Kazuko Iwata

Restriction of dietary calories, fat and iron improves non‐alcoholic fatty liver disease

Background:  The pathogenesis of non‐alcoholic steatohepatitis (NASH) is unclear. Recent studies suggested that oxidative stress plays an important role in the mechanism of NASH. Excessive accumulation of iron in the liver causes oxidative stress. The aim of the present study was to evaluate the grade of hepatic iron accumulation and the therapeutic response to restriction of calories, fat and iron in patients with non‐alcoholic fatty liver disease (NAFLD).

Sarcopenia and Sarcopenic Obesity Are Prognostic Factors for Overall Survival in Patients with Cirrhosis

OBJECTIVE Although the prognosis is known to be poor in cirrhosis patients associated with sarcopenia, the relationships among skeletal muscle, visceral fat, and the liver have not yet been thoroughly investigated. Therefore, the prognosis and its associations with body composition and the severity of liver disease were examined in patients with cirrhosis. METHODS The skeletal muscle mass and visceral fat area were measured in 161 patients with cirrhosis, the effects of body composition on the prognosis were analyzed, and any factors that contribute to changes in body composition were assessed. RESULTS During the mean observation period of 1,005 days, 73 patients died. Patients with sarcopenia or sarcopenic obesity had a poor prognosis, and this difference was pronounced in the subset of patients classified as Child-Pugh class A. A decreased skeletal muscle mass was strongly correlated with decreased serum albumin levels. Sarcopenia is a common feature of advanced cirrhosis, and transitions were observed from normal body composition to sarcopenia and from obese to sarcopenic obesity. CONCLUSION The body composition is a prognostic factor for cirrhosis, and a better body composition may be advantageous for obtaining a long-term survival in patients with cirrhosis.

Nutrition therapy using a multidisciplinary team improves survival rates in patients with liver cirrhosis

OBJECTIVES Very few reports thus far have clinically elucidated the advantages of a nutrition support team (NST) in the field of liver diseases. The present study retrospectively analyzed whether nutrition therapy for liver cirrhosis (LC), performed by a multidisciplinary team that includes registered dieticians, improves survival rates. METHODS In study 1, we compared survival rates between two groups of patients with LC to elucidate the effects of nutrition management by registered dieticians. The first group was comprised of 101 patients that received no dietary counseling from a dietician, and the second group was comprised of 133 patients that received nutritional counseling following nutrition assessment. In study 2, we split the patients who received nutritional counseling in study 1 into two groups and compared their survival rates with the objective of investigating the effects of a multidisciplinary team approach on survival rate. The first group was comprised of 51 patients that, in addition to regular nutritional counseling given by a dietician, regularly attended courses on liver disease given every 3 to 6 mo. The second group was comprised of 82 patients that did not attend the liver-disease courses. RESULTS During study 1, 34 patients in the first group and 20 patients in the second group died, representing a significant difference (P < 0.05). This difference was even more pronounced in the subset of patients classified as Child-Pugh class A (P < 0.01), but no differences were seen among patients in classes B and C (P = 0.378). During study 2, four patients in the first group and 15 patients in the second group died, representing a significant difference (P < 0.05). CONCLUSIONS This study showed that nutritional intervention using a multidisciplinary team during the treatment of LC improves survival rates and quality of life of the patients.

Restriction of calorie and iron intake results in reduction of visceral fat and serum alanine aminotransferase and ferritin levels in patients with chronic liver disease.

Aim:  To clarify the impact of visceral fat on chronic liver diseases such as non‐alcoholic fatty liver disease (NAFLD) and hepatitis C, we investigated the effects of lifestyle modifications on the amount of visceral fat, liver biochemistry and serum ferritin levels in patients with liver disease.

Value of the extracellular water ratio for assessment of cirrhotic patients with and without ascites

Aims:  Ascites, which often complicates liver cirrhosis, is reported to be a factor that worsens the outcome. The aims of this study were to quantify body water compartment changes in cirrhotic patients, with and without ascites, and to elucidate the value of body water analysis for predicting the development of ascites.

Elevation of branched-chain amino acid levels in diabetes and NAFL and changes with antidiabetic drug treatment.

