NSSRT for NAFLD - No Snacks, Adequate Sleep & Regular Training | Plus: 3+1 Step Program to Helps Friends & Family Making Progress Towards a Healthier Lifestyle

Sleep is a constantly underestimated factor in getting and staying lean. Don't be fooled by statistics.

As a SuppVersity reader you know about the role of compromised liver health in the etiology of the diabesity epidemic: When the liver is clogged up with fat, your blood glucose and lipid levels will go overboard. Against that background it is all the more important to know that it's not overtly difficult to prevent that from happening.

If we put some faith into the results of a recent study from the Department of Gastroenterology and Metabology at the Ehime University Graduate School of Medicine in Japan (Miyake. 2014), you just have to follow three simple rules: Don't snack, get 7+ hours of sleep and by God, don't sit around all day!

You can learn more about snacking & co at the SuppVersity

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Protein Snack Shifts Macro Ratio for the Better

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Alternate Fasting: Eating only a snack

Snacking Increases Obesity Risk

High or Low Protein? Casein or Whey?

I know that this is not revolutionary new. If you look around, though, most people still believe in the all or nothing approach that's doomed to failure for 99% of the people.

Instead of eating only chicken, broccoli and rice or, even worse and totally en vogue these days, eggs, bacon and ... well, eggs and bacon, of course, a first and, according to the results Teruki Meyake and colleagues present in the latest issue of the Journal of Gastroenterology very promising first step would be to stop snacking (learn more about snacking).

Figure 1: Association between the habit of snacking and prevalence of NAFLD by sex; the asterisks indicate statistical significance with * p < 0.05, ** p = 0.002 (Miyake. 2014)

In fact, a brief glance at the prevalence of NAFLD in men and women in Figure 1 should suffice to tell you: Snacking and not giving your liver and the rest of your organs a "clean up the mess and ramp up the fatty acid oxidation" timeout from time to time is about the worst thing you can do for your liver.

Ladies, you better have a big steak for lunch and skip the cupcake in the afternoon!

What's interesting, though is that the statistical significance* of the difference between no-snackers and snackers is particularly pronounced in women and that in spite of an overall lower prevalence of NAFLD + snacking in the fairer sex (see Figure 1, right).

*What is statistical significance? Usually we simply speak of "p", the probability that a certain observation, in the study at hand, the difference in NAFLD rates between snacker and non-snackers, is just coincidence. In that, at value of p = 0.05 or in words, a probability of 5% that the observation is mere coincidence is considered "statistically significant" - everything else is "non-significant" and usually discarded as mere chance.

Apropos sex-differences, if you look at the effects of bad sleep habits you will realize that the visible differences between the number of NAFLD cases among the short (and insufficient) and the long (and sufficient) sleepers is significant only for the women among the 11,094 Japanese subjects.

Figure 2: Association between the habit of sleep duration (in h) and prevalence of NAFLD by sex; the asterisks indicate statistical significance with * p < 0.05, ** p = 0.002 (Miyake. 2014)

For the men, on the other hand, there is only a non-significant trend towards reduced NAFLD rates with longer sleep. Moreover, unlike for women, for men sleeping more than 8h does not offer an advantage.

The participants of a 10,000 steps a day challenge / study by scientists from Arizona State University lost 3 cm off his / her waist - in spite of a hilariously low overall adherence (Walker. 2014)

Now the latter is actually something I would have expected for the female subjects as well, because most of the studies that investigate optimal sleeping pattern estimate the "optimal sleep duration" to be ~7-8h and not in the 9h+ zone. Things may differ, though, for people living above the Arctic Circle. People such as the 6413 persons aged between 30–65 years who participated in the Tromsø Study and for whom the optimal sleep duration for obesity protection appears to be 8–9 hours, i.e. one hour longer than for folks who live in parts of the world with longer days and shorter nights (Johnsen. 2013). In the end, sleeping enough and not snacking alone is not enough to escape the pro-obesogenic steatosis of your liver, anyway. 

Both will work only, if the one and only independent predictor of non-alcoholic liver disease is in place: Exercise... well, or at least regular physical activity that goes beyond walking from the sofa to your snack cabinet to grab another candy bar.

In their latest study, Myiake et al. report an almost linear relation between the rate of physical activity on the one hand, and the prevalence of non-alcoholic fatty liver disease, on the other hand.
This relationship holds in men and pre-menopausal women. Among the post-menopausal women, on the other hand, periodical exercise alone (probably misreported, anyways ;-) was not associated with a reduced NAFLD prevalence compared to women who did not exercise at all.

