletal muscles
4. Reduction of the adipocyte size and visceral fat content
5. Activation of insulin-dependent glucose transporter in the adipose tissue
Protein Intake
Protein deficiency, as well as malnutrition, can lead to NASH development. A high-protein and
low-carbohydrate diet ameliorates carbohydrate metabolism and decreases liver steatosis by
inhibition of de novo lipogenesis. Dietary protein has a beneficial effect on carbohydrate
metabolism and decreases insulin output. Protein intake is essential for the regeneration of
hepatocytes and supplies crucial amino acids that prevent excessive fat accumulation within
hepatocytes. A high-protein diet (40% of total calories as protein) decreases body fat content
and reduces the risk of cardiovascular disease development more than a diet which supplies
15% of total calories as protein does.
A moderate protein intake (25% of total calories as protein) is as efficient in reducing body fat
content as a high-protein diet is. It is said that a moderate protein intake is optimum for patients
with NAFLD, due to the positive impact on weight loss and insulin sensitivity.
Probiotics as part of the Diet
Probiotics in the form of oligofructoses. Oligofructose is an indigestible fructose oligomer that is
found in plant food. Food products rich in oligofructose include chicory, artichoke, leek,
asparagus and garlic. Clinical trials conducted on humans showed that oligofructose ingestion
causes a reduction in triglycerides and glucose serum levels. Oligofructose supplementation in
overweight and obese patients contributes to a decrease in postprandial glucose levels and it
beneficially influences glycemia control. A diet rich in oligofructose stimulates satiety through
bacterial fermentation and the increase in free fatty acid concentrations in the large intestine.
Oligofructose consumption attenuates the inflammation within hepatocytes. The influence of
oligofructose is allegedly related to the action of GLP-1 and its concentration in brain cells and
serum. Oligofructose intake also causes a decrease in a ghrelin concentration. Ghrelin is an
orexigenic hormone which stimulates food ingestion.
Exercise
The increasing prevalence of obesity has made nonalcoholic fatty liver disease (NAFLD) the
most common chronic liver disease.
Physical inactivity is related to the severity of fatty liver disease irrespective of body weight,
increasing physical activity through exercise can improve fatty liver disease.
In the liver, exercise increases fatty acid oxidation (β-oxidation), it decreases fatty acid synthesis
(lipogenesis) and prevents mitochondrial and hepatocellular damage.
The diagram shows the effects of exercise on hepatic fatty acid accumulation. Exercise reduces VITAMIN SUPPLEMENTATION
the expression of various enzymes that mediate the conversion of acetyl-CoA to free fatty acids.
An increase in AMP-activated protein kinase (AMPK) by exercise stimulates the phosphorylation Vitamin E
and therefore inactivation of these enzymes, Acetyl CoA carboxylase (ACC) and Sterol
regulatory element-binding protein-1 (SREBP-1), which is a main transcription factor for
expression of other enzymes involved in this process (ACC, Fatty acid synthase, elongase).
The Role of AMPK in Exercise-Mediated Improvement of Liver Lipid Metabolism
When ATP consumption is increased during physical exercise, the formation of ADP and AMP
is sensed by AMP-activated protein kinase (AMPK). AMPK shifts liver lipid metabolism away
from FFA synthesis through phosphorylation (and thereby suppression) of ACC and FAS, and of
SREBP-1 to reduce expression of these lipogenic enzymes. In addition, AMPK increases fatty
acid oxidation through activation of CPT-1. Several basic scientific studies have documented
that exercise activates AMPK-regulated pathways of lipid metabolism in the liver. Treadmill
exercise resulted in increased levels of phosphorylated AMPK and ACC the liver showed that
this effect can be mediated by macrophage migration inhibitory factor.
Mechanism of Action: Vitamin E is a general term used to refer to a large number of natural or synthetic
compounds. Tocopherols, particularly the alpha tocopherols, are the most active and widely distributed.
