**2.4 Loss of weight/diet**

The loss of weight is the main treatment for most patients with NAFLD/NASH. It is suggested for all patients that are overweight (BMI > 25 kg/m2) or obese (BMI > 30 kg/m2), because weight loss can lead to amelioration of liver function tests, histologic findings, and insulin resistance. It mainly consists of the restriction of intake calories through the decrease of the metabolism of carbohydrates **Table 1.** This reduces the glycemic load, and improves the pancreatic b-cell insulin secretion, it increases HDL-C and further decreases serum triglycerides and glucose [6]. The patients are consulted to lose 5 to 7% of the initial body weight with a rate of 0.5 to 1 kg per week. For patients with NASH (suspected or proven by biopsy), the target of

### **Table 1.**

*Indicative diet for weight loss in NAFLD/NASH.*

weight loss is even higher (7 to 10% of the initial body weight). For some patients, an even greater body loss may be required. If the values of ALT are not normalized, after the achievement of the above-mentioned targets, they are advised to lose even more weight. It has been shown from several studies that at least 5% of the initial body weight is required for the improvement of the hepatic steatosis [7]. In a meta-analysis of eight studies, which include 373 patients, the loss of equal or more to 5% of body weight resulted in the improvement of hepatic steatosis, while the loss of at least 5% of body weight was correlated with a further amelioration of NAFLD/NASH [8]. The above changes need at least a timeline of 6 months to be implemented and reveal significant results.

## **2.5 Bariatric surgery**

Bariatric surgery is an option in patients unresponsive to lifestyle changes and pharmacotherapy. It is currently recommended for patients with BMI > 40 kg/m2 and no comorbidities, or in patients with BMI > 35 kg/m2 and serious comorbidities (T2DM, Hypertension, NAFLD/NASH). A review of 29 studies of patients that underwent bariatric surgery showed a significant improvement in liver function tests and a metaanalysis reported a decrease in steatosis, inflammation, and fibrosis [9, 10].

## **2.6 Immunization**

Patients who do not have serologic verification of immunity should receive the hepatitis A and B vaccines. Pneumococcal vaccination and common immunizations offered to the public are additional vaccines for those with chronic liver disease.
