DOI QR코드

DOI QR Code

Non-alcoholic fatty liver disease and lifestyle modifications, focusing on physical activity

  • Kwak, Min-Sun (Department of Internal Medicine, Healthcare Research Institute, Seoul National University Hospital Healthcare System Gangnam Center) ;
  • Kim, Donghee (Division of Gastroenterology and Hepatology, Stanford University School of Medicine)
  • 투고 : 2017.10.09
  • 심사 : 2017.10.25
  • 발행 : 2018.01.01

초록

Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease, and the prevalence of non-alcoholic steatohepatitis (NASH) with fibrosis is increasing as the population with NAFLD ages. To date, lifestyle modifications including weight loss, increased physical activity, and dietary changes remain the treatment of choice for NAFLD because there are no approved effective pharmacologic agents. Increased physical activity has therapeutic effects on NAFLD by reducing hepatic fat independent of weight reduction. Indeed, even minimal physical activity below the recommended threshold may have a beneficial impact on NAFLD. Aerobic activity and resistance training have similar effects on NAFLD. Universal recommendations for the optimal intensity and dose of physical activity have not been established. Therefore, physical activity should be tailored based on a patient's clinical characteristics, comorbidities, and fitness capacity. Physical activity also prevents the development of NAFLD and may represent a valuable strategy for reducing the public health burden. However, there are insufficient data supporting the effects of physical activity on the progression of non-alcoholic fatty liver to NASH with advanced fibrosis, and on extrahepatic disease-related morbidity and mortality. In this paper, we review the role of physical activity in the management of NAFLD.

키워드

참고문헌

  1. Sayiner M, Koenig A, Henry L, Younossi ZM. Epidemiology of nonalcoholic fatty liver disease and nonalcoholic steatohepatitis in the united states and the rest of the world. Clin Liver Dis 2016;20:205-214. https://doi.org/10.1016/j.cld.2015.10.001
  2. Younossi ZM, Stepanova M, Afendy M, et al. Changes in the prevalence of the most common causes of chronic liver diseases in the United States from 1988 to 2008. Clin Gastroenterol Hepatol 2011;9:524-530. https://doi.org/10.1016/j.cgh.2011.03.020
  3. Satapathy SK, Sanyal AJ. Epidemiology and natural history of nonalcoholic fatty liver disease. Semin Liver Dis 2015;35:221-235. https://doi.org/10.1055/s-0035-1562943
  4. Kwak MS, Kim D. Long-term outcomes of nonalcoholic fatty liver disease. Curr Hepatol Rep 2015;14:69-76. https://doi.org/10.1007/s11901-015-0258-6
  5. Paschos P, Paletas K. Non alcoholic fatty liver disease and metabolic syndrome. Hippokratia 2009;13:9-19.
  6. Kwon H, Kim D, Kim JS. Body fat distribution and the risk of incident metabolic syndrome: a longitudinal cohort study. Sci Rep 2017;7:10955. https://doi.org/10.1038/s41598-017-09723-y
  7. Kim D, Chung GE, Kwak MS, et al. Body fat distribution and risk of incident and regressed nonalcoholic fatty liver disease. Clin Gastroenterol Hepatol 2016;14:132-138. https://doi.org/10.1016/j.cgh.2015.07.024
  8. Grundy SM, Cleeman JI, Daniels SR, et al. Diagnosis and management of the metabolic syndrome: an American Heart Association/National Heart, Lung, and Blood Institute Scientific Statement. Circulation 2005;112:2735-2752. https://doi.org/10.1161/CIRCULATIONAHA.105.169404
  9. Chalasani N, Younossi Z, Lavine JE, et al. The diagnosis and management of non-alcoholic fatty liver disease: practice guideline by the American Association for the Study of Liver Diseases, American College of Gastroenterology, and the American Gastroenterological Association. Hepatology 2012;55:2005-2023. https://doi.org/10.1002/hep.25762
  10. Korean Association for the Study of the Liver (KASL). KASL clinical practice guidelines: management of nonalcoholic fatty liver disease. Clin Mol Hepatol 2013;19:325-348. https://doi.org/10.3350/cmh.2013.19.4.325
  11. Chalasani N, Younossi Z, Lavine JE, et al. The diagnosis and management of nonalcoholic fatty liver disease: practice guidance from the American Association for the Study of Liver Diseases. Hepatology 2017 Jul 17 [Epub]. https://doi.org/10.1002/hep.29367.