Effects of Exercise on Fatty acid oxidation and liver mitochondria Alpha tocopherols occur naturally in the d optical isomer form which is more active than the dl synthetic
The liver can neutralize metabolically and immunologically active free fatty acid in three major racemic form. Vitamin E is a fat-soluble vitamin that inhibits Vitamin A and C oxidation. It protects the
pathways: polyunsaturated fatty acids in the membrane from the attack of free radicals and the RBCs against
hemolysis. It may be given as d- or dl-alpha tocopherol or as the respective acetates or acid succinates.
a. Esterification of FFA into Triglycerides and sequestration of lipid droplets in hepatocytes
b. Excretion in Very-Low-Density Lipoproteins
c. β-oxidation in hepatocytes mitochondria
Metabolism: Metabolized in the liver into glucuronides of tocopheronic acid and its γ-lactone.
Physical exercise stimulates Peroxisome proliferator-activated receptor-α (PPARα) regulates the
expression of enzymes responsible for mitochondrial fatty acid oxidation and thereby stimulates Excretion: Mainly via bile; remainder via urine.
β-oxidation in the liver. PPARα has beneficial effects on multiple aspects of β-oxidation and Vitamin E, in addition to the role of being an antioxidant, some studies have also proposed that `it
improves mitochondrial quality and function. Increased β-oxidation in the liver may damage the improves the liver integrity by down-regulating hepatic cluster of differentiation 36 protein (CD36)—a
mitochondria of hepatocytes, so with the regulation of PPARα, this effect on the mitochondrial membrane transporter responsible for the uptake of fatty acids into the liver.
hepatocytes is avoided.
Treatment with vitamin E combined with vitamin C and atorvastatin was demonstrated to be effective in
reducing the odds of having hepatic steatosis in individuals with computed tomography (CT)-diagnosed
NAFLD after 4 years of active therapy.
 Glutathione
Mechanism of Action: Glutathione is involved in the detoxification of both xenobiotic and endogenous
compounds. It facilitates excretion from cells (Hg), facilitates excretion from body (POPs, Hg) and directly
neutralizes (POPs, many oxidative chemicals).
Metabolism: In the GCS reaction, the γ-carboxyl group of glutamate reacts with the amino group of
cysteine to form a peptidic γ-linkage, which protects GSH from hydrolysis by intracellular peptidases.
Excretion: Glutathione is excreted in a dose-dependent, non-stoichiometric fashion from Saccharomyces
cerevisiae cells expressing and secreting Bovine Pancreatic Trypsin Inhibitor (BPTI), a small, disulfide-
bonded protein. Glutathione excretion commences 40 hours following induction of BPTI synthesis.
Twenty-nine patients finished the protocol. ALT levels significantly decreased following treatment with
glutathione for 4 months. In addition, triglycerides, non-esterified fatty acids, and ferritin levels also
decreased with glutathione treatment. Following dichotomization of ALT responders based on a median
12.9% decrease from baseline, we found that ALT responders were younger in age and did not have
severe diabetes compared with ALT non-responders. The controlled attenuation parameter also
decreased in ALT responders.
PHOSPHOLIPIDS + CHOLINE (VITAMINS)
Choline is a nutrient obtained through both dietary intake and endogenous synthesis. In chemical terms
it is a methyl rich quaternary amine, present in free or esterified forms in all mammalian tissues. Choline
is used for the synthesis of the neurotransmitter acetylcholine, and is also involved in methyl-group
metabolism, particularly in the liver, because it is a major dietary source of methyl groups via its
irreversible oxidation to betaine and the subsequent synthesis of S-adenosylmethionine. The other
sources of methyl groups are dietary methionine and betaine, and de novo synthesis via the one-carbon
folate pool.
The liver is the major site of choline metabolism, where it is found primarily as phosphatidylcholine.
Phosphatidylcholine and other choline-containing phospholipids, lysophosphatidylcholine,
sphingomyelin, and choline plasmalogen, are components of plasma and organelle membranes. The
choline moiety provides these phospholipids with a larger and more cylindrical head group than the
smaller and more conical shapes of other membrane phospholipids. Phosphatidylcholine is also required
for the assembly/secretion of lipoproteins and for solubilizing cholesterol in bile. It undergoes
enterohepatic circulation, with estimates of the amount of human biliary phosphatidylcholine ranging
from 5 mmol to 10–20 g/d, thus possibly making a greater contribution to phosphatidylcholine entering
the small intestinal lumen than dietary phosphatidylcholine, the most abundant form of choline in the
diet.
