本文是留学生美国医学论文范例，题目是“Management of Non-Alcoholic Fatty Liver Disease（非酒精性脂肪性肝病的治疗）”，非酒精性脂肪性肝病(NAFLD)正逐渐成为美国最常见的肝病。30%的美国人患有非酒精性脂肪性肝病。非酒精性脂肪性肝病的诊断是当肝脏中有过多的脂肪堆积时，也被称为肝脂肪变性。可以通过一系列测试进行诊断以确认此诊断。从侵入性较小的超声、瞬时弹性成像、cat扫描、磁共振成像(MRI)开始，到侵入性最大的肝脏活检。可进行实验室检查，如肝功能检查(LFT’s)，包括:天冬氨酸转氨酶(AST)和丙氨酸转氨酶(ALT)水平，提示肝损害和疾病、血脂谱、全血计数、空腹血糖测试和糖化血红蛋白(HgA1C)，但不能确诊。
Non-alcoholic fatty liver disease (NAFLD) is progressively becoming the most common liver disease in the United States. Thirty percent of people in the United States have non-alcoholic fatty liver disease. The confirmation of diagnosis of non-alcoholic fatty liver disease is when there is excessive fat buildup in the liver, also known as hepatic steatosis. Diagnostics to confirm this diagnosis can be done with a range of tests. Starting with less invasive of an ultrasound, transient elastography, cat scan, magnetic resonance imaging (MRI), to most invasive of a liver biopsy. Laboratory tests, such as liver function tests (LFT’s), that include: aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels which indicate liver damage and disorders, lipid profile, complete blood count, fasting glucose test, and hemoglobin A1C (HgA1C), can be performed, but are not confirmative of a diagnosis. These laboratory tests are not always abnormal in a patient with non-alcoholic fatty liver disease.
Researchers and experts do not fully understand the why some patients accumulate fat in the liver compared to others. Therefore, there is not a definitive pharmacological treatment for non-alcoholic fatty liver disease. The best option for patients with this diagnosis is to manage their associative risk factors to the disease. Researchers believe that non-alcoholic fatty liver disease is becoming so prevalent due its association and increase of obesity and diabetes in the United States as well (Arab et al., 2014). Managing obesity is best seen with exercise and dietary regimens and managing diabetes with pharmacological and dietary regimens, as well. Obesity, diabetes, and non-alcoholic fatty liver disease puts the patient at cardiovascular disease risk as well. Prevention of cardiovascular risk, based off of studies, have shown to prevent and improve non-alcoholic fatty liver disease as well.
研究人员和专家们还没有完全理解为什么有些病人比其他人在肝脏中积累脂肪。因此，对于非酒精性脂肪肝尚无明确的药物治疗方法。对这种诊断的患者来说，最好的选择是管理他们与疾病相关的危险因素。研究人员认为，非酒精性脂肪性肝病在美国也变得如此普遍，原因是它与肥胖和糖尿病的联系和增加(Arab et al.， 2014)。控制肥胖最好是通过运动和饮食疗法，控制糖尿病也最好是通过药理学和饮食疗法。肥胖、糖尿病和非酒精性脂肪肝也会使患者面临心血管疾病的风险。根据研究，预防心血管风险也可以预防和改善非酒精性脂肪肝疾病。
The goal of the literature review is to examine the best management options for non-alcoholic fatty liver disease that is evidenced based. A consolidative analysis will take place of current literature within the last five years. Many research articles, as evidenced within this review, examine what the best management plan is for non-alcoholic fatty liver disease since there is no clear-cut treatment option.
Eslami, Merat, Malekzadeh, Nasseri-Moghaddam, Aramin, 2013, performed a study with the main focus validating the beneficial and harmful effects of statin medications on non-alcoholic fatty liver disease. This study describes that treatment is unavailable in non-alcoholic fatty liver disease, but goes on to describe how statin medications can decrease elevated liver function tests or keep them low if they were never elevated to begin with and in result, help cure the disease in patients. The researchers believed that the intervention, of statins, may work by minimizing the intrahepatic cholesterol and influence the abnormal lipid metabolism that has been seen in patients diagnosed with non-alcoholic fatty liver disease.
