Dietary Intervention in Non-Alco- holic Fatty Liver Disease To the Editor: In a recent review by McCarthy and Rinella, 1 the authors reported that in non-alcoholic fatty liver disease (NAFLD) patients’ early identification and treatment could prevent the devel- opment of cirrhosis and its complica- tions. The prevalence of NAFLD in in- dustrialized countries is about 30%. 2 It has been reported that insulin resis- tance, type 2 diabetes mellitus, dyslipi- demia, and obesity are the central risk factors for NAFLD development. In par- ticular, visceral adipose tissue has an important role in the secretion of sev- eral adipokines and cytokines involved in the underlying fat accumulation mechanisms, hepatocyte injury and apoptosis, neutrophil chemotaxis, and hepatic stellate cell activation. 3 The first-line approach to NAFLD is cur- rently based on a diet and lifestyle modification. The literature suggests that the weight loss may have beneficial effects not only in fat accumulation in liver cells, but also in non-alcoholic steato- hepatitis. In this way, Garinis and col- leagues 4 carried out a 6-month pro- spective study in a series of the overweight patients with ultrasono- graphic diagnosis of hepatic steatosis. In total, 50 patients were enrolled and randomized into two groups: the first group (n=25) was given metformin (1 g per day) plus a dietary treatment (1,300 kcal/day), and the second group (n=25) was given a dietary treatment alone. At the end of the study, the proportion of patients with echographic evidence of fatty liver was reduced in both groups, the metformin (P0.0001) and the diet group (P=0.029). Moreover, the patient body mass index and waist circumfer- ence significantly decreased in both groups (P0.001). The weight loss as- sociated with the reduction of energy intake and a regular physical activity were the first-line approach to the pa- tients with NAFLD. 5 In addition, the composition of the diet, in particular lower in carbohydrates and saturated fat and higher in lean protein, fiber, and n-3 polyunsaturated fatty acid, could improve hepatic fat accumula- tion and reduce inflammation. On the basis of the available data, we support the idea that the dietary inter- vention on liver steatosis, in particular in the overweight patients, has impor- tant clinical implications given the in- creasing recognition that NAFLD is an emerging public health problem. It would be of great interest to know McCarthy and Rinella’s opinion on the Mediterranean diet for this type of pa- tient, which is relatively low in carbo- hydrates and high in monounsaturated fats. Ludovico Abenavoli, MD, PhD Assistant Professor of Medicine Department of Health Sciences University “Magna Græcia” Catanzaro, Italy Natasa Milic, PhD Assistant Professor of Medicine University of Novi Sad Novi Sad, Serbia Statement of Potential Conflict of In- terest: No potential conflict of interest was reported by the authors. Funding/Support: No funding was pro- vided for this article. References 1. McCarthy EM, Rinella ME. The role of diet and nutrient composition in nonalcoholic fatty liver disease. J Acad Nutr Diet. 2012; 112(3):401-409. 2. Bellentani S, Scaglioni F, Marino M, Bedogni G. Epidemiology of non-alcoholic fatty liver disease. Dig Dis. 2010;28(1):155-161. 3. Abenavoli L, Milic N, De Lorenzo A, Luzza F. A pathogenetic link between non-alcoholic fatty liver disease and celiac disease [pub- lished online ahead of print June 28, 2012]. Endocrine. doi:10.1007/s12020-012-9731-y. 4. Garinis GA, Fruci B, Mazza A, et al. Met- formin versus dietary treatment in nonal- coholic hepatic steatosis: a randomized study. Int J Obes. 2010;34(8):1255-1264. 5. Ratziu V, Bellentani S, Cortez-Pinto H, Day C, Marchesini G. A position statement on NAFLD/NASH based on the EASL 2009 spe- cial conference. J Hepatol. 2010;53(2):372- 384. doi: 10.1016/j.jand.2012.11.019 Authors’ Response: Non-alcoholic fatty liver disease (NAFLD) is a hepatic manifestation of metabolic syndrome; it is closely related to other clinical features of metabolic syndrome and, thus, to cardiovascular morbidity. The Mediterranean diet is a healthy diet that could be recommended as one of the treatments to NAFLD patients. As Abenavoli and Milic note in their corre- spondence, the Mediterranean diet in- cludes an eating plan rich in plant foods, healthy fats, fruits, vegetables, fish, and whole grains. It also limits un- healthy (saturated and trans) fats, so- dium, sweets, and high-fat meat. Avail- able data suggest that the traditional Mediterranean diet reduces the risk of heart disease. In fact, a meta-analysis of more than 1.5 million healthy adults demonstrated that following a Medi- terranean diet was associated with a re- duced risk of overall and cardiovascular mortality, a reduced incidence of can- cer and cancer mortality, and a reduced incidence of Parkinson’s and Alzhei- mer’s disease. 1 Furthermore, the diet has favorable effects on lipoprotein lev- els, endothelial function, insulin resis- tance, metabolic syndrome, and antiox- idant capacity in obese patients as well as in those with previous myocardial infarction. 2 Although the Mediterranean diet has long been celebrated for its impact on cardiovascular health, mounting evi- dence indicates a favorable effect on obesity and type 2 diabetes as well. 3 NAFLD represents the hepatic manifes- tation of metabolic syndrome. Certain individual food groups and compo- nents of the diet, such as monounsatu- rated fatty acids, fruits, vegetables, whole-grain cereals, dietary fiber, fish, and moderate consumption of alcohol, also may protect against the develop- ment of diabetes, possibly through the LETTERS TO THE EDITOR ARE WELCOME Letters to the Editor may be submitted at http://ees.elsevier.com/andjrnl for consid- eration regarding manuscripts published within the past 6 months. Letters should be no more than 500 words, can contain up to 20 references, and should include a funding disclosure, conflict of interest dis- closure, and copyright/authorship form. Publication of Letters to the Editor are at the discretion of the Editor-in-Chief based on timeliness, author response, and over- all quality. PRACTICE APPLICATIONS Letters to the Editor © 2013 by the Academy of Nutrition and Dietetics. JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 211