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. Nov 1, 2018; 256713
Prof. Giulio Marchesini
Prof. Giulio Marchesini

Access to this content is an EASL members and LiverTree™ Privileged Users benefit.

Journal Abstract
Discussion Forum (0)
Rate & Comment (0)
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
[1]. Z.M. Younossi - Global epidemiology of nonalcoholic fatty liver disease-Meta-analytic assessment of prevalence, incidence, and outcomes
[2]. G. Marchesini - Nonalcoholic fatty liver, steatohepatitis, and the metabolic syndrome
[3]. G. Vernon - Systematic review: the epidemiology and natural history of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis in adults
[4]. Z.M. Younossi - The economic and clinical burden of nonalcoholic fatty liver disease in the United States and Europe
[5]. S.A. Townsend - Review article: new treatments in non-alcoholic fatty liver disease
[7]. M.L. Petroni - Long-term treatment of severe obesity: are lifestyle interventions still an option?
[8]. S. Moscatiello - Cognitive-behavioral treatment of non-alcoholic fatty liver disease: a propensity score-adjusted observational study
[9]. K. Promrat - Randomized controlled trial testing the effects of weight loss on nonalcoholic steatohepatitis
[10]. C. Thoma - Lifestyle interventions for the treatment of non-alcoholic fatty liver disease in adults: a systematic review
[11]. V.W. Wong - Community-based lifestyle modification programme for non-alcoholic fatty liver disease: a randomized controlled trial
[12]. E. Vilar-Gomez - Weight loss through lifestyle modification significantly reduces features of nonalcoholic steatohepatitis
[13]. G. Marchesini - Diet, weight loss, and liver health in nonalcoholic fatty liver disease: pathophysiology, evidence, and practice
[14]. E. Centis - Stage of change and motivation to healthier lifestyle in non-alcoholic fatty liver disease
[15]. K. Kempf - Efficacy of the telemedical lifestyle intervention program TeLiPro in advanced stages of type 2 diabetes: a randomized controlled trial
[16]. W.R. Miller - Motivational Interviewing
[17]. G. Tarrini - Quanto mangio veramente?
[18]. R. Rossini - Effects of cognitive-behavioral treatment for weight loss in family members
[19]. C.L. Craig - International physical activity questionnaire: 12-country reliability and validity
[20]. G. Forlani - Are behavioural approaches feasible and effective in the treatment of type 2 diabetes? A propensity score analysis vs. prescriptive diet
[21]. G. Bedogni - The Fatty Liver Index: a simple and accurate predictor of hepatic steatosis in the general population
[22]. P. Angulo - The NAFLD fibrosis score: a noninvasive system that identifies liver fibrosis in patients with NAFLD
[23]. A. Vallet-Pichard - FIB-4: an inexpensive and accurate marker of fibrosis in HCV infection. Comparison with liver biopsy and fibrotest
[24]. N. Melchionda - Disease management of the metabolic syndrome in a community: study design and process analysis on baseline data
[25]. K.M. McTigue - Using the internet to translate an evidence-based lifestyle intervention into practice
[26]. T.J. Moore - Weight, blood pressure, and dietary benefits after 12 months of a Web-based Nutrition Education Program (DASH for health): longitudinal observational study
[27]. P. Sousa - Controlled trial of an Internet-based intervention for overweight teens (Next.Step): effectiveness analysis
[28]. R.M. Banos - An Internet-based self-administered intervention for promoting healthy habits and weight loss in hypertensive people who are overweight or obese: a randomized controlled trial
[29]. A.P. Cotter - Internet interventions to support lifestyle modification for diabetes management: a systematic review of the evidence
[30]. S. Kodama - Effect of Web-based lifestyle modification on weight control: a meta-analysis
[31]. K.M. Livingstone - Effect of an Internet-based, personalized nutrition randomized trial on dietary changes associated with the Mediterranean diet: the Food4Me Study
[32]. D. Sherifali - Evaluating the feasibility and impact of an internet-based lifestyle management program in a diabetes care setting
[33]. R. Eagleson - Implementation of clinical research trials using web-based and mobile devices: challenges and solutions
[34]. A.L. Fortmann - Dulce digital: an mHealth SMS-based intervention improves glycemic control in hispanics with type 2 diabetes
[35]. R.S. Rasu - Economic evaluation of an Internet-based weight management program
[36]. R. Dalle Grave - Major factors for facilitating change in behavioral strategies to reduce obesity
[37]. M.J. Armstrong - Motivational interviewing to improve weight loss in overweight and/or obese patients: a systematic review and meta-analysis of randomized controlled trials
[38]. P.D. O'Halloran - Motivational interviewing to increase physical activity in people with chronic health conditions: a systematic review and meta-analysis
[39]. S.A. Simpson - A feasibility randomised controlled trial of a motivational interviewing-based intervention for weight loss maintenance in adults
[40]. D. Smith West - Motivational interviewing improves weight loss in women with type 2 diabetes
[41]. X. Pi-Sunyer - A randomized, controlled trial of 3.0 mg of liraglutide in weight management
[42]. S.E. Nissen - Effect of naltrexone-bupropion on major adverse cardiovascular events in overweight and obese patients with cardiovascular risk factors: a randomized cinical trial
[43]. K.M. Gadde - Effects of low-dose, controlled-release, phentermine plus topiramate combination on weight and associated comorbidities in overweight and obese adults (CONQUER): a randomised, placebo-controlled, phase 3 trial
[44]. R. Dalle Grave - Continuous care in the treatment of obesity: an observational multicentre study
[45]. E. Grossi - Complexity of attrition in the treatment of obesity: clues from a structured telephone interview
[46]. A.L. Fracanzani - Risk of severe liver disease in NAFLD with normal aminotransferase levels: a role for insulin resistance and diabetes
[47]. B.A. Neuschwander-Tetri - Farnesoid X nuclear receptor ligand obeticholic acid for non-cirrhotic, non-alcoholic steatohepatitis (FLINT): a multicentre, randomised, placebo-controlled trial
[48]. V. Ratziu - Elafibranor, an agonist of the peroxisome proliferator-activated receptor-alpha and -delta, induces resolution of nonalcoholic steatohepatitis without fibrosis worsening
[49]. S.L. Friedman - A randomized, placebo-controlled trial of cenicriviroc for treatment of nonalcoholic steatohepatitis with fibrosis
[50]. M.J. Armstrong - Liraglutide safety and efficacy in patients with non-alcoholic steatohepatitis (LEAN): a multicentre, double-blind, randomised, placebo-controlled phase 2 study
Code of conduct/disclaimer available in General Terms & Conditions
Anonymous User Privacy Preferences

Strictly Necessary Cookies (Always Active)

MULTILEARNING platforms and tools hereinafter referred as “MLG SOFTWARE” are provided to you as pure educational platforms/services requiring cookies to operate. In the case of the MLG SOFTWARE, cookies are essential for the Platform to function properly for the provision of education. If these cookies are disabled, a large subset of the functionality provided by the Platform will either be unavailable or cease to work as expected. The MLG SOFTWARE do not capture non-essential activities such as menu items and listings you click on or pages viewed.

Performance Cookies

Performance cookies are used to analyse how visitors use a website in order to provide a better user experience.

Google Analytics is used for user behavior tracking/reporting. Google Analytics works in parallel and independently from MLG’s features. Google Analytics relies on cookies and these cookies can be used by Google to track users across different platforms/services.

Save Settings