When IT director Alvin Pang's doctor told him in August 2017 he was obese and had non-alcoholic fatty liver disease (NAFLD) after a check-up, he was puzzled. He had not heard of the term before.
The doctor referred him to a dietitian, who advised him to maintain a well-balanced diet, exercise regularly and lose weight.
There is currently no medicine to treat the disease except by lifestyle interventions, said Dr Lim Su Lin, chief dietitian at the National University Hospital (NUH) department of dietetics.
Mr Pang, 36, whose body mass index was 32, was worried that he would not be disciplined enough to achieve his weight loss target.
With the help of the Nutritionist Buddy (nBuddy) mobile app, Mr Pang, who weighed 88kg, lost 13kg within six months. The app tracks one's diet and physical activity and induces behavioural changes to achieve optimal weight.
Said Mr Pang: "It helped me make informed decisions as to which food is recommended when I have to decide between the lesser of two evils when options are limited."
After his weight loss, he showed no signs of having a fatty liver when he did a check-up in February 2018.
NAFLD is a chronic liver disease where excess fat is deposited in the liver of people who drink little or no alcohol. It can range from "good fat" or simple fat to "bad fat" or non-alcoholic steatohepatitis (Nash), a more serious liver disease. A simple fatty liver condition is reversible in most cases.
However, if it is not managed properly, it can lead to Nash, where the fatty liver becomes inflamed. Nash may progress to permanent scarring and hardening of the liver, a condition called liver cirrhosis. People with liver cirrhosis have a higher risk of liver cancer.
There are usually no early-stage symptoms for NAFLD but some people may experience tiredness, bloatedness, loss of appetite and pain in the right upper abdomen.
If NAFLD progresses to cirrhosis, symptoms such as yellow discoloration in the skin and eyes and swelling of the legs may appear in the advanced stage.
Those with metabolic risk factors including obesity, type 2 diabetes mellitus, hypertension and hyperlipidaemia have an increased risk of developing NAFLD.
"The overall prevalence of NAFLD in Asia is 30 per cent and can be as high as 40 to 50 per cent in some parts of the region, and up to 40 per cent of people in Singapore are estimated to have the disease," said Dr Loo Wai Mun, consultant and gastroenterologist from the division of gastroenterology and hepatology at NUH and Alexandra Hospital.
Dr Lim said previous studies have shown that weight loss of 5 per cent can help to reverse NAFLD. While it is recommended for patients who are at high risk or have been diagnosed with NAFLD, this can be difficult to achieve.
"The success of weight loss interventions is dependent on the intensity of nutrition counselling and frequency of visits to dietitians and exercise therapists. This renders the treatment modality resourceintensive and costly."
To solve this, Dr Lim conceptualised the nBuddy app.
The app was tested on 108 patients with NAFLD between July 2017 and November 2019, in a study by a team of dietitians and doctors from NUH, including Dr Lim and Dr Loo.
During the trial, it was found that patients who used the app and received dietary and lifestyle advice by a dietitian had a five-fold higher likelihood of achieving at least 5 per cent weight loss compared with those who received standard care, consisting of dietary and lifestyle advice by a trained nurse.
They also saw a significant reduction in liver enzymes, waist circumference and blood pressure.
The study was published in the journal, JMIR mHealth and uHealth, in April.
App users can set their own calorie goals and receive daily, weekly and monthly reports on weight, calorie intake and steps taken.
Dietitians can monitor the users' progress to give feedback and encouragement.
One of the highlights of the app is an automated response system that uses artificial intelligence to evaluate the suitability of food choices that users note in a diary system. It provides instant feedback, generating a list of healthier alternatives.
Mr Pang, who is about 75kg now, is still using the app to reduce his weight to 63kg.
Another participant, Mr Yap Chen Hwa, who was 78kg at the start of the trial, lost 16kg within six months when he used the app. He also showed no signs of having a fatty liver after the trial.
The 48-year-old senior operations manager said: "The live chat function with the dietitian helped as I could ask questions about food choices."
Being focused and motivated to cut down on an unhealthy diet can be a challenge, said Dr Rahul Kumar, consultant at Changi General Hospital's department of gastroenterology and hepatology.
"That's where physicians and dietitians play an important role. They can motivate patients and help them stay focused on their dietary goals," he said.
The app is not limited to NUH patients and dietitians. Dietitians from other healthcare providers can use it to coach patients. They can do so by contacting the developer Verita Analytics directly.
Verita Analytics, which manages the app, offers its own nutritionists to coach people who are not enrolled in the app by any healthcare provider.
nBuddy is not only for NAFLD patients. Anyone who wants to lose weight or maintain a healthy weight can also use it.
Dr Loo said that emerging preliminary data has shown that patients with Covid-19 who have chronic liver disease, including cirrhosis and advanced liver disease, are more susceptible to poor outcomes and death. "
The impact of NAFLD on Covid-19 is not clearly defined. But patients with NAFLD may have metabolic chronic or long-term underlying conditions such as obesity and diabetes predisposing them to an increased risk of a severe course of Covid-19 infection," she added.
However, she said there is not enough evidence to say that patients with stable chronic liver disease like hepatitis B or C have an increased risk of liver damage from Covid-19 infection.
The Centres for Disease Control and Prevention (CDC) in the United States reported that some patients hospitalised for Covid-19 have had increased levels of certain liver enzymes that indicate their livers are at least temporarily damaged.
Liver damage is also more common in patients who have severe Covid-19. However, the CDC is uncertain if the increase in liver enzyme levels is related directly to the virus that causes Covid-19 being in the liver or if the liver damage results from other factors.
A version of this article appeared in the print edition of The Straits Times on June 22, 2020, with the headline App to tackle fatty liver. Subscribe