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Children, Adolescents Considered Obese May Have Greater Risk of NAFLD


This new study from investigators at Tel Aviv University looked at predictors of nonalcoholic fatty liver disease (NAFLD) among children and adolescents considered obese, because its predictors are not well known in this group.

In this cross-sectional study of 57 pediatric patients with a mean (SD) body mass index (BMI) of 38.8 (9.7) mg/m2, classifying them as obese, a potential link between high BMI and severe liver steatosis was found, thereby indicating weight loss could alleviate hepatic fibrosis risk.

These findings were published recently in BMC Pediatrics.

“In view of the increased prevalence of obesity among children and adolescents, it is of upmost importance to identify young patients at risk for advanced fibrosis who may develop cirrhosis and liver failure,” the authors wrote. “Only few studies have aimed to find predictors for advanced fibrosis in pediatric NAFLD patients.”

All of the children and adolescents included in this subanalysis—part of another study investigating outcomes related to bariatric surgery and dietary intervention—were admitted to the Obesity Clinic at Dana-Dwek Children’s Hospital of the Tel Aviv Medical Center between December 1, 2018, and December 1, 2019; had a BMI above the 95th percentile for their age; and received multidisciplinary care from a gastroenterologist, hepatologist, registered dietitian, and psychologist. They could not have a current primary liver disease diagnosis.

Participants (N = 57; 61% male; 91.9% of Jewish ancestry; 8.1% of Arab ancestry) received advice on 2 fronts: nutritional recommendations, which consisted of a low carbohydrate, low glycemic load, and isocaloric diet (30%-40% carbohydrates, 35%-50% fats, 20%-25% proteins), individualized per patient and calorie requirements, and healthy lifestyle recommendations, such as reducing screen time and engaging in regular physical activity.

The following overall results were seen:

  • Impaired fasting glucose, elevated triglycerides, hypercholesterolemia, hypertension, and obstructive sleep apnea were evident in 39%, 45%, 25%, 9%, and 9%, respectively, at baseline
  • Most patients (92%) received a liver steatosis diagnosis at clinic admission
  • Of the 60% with liver fibrosis at admission, 70% had a moderate/severe case
  • A link found between a mean BMI of 43.8 (9.5) kg/m2 and fibrosis levels ≥ F2 (P < .001)
  • More cases of moderate/severe steatosis were seen in participants with fibrosis levels ≥ F2 (P = .02)
  • Significantly lower mean levels of low-density lipoprotein (92.4 [29.3] vs 116.7 [38.2] mg/dL) were seen in cases of moderate/severe fibrosis
  • Strong association was found between steatosis and liver fibrosis (r = 0.65; P = .001)]
  • Inverse association was found between serum cholesterol levels and liver fibrosis (r = –0.4; P = .01)

In addition, 17 patients (11 males, 6 females) completed both baseline and 3-month blood tests and elastography, with these results:

  • Following the dietary intervention among those aged 7 to 13 years, mean calories/day increased from 1939 (390) to 1984 (423) kcal/d, but percentages of diet improved for carbohydrates (54% to 30%), proteins (15% to 25%), and fats (30% to 45%)
  • Following the dietary intervention among those aged 14 to 18 years, mean calories/day fell from 2374 (410) to 2039 (450) kcal/d, and percentages of diet improved for carbohydrates (48% to 30%), proteins (20% to 25%), and fats (32% to 45%)
  • BMI z scores dropped from 2.6 (0.5) before the intervention to 2.4 (0.5) after
  • There was a significant decrease in liver fibrosis overall (P = .001)
  • Complete normalization of fibrosis was seen among all patients with F1 fibrosis at baseline (P = .001)
  • Significant mean decreases were seen in both alanine transaminase (61 [34] vs 42 [26.4] mg/dL) and triglyceride (147.6 [68] vs 102.2 [44.4] mg/dL) serum levels

The authors write that in light of their findings, there is a great need for early dietary intervention among children classified as obese, and that for those with moderate/severe vs minimal/no fibrosis, intervention may be necessary due to differences in metabolic parameters, “even if no other metabolic disorder is present.”

Possible limitations on the generalizability of the authors’ findings are the lack of liver biopsies, not having a control group, and the 3-month follow-up.

“Longitudinal and larger-cohort studies are needed to compare the effectiveness of a low carbohydrate diet with that of other dietary interventions,” the authors conclude, “for preventing the progression of NAFLD toward more severe forms of liver derangements early in its natural history.”


Moran-Lev H, Cohen S, Webb M, et al. Higher BMI predicts liver fibrosis among obese children and adolescents with NAFLD – an interventional pilot study. BMC Pediatr. Published online September 3, 2021. doi:10.1186/s12887-021-02839-1

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