Obesity is a dominant risk factor for developing NAFLD and subjects with severe obesity have a very high prevalence of NAFLD. Severely obese people with NAFLD are more likely to have advanced histologic forms of NAFLD than those with less severe forms of obesity. In general, serum ALT levels do not correlate with hepatic histology in the severely obese with NAFLD. Older age, higher BMI, and the presence of diabetes mellitus predict advanced hepatic histology in severely obese patients with NAFLD. Weight loss induced by gastric weight loss surgery or very low calorie diets leads to significant improvement in hepatic steatosis but in some patients it may lead to worsening hepatic inflammation or fibrosis. In the severely obese who are subjected to a very low calorie diet, the target weight loss should be less than 1.6 kg/week.
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