Fatty liver disease is a growing problem in India, as factors such as insulin resistance, metabolic syndrome and genetic predisposition play a key role in its development. The disease progresses from a simple accumulation of fat 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 diet, along with genetic variation, contribute significantly to the prevalence of the disease. NAFLD (non-alcoholic fatty liver disease) affects approximately 20% of non-obese individuals in India, in contrast to its usual association with obesity in the Western population. We spoke with Dr. Nishant Nagpal, Director of Gastroenterology at Fortis Hospital (Noida) to dig deeper into the issue.
What are the main causes of non-alcoholic fatty liver disease (NAFLD) and how is it different from non-alcoholic steatohepatitis (NASH)?
dr. Nishant Nagpal: The primary 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 predispositions such as certain genetic mutations (eg, PNPLA3) that affect fat metabolism in the liver. Environmental factors such as a sedentary lifestyle, unhealthy diet and exposure to toxins also play a role. NAFLD is a spectrum ranging from simple steatosis (accumulation of fat in liver cells) to the more aggressive NASH, which is characterized by inflammation and damage to liver cells.
How does FLD progress from simple steatosis to more serious conditions such as cirrhosis or hepatocellular carcinoma?
dr. Gross: FLD proceeds in stages. It starts with simple steatosis, where excess fat accumulates in liver cells. This can lead to non-alcoholic steatohepatitis (NASH), which involves inflammation and damage to the liver. Over time, this condition can lead to fibrosis (scarring) as collagen is deposited in the liver. If left untreated, it can progress to cirrhosis, characterized by advanced 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. Gross: In Indian patients, a sedentary lifestyle contributes significantly to insulin resistance and obesity, which are major risk factors for FLD. An unhealthy diet high in sugar, salt and saturated fat makes this problem worse. Central obesity, which is common in the Indian population, increases the risk of insulin resistance, and certain genetic mutations such as PNPLA3 and TM6SF2 further predispose people to the disease.
What are the most common symptoms of fatty liver and at what stage do they usually appear?
dr. Gross: The most common symptoms of fatty liver include fatigue, which is related to liver dysfunction and inflammation, and abdominal discomfort, which often manifests as pain or tenderness in the upper right abdomen. In advanced stages, patients may experience weight loss 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. Gross: 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 liver fat and fibrosis, while FibroScan is used to measure liver stiffness, which is indicative of fibrosis. MRI helps evaluate liver fat and inflammation. Liver biopsy may be required for definitive diagnosis and staging.
Can you explain the link between fatty liver and metabolic conditions such as diabetes, hypertension and obesity?
dr. Gross: The link between fatty liver and metabolic conditions lies in common 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 without obesity, especially in India where 20% of non-obese individuals are affected?
dr. Gross: Non-obese individuals may develop FLD due to genetic predispositions such as familial NAFLD. In some cases, these individuals may have sarcopenic obesity, where there is low muscle mass despite excess body fat. Also, metabolic dysfunction, including insulin resistance and dyslipidemia, may occur independently of obesity and contribute to the development of FLD.
What are the current treatment strategies to manage NAFLD and NASH given the absence of targeted drugs?
dr. Gross: Current treatment strategies focus on lifestyle modifications, such as improving diet, increasing physical activity, and achieving weight loss. Management of comorbidities such as diabetes, hypertension, and dyslipidemia is also essential. New therapies, including GLP-1 receptor agonists and FXR agonists, are being investigated for their potential in the treatment of NAFLD and NASH.
What lifestyle or dietary changes have been shown to be most effective in reversing or managing fatty liver disease?
dr. Gross: Adopting a Mediterranean diet that emphasizes whole grains, fruits, vegetables, and healthy fats has been shown to be effective in managing FLD. Increased physical activity, including aerobic exercise and strength training, also plays a key role. Losing 5-10% of body weight can significantly improve liver health.
How can patient compliance be improved with lifestyle modification in the context of fatty liver disease?
dr. Gross: Patient compliance can be improved by education in which patients are made to understand the consequences of NAFLD. Personalized advice and tailored lifestyle advice based on individual needs can also help. Regular follow-ups to monitor progress and adjust treatment strategies are also key to maintaining long-term compliance.
What are some India-specific challenges in the diagnosis and management of fatty liver disease given the diverse phenotypes in the Indian population?
dr. Gross: One of the major challenges in India is the diverse range of phenotypes, leading to different clinical manifestations and risk factors. Awareness of this disease among patients, healthcare providers and the general public is also limited. Insufficient health infrastructure in some regions also limits access to diagnostic and treatment facilities.
How can the InFLiMeN initiative help improve the understanding and management of metabolic liver disease in India?
dr. Gross: The Indo-French Network on Liver and Metabolic Diseases (InFLiMeN) aims to address key issues related to the common metabolic liver disorder, non-alcoholic fatty liver disease, through research into the pathogenesis, diagnosis and treatment of NAFLD. It also focuses on education, offers training to healthcare providers and patients, and promotes collaboration between researchers, clinicians and policy makers to address the growing burden of liver disease in India.
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