aerobic exercises versus low-caloric diet for mild fatty liver ......aerobic exercises versus...

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Aerobic exercises versus low-caloric diet for mild fatty liverpatients with central obesityHany F.E.M. Elsisia, Fatma M.M. Abdeen Sallamaa, Awny F. Rahmya,Mohammed A. Sweilamb

aPhysical Therapy of Cardiovascular/

Respiratory Disorder and Geriatrics, Cairo

University, Cairo, Egypt, bDepartment of

Clinical and Chemical Pathology, Tanta

University, Tanta, Egypt

Correspondence to Fatma Mohammed

Mohammed Abdeen Sallama, BS, Faculty of

Physical Therapy, Cairo University, Egypt, 2008

Gharbia, El-Santa, El Magles El Mahaly St;

Tel: 0404470526; fax: 01014101210;

e-mail: [email protected]

Received 22 December 2016Accepted 5 June 2017

Bulletin of Faculty of Physical Therapy2017, 22:74–82

© 2018 Bulletin of Faculty of Physical Therapy | Publishe

Background and aimsExercise and weight loss are the first-line therapy for patients with mild fatty liverwith central obesity. We aimed to (i) summarize a moderate aerobic exerciseprogram and low-caloric diet program and (ii) to compare the effect of moderateaerobic exercise program versus low-caloric diet program on liver biochemistry.The purpose of this studywas to determine the response of liver enzymes to aerobicexercise versus low-caloric diet in mild fatty liver patients with central obesity.Patients and methodsThe study was carried out on 40 patients with mild fatty liver, central obesity, andelevated liver enzymes. Their ages ranged between 30 and 45 years; the patientswere assigned to two groups equal in number. Group 1 received a program ofmoderate intensity aerobic exercise on electronic treadmill (60–70% of maximumheart rate) for 50min three times a week for 8 weeks. Group 2 followed a program oflow-caloric diet for 8 weeks. Liver enzymes, BMI, waist circumference, and fatcontent were measured for both groups before and after program.ResultsThe results of this study showed that there were no significant (P>0.05) differencesbetween the findings of both groups. However, there were significant (P

Aerobic exercises versus low caloric diet Elsisi et al. 75


In addition, hepatomegaly can be found on physicalexamination [5].

A 4-week aerobic exercise program results in asignificant reduction in visceral adipose tissue, thuspositively affecting the levels of circulating free fattyacids and hepatic lipid accumulation, but appearsto be too short a time frame to reduce insulinresistance. Unfortunately, the disruption of inflam-matory biomarkers has been not addressed byJohnson et al. [6]. Promrat et al. [7] were able todemonstrate this, providing evidence that patientsundergoing consistent abdominal adipose tissue losshave improved lobular inflammation and also reducedinsulin resistance [8].

Obese patients are advised to achieve a gradualand sustained weight loss through proper nutritionand exercise. For patients with nonalcoholicsteatohepatitis who are not overweight and notdiabetic, a low-fat diet is often recommended. It isalso recommended that people avoid drinking alcoholas it can cause and contribute to fatty liver disease.Patients with fatty liver disease should see their primaryhealthcare providers on a regular basis [9].

It was reported that short-term calorie restrictiondecreases intrahepatic TG before significant weightloss. It is clear that weight loss from reduced calorieintake is effective in reducing intrahepatic TG.However, similar to the overfeeding studies, it is notclear whether this benefit is due to weight loss orongoing negative caloric balance [10].

It was hypothesized that there may be no significantdifference between the effects of aerobic exercises andlow-caloric diet on fatty liver patients with centralobesity.

Patients and methodsForty patients with mild fatty liver and central obesitybetween 30 and 45 years of age were screened andselected randomly to be enrolled into this 8-weekblinded randomized comparative clinical trial. Theywere recruited from outpatient clinics of internalmedicine of El Santa Hospital to participate in thisstudy. This study was approved by the EthicsCommittee for Scientific Research of the Faculty ofPhysical Therapy, Cairo University No: P.T.REC/012/00818. Instructions and details of the studywere explained for each patient. Patients whoaccepted to participate in the study were asked tosign a consent form Appendix 1.