  12. Chung GE, Kim D. Epidemiology of nonalcoholic fatty liver disease. Korean J Med 2014;86:399-404. https://doi.org/10.3904/kjm.2014.86.4.399
  13. Younossi ZM, Koenig AB, Abdelatif D, Fazel Y, Henry L, Wymer M. Global epidemiology of nonalcoholic fatty liver disease-meta-analytic assessment of prevalence, incidence, and outcomes. Hepatology 2016;64:73-84. https://doi.org/10.1002/hep.28431
  14. Estes C, Razavi H, Loomba R, Younossi Z, Sanyal AJ. Modeling the epidemic of nonalcoholic fatty liver disease demonstrates an exponential increase in burden of disease. Hepatology 2017 Aug 12 [Epub]. https://doi.org/10.1002/hep.29466.
  15. Leite NC, Salles GF, Araujo AL, Villela-Nogueira CA, Cardoso CR. Prevalence and associated factors of non-alcoholic fatty liver disease in patients with type-2 diabetes mellitus. Liver Int 2009;29:113-119. https://doi.org/10.1111/j.1478-3231.2008.01718.x
  16. Kim D, Kim WR, Kim HJ, Therneau TM. Association between noninvasive fibrosis markers and mortality among adults with nonalcoholic fatty liver disease in the United States. Hepatology 2013;57:1357-1365. https://doi.org/10.1002/hep.26156
  17. Hsu CS, Kao JH. Non-alcoholic fatty liver disease: an emerging liver disease in Taiwan. J Formos Med Assoc 2012;111:527-535. https://doi.org/10.1016/j.jfma.2012.07.002
  18. Chen J, Talwalkar JA, Yin M, Glaser KJ, Sanderson SO, Ehman RL. Early detection of nonalcoholic steatohepatitis in patients with nonalcoholic fatty liver disease by using MR elastography. Radiology 2011;259:749-756. https://doi.org/10.1148/radiol.11101942
  19. Kim D, Kim WR, Talwalkar JA, Kim HJ, Ehman RL. Advanced fibrosis in nonalcoholic fatty liver disease: noninvasive assessment with MR elastography. Radiology 2013;268:411-419. https://doi.org/10.1148/radiol.13121193
  20. Nobili V, Vizzutti F, Arena U, et al. Accuracy and reproducibility of transient elastography for the diagnosis of fibrosis in pediatric nonalcoholic steatohepatitis. Hepatology 2008;48:442-448.
  21. Wong VW, Vergniol J, Wong GL, et al. Diagnosis of fibrosis and cirrhosis using liver stiffness measurement in nonalcoholic fatty liver disease. Hepatology 2010;51:454-462. https://doi.org/10.1002/hep.23312
  22. McPherson S, Stewart SF, Henderson E, Burt AD, Day CP. Simple non-invasive fibrosis scoring systems can reliably exclude advanced fibrosis in patients with non-alcoholic fatty liver disease. Gut 2010;59:1265-1269. https://doi.org/10.1136/gut.2010.216077
  23. Musso G, Gambino R, Cassader M, Pagano G. Meta-analysis: natural history of non-alcoholic fatty liver disease (NAFLD) and diagnostic accuracy of non-invasive tests for liver disease severity. Ann Med 2011;43:617-649. https://doi.org/10.3109/07853890.2010.518623
  24. Shah AG, Lydecker A, Murray K, et al. Comparison of noninvasive markers of fibrosis in patients with nonalcoholic fatty liver disease. Clin Gastroenterol Hepatol 2009;7:1104-1112. https://doi.org/10.1016/j.cgh.2009.05.033
  25. Hamaguchi M, Kojima T, Takeda N, et al. Nonalcoholic fatty liver disease is a novel predictor of cardiovascular disease. World J Gastroenterol 2007;13:1579-1584. https://doi.org/10.3748/wjg.v13.i10.1579
  26. Kim D, Choi SY, Park EH, et al. Nonalcoholic fatty liver disease is associated with coronary artery calcification. Hepatology 2012;56:605-613. https://doi.org/10.1002/hep.25593
  27. Park HE, Kwak MS, Kim D, Kim MK, Cha MJ, Choi SY. Nonalcoholic fatty liver disease is associated with coronary artery calcification development: a longitudinal study. J Clin Endocrinol Metab 2016;101:3134-3143. https://doi.org/10.1210/jc.2016-1525
  28. Valenti L, Bugianesi E, Pajvani U, Targher G. Nonalcoholic fatty liver disease: cause or consequence of type 2 diabetes? Liver Int 2016;36:1563-1579. https://doi.org/10.1111/liv.13185
