Non-alcoholic fatty liver disease: Asymptomatic & Under-Diagnosed

Arka De & Ajay Duseja

Non-alcoholic fatty liver disease (NAFLD) is a condition in which excess fat accumulates in the liver of people who drink little or no alcohol. NAFLD leads to inflammation (NASH) and scarring (fibrosis) in the liver, which can progress to cirrhosis and end-stage liver disease if left untreated. It is one of the most common causes of chronic liver disease globally and in India. NAFLD is also associated with an increased risk of heart attack, stroke and cancers, particularly liver. More than one-third of adults and children in India have NAFLD. It is particularly common in the North. A study in PGIMER, Chandigarh, found NAFLD in 50 per cent of otherwise healthy adult blood donors. The cases are expected to increase exponentially as obesity and diabetes numbers rise.

Although genetics and gut microbiota are some of the factors behind NAFLD, it is primarily a lifestyle disease driven by insulin resistance and metabolic dysfunction. The main risk factors are a sedentary lifestyle and unhealthy dietary habits, with an increased intake of calorie-rich foods. NAFLD is closely linked with other metabolic lifestyle diseases like obesity, diabetes mellitus, hypertension and dyslipidemia (lipid imbalance). People who are obese or diabetics are at more risk of NAFLD and vice versa, these metabolic co-morbidities are more common in NAFLD patients. Also, patients with these metabolic co-morbidities are at a higher risk of having severe forms of NAFLD, including NASH, fibrosis, cirrhosis and even liver cancer.

The barriers against this burgeoning public health problem are many, including low awareness. NAFLD is largely asymptomatic in the early stages and is usually detected only on investigations or when patients become symptomatic with complications of cirrhosis and end-stage liver disease. The Indian National Association for Study of the Liver has recommended that those who are obese or diabetic should be screened for NAFLD using abdominal ultrasonography.

Even the number of NAFLD specialists (hepatologists or gastroenterologists) is also quite less, given the humungous burden of NAFLD. Many NAFLD patients at low risk of developing significant liver disease can be managed at the primary care level. This risk stratification to identify low or high-risk patients can be accomplished through blood investigation parameters and elastography. The recent incorporation of NAFLD in the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) will also help in increasing awareness about the disease, promoting a healthy lifestyle and streamlining its overall management.

As NAFLD is primarily a lifestyle disease, prevention and treatment demand lifestyle changes. These include diet modification and increased physical activity and need to be sustained over a long term as NAFLD is a chronic disease. A weight loss of 7 to 10 per cent of the total body weight in overweight/obese individuals and 3 to 5 percent in patients with normal weight is beneficial. However, this weight loss should be gradual over a period of three to six months. as a rapid weight loss can be detrimental.

Calorie restriction by one-third or 500-1000 kcal/day is more important than any specific diet. Though some studies have found the Mediterranean diet to be beneficial, a healthy diet sourced from local foods that is sustainable is equally beneficial. A healthy diet will protect not only against NAFLD but also diabetes, hypertension, obesity, cardiovascular disease and stroke. Junk and fried foods rich in trans fats, free sugars and sugary beverages, cold drinks, etc, should be avoided. Alcohol should also be completely avoided. Coffee may be beneficial but only black and unsweetened. Intermittent fasting may also be promising. A recent study conducted at PGIMER, Chandigarh, found that intermittent fasting was better than standard calorie restriction in improving the metabolic profile, hepatic inflammation and fibrosis though both were found to be equally effective in weight reduction and improving hepatic steatosis in NAFLD.

The exercise regimen should consist of moderate intensity aerobic exercises like brisk walking, jogging, running, swimming, cycling, etc, for at least 30 to 45 minutes per day, at least 5 days a week (150- 200 minutes per week). Even without weight loss, exercise has added benefits on insulin resistance and the overall metabolic milieu. Resistance exercises and yoga can supplement aerobic exercises. Yoga has also been shown to have several health benefits, including prevention and control of obesity and diabetes, decrease in waist circumference, reduction of blood pressure, improvement in lipid profile and insulin resistance. Yoga may also enhance the psychological well-being of NAFLD patients, who often suffer from depression, anxiety, low self-esteem, and poor quality of life.

Tips for preventing and managing NAFLD

• Maintain healthy weight and BMI by following a diet low in saturated fats, sugar and refined foods, and high in fibre, fruits, vegetables and lean protein. Daily calorie intake should be restricted by 30 per cent/500-1000 kcal by cutting down on carbohydrates and fats . Total fat shouldn’t exceed 30 per cent of total calories, saturated fat should be < 10 per cent and trans fats < 1 per cent of total intake, with a shift to unsaturated fats .
• Intake of three or more cups of unsweetened, black coffee may help in reducing liver fat and scarring.
• Physical activity of at least 150 minutes of moderate-intensity, or 75 minutes of vigorous exercise per week, or a mix of both can improve insulin sensitivity, lower blood pressure and reduce inflammation.
• Avoid alcohol as it damages liver, increases fat accumulation in the liver, and worsens liver function synergistically with NAFLD.
• Managing other diseases linked to NAFLD, such as diabetes, high blood pressure and high cholesterol, can prevent or reduce liver damage and complications.
• Avoid self-prescribed medications, including complementary and alternative medicines and supplements that can potentially harm the liver. Consult with your doctor before taking any medication or supplement.
• Regular screening for liver functioning and NAFLD, particularly if you are diabetic, overweight/obese. Early detection and treatment can check progression to serious stages and reduce risk of liver failure and cancer.

— Dr De is Assistant Professor, Hepatology, PGIMER, Chandigarh. Dr Duseja is HoD, Hepatology, PGIMER, Chandigarh