Eslami, Merat, Malekzadeh, Nasseri-Moghaddam, Aramin, 2013年，开展了一项研究，主要验证了他汀类药物对非酒精性脂肪肝的有益和有害影响。这项研究描述了非酒精性脂肪性肝病的治疗是不可行的，但接着描述了他汀类药物是如何降低升高的肝功能测试的，或者如果它们一开始就没有升高，则保持在较低的水平，从而帮助治疗患者的疾病。研究人员认为，他汀类药物的干预可能通过最小化肝内胆固醇和影响非酒精性脂肪肝患者的异常脂质代谢来发挥作用。
From randomized clinical trials, statins were given to patients and compared to either no intervention or given a placebo. Imaging studies followed in order to evaluate the effectiveness of the drug versus no drug. A decrease in liver function tests appeared to be superior in participants who were given a statin when compared to the control group. Although, it was resulted on diagnostic imaging that simvastatin, a statin medication, when evaluated against a placebo had no effects on disease management. Atorvastatin, another statin medication, compared to fenofibrate (a non-statin lipid-lowering drug) likewise had no differences when comparing ultrasound reports. When the two results were joined into one, atorvastatin compared to be a more beneficial drug to fenofibrate.
The following year, Arab et al., 2014, conducted a study using the Delphi method to gather data on evidence-based management of non-alcoholic fatty liver disease. Thirteen experts of the disease process received a survey of seventeen open-ended specific questions that providers are consistently challenged with during the management of non-alcoholic fatty liver disease. The experts underwent three rounds where a level of agreement in the first round was 93.8% and then 100% the second and third rounds. The seventeen open-ended questions consisted of the following interventional categories for management: diet and weight loss, physical exercise, weight loss medications, bariatric surgery, insulin-sensitizing medications, hypolipidemic medications, and antioxidants.
The relationship between diet and weight loss was agreed to be recommended to all patients with non-alcoholic fatty liver disease. A caloric restriction of 25-30 kilocalories per kilogram per day was found to best assist with gradual weight loss. Dramatic weight loss was shown to correlate with progressive liver fibrosis and portal inflammation. Appropriate diet with at least thirty minutes of physical exercise at least three times a week was beneficial for the patient by reducing the risk of cardiovascular disease. Physical exercise in relation to liver enzymes had a significant normalization of levels, regardless of weight loss. Medications for weight loss had contraindicative results of not being fit to solely manage or treat NAFLD. One drug, orlistat was recommended to be used in combination with nutritional and exercise programs. Due to high risk of cardiovascular adverse events, the weight loss drug sibutramine was not recommended.
The importance of cardiovascular disease, in conjunction with non-alcoholic fatty liver disease, was further studied by Targher et al., 2013. Four hundred participants who previously had been diagnosed with type 2 diabetes were selected to be followed over a ten-year period. All participants were deemed free from atrial fibrillation during initial baseline assessment. Any participant who had a history of atrial fibrillation, atrial flutter, or taking an antiarrhythmic drug were excluded from the study. An ultrasound was also done at based line to confirm diagnosis of NAFLD. Out of the 400 participants, the number that met the clinical criteria to be diagnosed with NAFLD were 281. At that time, the remaining 281 participants underwent annual review, with the use of a twelve lead electrocardiogram and diagnosed with atrial fibrillation by a cardiologist when appropriate. At the ten-year completion, the study identified 10.5% of type 2 diabetic participants were diagnosed with NAFLD and atrial fibrillation respectively (Targher et al., 2013).
Individualization of the indication of bariatric surgery was recommended by Arab et al., 2014. The effects of bariatric surgery long term had not been studied. Though it possibly could play a part in weight loss for obese patients, per researchers, and complications of bariatric surgery may occur depending on the patient and place of operation. Three year later, Cazzo, Pareja, and Chaim, 2017, conducted a meta-analysis study of ninety-one individuals correlating bariatric surgery and non-alcoholic fatty liver disease. Different surgical techniques of bariatric surgery were taken into consideration when conducting the study. Overall, research showed that weight loss generated by bariatric surgery, improved or resolved entirely NAFLD in the bulk of individuals. Cazzo, Pareja, and Chaim, 2017, conclude that illimitable amount of patients with NAFLD are lean and overweight, but morbid obese patients with NAFLD are the patients who would benefit the most from bariatric surgery induced weight loss. In 2016, a control clinical trial was conducted utilizing twenty-four Sprague Dawley rats. The rates were randomly placed in sets of eight and identified as Sham or Roux-en-Y gastric bypass (RYGM) surgery group and compared to eight placed in the lean control group. To maintain obese rats, they were fed a high fat diet throughout the study. The rats were assessed ninety days’ post-surgery for insulin resistance, hepatic steatosis, triglyceride levels, endoplasmic reticulum (ER) stress and apoptosis. There was a significant difference between the groups and the RYGM group had decreased their baseline weight by 20% and showed increased insulin sensitivity (Mosinski et al., 2016).
