Impact of Weight Loss in Cirrhosis With Obesity and MAFLD

Liver disease is one of the main causes of hospital admissions worldwide and the 12th leading cause of mortality in many countries. Among all etiologies (toxic-metabolites, viral, autoimmune, and genetic disorders), nonalcoholic fatty liver disease (NAFLD) features as the most common cause, with increasing prevalence attributed to the epidemic of metabolic syndrome. According to the World Health Organization, in 2014, more than 30% of the United States population were obese and more than 60% overweight. Furthermore, 15% of all Western population and 35% of patients with obesity will develop steatohepatitis (NASH). Hence world over obesity is on a rise, the prevalence of obesity has consistently risen since past four decades in both genders. Indian similar scenario is seen not only in the urban but also in the rural population. This pandemic disease is attributed to both the increased amounts of processed foods high in fructose, sodium, and saturated fats, and the increasingly sedentary lifestyle. Obesity is considered a chronic state of low-grade inflammation, being associated with complications such as metabolic syndrome, type 2 diabetes, hypertension, and cardiovascular disease. It has also been linked with increased risks of certain cancers, such as colon, breast, breast, endometrium, kidney, esophagus, stomach, pancreas, and gallbladder. The combination of obesity, insulin resistance, and NASH is also thought to increase the risk of Hepatocellular Carcinoma (HCC). Most of all obesity in cirrhotics accelerates decompensation plausibly through an increase in portal hypertension. The risk of first clinical decompensation of cirrhosis is approximately three times higher in obese cirrhotics compared to those with normal weight. There are innumerable randomized controlled trials examining the role of various kinds of weight-loss diets and regimens in NAFLD patients, namely Mediterranean diets, Ornish diets, south beach diets, Atkins diets, Zone diet, weight watcher's diets, etc. However, once cirrhosis sets in or is diagnosed the concept of malnutrition akin to undernutrition is the prime consideration in a patient which baffles the physicians. The nutritional guidelines either European Society of Parenteral and Enteral Nutrition (ESPEN) or American Society of Parenteral and Enteral Nutrition (ASPEN) have always focused on a high calorie and a high protein diet in cirrhosis. These guidelines have not even touched upon the topic of obesity in cirrhosis. Moreover, for decades, investigator have been obsessed with the idea of protein restriction in patients with cirrhosis. In the recent past, our attention is drawn towards the other end of the spectrum of malnutrition i.e. obesity, which has been steadily on the rise world over and cirrhotics are no exception. Obesity is associated with poor survival, severe hepatic decompensation, poor post-transplantation outcomes as well as greater difficulty in liver transplantation, and also higher non-response to antiviral therapy in patients with cirrhosis. Hence weight reduction is the standard of care in such patients. A few studies have examined the role of a monitored exercise program including resistance training including cycle ergometric exercises have been shown to favorably change the body composition but none have been done in obese cirrhotics with the aim of weight loss. At the same time, low-calorie and even very-low-calorie ketogenic diets have been tried in obese cirrhosis and published as case series. Based on the magnitude of the problem of obesity in CLD and its detrimental impact on the clinical outcome investigator propose to assess the impact of weight loss with low calorie, high protein diet and moderate physical activity (lifestyle modifications- a non-pharmacological strategy) on liver fibrosis, body composition changes, functional capacity, clinical outcome in obese cirrhotics in this study.