Psychological aspects of health behaviours in NAFLD non-alcoholic fatty liver disease

Prof. Maya Balakrishnan (USA) discusses the importance of the behavioural psychology in the field of non-alcoholic fatty liver disease, NAFLD.
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Hi, my name is Maya Balakrishnan. I am a gastroenterologist, a hepatologist and an assistant professor of internal medicine at Baylor College of Medicine, which is in Houston,Texas in the United States. I’ll be spending the next 15 to 20 minutes discussing the psychological aspects of health behaviors.

Psychological aspects of health behaviors in NAFLD  

A topic that’s become highly relevant in the field of non-alcoholic fatty liver disease which all referred to as novel through my talk. It’s well established that NAFLD is highly prevalent and highly significant. It has an estimated global problem of 25 to 30 percent. It’s become the leading cause of chronic liver disease and it’s associated with reduced quality of life and increased healthcare costs compounding the problem is that we don’t have any approved pharmacotherapies for the condition. However, studies have shown that weight loss improves novels and as such weight loss is the first line treatment for non-alcoholic fatty liver disease.

Really any degree of weight loss is beneficial for NAFLD but we really aim for 5% weight loss or more and this is because 5% weight loss is associated with the greatest likelihood of improvement in liver fat and higher thresholds of 7 to 10 percent are associated with resolution of non-alcoholic stay out of hepatitis and fibrosis respectively.

So what’s the relevance of psychology to treating NAFLD you might be wondering. Well my goal during this talk is to convince you that behavioral psychology is highly relevant to NAFLD. There are several gaps pertaining to this field and many opportunities to translate the research of behavioral science to novels and I plan on convincing you of this through making these four main points first. I’ll highlight the influence of health behavior. 

So now second I’ll discuss the psychology of health behaviors. Third, I’ll very briefly review techniques that can improve the psychological aspects of health behaviors and they are by weight loss rates and finally I’ll touch on very briefly to psychiatric comorbidities that are very common in our patients with NAFLD and can adversely impact their behaviors and therefore have implications for how we approach behavioral change in them. 

Relevance of psychotherapy 

So first health behavior is central to novel treatment. Adhering to healthy dietary and physical activity behaviors are necessary to lose weight and throughout this talk when I refer to healthy behaviors I mean our diets that are calorie restricted and Mediterranean pattern and physical activity of 150 to 200 minutes a week of modern intensity.

Second, health behaviors are important for maintaining weight loss that’s achieved through pharmacologic agents and bariatric interventions that are gaining more and more traction in our field. The third health behaviors may directly benefit NAFLD independent of weight loss. So this schematic briefly lays out all the risk factors as we understand it for novel pathogenesis. And as you can see there’s some risk factors that we can’t change like genetics and there’s several acquired risk factors among these unhealthy behaviors stand out as a risk factor that can be that is highly modifiable interventions that Target unhealthy behaviors and that can promote healthy behaviors that can improve novels either through weight loss or through improvements in insulin resistance. Unfortunately, however, most of our patients with NAFLD don’t succeed in making behavioral changes or losing weight. For example at our center, we tracked weight loss grades over a 15-month period among about 322 patients with NAFLD to receive standard of care meaning these were patients who were engaged in hepatology care. They were seeing their habitologists every three to six months on a regular basis.Nevertheless we found that only 16% of these patients actually achieve clinically significant weight loss and our experience is not unique. Most patients with NAFLD have minimal weight loss. In a scoping review of longitudinal studies that we conducted we found that worldwide patients who receive standard of care again, meaning these are patients who are engaged in hepatology care experience 2% weight loss to 1% weight gain over one year. So why is this so difficult? Why is it so challenging to achieve behavioral change and why aren’t we doing better? Well, behaviors are complex. Behavior changes complex and it’s influenced by social, biological and psychological determinants and really to be successful. We need to intervene on all three fronts but there’s a lot that we can do within the psychology realm. There are cognitive factors that we can target and we can change to achieve behavioral changes and weight loss. So to understand this it’s helpful to examine what lives in health behaviors. So one way of thinking about health behaviors is as something that’s driven by two parallel psychological processes: an impulsive system and a reflective system. An impulsive system refers to a set of unconscious behaviors. These are behaviors that are automatic. They are driven by habits by immediate feelings and they’re triggered by our environmental stimuli. Unconscious behaviors driven by the impulsive system really require no cognitive capacity because they are reactive. These are behaviors that tend to dominate under suboptimal conditions. For example, when we feel stressed out when we’re sad or tired, this is the system that tends to dominate the reflective system. In contrast, this represents a set of conscious behaviors. These are behaviors that are intentional; they’re rational behaviors. They’re driven by rational assessments of the benefits of a behavior versus the negative consequences of not engaging in the behavior conscious behaviors driven by the reflective.

