Fatty liver disease is a growing issue in India with factors such as insulin resistance, metabolic syndrome and genetics playing an important role in its development. This disease progresses from simple fatty deposits in the liver to serious conditions such as liver disease and liver cancer if left untreated.
In India, lifestyle factors such as poor diet and lifestyle, along with genetic variation, are major contributors to the prevalence of the disease. NAFLD (Nonalcoholic Fatty Liver Disease) affects about 20% of non-obese people in India, unlike its common association with obesity in Westerners. We talked to Dr. Nishant Nagpal, Director of Gastroenterology at Fortis Hospital (Noida) to analyze this issue.
What are the main causes of Nonalcoholic Fatty Liver Disease (NAFLD), and how is it different from Nonalcoholic Steatohepatitis (NASH)?
Dr. Nishant Nagpal: The main causes of NAFLD include insulin resistance, which leads to increased glucose and lipid accumulation in liver cells. Other contributing factors are metabolic syndrome and conditions such as obesity, hypertension, dyslipidemia, and genetics such as certain gene mutations (eg, PNPLA3) that affect liver fat metabolism. Environmental factors such as a sedentary lifestyle, unhealthy diet and exposure to toxins also play a role. NAFLD ranges from mild steatosis (accumulation of fat in liver cells) to aggressive NASH, characterized by inflammation and damage to liver cells.
How does FLD progress from mild steatosis to more severe conditions such as cirrhosis or hepatocellular carcinoma?
Dr. Thickness: FLD progresses in stages. It starts with mild steatosis, where excess fat accumulates in the liver cells. This can progress to Nonalcoholic Steatohepatitis (NASH), which involves inflammation and damage to the liver. Over time, this condition can lead to fibrosis (bursting) when collagen is deposited in the liver. If left untreated, it can progress to cirrhosis, characterized by advanced scarring and poor liver function and in some cases, hepatocellular carcinoma, which is liver cancer.
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What lifestyle and genetic factors contribute most to the development of FLD in Indian patients?
Dr. Thickness: In Indian patients, a sedentary lifestyle contributes significantly to insulin resistance and obesity, which are major risk factors for FLD. Junk foods that are high in sugar, salt and fat make the problem worse. Central obesity common in the Indian population increases the risk of insulin resistance and certain genetic mutations such as PNPLA3 and TM6SF2, further predispose individuals to the disease.
What are the common symptoms of fatty liver disease, and at what stage do they usually appear?
Dr. Thickness: Common symptoms of fatty liver disease include fatigue associated with liver dysfunction and bloating and abdominal pain usually felt as pain or tenderness in the upper abdomen. Patients may lose weight in advanced stages due to decreased appetite and malabsorption as well as jaundice, which causes yellowing of the skin and eyes.
What diagnostic tools or tests do you recommend for assessing the severity of NAFLD or NASH in patients?
Dr. Thickness: Several diagnostic tools are used to measure the severity of NAFLD or NASH. Liver function tests (LFTs) help check liver enzyme levels. Ultrasound can detect liver fat and fibrosis, while FibroScan is used to measure liver stiffness, an indicator of fibrosis. MRI is helpful in evaluating liver fat and inflammation. For an accurate diagnosis and condition, a liver test may be required.
Can you clarify the relationship between fatty liver disease and metabolic conditions such as diabetes, high blood pressure and obesity?
Dr. Thickness: The link between fatty liver disease and metabolic conditions lies in shared risk factors such as insulin resistance, obesity and physical inactivity. These conditions often involve common pathophysiological mechanisms, including inflammation, oxidative stress and metabolic dysfunction that increase the risk of FLD and its progression.
Why do some patients develop FLD even without obesity, especially in India where 20% of non-obese people are affected?
Dr. Thickness: People who are not obese can develop FLD due to genetics, such as familial NAFLD. In some cases, these people may have sarcopenic obesity, where there is low muscle mass despite high body fat. Also, metabolic dysfunction, including insulin resistance and dyslipidemia, can occur independently of obesity and contribute to the development of FLD.
What are the current treatment options for managing NAFLD and NASH, given the lack of targeted drugs?
Dr. Thickness: Current treatment options focus on lifestyle changes such as improving diet, increasing physical activity and achieving weight loss. Managing comorbidities such as diabetes, hypertension and dyslipidemia is also important. Emerging therapies, including GLP-1 agonists and FXR agonists, are being studied for their potential to treat NAFLD and NASH.
What lifestyle or dietary changes have proven most effective in reversing or controlling fatty liver disease?
Dr. Thickness: Eating a Mediterranean diet, which emphasizes whole grains, fruits, vegetables and healthy fats, has been shown to be effective in controlling FLD. Increased physical activity, including aerobic exercise and strength training, also plays an important role. Losing 5-10% of your body weight can significantly improve liver health.
How can tolerance and lifestyle changes be improved in the case of fatty liver disease?
Dr. Thickness: Patient compliance can be improved through education, where patients are made to understand the consequences of NAFLD. Individual counseling and lifestyle counseling based on individual needs can be even more helpful. Regular follow-up to assess progress and adjust treatment strategies is also important for maintaining long-term compliance.
What are the specific challenges in India in diagnosing and managing fatty liver disease, given the different phenotypes in the Indian population?
Dr. Thickness: One of the major challenges in India is the diversity of phenotypes, leading to diverse contributions and risk factors. There is also little awareness of the disease among patients, health care providers, and the general public. Lack of health care infrastructure in some areas also reduces access to diagnostic and treatment facilities.
How can the InFLiMeN project help improve the understanding and management of metabolic liver diseases in India?
Dr. Thickness: The Indo-French Liver and Metabolic Disease Network (InFLiMeN) aims to address important issues related to the common liver metabolic disorder, non-alcoholic fatty liver disease by researching NAFLD pathogenesis, diagnosis and treatment. It also focuses on education, providing training to health care providers and patients, and promoting collaboration among researchers, clinicians and policy makers to address the growing burden of liver disease in India.
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