Fatty Liver the challnge of next decade; Let’s know it and prevent it.
Liver is the largest organ in the body performing around hundreds of essential tasks every day. Care for it is an essential job of everyone of us, but often ignored. The liver disases is one of the common cause for chronic disease globally. The common liver problems are alcohol related, viral hepatitis, fatty liver disease, liver cirrhosis and liver cancer. In India there is a shift in liver problems from hepatitis to life style related disease i.e. fatty liver. This fatty liver often ignored and progressed to cirrhosis, liver cancer and is going to be the most common cause for liver health issue in near future. Understanding the facts, caring for the preventive aspects and early diagnosis is the need for happy and healthy future. Through this article we tried to give an insight and help the reader for spreading the knowledge as we know “prevention is better than cure”. Every year 19th April was celebrated as World Liver Day to create awarness on the liver related illness among public. In view of the burden. Increasing trend and prevention as the main corner stone for this most common problem, the article was taken to commemorate this day.
What is Fatty Liver ?
The simple meaning is presence of fat in the liver. It is normal to have a certain amount of fat in our liver because of liver being a fat processing unit of body. However with increasing fat content in the liver (normally its less than 5% of liver weight), the problems start and the disease progress with increasing fat content in the liver and over long duration of ignoring it or unable to diagnose. This fatty liver problem often defined in medical term as Non Alcoholic Fatty Liver Disease (NAFLD) or Metabolic Associated Fatty Liver Disease (MAFLD).
Why we need to be worried of this Fatty Liver problem ?
Chronic liver disease is one of the major morbidity and its prevalence increasing day by day. With increasing obesity, diabetes, child hood obesity and other lifestyle related disease, the burden of fatty liver is increasing. At present more than 135 million Indians are affected by obesity, to add this problem around 20% of rural Indian adults will be either overweight or obese by 2030 and more than 27 million children will be obese by that year. The India is considered to be the diabetic capital of India with nearly 67 millions cases. Considering these two entity only the future burden is too much depressing.The estimated burden of fatty liver (8-32% of indian at present) will rise and may be upto 176 million polulation and the number is going to increase further over coming days and was described as “Silent Tsunami” by few authors. A fatty liver dvelop liver injury in 40-60%, leading to cirrhosis in 15-20% and liver cancer development at 2-3% per year. The disease course is slow and often taken lightly by individual and ignored by the many stake holders. Because of the gravity of situation, recently Govt of India included fatty liver into national health programmme on non communicable diseases.
What are the symptoms I can have?
Most of the initial stages are asymptomatic. Few cases present to us with mild pain or discomfort or heavyness in the right upper quadrant of abdomen, near the rightside lower rib cage. The associated problem of gastritis, vomiting, nausea, hyperacidity and reflux problem may encountered. With progression of disease to cirrhosis can present with weight loss and abdominal distension, even spontaneous nose/ gum bleed. Additionally, itching, fluid build-up and swelling of the legs (edema) can be seen.
Do I have the risk for developing a Fatty Liver?
It may not be there, but checking the high risk profile will guide you, when to call. So find few of the most common risk factors- 1) Diabetes (more often if its poorly controlled), 2)Over weight or Obesity including truncal obesity i.e. protubeant belly , 3)Prrsence of high blood pressure and cholesterol, 4)Alcohol intake, 5)Certain infections like Hepatitis C or hepatitis B 6)Thyroid problem, 7) Medications like steroid and 8) Family history of obesity, diabetes, heart disease, liver disease and kidney disease.
How should I get tested for fatty liver ?
The common thing is to check the high risk category as mentioned above, if you have any then its better to get tested. Very often fatty liver is diagnosed, when you are being evaluated for any other healty related issues. Ultrasonography is the most commonly used, cost effective, easily available & accurate investigation. Now at few places an easily available point of care device in varoius names i.e. Fibroscan, FibroTouch etc by which a rough idea on fatty content , liver stiffness can be known in few minutes. Apart from this, certain routine blood tests could tell about the blood sugar, cholesterol, uric acid and elevated liver enzymes (AST/ALT/GGT) often noted. Other tests like CT Abdomen, MRI abdomen or liver biopsy may be needed, but is only upon evaluation by an expert, to establish the diagnosis or rule out other causes.
Is uric acid and fatty liver related?
Serum Uric acid is an independent predictive marker for fatty liver. It also predicts as well as precedes the development of diabetes and Insulin resistance. Most often people hurried for medications for it, which is often not needed. Its often controlled by diet and weight reduction. Only your treating physician or if symptoms (joint pain in great toe or others) necesitates taking medication.
