Non-alcoholic fatty liver: the twin of diabetes

In an interview with Sunday Island, Prof. Anuradha Dassanayake, Consultant Physician and Professor in Pharmacology with special interest in liver disease from the Faculty of Medicine, University of Kelaniya throws light on non-alcoholic fatty liver disease (NAFLD) which is affecting almost 60% of middle aged and the elderly population and around 10% of adolescents in Sri Lanka. It is also known to be the ‘twin of diabetes’. The ‘grim and grave’ situation of NAFLD calls for recognition of it as a ‘health emergency’ today says Prof. Dassanayake

by Randima Attygalle

A precursor to cirrhosis and liver cancer, NAFLD is caused by accumulation of extra fat in liver cells that is NOT caused by alcohol. Largely triggered by fast food and lack of exercise, NAFLD is more prevalent among South Asians.

“The research confirms that even in countries such as the UK, NAFLD and cirrhosis are more common in those of South Asian origin,” explains Prof. Anuradha Dassanayake. He also says that genetic involvement of NAFLD is also notable. “Those with a family history of liver disease or liver cancer are more susceptible to develop NAFLD at a young age and they have a higher risk of developing cirrhosis by the age of 50 to 60.” Metabolic risk factors for NAFLD include cholesterol, heart disease and diabetes. Smoking and alcohol progress liver disease very rapidly.

Excess calorie intake which is accumulated as fat all over the body, leads to obesity which is a risk factor for NAFLD. This excess fat is harmful to multiple organs in the body including the brain, liver, kidney and the heart. The excessive fat however is not derived only by eating ‘fatty meals’ such as processed meat and fried food but also by excessive carbohydrates and sugar, all of which is converted to fat in the end, points out Prof. Dassanayake.

“Wherever there is fast food, NAFLD is inevitable along with diabetes and heart disease,” says the senior consultant. “While it takes about two hours for a square meal to be prepared at home, it takes just two minutes to get a fast food meal which has no fibres but fortified in calories and carbs which is a very dangerous combination.” Saturated fats and calories of fast food make permanent changes in gut microbiota by altering the ‘friendly microorganism’ (which is required for gut health) into dangerous organism. “Once such permanent change is made, it is hard to shed body fat, even if you eat very little,” Prof. Dassanayake explains. Fructose syrup which is made out of corn is also ‘deadly for the liver’ he says. “Fructose is sweeter and cheaper compared to table sugar and is often found in commercially prepared sweets and beverages.”

The sedentary lifestyle which compounded by the COVID-pandemic is likely to see a rise of increased number of NAFLD cases including children, observes the Consultant. “Lack of physical exercise, increased screen-time before computers, phones and TVs are making most children overweight or obese which is a precursor to NAFLD.” A recent study from the Central Province reveals that about 20% of the estate workers have NAFLD. This is largely attributed to their diet of all-carbs with no fibre, points out Prof. Dassanayake.

The condition which is also considered the ‘twin’ of diabetes, will lead to an epidemic of cirrhosis (the progressive phase of NAFLD where the liver is hardened) in the next 20 years, unless a global campaign declaring it a ‘healthy emergency’ is realized, warns the physician. “NAFLD is not yet found in any of the world’s non-communicable disease (NCDs) control programmes. The epidemic of cirrhosis which is predicted in the next 15 to 20 years is going to be an absolute tsunami-like disaster and worst of it is that the world is still not prepared for it.”

The strong link between diabetes and NAFLD is now established, points out Prof. Dassanayake. “Today Diabetes organizations world over, recommend the screening of all diabetics for NAFDL.” The physician also explains that almost all people who develop NAFDL will end up with diabetes and if it’s diagnosed early, lifestyle modifications such as healthy eating and reducing weight can reverse the condition. “Coffee is often encouraged among those with NAFDL,” he says.

A silent killer, NAFLD is mostly asymptomatic (showing no symptoms. “While a few may experience a dull pain on the right side of the stomach below the rib cage, most will not be aware until it has progressed to cirrhosis or worse, liver failure marked by swelling of legs and stomach and vomiting of blood, hence it is very sinister,” the physician warns.

Several blood tests and new tools such as the Fibro Scan can diagnose NAFLD. “If you catch it early of its onset, it can be reversed by losing 10% of the body weight. While management of NAFLD with drugs is minimal, lifestyle modification is what physicians encourage. However, if it has progressed to cirrhosis, as it happens in 10% of all people with NAFLD, there is no alternative other than a liver transplant which is a costly affair,” says Prof. Dassanayake.

Annually around 3,000 patients die of cirrhosis here at home and only about 10 transplants can be performed locally, says the physician. “This is due to lack of resources and the difficulty in finding suitable non-fatty liver donors. Only a few can afford to get a transplant overseas and the situation of a large majority is very grim. Sadly without a transplant, there is absolutely no hope for these patients.”

Debunking myths such as ‘long term diabetes drugs could cause fatty liver’ and that ‘fatty liver is harmless’ , Prof. Dassanayake reiterates that the condition is a red flag and urges people to eat healthy and watch their weight. “If you have a fatty liver at 25, you are likely to develop diabetes by 35 and suffer a heart attack by 45, such is the gravity of the condition. The good news is that unless you have a very nasty gene which triggers it, NAFLD is a preventable condition.”

Encouraging people to revert to the traditional Sri Lankan diet with moderate rice consumption, Prof. Dassanayake also calls for enhanced health literacy. “Unlike the good old days, where Sri Lankans were physically active, today many spend sedentary lives, hence they need to be conscious of their daily rice intake and also be conscious of the BMI value (Body Mass Index which articulates the ideal weight against height).