Mechanism of Action
Choline is a quaternary ammonium salt, and being an essential component of different membrane
phospholipids (PLs) contributes to the structural integrity of cell membranes. Choline-containing
phospholipids (CCPLs) include phosphatidylcholine (PC), sphingomyelin (SM), and choline alphoscerate
(GPC). PC is the major phospholipid in most eukaryotic cells. It is involved in SM synthesis,
choline/choline metabolite re-generation, and fatty acid/GPC formation.
Pharmacology:
Pharmacodynamics: Hepatoprotective effects found in numerous experimental models into acute liver
damage (induced by ethanol, alcyl alcohol, carbon tetrachloride, paracetamol and galactosamine).
Furthermore, it was also seen to inhibit steatosis and fibrosis in chronic liver damage models (induced by
ethanol, thioacetamide, organic solvents). Its suggested principal actions have been through accelerated
membrane regeneration and stabilization, inhibited lipid peroxidation and inhibited collagen synthesis.
Pharmacokinetics: Phospholipids are absorbed in the small intestine. Most of it is split by phospholipase
A to 1-acyl-lysophosphatidylcholine, 50% of which is reacylated immediately into polyunsaturated
phosphatidylcholine still during the process of absorption in the intestinal mucosa. This polyunsaturated
phosphatidylcholine reaches the blood via the lymph pathway and from there - mainly bound to HDL - it
passes in particular to the liver.
Treatment of fatty liver diseases with essential phospholipids (EPL)
Essential phospholipids form a double layer of cellular and subcellular membranes and control their
fluidity and biological activity. The efficacy of EPL in the treatment of liver disease has been confirmed by
the ability of some of its molecular components to integrate into damaged portions of liver cell
membranes (hepatocytes), thereby improving the liver‘s ability to regenerate and also increase fluidity
and function of hepatocyte plasma membranes. EPL have antioxidant, anticholestatic, anti-inflammatory,
antifibrotic and regenerative properties.
SELENIUM
The management of inflammatory processes in NAFLD may prevent the development of NASH
to liver fibrosis. Selenium deficiency could initiate inflammation by activating the NF-κB pathway
through multiple mechanisms at an organ level. Selenium supplementation can reduce pro-
inflammatory cytokines and the expression of inflammation-related proteins in the liver, such as
TLR4, NF-κB, JNK, and p38, as well as upregulating heme oxygenase-1 (HO-1) to reduce the
inflammatory response.
For circulating lipids, the liver serves as a metabolic hub. The net retention of lipids within
hepatocytes, usually in the form of triglycerides, is the first step in the initiation of fatty liver. The
major pathways of lipid metabolic abnormalities are related to the changes in lipid uptake,
lipogenesis, lipolysis, lipophagy, and expression of hepatic lipoproteins. Selenium
supplementation increased the hepatic mRNA expression of PPARα, which can mediate the
prevention of triglyceride accumulation.
Moreover, selenium deficiency could decrease the expression of intracellular antioxidant
enzymes, including Superoxide dismutase-1 (SOD1), which results in the development of fatty
liver. Furthermore, supplementing with selenium and magnesium inhibits the mRNA expression
level of hepatic lipogenesis genes liver X receptor alpha (LXRα), SREBP-1c, and FASN (fatty
acid synthase) to reduce the hepatic total cholesterol (TC) and attenuate liver steatosis by high-
fat diet. Moreover, a study found zinc and selenium co-supplementation could significantly
reduce the level of serum triglyceride and cholesterol.
Selenium is a trace element and serves as a cofactor for glutathione peroxidase and helps
minimize oxidative damage through cellular metabolism. Selenium, in combination with Vitamin
E protects cell membranes and organelles from peroxidative destruction.
Mechanism of Action: Selenium is first metabolized into selenophosphate and selenocysteine.
Selenium incorporation is genetically encoded through the RNA sequence UGA. This sequence
is recognized by RNA STE loop structures called selenocysteine inserting sequences (SECIS).
These structures require the binding of SECIS binding proteins (SBP-2) to recognize
selenocysteine. The specialized tRNA is first bound to a serine residue which is then
enzymatically processed to a selylcysteyl-tRNA by selenocysteine synthase using
selenophosphate as a selenium donor.
The most important selenoproteins are glutathione peroxidases and thioredoxin reductases
which are part of the body's defenses against reactive oxygen species (ROS). The importance
of selenium in these anti-oxidant proteins has been implicated in the reduction of
atherosclerosis by preventing the oxidation of low-density lipoprotein.