Time Restricted Eating for Non-Alcoholic Fatty Liver Disease & Obesity Enzo M. Di Battista PhD, MNutr, RD. Clinical Research Dietitian: Aneurin Bevan University Health Board Post-Doc Research Fellow (RCBC Wales): University of South Wales

Overview Describe NAFLD and the relationship with obesity Define Time Restricted Eating (TREating) Review the potential benefits of TREating on NAFLD & obesity Consider what research design can identify such potential benefits

Overview Describe NAFLD and the relationship with obesity Define Time Restricted Eating (TREating) Review the potential benefits of TREating on NAFLD & obesity Consider what research design can identify such potential benefits

Overview Describe NAFLD and the relationship with obesity Define Time Restricted Eating (TREating) Review the potential benefits of TREating on NAFLD & obesity Consider what research design can identify such potential benefits

Overview Describe NAFLD and the relationship with obesity Define Time Restricted Eating (TREating) Review the potential benefits of TREating on NAFLD & obesity Consider what research design can identify such potential benefits

Non-Alcoholic Fatty Liver Disease “NAFLD is defined as hepatic fat infiltration >5% of hepatocytes on liver biopsy with no evidence of viral, autoimmune, alcohol or drug-induced liver disease”

Non-Alcoholic Fatty Liver Disease Prevalence

NAFLD in general population Overweight and Obesity in general population NAFLD in severe obese population (i.e. BMI ≥40kg m/2)

NAFLD in general population Overweight and Obesity in general population NAFLD in severe obese population (i.e. BMI ≥40kg m/2)

NAFLD in general population Overweight and Obesity in general population NAFLD in severe obese population (i.e. BMI ≥40kg m/2)

NAFLD in general population Overweight and Obesity in general population NAFLD in severe obese population (i.e. BMI ≥40kg m/2)

Obesity increases risk of NAFLD by 3.5 fold (Li et al, 2016)

Main treatment for NAFLD is weight loss (if overweight / obesity present)

Dietary approaches to obesity & NAFLD Daily caloric restriction (400-600 calories) Meal Replacements Very low calorie diets (approx. 800 calories / day) Macronutrient specific (e.g. Mediterranean diet, high protein, low carb, high fat, low fat/high fibre) Fasting approaches (e.g. 5:2, alternate day, time restricted)

Dietary approaches to obesity & NAFLD Daily caloric restriction (400-600 calories) Meal Replacements Very low calorie diets (approx. 800 calories / day) Macronutrient specific (e.g. Mediterranean diet, high protein, low carb, high fat, low fat/high fibre) Fasting approaches (e.g. 5:2, alternate day, time restricted)

Dietary approaches to obesity & NAFLD Daily caloric restriction (400-600 calories) Meal Replacements Very low calorie diets (approx. 800 calories / day) Macronutrient specific (e.g. Mediterranean diet, high protein, low carb, high fat, low fat/high fibre) Fasting approaches (e.g. 5:2, alternate day, time restricted)

Dietary approaches to obesity & NAFLD Daily caloric restriction (400-600 calories) Meal Replacements Very low calorie diets (approx. 800 calories / day) Macronutrient specific (e.g. Mediterranean diet, high protein, low carb, high fat, low fat/high fibre) Fasting approaches (e.g. 5:2, alternate day, time restricted)

Dietary approaches to obesity & NAFLD Daily caloric restriction (400-600 calories) Meal Replacements Very low calorie diets (approx. 800 calories / day) Macronutrient specific (e.g. Mediterranean diet, high protein, low carb, high fat, low fat/high fibre) Fasting approaches (e.g. 5:2, alternate day, time restricted)

Dietary approaches to obesity & NAFLD Daily caloric restriction (400-600 calories) Meal Replacements Very low calorie diets (approx. 800 calories / day) Macronutrient specific (e.g. Mediterranean diet, high protein, low carb, high fat, low fat/high fibre) Fasting approaches (e.g. 5:2, alternate day, time restricted)

Time Restricted Eating: TREating defined “Consuming meals and calorific drinks within a 10 hour timeframe each day, extending night time fasting to 14 hours”

Time Restricted Eating: TREating defined “Consuming meals and calorific drinks within a 10 hour timeframe each day, extending night time fasting to 14 hours” First meal: 12pm Second meal: 4pm Final meal: 9pm

Time Restricted Eating: TREating defined “Consuming meals and calorific drinks within a 10 hour timeframe each day, extending night time fasting to 14 hours” First meal: 8am Second meal: 12pm Final meal: 5pm

Time Restricted Eating: Why TREating?

With general caloric restriction, approximately one-fourth to one-third of the weight loss is known to be of lean tissue.

TREating can turn the ‘metabolic switch’

Shift from utilization of glucose from glycogenolysis to fatty acids and fatty acid-derived ketones. The metabolic switch typically occurs when glycogen stores in hepatocytes are depleted and accelerated adipose tissue lipolysis produces increased fatty acids and glycerol The metabolic switch:12 and 36 hours after cessation of food consumption, depending on the liver glycogen content at the beginning of the fast, and on the amount of the individual’s energy expenditure/exercise during the fast.

Shift from utilization of glucose from glycogenolysis to fatty acids and fatty acid-derived ketones. The metabolic switch typically occurs when glycogen stores in hepatocytes are depleted and accelerated adipose tissue lipolysis produces increased fatty acids and glycerol The metabolic switch:12 and 36 hours after cessation of food consumption, depending on the liver glycogen content at the beginning of the fast, and on the amount of the individual’s energy expenditure/exercise during the fast.

Shift from utilization of glucose from glycogenolysis to fatty acids and fatty acid-derived ketones. The metabolic switch typically occurs when glycogen stores in hepatocytes are depleted and accelerated adipose tissue lipolysis produces increased fatty acids and glycerol The metabolic switch:12 and 36 hours after cessation of food consumption, depending on the liver glycogen content at the beginning of the fast, and on the amount of the individual’s energy expenditure/exercise during the fast.

TREating benefits?

The TREating Liver Feasibility Study

In Summary… NAFLD is prevalent in society and has 90% prevalence in severe obesity cases TREating is a novel concept with limited research that might have particular potential in weight management and improved insulin sensitivity / lean muscle mass retention to control or reverse NAFLD Acceptability of TREating needs to be studied in populations with obesity and NAFLD

Questions…