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 Table of Contents  
Year : 2017  |  Volume : 8  |  Issue : 1  |  Page : 10

The effect of a lifestyle modification education on adiposity measures in overweight and obese nonalcoholic fatty liver disease patients

1 Food Security Research Center; Department of Community Nutrition, School of Nutrition and Food Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Community Medicine and Family Physician, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
3 Department of Biostatistics and Epidemiology, School of Health; Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
4 Department of Radiology, Image Processing and Signal Research Center, Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
5 Isfahan Endocrine and Metabolism Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Submission12-Sep-2016
Date of Acceptance03-Jan-2017
Date of Web Publication23-Feb-2017

Correspondence Address:
Mojgan Nourian
Department of Community Nutrition, School of Nutrition and Food Sciences, Isfahan University of Medical Sciences, Isfahan
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Source of Support: None, Conflict of Interest: None

PMID: 28299034

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Background: Obesity is increasingly associated with nonalcoholic fatty liver disease (NAFLD) and weight loss through a combination of dietary modifications and increased physical activity is a primary goal of therapy in this disease. Therefore, this study was conducted to evaluate the effects of a lifestyle modification education on adiposity measures, physical activity, and total calorie intake in overweight and obese NAFLD patients.
Methods: During 8 weeks, 82 obese patients were randomly assigned into either an intervention group (n = 41) receiving a lifestyle modification education or to a control group (n = 41) receiving usual care. Total calorie intake, physical activity, and body composition indices were measured before and after the intervention.
Results: Thirty-six patients in intervention group and 33 in control group completed the study. The analysis of body composition variables did not show any significant reduction for percent of body fat, abdominal circumference, waist to hip ratio, visceral fat area, age matched of body, and soft lean mass (SLM) of the trunk (P > 0.05). On the other hand, a significant reduction in weight, body mass index, mass of body fat (MBF), SLM, and MBF of the trunk was observed after 2 months of intervention compared to the controls (P < 0.05). A significant reduction was observed in total calorie intake of intervention group as compared to the control group. Physical activity status did not show any significant improvements after 2 months of intervention.
Conclusions: Our lifestyle modification education and its guidelines could be used in obese patients with NAFLD to improve their body composition measurements and to lose weight. This could result in significant long-term benefits in NAFLD patients.

Keywords: Adiposity, lifestyle, nonalcoholic fatty liver, physical activity

How to cite this article:
Arab A, Askari G, Golshiri P, Feizi A, Hekmatnia A, Iraj B, Nourian M. The effect of a lifestyle modification education on adiposity measures in overweight and obese nonalcoholic fatty liver disease patients. Int J Prev Med 2017;8:10

How to cite this URL:
Arab A, Askari G, Golshiri P, Feizi A, Hekmatnia A, Iraj B, Nourian M. The effect of a lifestyle modification education on adiposity measures in overweight and obese nonalcoholic fatty liver disease patients. Int J Prev Med [serial online] 2017 [cited 2020 Jun 4];8:10. Available from: http://www.ijpvmjournal.net/text.asp?2017/8/1/10/200854

  Introduction Top

The increasing rate of obesity incidence and prevalence has been warning in recent years.[1] On the basis of the current trend, by 2030, about 20% of world population will be obese.[2] The implications of this increasing trend are clear since obesity is associated with various systemic diseases including diabetes, high blood pressure, heart disease, and nonalcoholic fatty liver disease (NAFLD).[3]

NAFLD, as one of the most common causes of liver disease worldwide, has increased proportionately together with the rise in obesity.[3] The prevalence of NAFLD in obese patients is reported to be up to 80%.[4] NAFLD is associated with the metabolic syndrome and its related conditions such as hypertension, hyperlipidemia, insulin resistance, and abdominal adiposity.[5]

Insulin resistance due to obesity appears to be central to the pathogenesis of NAFLD. Thus, treatment should be focused on a weight loss strategy.[3] Currently, no agents with proven safe and sustainable weight loss results in terms of improved biochemical profiles and a regression of steatohepatitis and fibrosis exists in the market.[3] Therefore, a combination of dietary amendments and higher level of physical activity is thought to have significant long-term benefits.[6] In 2009, fifty patients with NAFLD were enrolled in an uncontrolled trial in order to reduce calorie intake and had 3 h/week light aerobic activity. The results revealed a significant reduction in body mass index (BMI).[7] Another intervention has been done in 2014 among postmenopausal overweight and obese Indian women by calorie restriction, improvement of dietary content and recommendation to increase physical activity, which resulted in significant decrease in BMI and waist circumference.[8] However, more studies are warranted to provide answers regarding the best diet and exercise regimen for NAFLD patients. Thus, the current study was conducted to examine the weight reducing effects of a lifestyle modification education on adiposity measures included weight, BMI, lean body mass (LBM), soft lean mass (SLM), mass of body fat (MBF), percent of body fat (PBF), abdominal circumference (AC), waist to hip ratio (WHR), visceral fat area (VFA), age-matched of body (AMB), MBF of the trunk and SLM of the trunk. In addition, calorie intake and physical activity. The results could be used as effective preventive and therapeutic strategies toward reducing the burden of obesity and NAFLD.

