Validation of adherence prediction system for lifestyle interventions in nonalcoholic fatty liver disease

Abstract

This editorial delves into the research article by Zeng et al published in the latest issue of World Journal of Gastroenterology. The manuscript contributes significantly to addressing the global health issue of nonalcoholic fatty liver disease (NAFLD) by introducing and validating the Exercise and Diet Adherence Scale (EDAS). The article effectively conveys the importance of the study, highlighting the prevalence of NAFLD, the lack of approved drugs for its treatment, and the crucial role of lifestyle correction. The use of the Delphi method for scale deve-lopment and the subsequent evaluation of its reliability add scientific rigor to the methodology. The results demonstrate that the scale is correlated with key lifestyle indicators, which makes it a promising tool for assessing patient adherence to interventions. The identification of specific score thresholds for predicting adherence to daily calorie intake and exercise adds practical value to the scale. The differentiation among scores indicative of good, average, and poor adherence enhances its clinical applicability. In conclusion, the manuscript introduces EDAS, a valuable instrument that can contribute substantially to the field of NAFLD research and clinical practice.

Key Words: Nonalcoholic fatty liver disease, Lifestyle interventions, Adherence assessment, Exercise and Diet Adherence Scale, Delphi method

Core Tip: The study introduces the Exercise and Diet Adherence Scale (EDAS), a robust tool for assessing patient adherence to lifestyle interventions in non-alcoholic fatty liver disease (NAFLD). Developed using the Delphi method, the EDAS consists of 33 items across six dimensions, offering a comprehensive evaluation. Results indicate its significant correlation with key lifestyle indicators, allowing for precise differentiation of adherence levels. Clinically relevant thresholds make the EDAS a practical and valuable instrument for identifying patients with poor adherence. This contribution holds promise for advancing NAFLD research and enhancing clinical interventions through a targeted focus on lifestyle adherence assessment.

INTRODUCTION

Nonalcoholic fatty liver disease (NAFLD) poses a considerable global health challenge, affecting approximately 25% of the world’s population and contributing substantially to liver-related morbidity and mortality[1]. This condition encompasses hepatic steatosis, which is characterized by the deposition of fat in the liver and affects more than 5% of the hepatocytes. NAFLD is diagnosed in the absence of excessive alcohol intake, other liver diseases, and the consumption of steatogenic drugs[2-4]. Several factors, including the accumulation of triglycerides, free fatty acid-induced lipotoxicity, activation of inflammatory pathways, oxidative stress, and the initiation of fibrogenesis, contribute to disease progression from simple steatosis to nonalcoholic steatohepatitis (NASH), a severe form of NAFLD. The failure of the hepatocytes to replace and regenerate dead cells further leads to the evolution of NASH[5].

NAFLD is a complex and multifactorial ailment, earning a distinction as the most prevalent form of chronic liver disease globally. The trajectory of NAFLD includes four different clinicopathological entities, each representing a stage in the course of the disease. These entities comprise nonalcoholic steatosis, NASH, advanced fibrosis/cirrhosis, and hepatocellular carcinoma. The pathogenesis of NAFLD involves the intricate interplay of oxidative stress and insulin resistance, as reported by Dongiovanni et al[3], Dong et al[6], and Nobili et al[7] .

Despite the high prevalence of NAFLD in the general population, most individuals only exhibit simple steatosis, a condition characterized by the accumulation of fat in the liver. Only a small percentage of the affected individuals progress to inflammation, subsequent fibrosis, and the development of chronic liver disease[8]. NAFLD not only poses a threat to hepatic health but also increases the risk of other ailments, notably diabetes and ischemic heart disease[9].

The absence of approved pharmacological therapies accentuates the critical role of lifestyle interventions, such as dietary modifications and increased physical activity, in the comprehensive management of NAFLD. These interventions are the foundational strategies for ameliorating hepatic steatosis and mitigating the risk of disease progression[10,11].

While lifestyle interventions have been proven to be effective in alleviating the metabolic disturbances and long-term complications associated with NAFLD, their success hinges on consistent implementation and sustained adherence to lifestyle programs. The ability to obtain positive outcomes in managing the condition via lifestyle modifications may be compromised when faced with challenges pertaining to poor implementation or reduced adherence[12,13]. Owing to the multifaceted nature of these interventions, reliable tools must be developed that not only assess patient adherence but also guide personalized therapeutic approaches, thereby enhancing the overall clinical outcomes.

In response to this need, researchers have developed innovative instruments such as the Exercise and Diet Adherence Scale (EDAS), as presented in the referenced study. Developed using the rigorous Delphi method, EDAS is a comprehensive assessment tool that contains 33 items distributed across six dimensions. This intricate composition facilitates a nuanced and in-depth understanding of patient adherence levels, enabling clinicians to tailor interventions that cater to the specific needs of each patient.