STEM requires a high cognitive capacity. They require that a person has knowledge of their health condition, it requires that the person has an awareness or belief that the behavior under consideration is good for them, that they’re highly motivated and that they have a high level of self-efficacy. So let’s examine these two systems in action using what I’ll call a man in cake scenario.

So it could be that on the one hand upon seeing the desert triggers in this man and immediate feeling he feels hungry. He feels a sense of craving or perceived pleasure and you immediately respond to that feeling and he eats the desert. So that’s an impulsive or unconscious behavior. 

The dessert triggers an immediate feeling and a response or a behavior. Alternatively, it could be that this man sees the dessert and remembers that he has NAFLD and thinks losing weight is good for my disease and that sugars are unhealthy. He reasons to himself. I want to lose weight and he intentionally leaves the room leaving the dessert behind. So this is a rational decision. It’s a conscious behavior developed by the reflective system. So let’s examine the cognitive determinants that drove this behavior. It required that the man had a high level of knowledge about his disease and what could make it worse? He had a high level of awareness of the behavior on request and how it could impact his disease. He was highly motivated to lose weight and he had a high level of self-efficacy now. It’s important to keep in mind that these two processes run in parallel at all times. However, in general by default, most of our dietary behaviors are impulsive and they’re not reflective. So consider this statistic on average we adults make over hundred food decisions per day, but we really only know about 14 of them. So most of our food decisions, most of our eating decisions are unconscious. They’re driven by habit and they have to be otherwise you’d spend all day thinking about food and nothing else.

Second consider this at baseline most of our patients with NAFLD don’t have the cognitive tools to break their habits or impulsive behaviors. They don’t have the tools to succeed in reflective processing and achieve behavior change.This means that most of our patients seen in the clinic will continue with their baseline unhealthy behaviors, unless we intervene.

Three cognitively determined incipations 

So let’s dig into the second point and examine three cognitively determined incipations with no folds. So survey data have demonstrated that patients with novels have low levels of health knowledge and behavioral awareness and keep in mind that the survey data I’m about to review all outcomes from patients. Again, we’re engaged in specialty care with your hepatologists. Nevertheless, these survey data demonstrate that patients have low disease recognition meaning a large proportion of patients don’t even recognize their novel. There’s a real disease second.

There’s a high level a lack of understanding about how their behavior is caused NAFLD only about a third of patients recognized diet and a fifth the patients identify physical and activity as risk factors for the disease.Third patients have insufficient knowledge about what constitutes healthy physical activity and fourth patients have a high level of behavioral misperceptions. For example at my center we found that up to 40% of physically inactive and 35% of unhealthy eaters actually self perceive themselves as engaging in healthy behaviors.

So clearly knowledge and awareness are aspects of our cognitive determinants that we need to target and improve in our patients. But keep in mind that knowledge and awareness are necessary for behavioral change, but they’re not sufficient to promote behavioral change. So if efficacy on the other hand has been shown to be a strong determinant of behavior change.So self-advocacy refers to a person’s confidence to persist with healthy behaviors despite barriers and challenges that they face. So returning to our man in case scenario.

What high dietary self-advocacy means is that this person is highly motivated to lose weight. He strongly believes that avoiding sugar will help and he would avoid that cake. Even if it’s challenging or he faces barriers, for example, even when he’s hungry or tired or it means that he needs to cook something else to eat. So the data has worn out that self-efficacy is a strong determinant of behaviors studies have shown. These are studies conducted in patients who are overweight and obese.

Finding through research 

 These studies have demonstrated that interventions that increase patient self-efficacy led to greater weight loss. So how about our patients with NAFLD again, the survey data demonstrate that our patients with NAFLD have low levels of self-efficacy. They perceive multiple barriers to making behavioral change both to dietary changes and physical activity. They have low dietary self-efficacy. For example one survey demonstrated that 40% of patients.They couldn’t consistently eat smaller portions or avoid junk food and third there are very low levels of physical activity self-efficacy. In fact one survey demonstrated that the median exercise self-efficacy score among our patients with NAFLD was actually zero. So the bottom line is that there are several cognitive determinants that shape the likelihood that someone will engage in health behavior and we covered the levels of three of them in patients with novel knowledge awareness and self-efficacy, but there’s several others. The bottom line is that these are not optimal among our patients with NAFLD at baseline. However, behavioral obesity research has demonstrated that there are ways to intervene on these cognitive determinants that can promote healthy behaviors and a cascade of positive outcomes that could potentially improve natural outcomes. 

So these interventions involve cognitive techniques that target and improve cognitive determinants of behaviors. So on this slide, I’ve placed a small handful of these cognitive techniques that have been used and described to promote healthy behaviors on patients who are overweight and obese. Some of them may be more familiar to you like goal setting and self monitoring but I’ll highlight a couple that are less discussed, one is stimulus control, which is a method of helping patients break their impulsive behaviors by making them aware of the environmental triggers that drive their eating behaviors. The second is cognitive restructuring, another technique designed to break patients’ impulsive behaviors by making them aware of how their mood affects their behaviors.