Outcome measuresBoth groups underwent an identical battery oftests: baseline (before training) and after 8 weeks (aftertraining). Initially, data on the participants’ characteristicswere collected in the first session, including alanineaminotransferase (ALT) and aspartate aminotransferase(AST)using3 cmofblood for blood analysis.Weightwasmeasured using a standard weight scale. Height wasmeasured with the participant standing in an erectposition against a vertical scale. BMI and fat contentweremeasured using the Body Stat device (Bodystat Ltd.P.O. Box 50 Douglas isle of Man IM99 1DQ British,Isles). Waist circumference (WC) was measured usingsimple tapemeasurement fromthe level ofumbilicus.Theprimary outcome measures in this study were ALT andAST, and the secondaryoutcomemeasureswereBMI, fatcontent, and WC.

Sample size calculationA preliminary power analysis [power (1α error P)=0.85, α=0.01, effect size=0.5] determined a sample sizeof 40 for this study. This effect size was chosen becauseit yielded a realistic sample size.

Procedures of the studyInitialmedical screeningwas performed for every patientby thephysician, diagnosedasmild fatty liverbymeansofabdominal ultrasound by the radiologist and liverenzymes were measured in the laboratory.

Initially, 74 patients were selected from the outpatientclinic of internal medicine of El-Santa Hospital fromMarch 2015 to June 2016 and identified as potentiallyeligible for the study as mild fatty liver patients withcentral obesity. On blood analysis for measuring liverenzymes for each patient, 34 patients were found to beineligible according to inclusion and exclusion criteriaand therefore excluded. Forty patients were found tobe eligible and already participated in the study. All40 participants had completed the 8 weeks’ programto the end. The study was conducted at Abed PhysicalTherapy Center in El-Santa, Gharbia governorate,Egypt.

Eligibility criteria: all participants had mild fatty liverwith liver enzymes above accepted cutoffs withcentral obesity, free from any immunodeficiencydisorders or diseases that can affect the treatmentprocess. Criteria of fatty liver: patients werediagnosed with mild fatty liver using abdominalultrasound when more than 5–10% of liver cellswere filled with fat droplets with mild elevatedliver enzymes with cutoffs of 20 U/l for female and30U/l for male patients.

76 Bulletin of Faculty of Physical Therapy, Vol. 22 No. 2, July-December 2017


The 40 eligible participants were randomly assignedto two groups equal in number, groups 1 and 2. It wasa randomized trial using sealed envelope allocationsequence method. Group 1 received a program ofmoderate intensity aerobic exercise. Group 2 followed aprogram of low-caloric diet program. Each patient hadbeenre-evaluatedafter8weeksof their treatmentprogramfor BMI, body fat content, WC, ALT, and AST.

Equipment

(1)
Assessment equipment:(a) Height and weight scale: RGZ 220 (China).(b) Tape measurement: 150 cm.(c) Body Stat 1500: SN 213056 (UK).(d) Liver enzyme measuring machine: Microlab
300 SN 11-5046 (France).(e) Liver enzyme measuring kits: BioSystems

(Spain).(f) Ultrasonography: SonoScope SN 3322415

made in China.

Therapeutic equipment:

(2)

Electronic treadmill: Grand Fit AC 999 (China).obic exercise is defined as any activity that uses large
Aer
muscle groups working continuously for a long durationand rhythmic in naturewithmoderate intensity.Aerobicmeans ‘with oxygen’, involves or improves oxygenconsumption by the body, and refers to the use ofoxygen in a muscle’s energy-generating process. Manytypes of exercises are aerobic and by definition areperformed at moderate levels of intensity for extendedperiods of time [11].

Training programThe purpose of training program was explained toeach patient. Each patient participated in theexercise training program on electronic treadmillwith moderate intensity for 30–50min three times aweek day after day for 8 weeks.

