| Objective:Childhood non-alcoholic fatty liver disease(NAFLD)is the most common chronic liver disease in children.It includes a range of liver injuries ranging from simple steatodegeneration to steatohepatitis(NASH),cirrhosis,and even hepatocellular carcinoma,and is a multisystem disease affecting extrahepatic organs with long-term health effects extending into adulthood.It is closely related to atherosclerosis,cardiovascular disease(CVD)morbidity and total mortality,which brings a heavy economic burden to the society.Free sugars include monosaccharides and disaccharides added to foods and beverages by manufacturers,chefs or consumers,as well as sugars found naturally in honey,syrups,fruit juices and fruit juice concentrates.However,free sugars do not include sugars naturally found in fresh whole fruits,lactose found in milk,or potato and potato starch.For children,the main food sources of free sugar intake are sweetened beverages and snacks(added sugars in fruit juices","soft drinks","dairy products" and "sweets and desserts").As non-essential nutrients,free sugars have no beneficial effects on children’s growth and development.In this study,based on the mechanism of free sugars in liver metabolism,a diet intervention program with low free sugars in children’s non-alcoholic fatty liver was developed to form a health management prescription.Randomized controlled clinical trials were conducted to evaluate the effectiveness of intervention programs and health management prescriptions in the disease outcome and dietary behavior improvement of children.For the validated intervention programs and health management prescriptions,how to implement them in primary medical and health institutions was discussed,so as to build the community health management path for children with NAFLD.Methods:First,meta-analysis was performed to evaluate the effect of limiting free sugar intake on improving non-alcoholic fatty liver disease.Dietary intervention measures for children with NAFLD at home and abroad were collected by literature method and summarized into a pool of dietary intervention measures.Semi-structured interviews were used to collect clinical medical experts’ experience in the treatment of children with NAFLD,as well as evaluation results of the effectiveness and compliance of various interventions.By summarizing the results of the above three parts,the "dietary intervention program for children with low free sugars in non-alcoholic fatty liver disease" was developed.The contents of the program included intervention objects,intervention sites,overall intervention design,intervention objectives,intervention implementation plan and specific intervention measures,and the formulation of health management prescription for further effectiveness evaluation.Secondly,a randomized controlled trial was conducted to select 146 overweight and obese children diagnosed with NAFLD and randomly divide them into the intervention group and the control group,with 73 persons in each group.The control group received conventional treatment,and the intervention group took the children and their families as intervention objects based on the conventional treatment and according to the developed intervention plan and health management prescription.The intervention time was 6 months,and the two groups were followed up until 12 months after the initial diagnosis.The dietary status,exercise status and related laboratory examination of the children were evaluated and measured at each follow-up.Collected as a result,the generalized estimating equations,t test,x2 test,statistical analysis methods such as contrast intervention group and control group in children with dietary intake before and after the intervention,free sugars intake,physical activity,hepatic fatty infiltration situation,glucolipid metabolic index,evaluation of the effectiveness of the intervention plan.Finally,the community health management path was constructed for the validated intervention programs and health management prescriptions.The RAND-UCLA expert panel discussion method was adopted to conduct expert letter evaluation and expert panel discussion on the management path successively,so as to form a program management path for children’s fatty liver health with hierarchical risk assessment,three-level target management and intervention feedback modification.Results:1.Based on evidence-based medicine,9 randomized controlled studies on dietary intervention with low free sugars in the treatment of NAFLD were included in the meta-analysis,which suggested that dietary intervention with low free sugars could reduce the degree of hepatic steatosis in patients with NAFLD compared with dietary intervention with non-low free sugars.The difference was statistically significant(MD:4.78,95%CI:-10.18～0.63,p=0.019,12=65.9%).Meta-analysis showed that dietary intervention with low free sugars could reduce liver fat infiltration.2.A systematic review of the literature was conducted to extract intervention methods for children with NAFLD.30 studies involving 1774 children aged 3-18 years were included to extract information about intervention items,including simple dietary intervention(7 items),lifestyle intervention(6 items)and dietary supplement(17 items).Among the studies involving dietary intervention,there were 2 studies involving low-carbohydrate diet and low-fat diet,and 3 studies involving free sugar intake;Seven studies intervened from the fatty acid composition of dietary