Don't give up on exercise, Ladies! Needless to say that the lack of an association of regular physical activity with reduced NAFLD risk is a result that stands in stark contrast with dozens of controlled experimental trials. If anyone benefits from exercise, specifically resistance training, it's women in their best (post-menopausal) years. So, ladies, don't even think about decreasing your physical activity and trying to achieve optimal health by starving yourselves or surgery!

It's also worth mentioning that I underlined the word "independent" in a previous paragraph for a purpose.It is after all easy to find a statistical significant association between two parameters (in this case short sleep duration ⇆ NAFLD and snacking ⇆ NAFLD).

Figure 3: Unadjusted and adjusted* increase in NAFLD risk for snacking, no exercise, and short sleep duration; *adjusted for see paragraph below (Miyake. 2014)

It is yet rare and a much better indicator of a causal relationship to find a statistically relationship between two parameters like physical activity ⇆ NAFLD (see Figure 3), that remains statistically significant after being controlled for age, BMI, high blood pressure, triglycerides, HDL-c, fasting blood sugar, uric acid, ALT (liver health), creatinine (kidney health), snacking and sleep duration. The latter, i.e. an independent association between a given lifestyle parameter and the prevalence of NAFLD was observed only for physical activity.

This is how you start a family member out: If you know someone (men or women, this works for both) you want to help overcome his unhealthy lifestyle, this is how you do it:

(1) No snacking: Have him eat three square meals. No snacks or caloric beverages (coffee or tea with milk and sweeteners are allowed) in between.

(2) 7-8h of sleep: Make sure that he gets 7-8h of sleep regularly. That means that the occasional day with less sleep is allowed. What's important and often overlooked, though, is that the rhythm must remain intact. It's thus better to get only 5h of sleep once and maintain your regular wake up routine and time, e.g. 7am, than sleeping 7-8h everyday, but from 10pm to 6pm on day one, from 2am to 10am on day to and so on.

(3) Walking + body weight workouts: Buy a pedometer and tell him about the 3 cm reduction in waist circumference the participants of the ASUKI study lost over 6 months. Start him out on a 5,000 step minimum in the first month tell him to increase the volume by 1,000 steps every other week until he is walking 10,000 steps a day. Make it clear that additional 3x body-weight workouts (details on the left), will ensure that there are visible changes in the mirror (not necessarily on the scale!) after only one month.

(*) No processed foods + 30g protein per meal: While it is obligatory to remind him constantly that it is necessary to minimize the amount of processed food in his diet don't overwhelm him by having him stop "cold turkey". Start with one "zero processed food" meal every other day and 10g protein per meal and have him  build from there - the goal, obviously is to eat 100% unprocessed meals with 30g+ of protein per meal 90% of the time.

In case you are asking yourselves, why I am highlighting a study like this, I would like to invite you to think about your friends and family members. How many of them have found their way to physical culture, already? How many of them are eating clean like yourself? And how many of them are fed up of failing time and again with a radical all-or-nothing approach to a "healthy lifestyle"?

Remember, even the small things matter. If you want to help a friend or family member to make a change, start them out on the  NSSRT-10,000 approach: No snacks, enough sleep and regular exercise; with the latter being as little as a 5,000-10,000 steps a day + thee full body workouts per week which consist of 3-5 body-weight circuit of squats, push ups, and burpees with a build in progression of +1 "rep" of squats + push ups + burpees per week and an additional set (max. 5) every two months.

If you also manage to have him cut out all processed foods from his / her diet progressively, while increasing his / her protein intake to 30g per meal, you and your friend / family member will be surprised about the changes the will see in the mirror after only 6 months.

And if there is one thing you must always remember, it's to never ask too much at once. There is nothing that reduces adherence to diet and exercise programs as much as feeling overwhelmed. The changes have to be feasible and they must look feasible. 

Take a baby-step approach, commend every step on the way and encourage your friend or family member to get back on the wagon, whenever he or she falls off or feels as if he or she had fallen off the wagon, and you will succeed. The change won't happen overnight, but in contrast to the notorious all-or-nothing approach, it will happen.

Reference:

• Johnsen, May Trude, Rolf Wynn, and Trond Bratlid. "Optimal Sleep Duration in the Subarctic with Respect to Obesity Risk Is 8–9 Hours." PloS one 8.2 (2013): e56756.
• Miyake, Teruki, et al. "Significance of exercise in nonalcoholic fatty liver disease in men: a community-based large cross-sectional study." Journal of Gastroenterology (2014): 1-8.
• Walker, Jenelle R., et al. "US Cohort Differences in Body Composition Outcomes of a 6-Month Pedometer-Based Physical Activity Intervention: The ASUKI Step Study." Asian Journal of Sports Medicine (2014).