  29. Goessling W, Massaro JM, Vasan RS, D'Agostino RB Sr, Ellison RC, Fox CS. Aminotransferase levels and 20-year risk of metabolic syndrome, diabetes, and cardiovascular disease. Gastroenterology 2008;135:1935-1944, 1944. https://doi.org/10.1053/j.gastro.2008.09.018
  30. Lonardo A, Ballestri S, Marchesini G, Angulo P, Loria P. Nonalcoholic fatty liver disease: a precursor of the metabolic syndrome. Dig Liver Dis 2015;47:181-190. https://doi.org/10.1016/j.dld.2014.09.020
  31. Calori G, Lattuada G, Ragogna F, et al. Fatty liver index and mortality: the Cremona study in the 15th year of follow-up. Hepatology 2011;54:145-152. https://doi.org/10.1002/hep.24356
  32. Guturu P, Duchini A. Etiopathogenesis of nonalcoholic steatohepatitis: role of obesity, insulin resistance and mechanisms of hepatotoxicity. Int J Hepatol 2012;2012:212865.
  33. Kim D, Kim WR. Nonobese fatty liver disease. Clin Gastroenterol Hepatol 2017;15:474-485. https://doi.org/10.1016/j.cgh.2016.08.028
  34. Armstrong MJ, Adams LA, Canbay A, Syn WK. Extrahepatic complications of nonalcoholic fatty liver disease. Hepatology 2014;59:1174-1197. https://doi.org/10.1002/hep.26717
  35. Targher G, Day CP, Bonora E. Risk of cardiovascular disease in patients with nonalcoholic fatty liver disease. N Engl J Med 2010;363:1341-1350. https://doi.org/10.1056/NEJMra0912063
  36. European Association for the Study of the Liver (EASL); European Association for the Study of Diabetes (EASD); European Association for the Study of Obesity (EASO). EASL-EASD-EASO clinical practice guidelines for the management of non-alcoholic fatty liver disease. J Hepatol 2016;64:1388-1402.
  37. Panagiotakos DB, Pitsavos C, Chrysohoou C, et al. Impact of lifestyle habits on the prevalence of the metabolic syndrome among Greek adults from the ATTICA study. Am Heart J 2004;147:106-112. https://doi.org/10.1016/S0002-8703(03)00442-3
  38. Dalle Grave R, Calugi S, Centis E, Marzocchi R, El Ghoch M, Marchesini G. Lifestyle modification in the management of the metabolic syndrome: achievements and challenges. Diabetes Metab Syndr Obes 2010;3:373-385. https://doi.org/10.2147/DMSO.S13860
  39. Perez-Martinez P, Mikhailidis DP, Athyros VG, et al. Lifestyle recommendations for the prevention and management of metabolic syndrome: an international panel recommendation. Nutr Rev 2017;75:307-326. https://doi.org/10.1093/nutrit/nux014
  40. Vilar-Gomez E, Martinez-Perez Y, Calzadilla-Bertot L, et al. Weight loss through lifestyle modification significantly reduces features of nonalcoholic steatohepatitis. Gastroenterology 2015;149:367-378.e5. https://doi.org/10.1053/j.gastro.2015.04.005
  41. Orci LA, Gariani K, Oldani G, Delaune V, Morel P, Toso C. Exercise-based interventions for nonalcoholic fatty liver disease: a meta-analysis and meta-regression. Clin Gastroenterol Hepatol 2016;14:1398-1411. https://doi.org/10.1016/j.cgh.2016.04.036
  42. Katsagoni CN, Georgoulis M, Papatheodoridis GV, Panagiotakos DB, Kontogianni MD. Effects of lifestyle interventions on clinical characteristics of patients with non-alcoholic fatty liver disease: a meta-analysis. Metabolism 2017;68:119-132. https://doi.org/10.1016/j.metabol.2016.12.006
  43. Oh S, Shida T, Yamagishi K, et al. Moderate to vigorous physical activity volume is an important factor for managing nonalcoholic fatty liver disease: a retrospective study. Hepatology 2015;61:1205-1215. https://doi.org/10.1002/hep.27544
  44. Thoma C, Day CP, Trenell MI. Lifestyle interventions for the treatment of non-alcoholic fatty liver disease in adults: a systematic review. J Hepatol 2012;56:255-266. https://doi.org/10.1016/j.jhep.2011.06.010