Phases of exercise

(1)
Warming up phase: 5–10min with mild intensity[30–40% maximum heart rate (HRmax)].HRmax=211–0.64 age [12].
(2)
Training phase: each patient trained for 20–30minwith moderate intensity (60–70% HRmax).
(3)
Cooling down phase: 5–10min with mild intensity(30–40% HRmax).
Low-caloric diet programIn a professional review, a low-caloric diet of about1200–1500 kcal/day is recommended for patients withNonalcoholic Steatohepatitis (NASH) [13]. A diet of

1400 kcal/day could be effective in improving histologyin patients with biopsy-proven NASH [14].

In this study, four different graduated low-caloricdiet programs were established. Every 2 weeks thediet program had been changed gradually from1800 kcal/day to 1500 to 1200 to 1000 kcal.

Following is an example for 1800 kcal/day diet program:

Breakfast: One leaf of dark bread+three spoonfuls ofbeans with olive oil+light cheese+two vegetables.Snack: One fruit+small cup of coffee or tea with ateaspoonful of sugar.Lunch: Nine spoonfuls of rice or macaroni+green salad+250 g of any type of skimmed protein (fish, tuna,meat, chicken, and, liver).Snack: One fruit+a cup of cinnamon with a teaspoonfulof sugar.Dinner: Half loaf of dark bread+boiled egg+grilled orboiled eggplant+two vegetables.Snack: One fruit+a cup of green tea.

Calorie intake was gradually reduced every 2 weeksuntil reaching 1000 kcal/day at the last 2 weeks.

Statistical analysisResults areexpressedasmean±SDornumberandpercent.Comparison between categorical data [n (%)] was madeusing the χ2-test. According to test of normality,comparison between different variables in the twogroups was performed using either the unpaired t-testor the Mann–Whitney test whenever it was appropriate.Within-group comparison (pretreatment vs. post-treatment) was performed using either the paired t-testor the Wilcoxon signed-ranks test whenever it wasappropriate. Statistical package for the social sciences(SPSS) (IBM corporation in Armonk, New York,USA) computer program (version 19 Windows) wasused for data analysis. A P value less than or equal to0.05 was considered significant.

ResultsThere were no statistically significant differencesbetween the two groups at baseline in the meanvalues of age, height, and weight.

Comparison between the mean values of body massindex in the two studied groups measured before andafter treatmentWithin-group comparison

In the exercise group, there was a statisticallysignificant difference in the mean value of BMImeasured before treatment (44.24±5.47 kg/cm2)



when compared with its corresponding value aftertreatment (43.56±5.46 kg/cm2) (P=0.002).

In the diet group, there was no statistically significantdifference between the mean value of BMI measuredbefore treatment (43.41±4.97 kg/cm2) and its corres-ponding value after treatment (42.24±5.17 kg/cm2)(P=0.436).

The percentage of decrease in BMI in both the exerciseand diet groups was 1.54 and 2.17%, respectively.

Between-group comparison

Before treatment, there was no statistically significantdifference between the mean value of BMI inthe exercise group (44.24±5.47 kg/cm2) and itscorresponding value in the diet group (43.41±4.97 kg/cm2) (P=0.615). After treatment, there wasno statistically significant difference betweenthe mean value of BMI in the exercise group(43.56±5.46 kg/cm2) and its corresponding value inthe diet group (42.24±5.17 kg/cm2) (P=0.436) (Fig. 1).

Figure 2

Mean values ofWC in both groupsmeasured pre- and post-treatment

Table 1 Comparison between mean values of body massindex and waist circumference in the two studied groupsmeasured before and after treatment

Exercise (n=20) Diet (n=20) P value

BMI

Comparison between mean values of waistcircumference in the two studied groups measuredbefore and after treatmentWithin-group comparison

In the exercise group, there was a statisticallysignificant difference in the mean value of WCmeasured before treatment (124.50±10.50 cm) whencompared with its corresponding value after treatment(120.30±10.29 cm) (P=0.001).

In the diet group, there was a statistically significantdifference between the mean value of WCmeasured before treatment (124.00±6.81 cm) and itscorresponding value after treatment (119.55±7.90 cm)(P=0.001).