Insulin-sensitizing medications, act by improving the sensitivity of peripheral tissues to insulin, which results in decreased circulating insulin levels. Insulin-sensitizing medications, such as Metformin, were not recommended for regular use to prevent insulin resistance in non-alcoholic fatty liver disease. Unless, these medications were used in patients who were already diagnosed insulin-resistant. In which case, Metformin, helped with insulin resistance, but continued to not show any improvement in NAFLD. A verdict was able to be reached that reinforced the importance of lifestyle changes of diet and exercise within these patients. (Arab et al., 2014).
As found in the research done by Eslami et al., 2013 on statin use in non-alcoholic fatty liver disease patients, Arab et al., 2014 verified further that regular use of statins in the NAFLD patient is not supported. Statin use for the management of lowering lipid profile results in the NAFLD patient, despite the fact, can be used to support reduction of risk factors associated. Del Ben et al., 2017, studied NAFLD in 605 patients with cardio-metabolic disorders and the use lipid-lowering medications. It was proven in this study, the use of lipid-lowering medications, such as statins, was highly under prescribed to patients at all levels of cardiovascular disease. Fifty percent of patients who had an indication for statin use were not prescribed any. A correlation of under prescribing was found in patients with NAFLD as a major consideration. Even though statin use for the treatment of NAFLD is still an ongoing debate with no clear evidence-based results, some studies have shown improvement of liver function tests as others have not. Nevertheless, Del Ben et al., 2017 recommends their use for management of cardiovascular risk in the NAFLD patient.
Antioxidant use, such as vitamin E, has been shown to be beneficial in nondiabetic patients who’ve had biopsy diagnosed non-alcoholic fatty liver disease. Reversal effects of the liver have taken place with discontinuation of vitamin E suggesting that long-term use is needed in order to be used as management of NAFLD (Arab et al., 2014). Similarly, Eslamparast, Eghtesad, Poustchi, and Hekmatdoost, 2015, concluded that Vitamin E is recommended in adults who are without diabetes. This study also agreed with Arab et al., 2014 that studies completed to evaluate and support long term effects of vitamin E and non-alcoholic fatty liver disease are lacking. The literature goes on to reveal that vitamin E does not yield greater outcomes for NAFLD management when compared to diet and exercise.
Dietary supplementation advances, as evidenced by studies conducted and released in literature, have shown to be beneficial. Green tea extract, in a study conducted in mice, proved to have beneficial effects on obesity, components of metabolic syndrome, and liver steatosis. Studies in humans are needed as the next step in furthering the green tea extract advancement. Anti-oxidative, anti-inflammatory, and anti-fibrotic properties of coffee are to blame for the hepatoprotective response. Among the NAFLD patients, coffee consumption has been associated with a decreased in the risk of fibrosis and a lower risk of developing type two diabetes (Eslamparast, Eghtesad, Poustchi, & Hekmatdoost, 2015).
In addition to green tea extract and coffee, the benefits of probiotics were also studied, utilizing the method of a double-blind, randomized, controlled clinical trial. Seventy-two participants, diagnosed with NAFLD were selected, and placed into a group of thirty-six who ate 300 grams a day of probiotic yogurt and the thirty-six participants placed in the control group ate 300 grams a day of conventional yogurt. Upon concluding the study, after an eight-week interval, there was no noted change, of the controlled group, in their serum liver enzymes, glucose or lipid levels at their baseline. However, the probiotic group showed reductions in their serum liver levels of aspartate aminotransferase and alanine aminotransferase (Nabavi, et al, 2014). These results show improvement in the serum indicators for liver disease and damage.