  Methods Top

Study design and participants

Of 327 patients who were invited to fatty liver research center (Isfahan, Iran) and assessed for eligibility, 82 patients met the inclusion criteria and were enrolled in this intervention. The presence of NAFLD was confirmed by an expert physician in our department based on the results of liver sonography (presence of steatosis) and laboratory tests (aspartate aminotranferase and alanine aminotransferase more than 31 mg/dl).[9] This study was approved and performed under the guidelines of the research ethics committee of Isfahan University of Medical Sciences (Ethic code; 393583) and also registered in Iranian Registry of Clinical Trials (registration number; IRCT2016071211763N24). Moreover, a written informed consent was obtained from all subjects. All 82 participants were randomly assigned into two groups using blocked randomization method and were matched based on confounding factors included age, sex, and education level to take lifestyle modification program (n = 41) or to take usual care (n = 41). Randomization was carried out using computer-generated random numbers. Thirty-six patients in intervention group and 33 of controls completed the study. The characteristics of participants are shown in [Table 1].
Table 1: Baseline characteristics of participants

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The inclusion criteria were age 20–50 years; BMI ≥25; no use of alcohol and the exclusion criteria were missing more than two out of eight sessions; weight loss during the last 6 months; special dietary or physical activity regimens, menopause or pregnancy before or during intervention; use of medications with known effects on weight, for example, drugs acting on central nervous system, thyroid supplements, diuretics, and selective serotonin reuptake inhibitors or specialized weight loss agents such as orlistat or any herbal weight loss preparations; psychosocial disorders such as bulimia nervosa, anorexia nervosa, drug abuse, significant clinical depression or under psychiatric care; other diseases such as renal and hepatic disease, malignancy, thyroid disorder, psychosis, and autoimmune diseases.

Procedure and assessment of variables

Patients in the intervention group attended eight sessions of lifestyle modification education based on healthy eating guidelines during 2 months in which food pyramid, my plate, and each food group in exchange list were expanded and explained for them. Also bad and good choices in each group were explained. Participants were encouraged to consume more fruits and vegetable, low fat dairy, complex carbohydrates, white meat and fish and avoid the intake of unhealthy fats and refined carbohydrates. Moreover, one session was allocated to physical activity and regular 30–60 min exercise during at least 5 days of the week was recommended [Table 2]. On the other hand, the controls were followed up for 2 months and were asked to follow usual care which included usual dietary recommendations.
Table 2: Lesson plan of nutrition education based on health belief model

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Physical activity was evaluated using 3-day physical activity records completed for 3 consecutive days in the beginning and at the end of the study. Participants were asked to record all of their activity during 2 weekdays and on weekend day. Then, all of the activity get a relevant metabolic equivalents of task (MET) points and the overall score calculated by dividing it on 24 (hours of a day).[10]

Dietary information was collected by 3-day food records and an average of 3-day calorie intake was calculated by nutritionist 4 software (First Databank, Hearst Corp, San Bruno, CA, USA). Three-day food records were completed by participants during 2 week days and a weekend day in the beginning and at the end of intervention.

Body Composition Analyzer Model ioi 353 (Jawon, Seol, Korea) was used to estimate weight, BMI, AC, WHR, PBF, MBF, LBM, SLM, VFA, AMB, SLM of trunk and MBF of trunk. The device employs bio-electrical impedance analysis (BIA) method and eight electrodes are placed on hands and feet, and then measure body composition using an experimentally derived algorithm. Furthermore, height was measured using a stadiometer (Seca, Hamburg, Germany) with 0.1 cm accuracy without shoes. Anthropometric measurements were performed by a trained personnel in the fatty liver Institute in the morning with an empty stomach.

Statistical analysis

Quantitative and qualitative data were presented as mean ± standard error and frequency (percentage), respectively. Normality of quantitative variable was assessed using Kolmogrov–Smirnov test and Q-Q plot. Nonnormal data were subjected to logarithmic transformation. Qualitative data were compared between two groups using Chi-square test. Within group analysis based on quantitative data was conducted using paired samples t-test. Between group analysis was performed using analysis of covariance based on after intervention values, adjustment was made for baseline values and energy intake. SPSS version 21 (SPSS Inc., Chicago, IL, USA) software was used for statistical analysis.