  45. Keating SE, Hackett DA, George J, Johnson NA. Exercise and non-alcoholic fatty liver disease: a systematic review and meta-analysis. J Hepatol 2012;57:157-166. https://doi.org/10.1016/j.jhep.2012.02.023
  46. Thompson PD, Buchner D, Pina IL, et al. Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity). Circulation 2003;107:3109-3116. https://doi.org/10.1161/01.CIR.0000075572.40158.77
  47. Pate RR, Pratt M, Blair SN, et al. Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273:402-407. https://doi.org/10.1001/jama.1995.03520290054029
  48. Fletcher GF, Balady GJ, Amsterdam EA, et al. Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association. Circulation 2001;104:1694-1740. https://doi.org/10.1161/hc3901.095960
  49. Craig CL, Marshall AL, Sjostrom M, et al. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc 2003;35:1381-1395. https://doi.org/10.1249/01.MSS.0000078924.61453.FB
  50. Hashida R, Kawaguchi T, Bekki M, et al. Aerobic vs. resistance exercise in non-alcoholic fatty liver disease: a systematic review. J Hepatol 2017;66:142-152. https://doi.org/10.1016/j.jhep.2016.08.023
  51. Kistler KD, Brunt EM, Clark JM, et al. Physical activity recommendations, exercise intensity, and histological severity of nonalcoholic fatty liver disease. Am J Gastroenterol 2011;10:460-468.
  52. Houghton D, Thoma C, Hallsworth K, et al. Exercise reduces liver lipids and visceral adiposity in patients with nonalcoholic steatohepatitis in a randomized controlled trial. Clin Gastroenterol Hepatol 2017;15:96-102. https://doi.org/10.1016/j.cgh.2016.07.031
  53. Bacchi E, Negri C, Targher G, et al. Both resistance training and aerobic training reduce hepatic fat content in type 2 diabetic subjects with nonalcoholic fatty liver disease (the RAED2 Randomized Trial). Hepatology 2013;58:1287-1295. https://doi.org/10.1002/hep.26393
  54. Shamsoddini A, Sobhani V, Ghamar Chehreh ME, Alavian SM, Zaree A. Effect of aerobic and resistance exercise training on liver enzymes and hepatic fat in iranian men with nonalcoholic fatty liver disease. Hepat Mon 2015;15:e31434.
  55. Slentz CA, Bateman LA, Willis LH, et al. Effects of aerobic vs. resistance training on visceral and liver fat stores, liver enzymes, and insulin resistance by HOMA in overweight adults from STRRIDE AT/RT. Am J Physiol Endocrinol Metab 2011;301:E1033-E1039. https://doi.org/10.1152/ajpendo.00291.2011
  56. Hallsworth K, Fattakhova G, Hollingsworth KG, et al. Resistance exercise reduces liver fat and its mediators in non-alcoholic fatty liver disease independent of weight loss. Gut 2011;60:1278-1283. https://doi.org/10.1136/gut.2011.242073
  57. Koo BK, Kim D, Joo SK, et al. Sarcopenia is an independent risk factor for non-alcoholic steatohepatitis and significant fibrosis. J Hepatol 2017;66:123-131. https://doi.org/10.1016/j.jhep.2016.08.019
  58. Keating SE, Hackett DA, Parker HM, et al. Effect of aerobic exercise training dose on liver fat and visceral adiposity. J Hepatol 2015;63:174-182. https://doi.org/10.1016/j.jhep.2015.02.022
  59. Ryu S, Chang Y, Jung HS, et al. Relationship of sitting time and physical activity with non-alcoholic fatty liver disease. J Hepatol 2015;63:1229-1237. https://doi.org/10.1016/j.jhep.2015.07.010
  60. Kwak MS, Kim D, Chung GE, Kim W, Kim YJ, Yoon JH. Role of physical activity in nonalcoholic fatty liver disease in terms of visceral obesity and insulin resistance. Liver Int 2015;35:944-952. https://doi.org/10.1111/liv.12552
  61. Hickman IJ, Byrne NM, Croci I, et al. A pilot randomised study of the metabolic and histological effects of exercise in non-alcoholic steatohepatitis. J Diabetes Metab 2013;4:300.
