It seems likely that both the inflammatory nature of adipose tissue and the amount

of abdominal fat accumulation are critical factors in tissue damage. This is what we have previously observed for cardiac dysfunction and morpho-functional abnormalities.3, 4 Thus, both these targets should be addressed in the treatment. Indeed, NASH develops, and potentially progresses to cirrhosis, on a chronic inflammatory background.5, 6 However, liver disease seems to be associated with systemic degenerative disease and metabolic derangements independently of VAT accumulation.7 Adipose tissue is a dynamic organ resulting from the balance of new fat deposition and reabsorption. Several factors are involved in this turnover, such as diet, physical activity, but also inflammation, which is considered per Saracatinib supplier se a major determinant of insulin resistance.8, 9 The portal/fatty acid flux theory suggests that visceral fat, via its unique location and enhanced lipolytic activity, releases toxic free fatty acids, which are delivered in high concentrations

directly to the liver. This leads to the accumulation and storage of hepatic fat and the development of hepatic insulin resistance.9 Nonetheless, a study by van der Poorten et al. has recently shown that visceral fat remained an Nutlin-3a in vitro independent predictor of liver inflammation and fibrosis even when measures of insulin resistance, adipokines, and increasing age are considered.10 A 4-week aerobic program can result in a significant reduction of VAT, thus positively affecting the levels of circulating free fatty acids and hepatic lipid accumulation, but appears to be too short a time frame to reduce insulin resistance. Monoiodotyrosine Unfortunately, the disruption of inflammatory biomarkers has been not addressed by Johnson et al.1 This is what Promrat et al. were able to demonstrate,2 providing evidence

that patients undergoing consistent abdominal adipose tissue loss have improved lobular inflammation and also reduced insulin resistance. Altogether, these results support that both the disruption of inflammation and the reduction of VAT should be targets of therapeutic strategies to reduce local tissue damage. This has been supported for cardiac dysfunction11, 12 and there is some rationale also for treatment of both NAFLD and NASH. However, it must be recognized that it is frequently difficult to keep the patient focused on maintaining changes in lifestyle habits. Alexis Elias Malavazos M.D.*, Giulia Gobbo M.D.†, Roberta Francesca Zelaschi M.D.*, Emanuele Cereda M.D., Ph.D.

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