Fatty Liver Disease in India The Path Ahead

The liver is a vital organ that performs greater than a hundred vital functions including cleansing, manufacturing, detoxification and digestion. It also possesses an amazing ability to regenerate and can grow back to normal size. Fatty liver disease is caused by a mismatch between the energy from food we consume and the intensity of workout which burns off the food calories. This mismatch leads to the building up of extra fat in the liver.

The abnormal accumulation of fat within the liver in the absence of secondary causes of liver disease causes fatty liver disease. It’s a serious health concern as it encompasses a spectrum of liver abnormalities, from a simple non-alcoholic fatty liver (NAFLD, simple fatty liver disease) to more advanced ones like non-alcoholic steatohepatitis (NASH), cirrhosis and even liver cancer.

It is believed that one-third of the world’s population suffers from some form of fatty liver disease. Over the last 20 years, the global burden of NASH has almost doubled. On a country wide basis, fatty liver disease is increasing and has now percolated into all socio-economic strata. Sedentary lifestyle and over eating clubbed with diabetes, hypertension and high cholesterol levels commonly known as metabolic syndrome usually leads to fatty liver (Lifestyle Liver Disease). Genetic predisposition e.g. PNPLA3 has also been linked to fatty liver disease. Fatty Liver Disease is classified into two types – Non-Alcoholic Fatty Liver Disease (NAFLD) and Alcoholic Fatty Liver Disease (AFLD). Fat can accumulate in the liver and upto 5% fat in the liver is considered normal. Individuals who are non-alcoholic but indulge in lifestyles which promote fat in the liver develop NAFLD while those who consume alcohol regularly deposit more fat in the liver which is termed AFLD.

Implications of Fatty Liver Disease

It all begins with a simple fatty liver remaining silent for one or two decades. If there is just fat without liver cell damage, the disease is called non-alcoholic fatty liver disease (NAFLD) and  if accompanied with signs of inflammation and liver cell damage, the disease is called nonalcoholic steatohepatitis (NASH). This ultimately can lead to the formation of scar tissue (fibrosis) and cirrhosis at advanced stage. Even without underlying fibrosis, this could also lead to liver cancer. It’s important to note that majority of the patients may remain asymptomatic throughout this progression. So it’s of paramount importance to diagnose this before it reaches a critical level as there is no going back from the stage of cirrhosis.  Once this advanced stage is reached, treatment modalities are limited and the condition continues to deteriorate despite control of metabolic factors and liver transplantation remains the only life-saving option. Early recognition of the issue at the asymptomatic stage can halt progression or can potentially reverse it. The biggest challenge is to screen and diagnose asymptomatic patients early, before it becomes too late.

Why does NAFLD need specific attention?

NAFLD, though a non-communicable disease, is an independent predictor of future risk of cardiovascular disease, Type 2 diabetes and other metabolic syndromes like hypertension, abdominal obesity, dyslipidaemia and glucose intolerance. “Epidemiological studies suggest the prevalence of NAFLD is around 9 to 32 per cent of the overall population in India with higher prevalence in those with overweight or obesity and people with diabetes or prediabetes.” There is high prevalence of insulin resistance and nearly half of Indian patients with NAFLD have evidence of full-blown metabolic syndrome. Researchers have found NAFLD in 40% to 80% of people who have type 2 diabetes and in 30% to 90% of people who are obese. Studies also suggest that people with NAFLD have a greater chance of developing cardiovascular disease.

Cardiovascular disease is the most common cause of death in NAFLD. Once the disease develops, there is no specific cure available, and health promotion and prevention aspects targeting weight reduction, healthy lifestyle, and control of aforementioned risk factors are the mainstays to disease progression and to prevent the mortality and morbidity due to NAFLD.

How serious is India’s situation compared to other countries?

India’s future which looks promising.can be put at jeopardy. The increasing affluence and associated societal changes have come along with its own health challenges. Unhealthy food habits, sedentary lifestyle, alcohol consumption and lifestyle changes have ushered in obesity, diabetes, hypertension, high cholesterol, liver disease, which are all on the rise.

A study done in Kerala, India reported a prevalence of 49% and a staggering 60% prevalence among obese school going children. NAFLD is emerging as one of the major causes of liver disease in India.” . There is currently no approved drug for the treatment of NASH anywhere in the world except in India where Saroglitazar Mg has been recently approved for the treatment of both NAFLD and NASH. Liver transplant is the only option for managing advanced cirrhosis with liver failure. Rising cases of obesity due to sedentary lifestyle is an equally alarming issue. About 3-15 per cent of obese patients with NASH progress to cirrhosis and about 4-27 per cent of NASH with cirrhosis patients transform to HCC (Hepatocellular Carcinoma). An alarming rise in metabolic diseases, in the developing and developed world, is expected to result in NAFLD/NASH-HCC posing a serious health threat in future.

Lean NAFLD

Being lean does not guarantee good health. Sometimes lean patients can have defective energy metabolism due to genetic reasons which contribute to metabolic disorders like diabetes, high cholesterol levels and fatty liver disease as a consequence. Common myth amongst lean people that they are healthy and protected from fatty liver, is incorrect. The fact is that they can also have fatty liver and related complications.

Solution and way forward

Following a healthy lifestyle at the early asymptomatic stage can change the course of the illness. Simple steps such as watching your diet and sufficient exercise prevent fat accumulation within the liver and subsequent liver inflammation and scarring.  The age old adage, “Prevention is better than cure” applies here since treatment of advanced disease particularly liver transplantation costs a pretty penny. To completely avoid fatty liver disease matching one’s food intake with the level of physical exercise is the key. Hence public awareness of these facts should ideally start at schools or at a young age.  Diet and exercise should be the focus. A healthy balanced diet. with moderation of carbohydrates, proteins and healthy fats should be promoted together with regular exercise which cannot be stressed enough especially for the times we live in.

Ingrain a healthy lifestyle. You are your best health supervisor.

Choose life, love your liver.

(The writer is Consultant in the Department of Gastroenterology at Sir H. N. Reliance Foundation Hospital and Research Centre. Mumbai)