  Results Top

There were two participants in the control group and one in the intervention group who decided to follow an especial weight-loss plan during our intervention, these individuals were excluded from the study. On the other hand, two participants of the intervention group were excluded because of recurrent lumbar disk, which made them unable to follow the coarse. Moreover, six patients in control group and two in the intervention group did not continue the study for unknown reasons. The final data analysis included 36 patients in education group and 33 in the control group [Figure 1].
Figure 1: Flow diagram of the study

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The baseline characteristics, including age, gender, educational level, weight, and BMI of participants in two groups were similar and there were no significant differences in the baseline characteristics between the two groups, as shown in [Table 1].

The results of our lifestyle modification intervention are: Weight, BMI, MBF of the trunk, and energy intake showed a strong significant reduction after 2 months in intervention group (P < 0.001). Furthermore, significant reduction was observed in the intervention group compared to control group. For PBF, SLM, LBM, AC, WHR, VFA, AMB and physical activity variables significant improvement was observed in the intervention group; however, no significant differences were observed between two groups. For SLM of trunk, no significant differences were observed within or between groups [Table 3].
Table 3: Results of within group and between groups comparison

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  Discussion Top

The 2-months of lifestyle modification education in the present study resulted in significant reduction in weight, BMI, MBF, SLM, and MBF of the trunk in overweight patients with NAFLD. Since the physical activity level of patients did not change significantly it could be concluded that these improvements in body composition variables could be only the result of the reduction in total calorie intake.

There was a statistically significant reduction in anthropometric measurements except for AC and WHR in the study group when compared to control group. A recent study in 2016 revealed the beneficial effects of lifestyle modification on weight, after 3 and 6 months of intervention in type 2 diabetic patients.[11] Another trial in 2014 showed a significant reduction in weight and BMI after 3 months of intervention same as our study, but it also showed a significant reduction in WHR contrary to our study.[12] The probable reasons for insignificant results regarding WHR could be the short period of intervention and insignificant change in physical activity level as well. In 2014, a 4-months intervention was done in low income hispanic women which resulted in significant reduction of WHR alongside with elevation of physical activity level, but it did not show any significant differences for weight and BMI.[13] This could be the answer to our hypothesis about insignificant reduction of WHR.

In our study, the variables which shown fat mass included: MBF, PBF, and MBF of the trunk which were only PBF stayed insignificant after intervention. In 2014, another same study repeated our results, which were revealed a reduction of fat mass and trunk fat mass but not fat-free mass after 3 months of intervention.[14] Macfarlane et al. in 2016 showed a significant reduction in fat mass after 10 weeks of intervention, but this result did not repeat for LBM.[15] The possible answer for insignificant change in LBM could be the tools of measurements. In our study, we used a BIA. BIA was only being able to detect changes in fat mass when compared to dual-energy X-ray absorptiometry (DXA), which is used to measure total body composition and fat content. On the other hand, BIA overestimate LBM and underestimate fat mass in comparison with DXA.[14],[15] VFA is referred to visceral fat, which is stored in the abdominal cavity. VFA showed a significant reduction in the intervention group but when it compared to control group did not stay significant. In 2013, Takihata et al. showed a significant reduction in VFA after 6 months of intensive lifestyle modification. On the other hand, it stated that VFA associated with NAFLD and also is affected by not only weight reduction but also unknown factors. It should be the reason of insignificant reduction in VFA alongside with a short period of intervention.[16]

The last variable which was extracted from body composition analysis and did not show a significant reduction, was AMB that refers to biologic age. Based on recent studies, biologic age is correlated with physical activity and exercise capacity, which were expressed as MET.[17] Hence, insignificant change in physical activity which was calculated as MET could be the reason of insignificant reduction in AMB level.

The results of our study showed a significant reduction in weight, independent of physical activity level. A recent study exactly showed our result in which weight loss after 52 weeks of lifestyle modification did not show significant correlation with physical activity.[18]

Our study had some limitations including the small sample size, short period of intervention and absent of the follow-up period after the end of lifestyle modification education.

  Conclusions Top

Based on the results of this trial, clear differences in body composition variables and calorie intake were revealed after lifestyle modification education. It means that changing the lifestyle could have resulted in remarkable changes in anthropometric measurements. A lifestyle modification program and its guidelines could be used in NAFLD patients with obesity, in order to improve their body composition measurements and lose weight. With this in mind, further studies and more trials are needed to draw a firm conclusion about the connection between lifestyle modification and body composition variables.

Financial Support and Sponsorship


Conflicts of Interest

There are no conflicts of interest.