The percentage of decrease in WC in both the exerciseand diet groups was 3.37 and 3.59%, respectively.

Figure 1

Mean values of BMI in both groupsmeasured pre- and post-treatment

Between-groups comparison

Before treatment, there was no statistically significantdifference between the mean value ofWC in the exercisegroup (124.50±10.50 cm) and its corresponding valuein the diet group (124.00±6.81 cm) (P=0.859). Aftertreatment, there was no statistically significantdifference between the mean value of WC in theexercise group (120.30±10.29 cm) and its corres-ponding value in the diet group (119.55±7.90 cm)(P=0.797) (Fig. 2 and Table 1).

Comparison between mean values of fat content in thetwo studied groups measured before and aftertreatmentWithin-group comparison

In the exercise group, there was a statistically significantdifference in the mean value of fat measured beforetreatment (56.82±12.42 kg) when compared with itscorresponding value after treatment (54.17±12.26 kg)(P=0.001).

In the diet group, there was a statistically significantdifference between the mean value of fat measured

Pretreatment 44.24±5.47 43.41±4.97 0.615 (NS)

Post-treatment 43.56±5.46 42.24±5.17 0.436 (NS)

Mean difference 0.68 1.17

% Change 1.54↓↓ 2.7↓↓

t-Value 3.624 1.624

P value 0.002 (S) 0.121 (NS)

WC

Pretreatment 124.50±10.50 124.00±6.81 0.859 (NS)



% Change 3.37↓↓ 3.59↓↓

t-Value 12.178 10.156

P value 0.001 (S) 0.001 (S)

Data are expressed as mean±SD. WC, waist circumference.P0.05, NS. ↓↓Decrease.



before treatment (53.79±11.77 kg) and its corres-ponding value after treatment (49.27±12.00 kg)(P=0.001).

The percentage of decrease in fat in both theexercise and diet groups was 4.66 and 8.40%,respectively.


Before treatment, there was no statistically significantdifference between the mean value in the exercisegroup (56.82±12.42 kg) and its corresponding valuein the diet group (53.79±11.77 kg) (P=0.433). Aftertreatment, there was no statistically significantdifference between the mean value of the exercisegroup (54.17±12.26 kg) and its corresponding valuein the diet group (49.27±12 kg) (P=0.210) (Fig. 3and Table 2).

Comparison between the mean values of alanineaminotransferase (serum glutamic-pyruvictransaminase) in the two studied groups measuredbefore and after treatmentWithin-group comparison

In the exercise group, there was a statisticallysignificant difference in the mean value of ALTmeasured before treatment (33.90±17.53 IU/l) whencompared with its corresponding value after treatment(28.90±14.80 IU/l) (P=0.001).

Figure 3

Mean values of fat content in both groups measured pre- and post-treatment

Table 2 Comparison between mean values of fat in the twostudied groups measured before and after treatment

Fat Exercise (n=20) Diet (n=20) P value

Pretreatment 56.82±12.42 53.79±11.77 0.433 (NS)



% Change 4.66↓↓ 8.40↓↓

t-Value 11.329 7.114

P value 0.001 (S) 0.001 (S)

Data are expressed as mean±SD. P0.05, NS. ↓↓Decrease.

In the diet group, there was a statistically significantdifference between the mean value of ALT measuredbefore treatment (33.80±11.47 IU/l) and its corres-ponding value after treatment (27.10±8.68 IU/l)(P=0.001).

The percentage of decrease in ALT in both the exerciseand diet groups was 14.75 and 19.82%, respectively.


Before treatment, there was no statistically significantdifference between the mean value of ALT inthe exercise group (33.90±17.53 IU/l) and itscorresponding value in the diet group (33.80±11.47IU/l) (P=0.598). After treatment, there was nostatistically significant difference between the meanvalue of ALT in the exercise group (28.90±14.8 IU/l)and its correspondingvalue in thedietgroup(27.10±8.68IU/l) (P=0.882) (Fig. 4).

