<unk>  warrants treatment regardless of whether the affected person is overweight or not.<unk>  is a preventable cause of death. Guidelines are available from the American Association for the Study of Liver Diseases (AASLD), American Association of Clinical Endocrinologists (AACE) National Institute for Health and Care Excellence (NICE), the European Association for the Study of the Liver (EASL), and the Asia-Pacific Working Party on<unk> . Lifestyle Weight loss is the most effective treatment for<unk> . A loss of 4% to 10% body weight is recommended, with 10% to 40% weight loss completely reversing NASH without cirrhosis. A structured weight loss program helps people with<unk>  lose more weight compared with advice alone. This type of program also leads to improvements in<unk>  measured using blood tests, ultrasound, imaging, or liver biopsies. Although fibrosis improves with lifestyle interventions and weight loss, there is limited evidence for cirrhosis improvement. A combination of improved diet and exercise, rather than either alone, appears to best help manage<unk>  and reduce insulin resistance. Motivational support, such as with cognitive behavioral therapy, is helpful, as most people with<unk>  do not perceive their condition as a disease, and thus have a low motivation to change. Higher-intensity behavioral weight loss therapies (diet and exercise combined) may produce more weight loss than lower-intensity ones. Weight loss is associated with improvements in biomarkers,<unk>  grade, and reduced chances of NASH, but their impact on long-term health is yet unknown. A 2019 systematic review thus suggests a change of guidelines to recommend these therapies for<unk>  management. As of 2021, there is limited evidence to indicate that lifestyle modifications and nutritional supplementation have an effect on mortality, liver cirrhosis, liver decompensation, liver transplantation, and hepatocellular carcinoma in people with<unk> alcohol-related<unk>  liver disease. Diet Treatment of<unk>  typically involves counseling to improve nutrition and calorie restriction. People with<unk>  can benefit from a moderate to low-carbohydrate diet and a low-fat diet. The Mediterranean diet also showed promising results in a 6-week study with a reduction of NASH induced inflammation and fibrosis, independently from weight loss. Tentative evidence supports dietary interventions in individuals with<unk>  liver who are not overweight. The EASL recommends energy restriction of 500–1000 kcal per week less than the normal daily diet, a target of 7–10% weight loss for obese/overweight<unk> , a low- to moderate-fat, and moderate- to high-carbohydrate diet, or a low-carbohydrate ketogenic or high-protein diet such as the Mediterranean diet, and avoiding all beverages and food containing fructose. Alcohol is an aggravating factor, and the AASLD recommends that people with<unk>  or NASH avoid<unk> onsumption. The EASL allows<unk> onsumption below 30g/day for men and 20g/day for women. The role of coffee consumption for<unk>  treatment is unclear though some studies indicate that regular coffee consumption may have protective effects. Vitamin E does not improve established liver fibrosis in those with<unk>  but seems to improve certain markers of liver function and reduces inflammation and<unk> ness of the liver in some people with<unk> . The Asia-Pacific Work Group advises that Vitamin E may improve liver condition and aminotransferase levels, but only in adults without diabetes or cirrhosis who have NASH. The NICE guidelines recommend Vitamin E as an option for children and adults with<unk>  with advanced liver fibrosis, regardless of whether the person has diabetes mellitus. Herbal compounds such as silymarin (a milk thistle seed extract), curcumin, a turmeric extract, and green tea appear to improve<unk>  biomarkers and reduce the grade of<unk> . Studies suggest an association between microscopic organisms that inhabit the gut (microbiota) and<unk> . Reviews reported the use of probiotics and synbiotics (combinations of probiotics and prebiotics) were associated with improvement in liver-specific markers of hepatic inflammation, measurements of liver stiffness, and steatosis in persons with<unk> . Physical activity Weight loss may improve<unk>  and is recommended particularly for obese or overweight people; similar physical activities and diets are advisable for overweight people with<unk>  as for other obese and overweight people. Although physical activity is less important for weight loss than dietary adaptations (to reduce caloric intake), the NICE advises physical activity to reduce liver fat even if there is no overall bodyweight reduction. Weight loss, through exercise or diet, is the most effective way to reduce liver fat and help NASH and fibrosis remission. Exercise alone can prevent or reduce hepatic steatosis, but it remains unknown whether it can improve all other aspects of the liver; hence a combined approach with diet and exercise is advised. Aerobic exercise may be more effective than resistance training, although there are contradictory results. Vigorous training is preferable to moderate