Diabetes mellitus (DM), non-alcoholic fatty liver (NAFL), and obesity are associated with elevated branched-chain amino acid (BCAA) levels, but the mechanism and significance of this has not been elucidated. Eighty-four subjects were enrolled including 43 with DM. Serum BCAA levels were positively correlated with waist-hip ratio and ALT. Serum BCAA levels in subjects with DM were higher than non-DM and those in subjects with NAFL were also higher than non-NAFL. Treatment with pioglitazone and alogliptin (19 of 43 DM subjects) improved serum haemoglobin A1c and decreased BCAA levels. The decrease in BCAAs with improved glucose metabolism suggests that abnormal glucose metabolism is also a factor in elevated BCAA levels.

Evaluation and prognosis of sarcopenia using impedance analysis in patients with liver cirrhosis

Dear Editor, We recently read an interesting article on sarcopenia in liver cirrhosis (LC) by Hayashi et al. in Hepatology Research. They evaluated sarcopenia based on skeletal muscle mass (SMM) using impedance analysis and measurement of handgrip strength, and reported that sarcopenia in LC patients was associated with physical inactivity and insufficient dietary intake. Sarcopenia has received attention as an important predictor of prognosis in LC. Evaluation of sarcopenia has included anthropometry of upper arm circumference, dual-energy X-ray absorption, and measurement of SMM using trunk computed tomography. Impedance analysis has been used more recently as a convenient modality that does not involve radiation exposure. Hayashi et al. used SMM / height as an index. Multifrequency impedance analysis enables separate calculation of SMM at different sites, such as the arms, trunk and legs. The influence of edema of the lower extremities in LC can thus be eliminated. We therefore evaluated the usefulness of measuring SMM at different sites in LC, and also examined the influence on prognosis of sarcopenia. Participants in our study comprised 137 patients with LC (80 men, 57 women; mean age, 66 1 9 years; mean Child–Pugh score, 6.7 1 3.0). SMM was measured at different sites using a body composition analyzer (InBody 720; Biospace, Seoul, Korea) and compared with SMM in 554 patients with type 2 diabetes mellitus (DM) (323 men, 231 women; mean age, 65 1 9 years). In the DM group, exclusion criteria were as follows: positive test results for hepatitis B surface antigen or hepatitis C virus RNA; significant thrombocytopenia (platelet count <10 × 10/μL); or ultrasonographic features of cirrhosis. Measurement of SMM included arm index (arm SMM / height), leg index (leg SMM / height) and appendicular index (appendicular SMM / height). The prognosis of LC with sarcopenia was then analyzed using Kaplan–Meier analysis. Appendicular SMM / height tended to be lower in LC than in DM, but the difference was not significant (men: LC, 7.37 1 1.06 kg/m; DM, 7.52 1 0.92 kg/m; women: LC, 6.31 1 0.88 kg/m; DM, 6.48 1 1.12 kg/m). In particular, arm index was significantly lower in LC (men: LC, 1.87 1 0.32 kg/m; DM, 2.00 1 0.32 kg/m; P < 0.01; women: LC, 1.50 1 0.31 kg/m; DM, 1.63 1 0.37 kg/m; P < 0.05). In this study, sarcopenia was defined based on the result of the arm index. Values less than −1 standard deviation from the mean values in the DM group, namely, less than 1.7 kg/m in men and 1.2 kg/m in women, were considered to be indicative of sarcopenia. Comparison of patient background characteristics between the groups with and without sarcopenia showed a significantly greater proportion of men in the group with sarcopenia (23 men, seven women) than in the group without sarcopenia (57 men, 50 women; P < 0.05), but no significant differences in mean age (68 1 9 vs 66 1 9 years). Child–Pugh score was higher (men, 6.9 1 1.7 vs 6.5 1 1.7; women, 8.1 1 2.7 vs 6.7 1 1.6) and hepatic functional reserve was lower in LC with than in LC without sarcopenia. In addition, analysis of prognosis with stratification for arm index showed that prognosis was significantly poorer in the arm index subgroup with lower values (Fig. 1, P < 0.05). Sarcopenia may coexist in LC, particularly in LC with decreased hepatic functional reserve, and measurement of arm SMM can be useful in evaluation. LC patients should be monitored for sarcopenia using arm SMM, because nutritional therapy can readily improve the prognosis.