Comparison between mean values of aspartateaminotransferase (serum glutamic oxaloacetictransaminase) in the two studied groups measuredbefore and after treatmentWithin-group comparison

In the exercise group, there was a statisticallysignificant difference in the mean value of ASTmeasured at after treatment (40.00±13.97 IU/l)when compared with its corresponding value aftertreatment (32.50±13.37 IU/l) (P=0.001).

In the diet group, there was a statistically significantdifference between the mean value of AST measuredbefore treatment (38.85±15.73 IU/l) and itscorresponding value after treatment (31.05±11.42IU/l) (P=0.001).

The percentage of decrease in AST in both theexercise and diet groups was 18.75 and 20.08%,respectively.

Figure 4

Mean values of ALT (SGPT) in both groups measured pre- and post-treatment

Figure 5

Mean values of AST (SGOT) in both groups measured pre- and post-treatment

Table 3 Comparison between mean values of alanineaminotransferase (serum glutamic-pyruvic transaminase) andaspartate aminotransferase (serum glutamic oxaloacetictransaminase) in the two studied groups measured beforeand after treatment

Exercise(n=20)

Diet (n=20) Zvaluea

P value

ALT

Pretreatment 33.90±17.53 33.80±11.47 −0.528 0.598(NS)

Post-treatment

28.90±14.80 27.10±8.68 −0.149 0.882(NS)

Meandifference

5.0 6.7

% Change 14.75↓↓ 19.82↓↓

Z valueb −3.933 −3.924

P value 0.001 (S) 0.001 (S)

AST

Pretreatment 40.00±13.97 38.85±15.73 −0.054 0.957(NS)

Post-treatment

32.50±13.37 31.05±11.42 0.002 0.991(NS)

Meandifference

7.5 7.80

% Change 18.75↓↓ 20.08↓↓

Z valueb −3.832 −3.709

P value 0.001 (S) 0.001 (S)




Before treatment, there was no statistically significantdifferencebetween themeanvalueofAST in theexercisegroup (40.00±13.97 IU/l) and its corresponding valuein the diet group (38.85±15.73 IU/l) (P=0.957). Aftertreatment, therewasno statistically significantdifferencebetween the mean value of serum glutamic-pyruvictransaminase in the exercise group (32.50±13.37 IU/l)and its corresponding value in the diet group(31.05±11.42 IU/l) (P=0.991) (Fig. 5 and Table 3).

Data are expressed as mean±SD. ALT, alanine aminotransferase;AST, aspartate aminotransferase. aMann–Whitney test.bWilcoxon’s signed-rank test. P0.05, NS.↓↓Decrease.
Discussion
The results of this study showed that there was nosignificant difference between the effects of moderateintensity aerobic exercise versus low-caloric diet onliver enzymes in fatty liver patients.

All patients had mild fatty liver with liver enzymesabove 20U/l for female and 30U/l for male with BMIgreater than or equal to 30 kg/m2. There were no otherdiseases or problems affecting the patient except fattyliver.

Sample size of the study was calculated by means ofpower analysis to avoid errors. Duration of the studywas determined according the previous studies as asuitable time for the treatment program [15].

Rohollah et al. [15] in their experimental researchreported that 8-week aerobic exercise showed adecrease in the levels of ALT and AST.

Rusu et al. [16] reviewed that there is no consensusas to what diet or lifestyle approach is the best forNAFLD patients. However, patients with NAFLDmay benefit from a moderate-to-low carbohydrate(40–45% of total calories) diet, coupled withincreased dietary Mono Unsaturated Fatty Acids(MUFA) and n-3 Poly Unsaturated Fatty Acid(PUFAs) and reduced Saturated Fatty Acid (SFAs).

More Clinical Randomized Trial (CRT) is needed toclarify the specific effects of different diets and dietarycomponents on the health of NAFLD patients. Asmall clinical randomized trial showed that short-term carbohydrate restriction is more efficacious inreducing intrahepatic TG.

Petersen et al. [17] showed that a low-fat diet reducedcalorie intake (daily intake 1200 kcal/day) andeffectively reduced body weight and intrahepaticlipid content with improvement in insulin resistancein NAFLD patients.