nutrients.3.The formative results showed that dietary management should be started from three aspects:increasing the cognition of disease and dietary choice of children and their families,strengthening follow-up,increasing food choice and operability of intervention self-evaluation;Specific dietary interventions include controlling the total amount of food and changing the diet structure.Most of the experts gave the experience and suggestions on the total follow-up time,each follow-up interval and examination content of children with NAFLD.Most experts believe that free sugars can aggravate obesity,NAFLD and insulin metabolism disorders,so it is necessary to reduce the intake of foods high in free sugars as much as possible,control intake gradually and in a planned way,and avoid overeating.Multidisciplinary joint clinic education has advantages in the realization of comprehensive health management,but the problems of patient compliance and the current medical environment should be considered.Health education prescription is a further supplement to multidisciplinary joint diagnosis and treatment,and is a strong feasible intervention means.The chronic disease management of children with NAFLD will be gradually carried out in primary health institutions,which is the development trend of chronic disease community management in the future.4.For the "Dietary Intervention Program for Children with NAFLD with Low free sugars" developed based on the formation research in this study,overweight and obese children with NAFLD were selected as the intervention objects for the assessment of dietary intake,which was divided into extremely high,extremely high and high energy intake states.The intervention goal was to improve the children’s dietary calories,dietary balance and reducing the intake of free sugars.Intervention measures of energy intake and free sugar intake were taken according to different energy intake states.5.Baseline data of intervention studies showed that,before the intervention,there were no significant differences in BMI,waist height ratio,ALT,AST,GGT,total bile acid,total bilirubin,uric acid,triglyceride,HDL-C,VLDL-C,fasting blood glucose,fasting insulin,severity of fatty liver,dietary balance index,daily energy intake,free sugar intake and physical activity level.After intervention,the dietary behavior of the children in the intervention group was significantly improved,the intake of free sugars decreased from 45.86±29.75 g/day before intervention to 17.06± 17.86 g/day,and the proportion of severe fatty liver in the intervention group before and after intervention decreased by 16.4%.BMI,waist height ratio,systolic blood pressure,liver function,blood glucose,blood lipid,insulin level and dietary balance index were significantly improved,with statistical significance.Compared with the control group,the difference of BMI,waist height ratio,uric acid,blood glucose,VLDL-C and insulin level before and after intervention was more obvious in the intervention group.6.The basic framework of community health management prescription and health management path for children with non-alcoholic fatty liver disease includes setting evaluation criteria for management path,constructing standardized procedure management system,establishing intervention follow-up feedback mechanism and establishing scientific quality evaluation system.The specific process includes screening the target population for children’s NAFLD health management,conducting hierarchical assessment of NAFLD,setting management objectives,formulating corresponding follow-up management programs,and carrying out intervention follow-up from five dimensions,including medical indicator monitoring,health guidance,lifestyle intervention,drug/dietary additive intervention,and monitoring of acute events and complications.And timely and orderly intervention effect feedback and correction,forming a closed-loop health management mechanism.Conclusions:1.Long-term lifestyle guidance is needed for children with NAFLD,and multidisciplinary health education prescription can improve the effectiveness and compliance of the treatment.2.The "Dietary Intervention Program for Children with NAFLD with Low free sugars" developed in this study can effectively reduce the intake of dietary free sugars in children and improve the degree of liver fat infiltration and the status of glucose and lipid metabolism in children during the intervention period,which can be used as a reference for the clinical intervention treatment of children with NAFLD.3.Six months after dietary intervention with low free sugars in children with NAFLD,hepatic steatosis and glycolipid metabolism were significantly improved,and the dietary behavior with low free sugars was still well adhered to six months after the intervention prescription was stopped.4.Dietary intervention based on family support is more feasible,and hierarchical and phased dietary intervention based on initial dietary status can enhance children’s compliance and adherence.5.A community health management path for children with NAFLD has been established,a closed-loop management model of general practice and health management has been established,and programmed intervention management has been provided,so as to ensure that children with NAFLD and high-risk groups can get the best care,improve the prognosis of the disease and reduce the occurrence of related complications. |
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