Multiple types of diets have been used by patients to promote their health. A study done by, Mohseni et al., 2016 evaluated the adherence to the Mediterranean diet pattern in seventy-five patients with NAFLD. Mohseni et al., 2016 and Eslamparast et al., 2015 both concluded diets that included unsaturated fats and excluded saturated fats were beneficial for patients with NAFLD. The development of NAFLD was prevented by unsaturated fats reducing the oxidation of low-density lipoprotein (LDL), serum levels of LDL and cholesterol totals. Body fat accumulation was also shown to decrease. It is evident, according to Mohseni et al., 2016, that dietary modifications are efficient in reducing the metabolic risk factors of chronic diseases, including non-alcoholic fatty liver disease.
In addition to studying types of diets, studies have also been completed to review eating styles and behaviors. A retrospective cohort study, comparing participants who ate before bedtime and participants who did not, was completed in the year 2016. Nishi, et al., 2016, chose participants with a median age of forty-eight years old and who were free of a history of stroke, coronary heart disease, chronic kidney disease, liver cancer, liver fibroids, anemia, chronic viral hepatitis, alcoholic liver disease or anemia and were not treated with corticosteroids. The results showed a significant increase in NAFLD in participants who ate before bedtime, when compared to those who did not.
A cross sectional study of self-reported eating habits was completed by Lee et al., (2016) during routine medical exams. The subject sample consisted of 7,917 Korean adults without a medical history of a positive hepatitis B surface antigen (HBsAg positive), a positive hepatitis C antibody (HCV Ab positive), liver cirrhosis, hepatocellular carcinoma, elevated liver enzymes, or elevated gamma-glucronyl transpeptidase. Also incorporated in the exclusions were participants who had been taking medicine due to a liver disease or had a history of alcohol consumption of more than 20 grams per day for participants under the age of twenty and those who didn’t comply with questionnaires and ultrasonography. The results were reported that faster eating groups showed an increased proportion of participants with advanced grade NAFLD. Lee et al., 2016, describe that faster eating habits may not directly affect NAFLD, but recommend the importance of education to patients regarding eating speeds. Education should include how slower eating speeds can prevent overeating, which may lead to obesity.
Endothelial nitric oxide synthase (eNOS) function in patients with hepatic steatosis, the first stage of non-alcoholic fatty liver disease and steatohepatitis, the second stage, was investigated in as study completed by Persico et al., 2017. It is already known that NAFLD is related to insulin resistance and insulin resistance is responsible for endothelial dysfunction. Two groups, steatosis and steatohepatitis, were divided out of the fifty-four patients enrolled in the study. Clinical, laboratory tests, and liver biopsies were taken to evaluate the eNOS function in platelets and liver samples taken. The early stage, simple steatosis, was correlated with a worse eNOS impairment when compared to steatohepatitis. Endothelial damage and deterioration of endothelial regulatory mechanisms serve as the pathophysiological foundation of cardiovascular disease. Persico et al., 2017 supports the other literature texts in this review by breaking down the damage done by NAFLD and reinforcing the need to manage and maintain risk factors such as cardiovascular disease and diabetes.
One cohort study was reviewed in regards to the accuracy of liver marker when diagnosing the presence of steatosis. Three hundred and twenty-four liver biopsies were performed and assessed for steatosis. Steatosis was then categorized into levels classified as none, mild, moderate or severe. Five biomarkers were used to measure fatty liver index, NAFLD liver fat score, hepatic steatosis index, visceral adiposity index and triglyceride X glucose index (Fedchuk et al., 2014). Reported findings state 81% were diagnosed with fatty liver as they showed bright red patterns on liver ultrasounds and only 5% did not have steatosis. In addition, all of the fatty liver markers displayed were accurate in estimating the presence of any steatosis (Fedchuk et al., 2014).
Another cohort study was completed in 2016 with fifty-seven patients who had biopsy proven non-alcoholic fatty liver disease and the union with gut dysbiosis. Following liver biopsies, patients were asked to give a stool sample, genomic DNA was isolated and then the sample was frozen. The study spanned from October 2012 to September 2013 and excluded hepatitis infections, alcohol consumption, cirrhosis, bariatric surgery, ingestion of steatosis inducing drugs, other chronic liver diseases and antibiotic use within the preceding two months (Boursier et al., 2016). The findings report an increase level of bacteroides in non-alcoholic steatohepatitis (the second stage of NAFLD) patients and ruminococcus bacteria was higher with fibrosis. “Recent animal studies have placed the gut microbiota as a potentially important player in the pathogenesis of NAFLD” (Boursier et al., 2016). Although the results were obtained after liver biopsy, the results are a promising indicator for future diagnostics.