  62. Sreenivasa Baba C, Alexander G, Kalyani B, et al. Effect of exercise and dietary modification on serum aminotransferase levels in patients with nonalcoholic steatohepatitis. J Gastroenterol Hepatol 2006;21(1 Pt 1):191-198. https://doi.org/10.1111/j.1440-1746.2005.04233.x
  63. Keating SE, George J, Johnson NA. The benefits of exercise for patients with non-alcoholic fatty liver disease. Expert Rev Gastroenterol Hepatol 2015;9:1247-1250. https://doi.org/10.1586/17474124.2015.1075392
  64. Barengo NC, Antikainen R, Borodulin K, Harald K, Jousilahti P. Leisure-time physical activity reduces total and cardiovascular mortality and cardiovascular disease incidence in older adults. J Am Geriatr Soc 2017;65:504-510. https://doi.org/10.1111/jgs.14694
  65. Barengo NC, Hu G, Lakka TA, Pekkarinen H, Nissinen A, Tuomilehto J. Low physical activity as a predictor for total and cardiovascular disease mortality in middle-aged men and women in Finland. Eur Heart J 2004;25:2204-2211. https://doi.org/10.1016/j.ehj.2004.10.009
  66. Mora S, Redberg RF, Cui Y, et al. Ability of exercise testing to predict cardiovascular and all-cause death in asymptomatic women: a 20-year follow-up of the lipid research clinics prevalence study. JAMA 2003;290:1600-1607.
  67. Ekelund LG, Haskell WL, Johnson JL, Whaley FS, Criqui MH, Sheps DS. Physical fitness as a predictor of cardiovascular mortality in asymptomatic North American men. The Lipid Research Clinics Mortality Follow-up Study. N Engl J Med 1988;319:1379-1384. https://doi.org/10.1056/NEJM198811243192104
  68. Kodama S, Saito K, Tanaka S, et al. Cardiorespiratory fitness as a quantitative predictor of all-cause mortality and cardiovascular events in healthy men and women: a meta-analysis. JAMA 2009;301:2024-2035. https://doi.org/10.1001/jama.2009.681
  69. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393-403. https://doi.org/10.1056/NEJMoa012512
  70. Fagard RH. Exercise characteristics and the blood pressure response to dynamic physical training. Med Sci Sports Exerc 2001;33(6 Suppl):S484-S492. https://doi.org/10.1097/00005768-200106001-00018
  71. Thompson PD, Crouse SF, Goodpaster B, Kelley D, Moyna N, Pescatello L. The acute versus the chronic response to exercise. Med Sci Sports Exerc 2001;33(6 Suppl):S438-S445. https://doi.org/10.1097/00005768-200106001-00012
  72. Couillard C, Despres JP, Lamarche B, et al. Effects of endurance exercise training on plasma HDL cholesterol levels depend on levels of triglycerides: evidence from men of the Health, Risk Factors, Exercise Training and Genetics (HERITAGE) Family Study. Arterioscler Thromb Vasc Biol 2001;21:1226-1232. https://doi.org/10.1161/hq0701.092137
  73. Kwak MS, Kim D, Chung GE, Kim W, Kim JS. The preventive effect of sustained physical activity on incident nonalcoholic fatty liver disease. Liver Int 2017;37:919-926. https://doi.org/10.1111/liv.13332
  74. Sung KC, Ryu S, Lee JY, Kim JY, Wild SH, Byrne CD. Effect of exercise on the development of new fatty liver and the resolution of existing fatty liver. J Hepatol 2016;65:791-797. https://doi.org/10.1016/j.jhep.2016.05.026
  75. Tsunoda K, Kai Y, Kitano N, Uchida K, Kuchiki T, Nagamatsu T. Impact of physical activity on nonalcoholic steatohepatitis in people with nonalcoholic simple fatty liver: a prospective cohort study. Prev Med 2016;88:237-240. https://doi.org/10.1016/j.ypmed.2016.04.020
  76. Jan CF, Nfor ON, Huang JY, et al. Exercise might prevent cirrhosis in overweight and obese adults. Liver Int 2017 Aug 19 [Epub]. https://doi.org/10.1111/liv.13553.

