As Indians have become more health conscious, there is an increase in the number of annual health check-ups being done. An ultrasound examination of the abdomen is usually done as part of the panel ofinvestigations, and one of the most common findings is that of fatty liver. Asa bariatric surgeon I have a lot of people come up to me and ask, "Doctor,what is this fatty liver disease? Why do I have it, I don’t even drink alcohol!Do I need to be worried? How can we treat it?" In fact it is also one of the most common questions asked on Practo.
What is fatty liver disease?
The medically correct terminology for this is Non-alcoholicfatty Liver disease (NAFLD). It means that there is deposition of fat in the liver, in the absence of significant alcohol consumption (less than 20 g/day; 10 g of alcohol =30 ml ofwhisky = 100 ml of wine = 240 ml of beer).NAFLD is now the most common cause of liver disease world-over, even more common than alcoholic related liver problems or viral liver disease. In India,10-32% of the population, that is nearly 244 million people, have NAFLD.
One reason for these high numbers is the explosion of the obesity epidemic. NAFLD is associated with over-weight and obesity. Indians also tend to develop fatty liver at lower levels of obesity, as compared to westernsociety. Another important factor is the pattern of fat distribution in thebody. Indians are prone to accumulate fat on the belly, and this so-called central or abdominal obesity strongly correlates with the development of fatty liver.
Why should I be worried about it?
Although fatty liver is becoming very common among Indians,it is not to be considered normal or taken lightly. In some cases it can progress to a severe form, non-alcoholic steato-hepatitis (NASH) and even to livercirrhosis, increasing the chances of developing hepatocellular carcinoma (livercancer). Although it may seem surprising and unbelievable, those with NAFLD have a higher chance of developing insulin resistance/diabetes mellitus,hypertension and hyperlipidemia, as well as heart disease.
What should do if I have a fatty liver?
In order to evaluate fatty liver disease, we need to start off with measuring your height and weight and then calculation of your Body Mass Index (BMI). The formula for this is BMI = weight (in kg)/ Height2(in meters), or you can use a BMI calculator, easily available on the internet.[https://www.nhlbi.nih.gov/health//public/heart/obesity/lose_wt/BMI/bmi-m.htm] A BMI > 30 kg/m2 falls in the obese category as per international standards. However for Indians, BMI > 23 kg/m2 isconsidered over weight and BMI ≥ 25 kg/m2 is considered obese.
The next step is to measure your waist circumference which should be less 90 cm for men and less than 80 cm in women. Waist circumference is a measure of fat distribution and is an indicator of the degree of abdominal or central obesity.
After this you should plan a visit to a gastroenterologist or general physician. They will do a general and abdominal examination including measurement of blood pressure. After ruling out viral liver diseases like Hepatitis B and C, they may advise further investigations including Liver function tests (LFTs) - Indians with fatty liver disease may have higher than normal levels of liver enzymes called transaminases (SGOT/SGPT). However it is highly likely that LFTS may remain absolutely normal till the end stages of liver disease. A complete blood count may show low level of platelets in later stages of liver disease.
Tests may be done to check if you have diabetes – these includefasting/post-prandial blood glucose/glycosylated hemoglobin or a glucose tolerance test. A Lipid profile will help determine your blood levels ofcholesterol and triglycerides.
Severity of fatty liver disease - the ultrasonography may mention a grade of severity of fatty liver, with 1 being mild and 3 being the most severe stage. A FibroScan is a modified type of ultrasonography, which measures the elasticity of the liver. As liver disease progresses the liver becomes less elastic. Both these investigations can give an idea of severity but are not 100% accurate.
The final test that may be required is a liver biopsy. This is an office based procedure, and usually the patient does not need to be admitted. A special needle is inserted into the liver, usually under ultrasound guidance, and small amount of liver tissue is obtained for examination under the microscope. This is the most accurate test to detect the severity of fatty liver disease. As it is an invasive procedure it is usually done only if absolutely necessary.
How do we treat fatty liver disease?
The good news is that even the more severe forms of fatty liver disease can be reversible although once a person develops cirrhosis reversal is usually not possible. Most people will benefit from regular exercise as well as diet and lifestyle modification. Needless to say it is preferable to stop consuming even the smallest amount of alcohol. One should aim at achieving BMI of 22 kg/m2, but one should not getdisheartened if this is hard to achieve as even a 5-7 kg decrease in weight will result in improvement of fatty liver disease. Moderate exercise for 60 minutes three times a week will also help, as will a healthy balanced diet.
There is no proven drug therapy that can be recommended for fatty liver disease. However it is important to treat diabetes mellitus, hypertensionand hyperlipidemia as needed.
Bariatric surgery has proven benefits in improving and reversing fatty liver disease However, the criteria for this are strict, and only those with a BMI of >37.5 kg/m2 in the absence of obesity-related diseases or those with a BMI >32.5 kg/m2 with one or more obesity-related disease, qualify for surgery. Bariatric surgery is not to be undertaken lightly. It requires a thorough evaluation by a bariatric surgeon as well as a life-long commitment to a healthier life-style, with regular follow-up with a bariatric team, including a nutritionist.
To conclude, for most of us, the presence of fatty liver disease on our ultrasonography reports should serve as a wake-up call. It should motivate us to get serious about our health, get evaluated and investigated and to commit to a healthier life-style.