Diabetes and Fatty liver – A dangerous combination
Liver disease accounts for 4% mortality among diabetics and is a major associated comorbidity. The presence of fatty liver increases the incidence of diabetes and accelerates the development of complications among diabetes . fatty liver seen in 50-80% diabetics at any point of time and is nearly 100% among diabetics with obesity. Association of NAFLD with diabetes is broad, often with liver injury (NASH) in more than 50%, advanced fibrosis in 30-40% and cirrhosis upto 19% and with a 10 fold increased risk of primary liver cancer i.e. HCC. These conditions often attributes to the liver related mortality among diabetes. In the population-based Verona Diabetes Study cirrhosis was the fourth leading cause of death and accounted for 4.4% of diabetes- related deaths. Cirrhosis accounted for 12.5% of deaths in patients with diabetes
Obesity and Fatty liver – Another dangerous combination
Presence of fatty liver increases in parallel with obesity. With moderate obesity the prevalence is upto 60% and is nearly in all for people with morbid obesity. Among those diagnosed to have fatty liver about 51% were obese and with liver injury (NASH) obesity seen in 80% more of them. The risk of fatty liver increased by 4.1 to 14-fold with higher BMI. Similarly in absence weight reduction measures, long standing obesity led to increased liver injury, development of fibosis, cirrhosis and liver cancer over time. To know your ideal weight various online calculator and mobile apps are available based upon body mass index (BMI) or by waist circuimference. But the simplest thumb rule to calculate your desired weight like this
- Weight in kg for male = height in cm -100 (e.g. if your height 5’ and 6” i.e. 165 cm, then weight desired is 165-100=65 kg)
- Weight in kg for female = height in cm -105 (e.g. if your height 5’ and 6” i.e. 165 cm, then weight desired is 165-105= 60 kg)
Can Fatty liver happen in absence of obesity i.e. Lean NAFLD ?
Fatty liver is a problem often seen among obese. However 15% of NAFLD are lean, their BMI often normal or low <22 kg/m2 . hence a term lean NAFLD was used. This is more seen in Asia, perticulary India and more common in Estern India. The risk factors in lean patients include high body fat, body weight gain even within normal weight limits, high fructose and high cholesterol intake, and genetic risk factors. The disease progression happen like others, but detail is not known. Lifestyle modification, including diet and physical activity remains the mainstay in the management of patients with non-obese NAFLD.
So, does the fatty liver (NAFLD) have any genetic predisposition & run in the family?
Yes. Obesity, diabetes, hypertension, deranged lipids run in the family. If anyone of the family members have or had NAFLD-related cirrhosis, then chances of cirrhosis due to fatty liver in family members increases by 12 times. If anyone in the family member has this, you cannot avoid the genetic risk, but can negate the additional things i.e. lifestyle. A proper diet, adequate exercise and preventing weightgain or mantaining the ideal weight will reduce the chance significantly.
Is it risk to for my kids too?
Yes, as it has genetic predisposition & runs in the family. Proper exercise and diet can reduce the chances tremendously.
Can children suffer from fatty liver too?
Yes. It is the most common liver abnormality in children between 2-19 years of age. About one-third of overweight children & adolescents are having fatty liver disease. More prone are younger, heavier children with faulty dietary habit (junk food etc) and reduced physical activity.
Childhood obesity is a tickling bomb- are we ready for the challenge?
The number of children and adolescents aged 5–19 with obesity had increased to 50 million girls and 75 million boys. Previously its is USA, but now China had the most obese boys and girls, followed by the USA and India. The number is going to increase in near future and with expandig poulation like in India, the threat is going to be alarming. Currently 5-8.8% of school children are obese in India and if the pace continue like this, 27 million Indian children will be obese by 2030. The digitalization, physical anctivity, faulty dietary habit and poor parental knwoledge is the main key and is increasing over time. Aware of this global emergency posed by excess weight in children in near future, World Health Organization (WHO) endorsed “no increase in childhood overweight by 2025” as one of the six global nutrition targets. It iself justifies parents and policy makers to think and act now, befor its late to intervene.
Childhood obesity and Consequences
Overweight or obesity during childhood has important short-term and long-term consequences. In the short term, children who are overweight or obese are more likely to suffer from psychological issues like depression, anxiety, low self-esteem and behavioural disorders, health issues like asthma, liver complications, joint problems, high blood pressure, cholesterol and diabetes. In the long term, being the weight remain for long time since childhood to adult increases the risk of developing cardiovascular diseases, diabetes, some can- cers, and musculoskeletal disorders in adulthood, which can lead to disability  and premature death [22–24]. In addition, the treatment of obesity in adulthood is difficult , with evidence suggesting that around three-quarters of children who are overweight or obese carry this status into adulthood . Strong persistence of overweight status and low efficacy of available treat- ments highlight the need to prevent overweight and obesity at the earliest possible stage of life.