Seasonal variation in visceral fat and blood HbA1c in people with type 2 diabetes

Seasonal variations in hemoglobin A1c (HbA1c) levels among patients with either type 1 or type 2 diabetes have been reported [1–4]. This phenomenon has been explained in part by weight gain due to increases in food intake and decreases in exercise during winter. Visceral fat accumulation also has been shown to have a negative impact on glycemic control in persons with diabetes [5]. However, there is no study showing the relationship between HbA1c and visceral fat area (VFA) in type 2 diabetes. We investigated the relationship between seasonal changes in body composition, especially visceral fat, and blood HbA1c levels in patients with type 2 diabetes to determine the factor that significantly contributes to the aggravation of HbA1c levels. There were 140 patients with type 2 diabetes (70 males, 70 females; mean age 60.2 12.2 years). All patients had achieved stable plasma glucose control for >2 years. Venous blood samples were drawn to determine HbA1c (Japan Diabetes Society) every 1–3 months for 2 years. % body fat (%BF), VFA, lean body mass (LBM) were determined every 1–3 months by the whole body 8-electrode approach using a multifrequency impedance analyzer (InBody 720, Seoul, Korea). Control by a

Visceral fat volume predicts new-onset type 2 diabetes in patients with chronic hepatitis C

Ninety seven patients with chronic hepatitis C (CHC) and 72 with non-alcoholic fatty liver disease (NAFLD) were enrolled. Increased visceral fat area (VFA) was associated with high values of HbA1c. The variables associated with a high risk of new-onset diabetes had a VFA>101 cm(2) in CHC, but not in NAFLD.

Iron content and consumption of health foods by patients with chronic hepatitis C

To the Editor: Iron toxicity to hepatocytes in patients with chronic hepatitis C (CHC) has attracted attention recently. In CHC patients, excessive iron deposition in the liver induces oxidative stress and aggravates the high oxidative stress state caused by hepatitis C virus, which in turn worsens liver lesions and leads to liver carcinogenesis.1 Phlebotomy has been reported to be effective as a new therapy to support the livers of CHC patients.2 Focusing on the iron content of food under these circumstances, we restricted the dietary iron intake of CHC patients and controlled their nutritional therapy for a long period. Our results showed that such a therapy lowered and stabilized serum transaminase levels.3 In Japan, consumption of health foods has been increasing year-by-year, and Kumashiro et al.4 have reported that 181 of 304 CHC patients (75.7%) consumed health foods. A similar survey in our institute revealed that 60% of CHC outpatients ate some health foods. It is considered necessary to estimate oral iron intake, including that from health foods, for the nutritional therapy of CHC patients, but the iron content of most health foods, including additives, is not displayed. In this study, by extracting at random a number of health foods that were eaten frequently and measuring their iron content, we determined the iron content ingested by CHC patients in health foods. Ion plasma emission spectrometry was used to measure the iron content. As shown in Table 1, the iron content of 100 g of turmeric (ukon) varied widely, from 0.4 to 77.4 mg. Patients ingested from 0.1 to 3.4 mg of iron daily. Other than turmeric, 100 g of a chlorella tablet, green juice, multilevel vitamins, chlorella, and gikouhaikeihoutsuhun contained as much as 138.3, 127.2, 118.7, 97.9, or 93.3 mg of iron, respectively. Iron was ingested from chlorella at 5.9–11.1 mg/day, from multilevel vitamins at 5.1mg/day, from green juice at 4 mg/day, and from protein at 3.0 mg/day. The dietary iron intake we recommend to CHC patients is 6 mg/day or less. It was revealed, however, that the dietary iron derived from health foods was not negligible, because CHC patients in Japan pay great attention to health foods, and turmeric (ukon), in particular, is often taken despite its high iron content. Health foods are often consumed by choice by patients, and it is difficult to determine their precise dietary status. On the basis of excellent physician–patient relationships, intake of health foods and changes in blood tests should be evaluated objectively. In addition, the iron content of health foods should be measured if necessary, and advice regarding the termination or continuation of health foods should be given to patients. Kazuko Iwata1, Motoh Iwasa2, Nagisa Hara1, Aki Matsumoto3, Yoshinao Kobayashi2, Shozo Watanabe4, Yukihiko Adachi2, and Masahiko Kaito2 1 Department of Nutrition Management, Mie University Hospital, Tsu, Japan 2 Department of Gastroenterology and Hepatology, Division of Clinical Medicine and Biomedical Sciences, Institute of Medical Science, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu 514-8507, Japan 3 Mie University Graduate School of Medicine, Tsu, Japan 4 Center for Physical and Mental Health, Mie University, Tsu, Japan