Fatty liver disease is a growing concern in India with factors such as insulin resistance, metabolic syndrome and genetic predisposition playing an important role in its development. The disease progresses from fatty accumulation in the liver to serious conditions such as cirrhosis and liver cancer if left untreated.
In India, lifestyle factors such as sedentary behavior and poor nutrition, as well as genetic differences, contribute significantly to the prevalence of the disease. NAFLD (Non-alcoholic fatty liver disease) affects about 20% of the non-obese population in India, in contrast to its common association with obesity in Western populations. We talked to Dr. Nishant Nagpal, Director of Gastroenterology at Fortis Hospital (Noida) to discuss the issue in detail.
What? what are the underlying causes of non-alcoholic fatty liver disease (NAFLD), and how does it differ from non-alcoholic fatty liver disease (NASH)?
Dr. Nishant Nagpal: The main causes of NAFLD include insulin resistance, which leads to increased accumulation of glucose and lipids in liver cells. Other contributing factors are metabolic syndrome and conditions such as obesity, hypertension, dyslipidemia, and genetic predisposition such as certain genetic mutations (eg, PNPLA3) that affect liver fat metabolism. Environmental factors such as a sedentary lifestyle, poor diet and exposure to toxins also play a role. NAFLD ranges from mild steatosis (accumulation of fat in liver cells) to the more severe NASH, which is characterized by inflammation and destruction of liver cells.
How does FLD progress from simple steatosis to more serious conditions like cirrhosis or hepatocellular carcinoma?
Dr. Thickness: FLD continues in action. It starts with simple steatosis, where excess fat accumulates in the liver cells. This can develop into non-alcoholic steatohepatitis (NASH), which involves inflammation and damage to the liver. Over time, the condition can lead to fibrosis (scarring) as collagen is deposited in the liver. If left untreated, it can progress to cirrhosis, characterized by extensive scarring and dysfunction of the liver and in some cases, hepatocellular carcinoma, which is cancer of the liver.
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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. Unhealthy diets high in sugar, salt, and fat exacerbate the problem. The obesity that is common in the Indian population increases the risk of insulin resistance and certain genetic mutations, such as PNPLA3 and TM6SF2, predispose people to the disease.
What? What are the common symptoms of fatty liver disease, and at what stage do they manifest?
Dr. Thickness: Common symptoms of fatty liver disease include fatigue related to liver failure and inflammation and abdominal discomfort often felt as pain or tenderness in the upper right 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 to assess the severity of NAFLD or NASH in patients?
Dr. Thickness: Several diagnostic tools are used to assess the severity of NAFLD or NASH. Liver function tests (LFTs) help monitor liver enzyme levels. Ultrasound can detect fatty liver and fibrosis, while FibroScan is used to measure liver stiffness, which is a sign of fibrosis. MRI helps evaluate liver fat and inflammation. For a definitive diagnosis and action, a liver biopsy may be required.
Can you explain the relationship between liver disease and metabolic conditions such as diabetes, high blood pressure, and obesity?
Dr. Thickness: The link between liver disease and metabolic status 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 development.
Why do some patients develop FLD even without obesity, especially in India where 20% of non-obese people are affected?
Dr. Thickness: Non-obese people can develop FLD due to a genetic predisposition, such as familial NAFLD. In some cases, these people may have sarcopenic obesity, where there is less muscle mass despite more 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 strategies for managing NAFLD and NASH, given the lack of targeted drugs?
Dr. Thickness: Current treatment strategies focus on lifestyle modifications such as improving nutrition, increasing physical activity and achieving weight loss. Controlling diseases such as diabetes, high blood pressure, and dyslipidemia is also important. Emerging therapies, including GLP-1 receptor and FXR agonists, are being investigated for their potential to treat NAFLD and NASH.
What lifestyle or dietary changes have proven to be most effective in reducing or controlling fatty liver disease?
Dr. Thickness: Adopting a Mediterranean diet, which emphasizes whole grains, fruits, vegetables, and healthy fats has proven effective in managing FLD. Increased physical activity, including aerobic exercise and strength training, also plays an important role. Losing 5-10% of body weight can improve liver health.
How can patient compliance and lifestyle modifications be improved in the context of fatty liver disease?
Dr. Thickness: Patient compliance can be improved through education, where patients are made to understand the consequences of NAFLD. Personal counseling and lifestyle advice tailored to individual needs can be most helpful. Regular follow-up to monitor progress and adjust treatment strategies is also important to maintain long-term compliance.
What are some India-specific challenges in diagnosing and managing fatty liver disease, given the diverse phenotypes in the Indian population?
Dr. Thickness: One of the major challenges in India is the diverse phenotypes, which lead to different clinical presentations and risk factors. There is also little understanding of the disease among patients, health care providers, and the general public. Inadequate health care infrastructure in some regions also prevents access to diagnostic and treatment equipment.
How can the InFLiMeN initiative help improve the understanding and management of metabolic liver diseases in India?
Dr. Thickness: The Indo-French Network of Liver and Metabolic Disease (InFLiMeN) aims to address important issues related to chronic metabolic liver disease, non-alcoholic fatty liver disease through research on NAFLD disease, diagnosis and treatment. It also focuses on education, training healthcare providers and patients, and promoting collaboration between researchers, clinicians and policy makers to address the growing burden of liver disease in India.
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