Nonalcoholic fatty liver disease prevalence in Western countries is high and there is a trend towards a further increase, with millions of people at risk of advanced liver disease. The epidemiological evidence, the lifestyle origin of the disease and the cost of pharmacotherapy make prevention a primary goal, and will contribute to making behavior therapy the background treatment. We need specific programs and carefully controlled, randomized studies to tackle simultaneously all the components of the metabolic syndrome.

Excessive weight gain, hypertension, hyperlipidemia, and diabetes are frequently observed in patients having undergone liver transplantation (LTx). These alterations are probably multifactorial in origin, and cluster to generate a metabolic syndrome (MS), increasing the risk of cardiovascular events. We assessed the prevalence of MS (National Cholesterol Education Program-Adult Treatment Panel III criteria) in 296 LTx patients in the course of regular follow-up, at least 6 months after transplantation (median, 38 months). Several pre-LTx and post-LTx data were collected to identify the factors associated with the presence of MS. In a subset of 99 patients, insulin resistance was measured by the homeostasis model assessment. High blood pressure was present in 53% of cases, hyperlipidemia in 51%, high glucose in 37%, and enlarged waist circumference in 32%. Overall, MS (defined as 3 or more of the above features) was present in 44.5% of cases. Insulin resistance (homeostasis model assessment Ͼ 2.7) was observed in 41% of cases. Hypertension and hyperlipidemia were more frequent in subjects on cyclosporine than in tacrolimus-treated cases, whereas the type of immunosuppressive drug had no effect on the prevalence of diabetes, enlarged waist, and MS. In a logistic regression analysis, only pre-LTx body mass index (odds ratio, 1.20), body mass index increase (odds ratio, 1.18), and pre-LTx diabetes (odds ratio, 2.36) predicted MS; age, gender, etiology of liver disease, time from LTx, type of immunosuppressive drug, and previous hepatocellular carcinoma were removed from the model. Disorders related to MS are frequent in LTx patients, and are related to both pre-LTx conditions and to weight gain. Weight control is mandatory in LTx patients to prevent risk factors of premature atherosclerosis. Liver Transpl 14: [1648][1649][1650][1651][1652][1653][1654] 2008 The survival and quality of life of patients after liver transplantation (LTx) has markedly improved during the last decades, but the survival curve has now flattened.1 The return to normal daily life and home and working activities, together with normalization of the hypermetabolic state of advanced liver failure 2 and free food intake, are accompanied by a progressive weight gain.3 In turn, this heralds the development of hypertension, changes in blood lipid profile with hyperlipidemia, and altered glucose regulation. 4,5 The origin of these alterations, apparently related to insulin resistance (IR) and characterizing the metabolic syndrome (MS), is under debate.In a very few cases, the occurrence of posttransplantation diabetes mellitus (PTDM) or full-blown posttransplantation metabolic syndrome (PTMS) might be the effect of recurrent liver disease, caused by etiologic factors also involved in the original liver cell failure, 6 via nonalcoholic steatohepatitis (NASH) and cryptogenic cirrhosis, 7 and encouraged by unhealthy lifestyles. In the vast majority of cases PTDM and PTMS might be lifestyle-related and induced by post-LTx immunosup-

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