Furthermore, the importance of lifestyle interventions in the context of NAFLD extends beyond hepatic implications and has the potential to address associated metabolic risk factors, such as obesity, insulin resistance, and dyslipidemia[14,15]. Understanding the significance of these interventions in their multifaceted context is crucial for the clinicians to optimize patient care and improve long-term outcomes in the dynamic landscape of NAFLD management.

COMMENTARY

This article published in the World Journal of Gastroenterology by Zeng et al[16] is a giant leap in the knowledge realm of NAFLD. By successfully introducing and validating EDAS, the authors have provided a robust instrument for evaluating patient adherence to lifestyle interventions in the context of NAFLD management. The meticulous methodology, employing a prospective study design and incorporating the Delphi method for scale development and validation, adds scientific rigor to the foundation of the study. The scale, with its intricate composition of 33 items across six dimensions, has emerged as a comprehensive tool that is not only strongly correlated with key lifestyle indicators, such as daily exercise and calorie reduction, but also predicts adherence to specific aspects of interventions, such as daily calorie intake. This predictive ability lends itself well to the nuanced nature of lifestyle modifications, thus offering clinicians a valuable method for understanding and addressing patient behaviors in a targeted manner.

One noteworthy aspect of the study is that clear thresholds have been established to characterize adherence levels, which simplifies the interpretation of the scores and augments the usability of the scale in real-world clinical scenarios. Clinicians can now utilize EDAS to stratify patients based on their adherence, thereby allowing a personalized approach to treatment. This aspect is aligned seamlessly with the evolving landscape of precision medicine in which interventions are tailored to the specific needs of each patient. The Core tip succinctly captures the essence of the study, emphasizing the pivotal role of EDAS in assessing and predicting adherence to lifestyle changes in patients with NAFLD. The mention of personalized treatments based on EDAS scores indicates the immediate and tangible impact of this research on clinical management. The study, with its meticulous execution and practical implications, is a step in the right direction in the ongoing pursuit of effective and tailored interventions for patients with NAFLD.

IMPLICATIONS FOR CLINICAL PRACTICE

The development and validation of EDAS by Zeng et al[16] is a significant breakthrough with profound implications for the clinical management of NAFLD. The scale is a tangible and practical tool that offers healthcare providers a systematic approach to categorize patients based on their adherence levels.

Such stratification empowers clinicians to tailor personalized treatment regimens, focusing the interventions on specific aspects of lifestyle modifications in which patients require additional support. The scale exhibits remarkable sensitivity and specificity in predicting adherence to daily reductions in calorie intake and exercise. These features enable the clinicians to promptly identify at-risk patients, facilitating closer monitoring and timely interventions to prevent disease progression and associated complications.

As EDAS is a quantifiable tool, it fosters improved communication between healthcare providers and patients. By utilizing the scale to discuss specific aspects of adherence, health care providers can engage in targeted and constructive conversations, which promotes a collaborative approach to lifestyle interventions. The longitudinal nature of the assessment allows clinicians to continuously monitor patients’ adherence over time, which enables the tracking of alterations in adherence patterns and adjusting the interventions accordingly. This longitudinal approach promotes sustained lifestyle modifications, a crucial aspect in effectively managing NAFLD.

In addition, effective resource allocation is paramount in healthcare delivery, and EDAS proves instrumental in this regard. By identifying patients who are likely to be highly benefited from additional support, the scale allows healthcare providers to effectively optimize resource allocation. This optimization, in turn, enhances the overall efficiency of healthcare delivery, a critical consideration in the contemporary healthcare landscape.

CONCLUSION

In essence, the incorporation of EDAS in clinical practice signifies a revolutionary strategy for addressing NAFLD. The scale can be practically applied in tailoring treatment strategies, identifying risks, fostering improved communication, facilitating long-term monitoring, and optimizing resource allocation. Therefore, it can serve as a crucial tool for clinicians committed to enhancing patient outcomes in the constantly evolving scenario of NAFLD management. EDAS does not merely expedite clinical decision-making but plays a pivotal role in cultivating a patient-centric and resource-efficient paradigm in the continual fight against NAFLD. The multifaceted capabilities of the scale enhance the precision of treatment plans and also enable a streamlined and economical approach, thereby fortifying the arsenal of healthcare professionals committed to combatting the complexities of NAFLD. This integration stands as a testament to the relentless pursuit of advancements in medical practice, aiming to redefine the standards of care and usher in a new era of efficacy in NAFLD management.