第24届亚太地区肝脏研究协会年会（APASL 2014）于2014年3月12～15日在澳大利亚布里斯班召开。Ingrid Hickman博士是澳大利亚布里斯班市亚历山德拉公主医院营养和饮食学系的主任。3月12日下午，她以“NAFLD的生活方式干预”为主题作了大会报告。以下是Hickman博士接受APASL日报记者采访的全部内容。
Ingrid Hickman博士
问：肝病专家是否同意减肥是预防脂肪肝所必需的说法？
Hickman博士：是的。我们同意，减肥，特别是减少脂肪，对预防脂肪肝非常重要。问题是，NAFLD是一种复杂的疾病。一个典型患者可患有糖尿病或高血压或心血管疾病，以及肝病。NAFLD的理想治疗是针对所有这些疾病治疗，减肥肯定能做到。减肥将改善糖尿病的血糖控制，降低血压，减少脂肪变性，并肯定会减少纤维化。普遍的共识是，减肥有益，争论更多的是我们如何让我们的患者成功减肥。如果我们的尝试不断失败，那么肝病专家将开始寻找替代治疗方案。
问：有几种方法可用于努力减肥的肥胖者。有哪些策略？由什么因素决定？
Hickman博士：这当然是患者优先，但除了医疗和手术因素外，考虑他们的减肥史同样重要。还有，到目前为止，还没有详细说明预防或治疗NAFLD的最佳饮食或运动类型的循证指南。目前，患者将接受可减少卡路里的各种信息：少吃，多运动。我们知道，如果患者能减轻3-5％的体重，他们的肝病将会明显改善，所以这是优先考虑的。但使用减肥药的整体结果则令人失望。实际上，这是由于这些药物对肝病的长期安全性尚未知晓，因而许多肥胖研究一般排除那些患有慢性肝病患者所致。
关于减肥手术，有大量的证据表明，它可明显改善NAFLD：它可以让患者减去更多的体重，且减肥速度更快。在治疗和预防2型糖尿病和脂肪肝方面，它对年轻患者（一般年龄小于40岁）益处较多。当然，也存在手术风险，特别是对于高度肥胖者而言，而且目前已有手术慢性长期不良事件的报告。在治疗这些患者时，医生要提高警惕。
问：可否举个例子？
Hickman博士：5到10年前，腹腔镜下可调式胃束带（LAGB）手术有所增加，多项研究观察了这一手术对NAFLD的影响。现在，患者报告了此手术的副作用，如束带侵蚀或松动。在布里斯班，有许多有关外科医生不得不移除束带的报道。有必要权衡任何策略的利弊。
问：澳大利亚是否存在以社区为基础的鼓励减肥措施？这里有哪些可获得的公众健康选择？
Hickman博士：有几种选择，但我认为最重要的地方是网络。网络上会有很多的技术，这些技术能使人们继续参与并激励他们追求减肥。通过论坛或智能手机，使用创建一种社交网络进行鼓励的心理学理论，是我们需要在社区中推行的东西。研究表明，正在进行的随访以及监测是保持减肥所必需的。
问：由于许多NAFLD患者都不肥胖，那么这些患者的最佳生活方式干预有哪些？
Hickman博士：现实情况是，考虑使用合适的BMI临界值来定义肥胖很重要。所有人不一定使用相同的临界值。虽然有些人可能属于健康BMI，但他们存在向心性肥胖。真正的较瘦的NAFLD只是少数，大多数人都会有一定程度的向心性肥胖或体重增加，而且大多身体活动较少。我们的目标是减少腰围，这可以通过减少热量以及通过身体活动来实现，如针对那些部位的耐力训练或循环训练。同时，避免含糖饮料也可能至关重要。
原文阅读》》》Encouraging Weight Loss in NAFLD
A:Can hepatologists agree that weight loss is essential for preventing NAFLD?
Dr: The short answer is yes. We can agree that weight loss, specifically fat loss, is important in preventing NAFLD. The problem is that NAFLD is a complex condition. A typical patient may have diabetes or high blood pressure or cardiovascular disease as well as their liver disease. An ideal treatment for NAFLD will target all of those conditions and fat loss certainly does this. This strategy will improve glucose control in diabetes, reduce blood pressure, reduce steatosis, and will certainly reduce fibrosis. While the general consensus is that weight loss is beneficial, the argument is more focused on how we get our patients to successfully reduce their weight. If our attempts continually fail, hepatologists begin to look for alternative treatment options.
A:Several options are available for obese persons trying to lose weight. What factors determine which strategies?
Dr:It would of course start with patient preference, but it is also important to consider their weight loss history in addition to medical and surgical factors. There are, as of yet, no evidence-based guidelines that detail the best dietary composition or exercise type to prevent or treat NAFLD. Currently, patients will receive generalized information about reducing calories: eating less, exercising more. We know that if patients can even lose 3-5% of their weight, they will have significant improvements in their liver disease, so this is the first line. With weight loss medication, the overall results have been disappointing. This is compounded by the fact that many of the studies in obesity generally exclude those patients with chronic liver disease, as the long-term safety of these drugs in liver disease is not currently known.
In terms of weight loss surgery, there is plenty of evidence to suggest that it results in a striking improvement to NAFLD: it allows patients to lose significantly more weight and faster. It tends to benefit younger patients more, typically younger than 40 years of age, in terms of their treatment and prevention of type-2 diabetes and NAFLD. Of course, there are risks to surgery, especially for highly obese people, and there are currently reports of chronic long-term adverse events from surgery. This has raised some caution when dealing with these patients.
A: What would be an example of those chronic conditions?
Dr: Five to ten years ago, there was an increase in laparoscopic adjustable gastric banding(LAGB), a procedure performed in a number of studies looking at its effect on NAFLD. Now, patients are reporting side effects such as erosion or loosening of the band. Locally, here in Brisbane, there are many reports of surgeons having to remove the bands. It is necessary to weigh the pros and cons of any strategy.
A: Are there any community-based measures to encourage weight loss in Australia? What public health options are available here?
Dr: There are several options, but I think the most important area is online. There will be a lot of technologies allowing people to remain engaged and motivated in their pursuit of weight loss. Having an intensive, case-worker style of program is only successful when you have the resources, and is not feasible on a long-term, population scale. Using that same psychological theory of creating a social network for encouragement, through forums or smart phones, is something we need to push for in the community. It has been shown that ongoing follow ups and monitoring are needed to maintain weight loss.
A: As many NAFLD patients are not obese, what is the best lifestyle intervention for these patients?
Dr: The reality is that it is important to think about the appropriate cut off for BMI to define obesity. We cannot necessarily use the same cut-off for all people. While some may fall into a healthy BMI, they have an unhealthy amount of central adiposity. Truly lean NAFLD is a minority, and most people will have a degree of central adiposity or increased weight and are mostly physically inactive. We aim to reduce waist circumference, which can be accomplished by reducing calories and through physical activity, such as resistance or circuit training to target those tissues. Avoiding sweetened beverages can also be crucial.
来源：APASL 2014 daily news
