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In a timely debut during the American Thanksgiving holiday, Surfing the NASH Tsunami hosts its first episode dedicated to nutrition and NASH with distinguished guest, Prof. Shira Zelber-Sagi. Surfing alongside in this rich discussion are Ken Cusi, Jörn Schattenberg, Louise Campbell and Roger Green. 

After sharing how she came to the intersection of nutrition and NASH, Shira leaps into the topic of weight reduction as a first line defense for the field of NAFLD. While identifying ≥7% weight reduction as a “golden number” for patient resolution, it’s noted that long-term adherence to lifestyle modification poses a significant challenge. Choosing the right diet in a diverse population of patients also poses a significant challenge. Jörn suggests hepatologists are not particularly effective at assessing diets or prescribing specific solutions. As such, he adheres to simple protocols like intermittent fasting. Ken comments that endocrinologists are better equipped to provide education on nutrition to patients. He notes that in the US, excess caloric intake can be treated with the prescription of weight-loss medications, like a GLP-1, or more NASH-specific agents, like pioglitazone. Louise adds that successful solutions begin with small, achievable goals.

Shira goes on to describe her own approach, termed weight-inclusive, which focuses on holistic coaching measures that extend to all facets of a healthy lifestyle. By including exercise with all other reachable means of positive feedback, patients are relieved from becoming too fixated on weight-loss. This approach also integrates setting and driving realistic goals, and dietician visits as a life-long therapy. Shira relates visits to the dietician to be as simple as returning for a haircut every month or two. She also suggests any healthy diet that works for the patient is permissible. Jörn comments on the value of biofeedback and highlights the ability to drive better health through digital tools. Shira is excited by the potential, but cautions negative feedback can be detrimental to progress.

Roger states that the reality of failure is unavoidable: everyone eventually makes poor dietary choices. The group agrees the key is to not let a fleeting shortcoming deter progress. From here they consider the psychology of decision making around diet in similar terms to that of addiction treatment. Louise notes that while the field of NAFLD deals with areas requiring immense psychological support, those resources are lacking for patients. Ken adds that working interprofessionally with dieticians is not well supported by insurance companies in the US. He states that in his dealings with insurance companies, obesity management has generally been regarded as an expense, not an investment. 

Roger revisits the theme of finding value in apps and digital interventions. Shira believes that while they can be a helpful tool for many, they cannot replace human interaction. Ken elaborates that while an app can catalyze momentum, motivation often wanes after several months. Those trying moments are exactly when he envisions human intervention to be critical. Recalling Shira’s statement that “diet is everyday,” Jörn emphasizes that behavior and diet can play a key role in improving patient self-care and overall health. Roger highlights that a combination of medications and self-management can be a powerful, reinforced and effective treatment solution.

Shira provides a step-by-step vision of how to work with patients in improving bad habits. She notes clinicians and leaders need to appreciate the importance of policy in supporting clinical goals. For the final question, Roger asks the panelists for a piece of advice for providers seeking to push behavioral change in their patients. This is a fun, applicable and endlessly important topic to be