Dr M Shafi Kuchay
Fatty liver disease is rapidly becoming more common in India, and some research suggests that as many as 20-30% of Indian adults have some degree of fatty liver disease, a condition that used to exist almost excessively in people who drink alcohol excessively. The epidemics of obesity and diabetes are to blame. Fatty liver affects between 50% and 70% of people with these conditions. As obesity and diabetes have become more common, so has fatty liver disease. In United States, fatty liver disease is the second most common cause of liver transplantation, first being hepatitis C-related liver disease. Although there is no formal data in India, fatty liver disease is thought to be a significant contributor to end-stage liver disease and liver transplantation.
What happens in liver cells
Fatty liver disease occurs when fat molecules accumulate inside liver cells. The presence of these fat-laden cells can then lead to inflammation in the liver and damage to surrounding liver tissue. Once that happens, the condition is called nonalcoholic steatohepatitis (NASH).It is estimated that 5% to 10% of people with fatty liver disease go on to develop NASH.
NASH is often a relatively stable, low-grade condition that people live with for years, with almost no symptoms. Only occasionally do people feel run-down, or they have an achy feeling in the upper right side of the abdomen, where the liver is located. So, more often, fatty liver disease is discovered incidentally. NASH can also start a cascade of serious damage to the liver and attempts by the organ to regenerate itself that culminate in an abundance of scar tissue and impaired liver function — a condition called cirrhosis. Cirrhosis is irreversible and can lead to total failure of the liver. It also is associated with an increased risk for developing liver cancer.
Some studies have shown as few as 3% of people with NASH developing cirrhosis, while others have shown as many as 26% doing so. There’s no test or risk factor that predicts who will develop cirrhosis and who won’t.
Relation between type 2 diabetes and fatty liver disease
Long-term over-nutrition and underactivity lead to accumulation of fat around abdominal organs. This type of obesity is called abdominal obesity which is more harmful to the body. Abdominal obesity in turn leads to insulin resistance, a basic pathogenic process that ultimately lead to type 2 diabetes, fatty liver disease, cholesterol problems, hypertension and other lifestyle problems. So, in other words, type 2 diabetes and fatty liver disease arise from the same process, i.e., insulin resistance. But when the two diseases exist in the same person, they worsen each other and worsen the overall health of the individual.
In addition to liver problems, people with fatty liver disease and NASH need to be more worried about heart disease and stroke. Their risk of dying from cardiovascular disease is twice as high as people that don’t have NASH. One reason may be related to the inflammatory factors pumped out by a fat-afflicted liver cells that promote damage to the insides of arteries and make blood more likely to clot, a combination that can lead to heart attack or stroke.
A simplified fatty liver process
1. Long-term over-nutrition and underactivity cause abdominal obesity
2. Abdominal obesity cause insulin resistance
3. Insulin resistance increases free fatty acid levels in the blood
4. Fat accumulates in liver cells
Up to 20-30% of Indians have fatty livers
Usually there are no symptoms
5. Fat in liver causes inflammation to liver tissue
The medical term is nonalcoholic steatohepatitis (NASH)
A liver biopsy is the only way to diagnose NASH
6. Further liver damage results in liver fibrosis and cirrhosis
Cirrhosis is a build-up of scar tissue in place of liver tissue
Between 3% and 26% of NASH patients develop cirrhosis
A few people with cirrhosis develop liver cancer
7. NASH is associated with an increased risk of heart attack and stroke
How to treat fatty liver disease
Life-style modification (diet and exercise) is the best strategy for many life-style diseases that stem from over-nutrition and underactivity. A healthy lifestyle canprevent and even resolve fatty liver disease. A healthy lifestyle consists of two components-physical activity and dietary pattern. Regular physical activity like brisk walk, jogging, cycling, etc., helps in maintaining normal weight. Exercise is beneficial to metabolic health independent of weight loss. That means if you are obese and you exercise regularly, even if you do not lose weight, you still are benefiting your body. Healthy dietary pattern means consuming a balanced diet. A diet that is high in fibre and low in refined carbohydrates and fats. Avoid fast and junk foods like sugary beverages, fruit juices, ice-creams, deep fried foods, chips and pizzas. Cut back on refined carbohydrates like white bread, white rice, white pasta and potatoes. Consume diet that is rich in fruits, vegetables, beans, whole grains, nuts and seeds. Reduce consumption of red meat and instead use chicken and fish.
Although life-style modification is very beneficial to fatty liver disease, but long-term studies have shown that diet and exercise are not sustained for prolonged period of time. It is a common experience in diabetes management that although diet and exercise are advised to all the patients but only a small proportion (<10%) of patients are actually able to adhere to the advice.
You will be surprised to know that there is not a single medicine that is approved for treating fatty liver disease. This is because no medicine has been proven sufficiently beneficial for this condition. Evidence is accumulating for two groups of anti-diabetes drugs that also improve fatty liver disease. One group is called GLP-1 receptor agonists. One member of this group, liraglutide, reduces not only liver fat but also improve inflammation of liver. At present this medicine is approved for type 2 diabetes and also helps in losing weight. It is an injectable medicine and is given as a daily shot. Second group of anti-diabetes drug that may reduce liver fat are called gliflozins. One member of that group, empagliflozin, has also been shown to reduce liver fat.
The two key messages from this article should be; first, most cases of fatty liver disease stay relatively stable and only a small number of patients develop serious liver diseases; second, the treatment is not an expensive drug but losing weight-and that will also improve your overall health.
The author is a Kashmiri Endocrinologist and Researcher, Division of Endocrinology and Diabetes, Medanta The Medicity, Gurugram.