LAUSR

Though there is no cure or effective drug therapy for nonalcoholic fatty liver disease (NAFLD), a leading cause of chronic liver disease worldwide, lifestyle modification with diet and regular physical activity remains the cornerstone of NAFLD treatment. Although there are weight lossindependent benefits of regular physical activity, including loss of liver fat and body fat, gains in physical fitness and improvement in endothelial dysfunction [1], lifestyle modification remains a vehicle to achieve modest weight loss with the ultimate goal of improving liver histology. The body of literature investigating lifestyle modification in patients with NAFLD is limited by strong heterogeneity, both in the population studied as well as the lifestyle intervention itself. Consequently, the optimal lifestyle modification in patients with NAFLD remains unknown. As NAFLD prevalence is expected to increase over 20% by 2030 [2], there is a clear, unmet need to determine the most effective lifestyle modification in order to lessen the large global public health burden this common disease presents. In recognition of this highly significant knowledge gap, the American Gastroenterological Association (AGA) published a recent clinical practice update in an attempt to standardize best practices for lifestyle modification in all patients with NAFLD [3]. In order to achieve the desired weight loss goal of 5–10%, the AGA guidance recommends creating a daily energy deficit of 500–1,000 kcal so as to induce a reasonable rate of medically safe weight loss. This deficit is created by combining a hypocaloric diet (which can include the Mediterranean diet or a diet of similar design) that minimizes saturated fatty acids, red and processed meats, and high fructose corn syrup, with regular physical activity that aligns with physical activity guidelines for all adults from the Department of Health and Human Services. Ideally, 150–300 min of moderate-intensity or 75–150 min of vigorous-intensity activity should be completed each week. Despite our longstanding understanding that lifestyle modification is important for overall and liver-specific health in patients with NAFLD, modest weight loss presents an onerous challenge to the clinician and patient alike. Even in a structured, highly supervised setting, weight loss goals are achieved by less than 10% of patients with NAFLD [4]. Moreover, 75% of patients with NAFLD will not achieve recommended amounts of physical activity despite almost all patients expressing desire to be more physically active [5]. What prevents patients with NAFLD from successfully attaining lifestyle modification? Common self-identified barriers include a lack of education and healthy lifestyle resources, physical discomfort, time and cost [5]. Mobile health (mHealth) applications offer the promise of removing many of these self-identified barriers, enabling the achievement of successful lifestyle modification. mHealth applications lead to higher quality clinical care, better patient-reported outcomes and improved self-management of chronic non-NAFLD metabolic disease, including obesity and pre-diabetes [6]. Whether or not mHealth is feasible, acceptable or effective remains an important knowledge gap in the care of patients with NAFLD. In this issue of Digestive Diseases and Sciences, Tincopa et al. [7] endeavor to answer this question with their sixmonth pilot study in which they assessed a priori defined feasibility and acceptability of a mHealth-based lifestyle modification program in 40 patients with NAFLD. The * Jonathan G. Stine [email protected]