피인용 문헌

  1. Current and Emerging Approaches for Nonalcoholic Steatohepatitis Treatment vol.19, pp.3, 2018, https://doi.org/10.3727/105221619x15536120524171
  2. Decreased lung function is associated with risk of developing non-alcoholic fatty liver disease: A longitudinal cohort study vol.14, pp.1, 2019, https://doi.org/10.1371/journal.pone.0208736
  3. The Mexican consensus on nonalcoholic fatty liver disease vol.84, pp.1, 2018, https://doi.org/10.1016/j.rgmxen.2019.02.003
  4. Exercise Programming for Nonalcoholic Fatty Liver Disease vol.41, pp.4, 2019, https://doi.org/10.1519/ssc.0000000000000462
  5. Aerobic capacity and exercise performance in nonalcoholic fatty liver disease vol.59, pp.8, 2019, https://doi.org/10.23736/s0022-4707.19.09231-4
  6. Dietary Patterns and Components in Nonalcoholic Fatty Liver Disease (NAFLD): What Key Messages Can Health Care Providers Offer? vol.11, pp.12, 2018, https://doi.org/10.3390/nu11122878
  7. Liver steatosis and nonalcoholic fatty liver disease with fibrosis are predictors of frailty in people living with HIV vol.34, pp.13, 2018, https://doi.org/10.1097/qad.0000000000002650
  8. Dietary Intervention Accelerates NASH Resolution Depending on Inflammatory Status with Minor Additive Effects on Hepatic Injury by Vitamin E Supplementation vol.9, pp.9, 2020, https://doi.org/10.3390/antiox9090808
  9. Inadequate Physical Activity and Sedentary Behavior Are Independent Predictors of Nonalcoholic Fatty Liver Disease vol.72, pp.5, 2018, https://doi.org/10.1002/hep.31158
  10. Resistance Exercise Regulates Hepatic Lipolytic Factors as Effective as Aerobic Exercise in Obese Mice vol.17, pp.22, 2018, https://doi.org/10.3390/ijerph17228307
  11. Recommended Musculoskeletal and Sports Medicine Curriculum for Internal Medicine Residency Training vol.20, pp.2, 2018, https://doi.org/10.1249/jsr.0000000000000811
  12. Effect of sour tea supplementation on liver enzymes, lipid profile, blood pressure, and antioxidant status in patients with non‐alcoholic fatty liver disease: A double‐blind randomized con vol.35, pp.1, 2018, https://doi.org/10.1002/ptr.6826
  13. Physical Activity and Low Glycemic Index Mediterranean Diet: Main and Modification Effects on NAFLD Score. Results from a Randomized Clinical Trial vol.13, pp.1, 2021, https://doi.org/10.3390/nu13010066
  14. Hepatocellular Carcinoma in Korea: an Analysis of the 2015 Korean Nationwide Cancer Registry vol.21, pp.1, 2018, https://doi.org/10.17998/jlc.21.1.58
  15. The Evaluation of Drug Delivery Nanocarrier Development and Pharmacological Briefing for Metabolic-Associated Fatty Liver Disease (MAFLD): An Update vol.14, pp.3, 2021, https://doi.org/10.3390/ph14030215
  16. Physical Comorbidity According to Diagnoses and Sex among Psychiatric Inpatients in South Korea vol.18, pp.8, 2018, https://doi.org/10.3390/ijerph18084187
  17. A review of non‐alcoholic fatty liver disease in non‐obese and lean individuals vol.36, pp.6, 2018, https://doi.org/10.1111/jgh.15353
  18. Serum Alanine Transaminase Is an Inadequate Nonalcoholic Fatty Liver Screening Test in Adolescents: Results From the National Health and Nutrition Examination Survey 2017-2018 vol.60, pp.8, 2018, https://doi.org/10.1177/00099228211020177
  19. Effect of Silymarin Supplementation in Lung and Liver Histological Modifications during Exercise Training in a Rodent Model vol.6, pp.3, 2018, https://doi.org/10.3390/jfmk6030072
  20. A qualitative study of self‐management experiences in people with non‐alcoholic fatty liver disease vol.8, pp.6, 2021, https://doi.org/10.1002/nop2.1025