So, how is my pregnancy a risk for fatty liver ?
It is a rare but serious complication of pregnancy, if left untreated, it poses serious health risks to the mother and growing baby. It usually appears in the third trimester of pregnancy.
If diagnosed, doctor will want to deliver your baby as soon as possible. Your liver health will likely return to normal within a few weeks of giving birth.
Fatty liver can predict the future diseases like diabetes, heart disease or cancer ?
Yes. Study has shown that many devlop fatty liver to start with in subsequent time cholesetrol, diabetes, heart problems –particularly coronary artery disease and certain cancers develop. Its not due to fatty liver, being a spectrum of disease, these entities very often develop in near future. So one you had fatty liver, then need to do regular check up, follow up with physician to avoid or diagnose early for better results.
Can I prevent fatty liver?
Yes, you can prevent fatty liver with proper control on diet, stop alcohol drinking and a regular exercise.
What advise do you suggest for protecting a fatty liver?
Follow the basic rules:
- Maintain body weight
- Do regular exercise
- Never Skip a meal
- Eat small frequent meals.
- 8-12 glass water intake/day
Will losing weight help me get rid of this disease?
Yes. Hepatologists primarily advise for losing weight. It’s been studied that loss of around 5% body weight can reduce the fat on liver and 7-10% gradual weight reduction can reverse. Browse through Mediterranean, Ketogenic, Paleo & Okinawa diet regimes, considered the healthiest diets of the world based on the foundation idea of Low carb, low fat, whole food diet. But its low fat low carbohydrate diet, enough water, avoidance of junk food and importantly regular exercise to burn calory is the key. A dietician or nutritionist guidance and follow up is better way to take care of fatty liver from dietary prospective.
It is called Non-alcoholic fatty liver Disease. So, is alcohol allowed ?
No. It is strictly prohibited. Diabetes and alcohol combo add oil to the fire. Alcohol (chemically, ethanol) undergoes metabolism and forms toxic products which will have a super-added damage to the liver. Hence, alcohol is advised to be avoided strictly. Various dosage has been desribed for safe limit, but its very well known when things start, hadly any one can control it. So better to avoid alcohol in any form.
Can NAFLD be reversed? How long can this process take?
In many cases, it’s possible to reverse fatty liver through lifestyle changes. These changes may help prevent liver damage and scarring. If the condition is not controlled , it can cause inflammation, damage to your liver, and potentially irreversible scarring if it’s not treated called Cirrhosis. That’s why it’s so important to prevent it from developing in the first place.
Is a successful treatment possible for a fatty liver?
Lifestyle changes are the first-line treatment for fatty liver disease. Depending on your current condition and lifestyle habits, it might help to:
- Lose weight
- Stop/ Reduce your alcohol intake
- Have a nutrient-rich diet that’s low in excess calories, saturated fat, and trans fats
- Get at least 30 minutes of exercise most days of the week
What are the drugs that can help in treating fatty liver ?
The medicine treatment is fatty liver disease, depends upon stage. Most often people have only fatty liver without deranged LFT or stiffness i.e. NAFL(Steatosis) and doctor advise is manily on diet, exercise and weight redcution. In next phase i.e. deranged LFT (NASH) with liver inflammation and the advanced stage i.e. fibrosis or cirrhosis limited drugs available at present. All these drugs helpful in adjunct to primary treatment i.e. diet life style and weight reduction as well as tretament of primary condition like cholesterol and diabetes and etc.
What should be my daily activities include?
Brisk walking, water exercise(swimming) and cycling are appropriate forms of exercise. Talk to your doctor about when you can safely add regular strength training, which helps build muscle to assist in weight loss.
- Start with just 20 to 30 minutes every day of low-intensity movement will help.
- Break this up into 10-minute intervals, if needed.
- Eventually, do up to 90 minutes daily and 5-6 days a week is needed to lose weight
What is the way forword
Fatty liver is problem at present in one of three indians, child hood obesity, lifestyle will complicate the situation. Awraness and understanding is the key. Keep three things in mind i.e. your Weight (what we have),Diet (what we take) and Exercise (what we do) for happy healthy long life.
(the writer is Associate Professor, Dept. of Hepatology and Liver transplant. Institute of Liver and Biliary Sciences. New Delhi)
(the writer is From Dept of Neurology, IMS Sum Hospital. Bhubaneswar)