Potential strategies to improve uptake of exercise interventions in non-alcoholic fatty liver disease

Background & Aims

The management of non-alcoholic liver disease (NAFLD) concerns lifestyle modification and exercise; however, adherence is poor. Factors such as lack of confidence to exercise, poor understanding of the benefits of exercise, and a fear of falling all influence engagement in physical activity. To increase exercise in NAFLD it is important to understand the barriers to performing it.

Methods

Three chronic liver disease cohorts were identified from the Newcastle Liver Database: NAFLD (n = 230), alcoholic liver disease (ALD, n = 110) and primary biliary cirrhosis (PBC, n = 97). Assessment tools were completed by all subjects: Outcome Expectation for Exercise Scale (OEES, understanding the benefits of exercise, lower scores indicate greater understanding), Self-Efficacy for Exercise Scale (SEES, confidence to exercise), Falls Efficacy Scale-International (FES-I, higher scores indicate greater fear of falling). Activity was analysed from a functional perspective using the PROMIS-HAQ.

Results

Understanding the benefits of exercise was similar across each group [median OEES scores: NAFLD 2.38 (range 0.0–5.0), ALD 2.25 (0.0–5.0), PBC 2.28 (1.0–5.0), p = 0.6]. In NAFLD confidence to exercise was significantly lower [median SEES score 0.0 (0.0–10.0), PBC 4.5 (0.0–10.0), p < 0.001]. Fear of falling was similar in NAFLD and PBC, and greatest in ALD [22 (0–64), 22 (3–64), 30 (0–64), p = 0.044]. In NAFLD, fear of falling was independently associated with increasing difficulty performing activity.

Conclusions

NAFLD patients understand the benefits of exercise but lack confidence to perform it. Fear of falling was independently associated with more difficulty performing activity. Fear of falling and confidence are modifiable and potential targets to improve uptake and adherence for exercise intervention.

Introduction

The incidence of non-alcoholic fatty liver disease (NAFLD) is increasing dramatically across the Western World, becoming the commonest cause for incidental abnormal liver function tests, affecting up to 30% of the population [1], [2], [3], [4]. At present, treatment options are limited and pharmacological management of NAFLD has had disappointing results [5]. Some of the best available evidence to improve NAFLD (normalisation of serum liver transaminases, reversal of hepatic steatosis or inflammation) concerns lifestyle modification [6]. NAFLD subjects have suboptimal cardio respiratory fitness, muscle strength and physical activity participation and are encouraged to exercise in order to improve their disease [7]. In general, implementation of dietary advice and/or exercise as a treatment are poor as evidenced by clinical experience and high drop out rates from trials [8], [9], [10]. The available evidence concerning reasons for dropping out of exercise-based treatments is rather scanty. Encouraging self-efficacy has been implicated as one of the most important strategies to engage NAFLD subjects in lifestyle modification [11].

Self-efficacy expectations are an individual’s judgement of confidence to carry out specific behaviours [12]. Confidence determines whether an individual chooses to perform exercise, the effort they invest and the length of time they will continue to exercise [13]. Expectations are beliefs that beneficial results will be produced by performing exercise [14], [15]. In addition to confidence and expectation, a fear of falling also strongly influences engagement in physical activity, with greater levels of fear strongly correlating with the levels of exercise performed [16]. As physical activity is encouraged in patients with NAFLD we thought it crucial to address confidence, expectations of exercise and fear of falling in this population, to understand further how to improve implementation and concordance.