Relevant articles for the purpose of this literature review were obtained using the State University of New York Polytechnic Institute of Technology, Cayan Library electronic database. CINAHL Plus with Full Text and Ebsco Clinical Ebook Collection were the primary databases utilized. Google Scholar was also utilized as an additional search.
The key terms used to reach this literature review were fatty liver disease, non-alcoholic fatty liver disease, management of fatty liver disease, literature review, treatment of fatty liver disease, bariatric surgery for fatty liver disease, diet for non-alcoholic fatty liver disease, lifestyle modifications for NAFLD. The literature search was restricted to peer-reviewed articles printed in the English language. The search was also restricted to published articles between the years of 2012 and 2017. An overwhelming total of twenty-two articles were found and reviewed for relevance to main focus of this literature review. Fifteen of those articles were chosen that focused on managing the risk factors associated with non-alcoholic fatty liver disease. A final analysis of the fifteen articles was performed to compare the results (see Appendix A).
Through comparison and contrast of findings, the results of the literature review support current evidence based practice for treating and reducing the risk of non-alcoholic fatty liver disease. At this time current, evidence-based, treatment is weight loss, healthy diet, exercise, lowering cholesterol, controlling diabetes, protecting the liver, and avoidance of alcohol (Mayo Clinic, 2017). Identified risk factors include, but are not limited to: obesity, elevated weight, diabetes, increased cholesterol and triglycerides, and poor eating habits. Upon review, the fifteen articles selected and identified in appendix A, can be subdivided into four categories that align and support current treatment. There are six articles supporting diet and nutrition, with two referencing weight management through surgical means, four identifying the use cholesterol reducing medications and the impact on cardiovascular disease, one addresses the need of “good” bacterial levels within the body, and two demonstrates the importance of diagnostics associated with NAFLD.
Diet and Nutrition饮食和营养
Excess weight and fat can influence multiple risk factors of non-alcoholic fatty liver disease. Poor diet and a sedentary lifestyle with a lack of exercise can not only increase weight but can also increase cholesterol and triglyceride levels. In addition, it can also cause insulin resistance, which causes the pancreas to increase insulin production to maintain regular blood sugar levels and can lead to the development of diabetes (Johns Hopkins, nd). In response to these concerns, research studies have addressed the potential impact of vitamin supplements, weight reduction surgery and eating habits.
超重和肥胖可影响非酒精性脂肪肝的多种危险因素。不良的饮食习惯和久坐不动的生活方式，加上缺乏锻炼，不仅会增加体重，还会增加胆固醇和甘油三酯水平。此外，它还会导致胰岛素抵抗，导致胰腺增加胰岛素分泌以维持正常的血糖水平，并可能导致糖尿病的发展(Johns Hopkins, nd)。为了回应这些担忧，研究已经探讨了维生素补充剂、减肥手术和饮食习惯的潜在影响。
Research done, by Arab et al., 2014, concluded that Vitamin E and pioglitazone in nondiabetic patients was a beneficial pharmacological therapy with biopsy proven steatohepatitis. Eslamparast et al., 2015 suggests that antioxidants, anti-inflammatory and insulin sensitizer dietary supplements have also shown beneficial effects. Mohseni et al., 2016 concluded that diet modifications were significant and effective in reducing risk factors of chronic disease and the study conducted by Abulnaja and El Rabey, 2015, of barley bran consumption demonstrated a significant decrease in overall organ weights.
The diet modifications that were identified included the Mediterranean diet. Consisting of lean sources of protein (fish and poultry) versus red meats and increased consumption of legumes, whole grains, fruits and vegetables. Red wine is also acceptable within this diet type, provided it is consumed in moderation (Mohseni et al., 2016). Eating styles, which include eating before bed and speed of food consumption, also indicate an association to non-alcoholic fatty liver disease. Subjects who ate before going to bed had a significant increase in NAFLD when compared to individuals who did not. When participants eating times were compared, there was also a correlation between an increased eating speed and an increase in the total body mass index (Nishi et al., 2016 & Lee et al., 2016).