Now each of these cognitive techniques can be used individually in patients. However, the strongest data or the strongest evidence showing that these cognitive techniques work really come from multi-component lifestyle interventions that have used several of these cognitive techniques together to promote behavioral change. There have been two landmark interventions both tested in populations who are overweight and obese who have that have demonstrated these positive outcomes. I’ll just highlight one which is the diabetes prevention program.

So the diabetes prevention program or the DPP was a lifestyle intervention funded by the National Institute of Health and the United States this lifestyle intervention used multiple cognitive strategies that were taught by lifestyle coaches and taught these strategies through 16 individual counseling sessions delivered over 24 weeks. The overall purpose of this lifestyle intervention was to use these cognitive strategies to get patients to achieve 15 minutes moderate intensity physical activity every week on a regular basis and to achieve 7% weight loss or more by the end of 24 weeks.So this intervention was tested in a large trial several years ago among about 3,000 adults who were overweight and pre-diabetic. Now the original trial was meant to see whether lifestyle intervention or metformin would prevent diabetes, but we learned a lot about the effects of lifestyle interventions on behavioral change through this trial which is why it’s worth reviewing it.

So these adults were randomized to standard of care to the diabetes prevention lifestyle intervention versus metformin and what they found was that at the end of four years the patients who received standard of care really had no significant change in their weights in contrast to people who participated in the lifestyle intervention. So they receive these cognitive techniques and strategies to change their behaviors at the end of six months. They achieve 6% weight loss from Baseline and although they regain some weight at the end of four years on average patients.maintain 4% weight loss from baseline the trial also demonstrated that lifestyle intervention improved physical activity patients who are engaged in the lifestyle intervention had more significant increase in physical activity that was maintained over the course of four years at in contrast to patients who receive standard of care. So the bottom line is that we have data that shows that lifestyle interventions that use cognitive strategies to target cognitive determinants can improve health behaviors and improve weight loss rates.

Several other studies beyond the diabetes prevention program have demonstrated the same now the data and NAFLD are far more limited. But the data that we do have also suggest that behavioral interventions can improve weight loss rates again in a scoping review that we conducted at my center. We identified 22 studies reporting weight loss outcomes of interventions that targeted cognitive determinants in patients with NAFLD. 11 of these interventions achieved clinically significant weight loss across participants. These interventions were quite varied in their designs, but they shared certain characteristics. They were characterized by weekly counseling sessions and the use of cognitive strategies like goal setting problem solving and self monitoring strategies. So overall these data suggest that cognitive strategies can improve weight loss rates in our patients with novel but there’s a great need for more research in the field assessing their impact. It’s also important to keep in mind that this is incredibly common among our patients with NAFLD and it’s important to be aware of how common these mental illnesses are screened for them and identify them because the presence of mental illness can hinder behavior change in two of the more common mental illnesses.

The patients with novels are depression and binge eating disorder each has a prevalence of approximately 20% among our patients with novels and each condition depression and binge eating disorder are associated with more adverse cognitive profiles for weight loss. For example patients with depression have lower self-efficacy and motivation then patients without depression patients with binge eating disorder tend to display higher impulsivity, especially in the setting of hunger stress or food stimuli and it’s also been shown that behavioral interventions that use these cognitive strategies that we just reviewed are less effective in people with mental illness. For example a small trial of diabetes.

Pension program among the community setting among 131 patients demonstrated that while about 42% of people without mental illness achieved clinically significant weight loss, far less successful among people with depression and binge eating disorder additional. So again, it’s important to be aware of the presence of these conditions in our patients with baffled as they may benefit from additional psychiatric treatments to manage their underlying mental illness and these additional psychiatric treatments, may improve weight loss and these include cognitive behavioral therapy psychotherapy and pharmacotherapy, but I’ll just point out that this is a gray area and requires a lot more research to understand how the specialized psychiatric treatments can fit in with lifestyle interventions to specifically target patients with novels and comorbid mental illness. So we’ve covered a lot of territory today and hopefully I have convinced you of the importance of behavioral psychology.

Findings and conclusions 

Field of NAFLD points are that there are several cognitive and psychological factors that influence behavioral change in weight loss success and the data show that most of our patients with NAFLD have adverse cognitive behavioral profiles. In addition, anywhere from 20 to 25 percent have coexisting mental illness. Thus without targeted intervention, behavior changes are unlikely and the data bear this out. They show that standard of care is ineffective as we’re not doing much for our patients who are engaged in routine hepatology care.However, by intervening on cognitive determinants, we can promote health behaviors and improve weight loss. This has been shown in the obesity research and cognitive strategies to do so exist. However, we need to translate these cognitive strategies and Implement obesity behavioral research to our patients with novels. So I thank you for your time that brings us to the end of this talk.

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Prof. Maya Balakrishnan

Prof. Maya Balakrishnan

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