Wang et al. [18] reported that central obesity isstrongly associated with hepatic steatosis (HS).Modification of lifestyle including dietary restrictionfor weight loss and control of risk factors such as type 2diabetes mellitus and dyslipidemia is recommended asthe first and most important approach to managepeople with NAFLD.

Huang et al. [14] conducted a study on reducing insulinresistance and included the following recommendationsfor caloric intake: 40–50% carbohydrates, with emphasison complex carbohydrates with fibers, 35–40% from fatwithemphasisonmonounsaturatedandpolyunsaturatedfats, and 15–20% from protein. After 12 months, there



was histological improvement in nine of 15 patients withbiopsy-proven NASH, as measured by steatosis gradeand NASH score.

Solga and Alkhuraishe [19] showed that the lowcaloric diet and diet low in saturated fats is oftenrecommended. However, little is known about theeffects of changes in dietary composition on liverhistopathology in NAFLD.

In contrast, Capristo et al. [20] reported thatrecommendation of a low-fat diet could actuallyworsen NAFLD histopathology.

Johnson et al. [6] showed that aerobic exercise trainingreduces hepatic and visceral lipids in obese patients withsedentary lifestyle. Thus, regular exercise may mitigatethe metabolic and cardiovascular consequences ofobesity, including fatty liver, and this is notcontingent upon weight loss.

Sreenivasa et al. [21] showed that moderate aerobicexercise helped normalize ALT in NASH but thisnormalization did not occur in the 15 patients whofailed to comply with the exercise program.

Stewart et al. [22] stated that aerobic exercise increasesinsulin sensitivity independent of weight loss, anddecreases peripheral lipolysis that probably interfereswith the development of steatosis, inhibitinghepatic lipid synthesis and stimulating fatty acidoxidation. A number of studies suggested thatNAFLD improves after weight loss. Improvementsin liver biochemistry and ultrasonography have beenfound with modest weight reduction, but few studieshave evaluated the effect of weight reduction onhepatic histology.

Suzuki et al. [23] reported body weight loss and lifestylemodifications with changes in serum ALT levels. Theyfound that weight loss and regular exercise resulted inimprovement in serum ALT. They suggested thatreducing body weight by at least 5% with subsequentweight control and exercising regularly may bebeneficial in treating fatty liver.

Adams et al. [24] reported that studies showed that asedentary lifestyle with reduced physical activity,independent of diet, is another determinant offatty liver. Although these risk factors maysuccessfully be modified by moderate lifestyleintervention, the existence of other risk factorsmost probably may necessitate more intensetreatment.

Keating et al. [25] showed clear evidence for theimportance of exercise therapy on liver fat but notALT levels. This benefit is apparent with minimalor no weight loss and at exercise levels below currentexercise recommendations for obesity management.

Kakarla et al. [26] reported that the exercise training byinducing antioxidant capacity protects against oxidativestress. Similar changes were reported in male animals,which clearly envisage no sex difference in theantioxidant enzyme system with regard to age andexercise. In conclusion, it can be stated that 12weeks of treadmill exercise training has beneficialeffect in improving the antioxidant defense capacityof the liver tissue by augmenting superoxide dismutase,catalase, glutathione reductase activities, andglutathione levels in older rats, thereby preventingoxidative damage to the liver tissue.

Shelby [27] reported that some findings suggestedthat short-term high-caloric feeding increases intrahepatic triglyceride (IHTG), whereas short-term low-caloric feeding decreases IHTG despite little changein total body weight, suggesting that ongoing excesscaloric delivery directly contributes to thedevelopment of NAFLD. Weight loss with low fator low carbohydrate diets can improve IHTG;however, specific macronutrients such as fructose,trans-fatty acids, and saturated fat may contributeto increased IHTG independent of total calorieintake. N-3 polyunsaturated fatty acids andmonounsaturated fatty acids may play a protectiverole in NAFLD. The mechanisms behind theseeffects are not fully understood. Diet has animportant role in the pathophysiology of NAFLD.Patients with NAFLD must be advised to reducecalorie intake with either low fat or lowcarbohydrate diets as well as limit intakes offructose, trans-fatty acids, and saturated fat.

