الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
NAFLD is the main cause of liver diseases worldwide. It is associated with different metabolic risks as obesity, diabetes, and metabolic syndrome. It can be diagnosed by simple abdominal ultrasound examination. It is a disease affected with lifestyle practices as nutrition and sedentary life. Therefore, the common treatment modality is weight loss through dietary restrictions and practicing exercise. Different dietary components as carbohydrate, fat and calories had different effects on the occurrence and prognosis of the disease. Therefore, different diets were examined to treat this disease as low fat diet, carbohydrate restricted diet, low glycemic index diet and Mediterranean diet. The health benefit of Mediterranean diet goes beyond weight loss to manage different metabolic risks as hypertension, dyslipidemia, elevated liver enzymes and decreasing the inflammatory condition and fatty liver. In the present study we studied the role of nutritional intervention in the treatment of nonalcoholic fatty liver disease. And specifically, we were aiming at assessing the dietary intake and physical status of patients diagnosed with NAFLD, plan and implement nutrition intervention program for these patients including both dietary and physical activity advice, and to reassess the patients’ nutritional, clinical and radiological conditions in response to the intervention program. An interventional study was conducted in the outpatient hepatology clinic of the Main University Hospital, in Alexandria. A 150 adult patients were enrolled in the study based on abdominal ultrasound examination that revealed the presence of NAFLD. All patients with suspected secondary causes of fatty liver were excluded. Patients had been examined and followed every 2 weeks for a period of 3 months. 1) Initial evaluation of the patients included the following: 1. A predesigned questionnaire including - Sociodemographic characteristics, medical, family, drug intake, and weight history. - Food frequency questionnaire that included common food items, to verify the frequency of intake of different food groups. - Dietary habits and some practices associated with eating as eating breakfast, meal pattern, eating different snacks. - Lifestyle practices including smoking, sleeping habits, drinking coffee or tea, and practicing exercises. 2. Clinical examination, including: abdominal examination, blood pressure measurements. 3. Body weight, height, and waist circumference was measured. Using the In Body, body composition analyzer, different components of body composition were analyzed. 4. A blood sample was drawn from patients after 12 hours fasting to examine lipid profile, fasting blood glucose, liver enzymes and uric acid. 5. Patients were subjected to ultrasound abdominal examination to estimate amount of fat deposited in the liver by using the Hepatorenal index (HRI). 6. Every patients was asked to keep a record of food intake for 3 days prior to dietary intervention. This was re-enforced with a 24 hour recall of food intake. Dietary data management. 1. Using the Egyptian Food Composition tables, analyses of the dietary intake of the 3-days diary and 24-hour recall. Estimation of the average intake of calories, total carbohydrate, fat, and protein was calculated. 2. Designing of 5- power point slides to be used in the intervention as a tool of education. 3. Estimation of the frequency of food intake according to glycemic index of food. 3) Dietary Intervention program • Dietary program was designed based on the Mediterranean diet principles. Moderate restriction of carbohydrate 40-45% of energy intake, fat intake 35-40%, while protein intake 15-20%. • Changing the quality and amount of carbohydrate food, as well as the type of fat consumed that based mainly on olive oil. • Moderate calorie restriction was implemented to allow gradual weight loss. • High consumption of vegetables 8-10 servings/day, with moderate fruit intake 2-3 servings/day. • Physical activity instructions were discussed with patients according to health condition. Suitable modifications were implemented to facilitate practicing exercises as exercising on a chair, and using different videos to encourage exercising. 4) Follow up, regular consultations were done every 2 weeks for 3 months. 5) Final evaluation: reassessment of the nutritional, clinical, radiological status of patients were performed. 6) Statistical analyses of data, and presentation by tables and different figures. from this work, we came to the following conclusions: • Nonalcoholic fatty liver disease and metabolic health parameters are closely related to the dietary and lifestyle practices. • Eating energy dense, carbohydrate and fat rich diet, with unhealthy snacking is deleterious for the health of the liver, body composition and metabolic health. • Dietary fat has different metabolic health effects, therefore, focusing on the quality of fat is as important as the quantity. • Mediterranean diet restricted in total carbohydrates, very low in refined sugars, rich in vegetables, moderate in fruits and low fat dairy, with more incorporation of fish, legumes, olive oil, nuts and seeds had significant positive impact on NAFLD and metabolic health of patients. • Therapeutic nutritional intervention was reflected on the improvement of metabolic syndrome criteria including lipid profile, blood pressure, fasting blood glucose and waist circumference. • Clinical improvement in elevated liver enzymes, and the amount of fat deposited in the liver all within 3months, signifies the importance of early and proper nutritional counselling in patients care.Dietary intervention focusing on the quantity and quality of meals with proper timing of eating, and healthy cooking was associated with much improvement in the gastrointestinal symptoms. • Following the changes in body composition is very important tool in weight management for better evaluation of body fat mass. • Healthy lifestyle practices including exercise is an essential part of NAFLD management. • Using multimedia and technology modalities was very useful in nutrition and exercise education. • Liver ultrasound examination by HRI is an opportunity for early screening and follow up, that allows prevention of a whole group of forthcoming diseases related to the liver as well as metabolic consequences including chronic liver diseases, cardiovascular diseases, diabetes mellitus, and gastrointestinal dysfunction. • Healthy cooking methods, and the whole meal composition have great impact on improving the amount of fat deposited in the liver. • No single dietary factor is curative of NAFLD or metabolic syndrome. • “All or none” does not exist in nutritional management. Any positive, small change has a great health impact. from this work we came to the following recommendations that could be implemented through different approaches: I. Population approach 1. Nutrition health education of the public through different mass media channels, on the following: - Nonalcoholic fatty liver disease, is not a simple fat deposited in the liver, but a risky disease. - The principles of healthy diet, especially Mediterranean diet that is rich in vegetables, nuts, seeds and other plant based foods, moderate in fruits as well as animal derived food, with olive oil as the principal added fat. - Fats are not an enemy, and not all fat had equal effect on health, with special emphasis on hidden fat sources. - Changing the type and amounts of dietary carbohydrates with less intake of refined carbohydrates and more inclusion of complex carbohydrates sources. - The healthy snacks with avoidance of biscuits, cookies, and different sugar loaded beverages and replaced by vegetables, nuts, seeds and low fat dairy products. - The importance of healthy lifestyle practices including dietary habits and practices on metabolic health. - The importance of practicing exercise for the health. - No single dietary factor is enough to treat NAFLD or retain the metabolic health. II. Clinical approach 1. Early incorporation of nutritional intervention in patient management in different health facilities, which is directed toward improving the metabolic health rather than only weight reductions. 2. Multidisciplinary team is the key for the success of any nutritional intervention that needs the cooperation of different health members for the benefit of the patients. 3. Follow up of NAFLD patients is mandatory as biannual visits are suggested to assess the hepatic and metabolic consequences of the disease. III. Ministerial approach 1. Careful and frequent assessment of the pattern of the Egyptian diet, to highlight the weak points that need careful intervention. 2. The conduction of a nationwide nutritional survey to develop different lists of glycemic index and load of locally produced and consumed food.