An internet-based approach for lifestyle changes in patients with NAFLD: Two-year effects on weight loss and surrogate markers
Author(s): ,
Giulio Marchesini
Department of Medical and Surgical Sciences, “Alma Mater” University, Bologna, Italy
Corresponding author. Address: “Alma Mater” University, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital 9, Via Massarenti, I-40138 Bologna, Italy; Tel.: +39 051 6364889; fax: +39 051 6364502.
Giampaolo Bianchi
Department of Medical and Surgical Sciences, “Alma Mater” University, Bologna, Italy
Elisabetta Bugianesi
Department of Medical Sciences, University of Turin, Turin, Italy
Salvatore Petta
Section of Gastroenterology and Hepatology, Di.Bi.M.I.S., University of Palermo, Palermo, Italy
Maria Luisa Forchielli
Department of Medical and Surgical Sciences, “Alma Mater” University, Bologna, Italy
Silvia Di Domizio
Department of Medical and Surgical Sciences, “Alma Mater” University, Bologna, Italy
Lucia Brodosi
Department of Medical and Surgical Sciences, “Alma Mater” University, Bologna, Italy
Maria Turchese Caletti
Department of Medical and Surgical Sciences, “Alma Mater” University, Bologna, Italy
Arianna Mazzotti
Department of Medical and Surgical Sciences, “Alma Mater” University, Bologna, Italy
EASL LiverTree™. Marchesini G. 11/01/18; 234549
Prof. Giulio Marchesini
Prof. Giulio Marchesini
Contributions Biography
Journal Abstract
Graphical abstract

Graphical abstract

Job/time constraints limit the engagement of patients with NAFLD in counseling programs. Web- and group-based programs promote similar calorie/physical activity changes. Surrogate markers indicate reduced fat in the liver and no changes in hepatic fibrosis. Web counseling results in clinically significant weight loss in motivated patients. Structured web-based program is as effective as group-counseling in selected patients with NAFLD.

Background & Aims

Interventions aimed at lifestyle changes are pivotal for the treatment of non-alcoholic fatty liver disease (NAFLD), and web-based programs might help remove barriers in both patients and therapists.


In the period 2010–15, 716 consecutive NAFLD cases (mean age, 52; type 2 diabetes, 33%) were treated in our Department with structured programs. The usual protocol included motivational interviewing and a group-based intervention (GBI), chaired by physicians, dietitians and psychologists (five weekly meetings, n = 438). Individuals who could not attend GBI entered a web-based intervention (WBI, n = 278) derived from GBI, with interactive games, learning tests, motivational tests, and mail contacts with the center. The primary outcome was weight loss ≥10%; secondary outcomes were alanine aminotransferase within normal limits, changes in lifestyle, weight, alanine aminotransferase, and surrogate markers of steatosis and fibrosis.


GBI and WBI cohorts had similar body mass index (mean, 33 kg/m2), with more males (67% vs. 45%), younger age, higher education, and more physical activity in the WBI group. The two-year attrition rate was higher in the WBI group. Healthy lifestyle changes were observed in both groups and body mass index decreased by almost two points;the 10% weight target was reached in 20% of WBI cases vs. 15% in GBI (not significant). In logistic regression analysis, after adjustment for confounders and attrition rates, WBI was not associated with a reduction of patients reaching short- and long-term 10% weight targets. Liver enzymes decreased in both groups, and normalized more frequently in WBI. Fatty liver index was reduced, whereas fibrosis remained stable (NAFLD fibrosis score) or similarly decreased (Fib-4).


WBI is not less effective than common lifestyle programs, as measured by significant clinical outcomes associated with improved histological outcomes in NAFLD. eHealth programs may effectively contribute to NAFLD control.

Lay summary

In patients with non-alcoholic fatty liver disease, participation in structured lifestyle programs may be jeopardized by job and time constraints. A web-based intervention may be better suited for young, busy patients, and for those living far from liver units. The study shows that, following a structured motivational approach, a web-based, interactive intervention coupled with six-month face-to-face meetings is not inferior to a standard group-based intervention with respect to weight loss, adherence to healthy diet and habitual physical activity, normalization of liver enzymes, and stable surrogate markers of fibrosis.

Diet, Liver enzymes, NAFLD progression, Physical activity
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