Kirk et al. [10] reported that moderate calorierestriction causes temporal changes in liver andskeletal muscle metabolism; 48 h of calorierestriction affects the liver (IHTG content, hepaticinsulin sensitivity, and glucose production), whereasmoderate weight loss affects muscle (insulin-mediatedglucose uptake and insulin signaling).

Petersen et al. [17] stated that weight loss as well asexercise is associated with improvement in insulinsensitivity and logical treatment modalities forpatients with NAFLD who are overweight or obese.Weight reduction is with caloric restriction andphysical exercise.



Suzuki et al. [23] showed that weight reduction andlifestyle modification with diet changes and increasedphysical activity are recommended as the first step inthe control of NAFLD. Achieving and maintainingweight reduction may improve NAFLD, but the resultof several reports is inconsistent.

Palmer and Schaffner [28] showed that, in overweightadults free fromprimary liver disease, a weight reductionof greater than or equal to 10% corrected abnormalhepatic test results decreased hepatosplenomegaly, andresolved some stigmata of liver disease. In similarlystudied overweight patients with primary liver disease,some findings improved, but the changes did notcorrelate with a greater than or equal to 10% weightloss. Increased ALT activity was the most frequenthepatic enzyme abnormality in this population. Forevery 1% reduction in body weight, ALT activityimproved by 8.1%.

In contrast, Jian-Gao et al. [29] reported that a studyindicated that it might be difficult to resolvesteatohepatitis by merely short-term low caloric diettherapy, long-term appropriate diet control orconcurrent administration of medications that candirectly reduce the severity of liver damage may bereasonable alternatives for the treatment of NASHpatients with obesity.

In contrast, Selezneva et al. [30] reported that low-caloric diet had poor compliance and little effect onALT and AST during short-term diet intervention inNASH patients. Diet modifications should bereconsidered in NASH patients in favor of fewercalories restricted and easy to follow diet.

In rehabilitation clinics, doctors should advise obesemild fatty liver disease patients with mild elevatedliver enzymes to follow regular moderate aerobicexercise or follow low-caloric diet according togeneral health status, lifestyle, co-operation, andpsychological state of each patient. Both low-caloric diet and moderate aerobic exercise improveliver histology and help in normalizing liverbiochemistry.

ConclusionIt was concluded that there was no significantdifference between results of both groups. After thetreatment both low caloric diet and moderate aerobicexercise showed a decrease in AST, ALT,WC, and fatcontent with no significant changes in the BMIcompared with that before treatment.

Financial support and sponsorshipNil.

Conflicts of interestThere are no conflicts of interest.

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Appendix IConsent form

I am freely and voluntarily consent to participate in this resMohammed Mohammed Abdeen Sallam.

Through description of the study procedure has been explconsent and discontinue participation in this research stu

Participant:

Date:

27 Shelby S. Implications of diet on nonalcoholic fatty liver disease. Curr OpinGastroenterol 2013; 26:160–164.

28 Palmer M, Schaffner F. Effect of weight reduction on hepatic abnormalitiesin overweight patients. Gastroenterology 1990; 99:1408–1413.

29 Jian-Gao F, Lan Z, Zheng-Jie X, Li-Yan T, Xiao-DongD, Min-Sheng L, Guo-LiangWEffects of low-calorie diet on steatohepatitis in rats with obesity andhyperlipidemia. World J Gastroenterol 2003; 15:2045–2049.

30 Selezneva K, Kirillova O, Vorozhko I, Isakov VA, Sentsova T. P844 short-term effect of low-calorie diet (LCD) versus isocalorie diet (ICD) on bloodaminotransferases level and lipids profile in patients with non-alcoholicsteatohepatitis (NASH). J Hepatol 2014; 60:S353.

earch study under the direction of the researcher/Fatma

ained to me and I understand that I may withdraw mydy at any time without prejudice to me.

aerobic exercises versus low-caloric diet for mild fatty liver ......aerobic exercises versus...

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