Two studies indicate a benefit of bariatric surgery to reduce weight and obesity. Both studies indicate this surgical measure, as beneficial as it, protected the liver against high fat density and improved the stage of NAFLD (Cazzo et al., 2017 & Mosinski et al., 2016). However, authors of both articles indicate the need for further studies to show overall effectiveness. The information in regards to bariatric surgery remains conflicting since rapid weight loss has also been identified as a NAFLD risk factor.
Increased cholesterol and triglycerides are significant in non-alcoholic fatty liver disease. The fats inside the liver impair its metabolic ability to break down fats and produce energy. Eslami et al., 2013, concluded that atorvastatin was superior to non-statin fenofibrate and research completed by Del Ben et al., 2017, demonstrated an underuse of prescribed statins with cardiovascular patients diagnosed with NAFLD. These results are of particular interest when compared with research analysis that found people diagnosed with NAFLD had increased eNOS dysfunction which can lead to a higher risk of cardiovascular disease. The study completed by Targher et al., 2013 showed that of 400 diabetic participants, 10.5% developed atrial fibrillation over a ten-year span. Making the correlation between NAFLD and cardiovascular disease and evidenced based risk factor. These increased risks of cardiovascular disease and gap in prescribed statins is alarming and produce evidence for the need of future implementation and further research.
Limited information is available in regard to normal body bacteria, also known as “good bacteria” and its effects on non-alcoholic fatty liver disease and the function of the liver. However; Nabavi et al., 2014, completed a study that indicated a lowering of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels when eating probiotic yogurt. This information is valuable as AST indicates levels of liver damage and ALT assists in diagnosing liver disorders. Though the study completed by Boursier et al, 2016 was done post diagnosis of NAFLD, it suggests that further studies are needed to prove that probiotic use as a preventative measure for NAFLD is evidenced-based.
The only way to diagnose non-alcoholic fatty liver disease with complete certainty is by performing a liver biopsy. However, studies have shown a correlation with biomarkers and diagnosis. One example is a research study that used multivariate analysis which resulted in showing an increased amount of bacteroides with NASH and increased amount of ruminococcus with fibrosis (Boursier et al., 2016). This is supported by the fact that bacteroides have an increased presence in the intestinal tract of a person who consumes a diet high in animal fat. Nonetheless, the increased presence of ruminococcus is not readily explainable. Another study utilized five steatosis biomarkers with 324 liver biopsies and determined that all the fatty liver markers “displayed an acceptable accuracy in estimating the presence of steatosis of any amount vs. no steatosis” (Fedchuk et al., 2014). The results of the study completed by Nabavi et al, 2014, also supports the use of diagnostics through the use of serum levels to assess AST and ALTs.
In conclusion, fifteen articles were selected to perform a literature review to examine the best management options for non-alcoholic fatty liver disease that is proven to be evidence based. Articles were referenced over the past five years and included various methods of research. Studies support the ongoing best standards of practice, with focus being on decreasing risk factors and prevention, with the most prevalent being obesity. Education of treatment and ongoing medical care needs to be reinforced to decrease the severity in non-alcoholic fatty liver disease. The current recommendations include follow up visits with a primary care provider every six months for assessment of body weight, body mass index, serum liver and serum metabolic testing. In addition, an annual liver and abdominal ultrasound should be obtained to monitor disease progression which may result in a gastroenterologist referral (Mayo Clinic, 2017).
总之，我们选择了15篇文章来进行文献综述，以研究非酒精性脂肪性肝病的最佳治疗方案，这些方案被证明是有证据基础的。在过去的五年里，文章被引用，包括了各种各样的研究方法。研究支持正在进行的最佳实践标准，重点是减少风险因素和预防，其中最普遍的是肥胖。治疗教育和持续的医疗护理需要加强，以减少严重的非酒精性脂肪肝疾病。目前的建议包括每六个月向初级保健提供者进行随访，以评估体重、身体质量指数、血清肝脏和血清代谢测试。此外，还应每年进行一次肝脏和腹部超声检查，以监测疾病进展情况，这可能会导致转诊到胃肠病学家(Mayo Clinic, 2017)。
The studies included in the literature review, readily identified the need for ongoing research as current treatment options are pharmaceutically limited and treatment requires behavior modifications. In addition to this challenge, the importance of effective treatment of non-alcoholic fatty liver disease is supported by it becoming the fastest growing liver disease, with 30% of the United States population being afflicted. Although research continues in this area the primary approach for treating non-alcoholic fatty liver disease is education and reducing previously identified risk factors.