Fatty liver accumulation results from an imbalance between lipid deposition and removal, driven by the hepatic synthesis of triglycerides and de novo lipogenesis. The habitual diet plays a relevant role in the pathogenesis of NAFLD, and both risky (e.g., fructose) and protective foods (Mediterranean diet) have been described, but the contribution of excess calories remains pivotal. Accordingly, weight loss is the most effective way to promote liver fat removal. Several controlled studies have confirmed that an intense approach to lifestyle changes, carried on along the lines of cognitive-behavior treatment, is able to attain the desired 7-10% weight loss, associated with reduced liver fat, NASH remission, and also reduction of fibrosis. Even larger effects are reported following bariatric surgery-induced weight loss in NAFLD, where 80% of subjects achieve NASH resolution at 1-year follow-up. These results provide solid data to evaluate the safety and effectiveness of the pharmacologic treatment of NASH. The battle against metabolic diseases, largely fuelled by increased liver fat, needs a comprehensive approach to be successful in an obesiogenic environment. In this review, we will discuss the role of hepatic lipid metabolism, genetic background, diet and physical activity on fatty liver. They are the basis for a lifestyle approach to NAFLD treatment. This article is protected by copyright. All rights reserved.
© 2015 by the American Association for the Study of Liver Diseases.