training, as only the high-intensity exercise reduced the chances of<unk>  developing into NASH or advanced fibrosis. The EASL recommends between 150 and 200 min/week in 3 to 5 sessions of moderate-intensity aerobic physical activity or resistance training. Since both effectively reduce liver fat, a pragmatic approach to the choice of physical activity that accounts for the individual's preferences for what they can maintain in the long-term is preferred. Any engagement in physical activity or increase over previous levels is better than remaining sedentary. Medication Treatment with medications is primarily aimed at improving liver disease and is generally limited to those with biopsy-proven NASH and fibrosis. No medicines specifically for<unk>  or NASH had received approval, , although anti-diabetic medications may help in liver fat loss. While many treatments appear to improve biochemical markers such as alanine transaminase levels, most do not reverse histological abnormalities or improve outcomes. Insulin sensitizers (metformin and thiazolidinediones, such as pioglitazone) and liraglutide are not specifically recommended for<unk>  as they do not directly improve the liver condition. They can be indicated for diabetic individuals, after a careful assessment of risks, to reduce insulin resistance and risks of complications. Indeed, the side effects associated with thiazolidinedione medications, which include osteopenia, increased fracture risk, fluid retention, congestive heart failure, bladder cancer, and long-term weight gain, have limited their adoption. Due to these side effects, the AASLD recommends the use of pioglitazone only for individuals with biopsy-proven NASH, and the Asia-Pacific Work Group recommends them only for individuals with<unk>  with known diabetic issues. However, the AASLD advises against the use of metformin as studies were inconclusive about the improvement of the liver's histological condition. Although there was an improvement in insulin resistance and serum aminotransferases, this did not translate into NASH improvements. The NICE provides similar guidelines to the AASLD regarding pioglitazone and recommends it be administered in secondary care to adults with advanced liver fibrosis irrespective of whether or not they have diabetes. Statin medications appear to improve liver histology and markers of liver biochemistry in people with<unk> . Since people with<unk>  are at a higher risk of cardiovascular disease, statin treatment is indicated. People with<unk>  are not at higher risk for serious liver injury from statins, according to AASLD and EASL. However, even if statins are safe to use in people with NASH cirrhosis, the AASLD suggests avoiding them in people with decompensated cirrhosis. Guidelines recommend statins to treat dyslipidemia for people with<unk> . According to NICE guidelines, statins can continue unless liver enzyme levels double within three months of starting statins. Treatment with pentoxifylline is not recommended. As of 2018, neither the AASLD nor the Asia-Pacific Working Group recommends obeticholic acid or elafibranor due to inconsistent results for NASH treatment and concerns about safety. Omega-3<unk>  acids may reduce liver fat and improve blood lipid profile but do not seem to improve liver histology (fibrosis, cirrhosis, cancer). The NICE does not recommend omega-3<unk>  acid supplementation since randomized trials were inconclusive. Previous systematic reviews found that omega-3<unk>  acid supplementation in those with<unk> /NASH using doses of one gram daily or more (median dose four grams/day with median treatment duration six months) has been associated with improvements in liver fat. According to AASLD guidelines, "omega-3<unk>  acids should not be used as a specific treatment of<unk>  or NASH, but they may be considered to treat hypertriglyceridemia for patients with<unk> ". Surgery severely obese individuals with<unk>  or NASH, bariatric surgery improves or cures the liver disease if there is no cirrhosis nor liver cancer. Bariatric surgery is an effective method for obese and diabetic individuals with<unk>  to induce weight loss and reduce or resolve NASH inflammation, including fibrosis, and improve longevity. For the AASLD, bariatric surgery can be considered only for NASH on a case-by-case basis by an experienced bariatric surgery program. Indeed, some individuals might develop new or worsened features of<unk> . About 92% of people with<unk>  saw an improvement in steatosis and 70% a complete resolution after bariatric surgery. A preoperative diet such as a low-calorie diet or a very-low-calorie diet is usually recommended to reduce liver volume by 16–20%. Preoperative weight loss is the only factor associated with postoperative weight loss. Preoperative weight loss can reduce operative time and hospital stay, although there is insufficient evidence whether preoperative weight loss reduces long-term morbidity or complications. Weight
Non-alcoholic fatty liver disease
Metabolic syndrome
Alcoholic liver disease
Alcoholic hepatitis
Fatty liver disease
Autoimmune hepatitis
Viral hepatitis
Polycystic liver disease