  References Top

Kopelman PG. Obesity as a medical problem. Nature 2000;404:635-43.  Back to cited text no. 1
Smith KB, Smith MS. Obesity statistics. Prim Care 2016;43:121-35, ix.  Back to cited text no. 2
Patel AA, Torres DM, Harrison SA. Effect of weight loss on nonalcoholic fatty liver disease. J Clin Gastroenterol 2009;43:970-4.  Back to cited text no. 3
Lazo M, Hernaez R, Eberhardt MS, Bonekamp S, Kamel I, Guallar E, et al. Prevalence of nonalcoholic fatty liver disease in the United States: The Third National Health and Nutrition Examination Survey, 1988-1994. Am J Epidemiol 2013;178:38-45.  Back to cited text no. 4
Blackburn GL, Mun EC, editors. Effects of weight loss surgeries on liver disease. Seminars in Liver Disease. New York, USA: Copyright© 2004 by Thieme Medical Publishers, Inc.; 2004.  Back to cited text no. 5
Baran B, Akyüz F. Non-alcoholic fatty liver disease: What has changed in the treatment since the beginning? World J Gastroenterol 2014;20:14219-29.  Back to cited text no. 6
Oza N, Eguchi Y, Mizuta T, Ishibashi E, Kitajima Y, Horie H, et al. A pilot trial of body weight reduction for nonalcoholic fatty liver disease with a home-based lifestyle modification intervention delivered in collaboration with interdisciplinary medical staff. J Gastroenterol 2009;44:1203-8.  Back to cited text no. 7
Tandon VR, Sharma S, Mahajan A, Mahajan S. Effect of life-style modification on postmenopausal overweight and obese Indian women: A randomized controlled 24 weeks preliminary study. J Midlife Health 2014;5:23-8.  Back to cited text no. 8
Pezeshki A, Safi S, Feizi A, Askari G, Karami F. The effect of green tea extract supplementation on liver enzymes in patients with nonalcoholic fatty liver disease. Int J Prev Med 2016;7:28.  Back to cited text no. 9
[PUBMED]  Medknow Journal  
Ainsworth BE, Haskell WL, Whitt MC, Irwin ML, Swartz AM, Strath SJ, et al. Compendium of physical activities: An update of activity codes and MET intensities. Med Sci Sports Exerc 2000;32 9 Suppl: S498-504.  Back to cited text no. 10
Moncrieft AE, Llabre MM, McCalla JR, Gutt M, Mendez AJ, Gellman MD, et al. Effects of a multicomponent life-style intervention on weight, glycemic control, depressive symptoms, and renal function in low-income, minority patients with type 2 diabetes: Results of the community approach to lifestyle modification for diabetes randomized controlled trial. Psychosom Med 2016;78:851-60.  Back to cited text no. 11
Yamauchi K, Katayama T, Yamauchi T, Kotani K, Tsuzaki K, Takahashi K, et al. Efficacy of a 3-month lifestyle intervention program using a Japanese-style healthy plate on body weight in overweight and obese diabetic Japanese subjects: A randomized controlled trial. Nutr J 2014;13:108.  Back to cited text no. 12
Koniak-Griffin D, Brecht ML, Takayanagi S, Villegas J, Melendrez M, Balcázar H. A community health worker-led lifestyle behavior intervention for Latina (Hispanic) women: Feasibility and outcomes of a randomized controlled trial. Int J Nurs Stud 2015;52:75-87.  Back to cited text no. 13
Lyra A, Bonfitto AJ, Barbosa VL, Bezerra AC, Longui CA, Monte O, et al. Comparison of methods for the measurement of body composition in overweight and obese Brazilian children and adolescents before and after a lifestyle modification program. Ann Nutr Metab 2015;66:26-30.  Back to cited text no. 14
Macfarlane DJ, Chan NT, Tse MA, Joe GM. Agreement between bioelectrical impedance and dual energy X-ray absorptiometry in assessing fat, lean and bone mass changes in adults after a lifestyle intervention. J Sports Sci 2016;34:1176-81.  Back to cited text no. 15
Takihata M, Nakamura A, Aoki K, Kimura M, Sekino Y, Inamori M, et al. Comparison of intragastric balloon therapy and intensive lifestyle modification therapy with respect to weight reduction and abdominal fat distribution in super-obese Japanese patients. Obes Res Clin Pract 2014;8:e331-8.  Back to cited text no. 16
Blaha MJ, Hung RK, Dardari Z, Feldman DI, Whelton SP, Nasir K, et al. Age-dependent prognostic value of exercise capacity and derivation of fitness-associated biologic age. Heart 2016;102:431-7.  Back to cited text no. 17
Wadden TA, Fujioka K, Toubro S, Gantz I, Erondu NE, Chen M, et al. A randomized trial of lifestyle modification and taranabant for maintaining weight loss achieved with a low-calorie diet. Obesity (Silver Spring) 2010;18:2301-10.  Back to cited text no. 18


  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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