FATTY LIVER SUPPORT GROUP OF INASI
Dr Rakesh Aggarwal
(Past President, INASL)
Non-alcoholic
fatty liver is a common condition that is currently receiving a lot of
attention. Importantly, the condition is heterogeneous and can vary from a
very innocuous condition that needs only simple variations in life-style to
a serious condition needing medical treatment. Given the high frequency and
variable outcomes, a lay person is often faced with conflicting messaging
and seeks answers. Unfortunately, these are often not easily available,
particularly in developing country settings.
This Fatty Liver Support Group being launched by INASL is an
attempt to fill this important public need. We hope to place here accurate
information in a simple language to help guide the general public as well as
patients with non-alcoholic fatty liver. We hope that this portal will go a
long way to improve awareness about and care of this important condition. We
plan to keep the information on the portal current by adding and changing
the material over time, and also look forward to adding dynamic features at
a future date.
We do look forward to input from our intended
audience about the usefulness of the available information, and suggestions
on how to improve it.
Non-alcoholic fatty liver disease
Dr Kaushal Madan
Director of
Hepatology and Gastroenterology,
Max Hospitals, Saket, New
Delhi, India
Non-alcoholic fatty liver disease (NAFLD) or
fatty liver if continues for long time can cause fibrosis (scarring
or shrinkage) in the liver which ultimately may damage the liver and
can cause cirrhosis liver and even liver cancer. Hence it is very
important to determine the presence and extent of fibrosis in
patients with fatty liver as early as possible so as to treat it and
to predict the outcome in those who already have advanced fibrosis
and cirrhosis.
Introduction
Liver is a large
organ present on the right, upper side of the abdomen. It has a
large number of functions such as production of body proteins,
filtration of toxins and ingested drugs, control of blood sugar,
cholesterol and proteins.
What is fatty liver?
Fatty liver refers to the
deposition of excessive fat in the liver.
What causes fatty liver?
Earlier, it was though
that fatty liver used to occur only due to excessive alcohol intake.
However it was recognized over last one decade, that patients who do
not drink also develop fatty liver. These patients are labeled as
having non-alcoholic fatty liver disease (NAFLD).
NAFLD is a
life style disease. The risk factors for NAFLD are obesity, diabetes
mellitus, abnormal lipid profile. Other causes of NAFLD include
certain drugs, malnutrition, i.v nutrition and certain genetic
diseases.
What are the symptoms of NAFLD?
Most patients
with NAFLD do not have any symptoms at the time of diagnosis and
they will come to light only by chance. Once the patients develop
symptoms of liver disease, it suggests that the disease may be
already quite advanced
How is NAFLD diagnosed?
As mentioned earlier
most patients are detected by chance when they undergo
ultrasonography or during investigation for abnormal blood tests
(LFT).
What other tests should a patient with NAFLD
undergo?
Once diagnosed, patients with NAFLD should undergo a
fibroscan. The Fibroscan test gives two informations:
1. It
tells us about the amount of fat in the liver. So there is an
objective measure of the quantity of liver fat which can then be
followed up over time in order to find if the fat is increasing or
decreasing.
2. It also tells about the presence of scarring in
the liver, also called fibrosis. Patients with long term fatty liver
and with other risk factors have persistent liver inflammation which
can lead to scarring and hardening of the liver. This can even lead
to cirrhosis. This can be picked up easily by fibroscan
Some
patients may have to under go a liver biopsy in order to determine
the stage of the disease.
Is it a serious disease?
Although most patients
tend to have a milder from of NAFLD. But, it is clear that NAFLD can
cause all the complications associated with any chronic liver
disease. So patients with uncontrolled NAFLD are at an increased
risk of developing cirrhosis, liver cancer and liver failure. So if
left untreated, NAFLD can have serious outcomes.
Not only liver
complications, it has been seen that patients with NAFLD are also at
an increased risk of later development of diabetes, hypertension,
and heart disease.
Which patient with NAFLD develop serious
complications?
Persons are risk of serious
outcomes in presence of NAFLD are those with uncontrolled diabetes,
those with sever obesity and those with a family history of advanced
NAFLD
What is the treatment for NAFLD?
Since NAFLD is
a lifestyle disease, the most effective treatment is ‘lifetyle
interventions’. So the back bone of therapy in NAFLD patients
is to increase physical activity along with dietary advice in order
to achieve weight reduction in overweight individuals. If patients
are able to reduce about 10% of their body weight, they are able to
benefit immensely and have significant improvement in their liver
complications.
This therapy not only reduces liver fat and
inflammation due to fat, but also prevents other lifestyle
conditions such as diabetes, hypertension and high cholesterol.
Treatment with pills is required only in patients with advanced
liver disease due to NAFLD.
In addition , other associated
conditions such as diabetes, hypertension and high cholesterol
should also be treated along side.
What not to do, if you have fatty liver?
� You
should avoid herbal medications since they can also cause
unpredictable harms to the liver.
� You should not self
medicate
� You should not eat foods which can make you gain
weight, like sweets and saturated fats.
� You should avoid
alcohol intake
Whom should you contact if you have NAFLD
For
more and specific advice on Fatty liver disease, you should contact
a Hepatologist or a liver specialist near you. In addition, if you
have other risk factors, like diabetes or hypertension or high
cholesterol, then you should meet the concerned specialists also.
FIBROSCAN IN NON-ALCOHOLIC FATTY LIVER DISEASE (NAFLD)
Prof. Ajay Duseja (MD, DM, FAASLD, FACG,
FAMS, FSGEI)
Department of Hepatology, PGIMER, Chandigarh,
India
Importance of fibrosis (scarring) in fatty
liver
Non-alcoholic fatty liver disease
(NAFLD) or fatty liver if continues for long time can cause fibrosis
(scarring or shrinkage) in the liver which ultimately may damage the
liver and can cause cirrhosis liver and even liver cancer. Hence it
is very important to determine the presence and extent of fibrosis
in patients with fatty liver as early as possible so as to treat it
and to predict the outcome in those who already have advanced
fibrosis and cirrhosis.
Limitations of doing liver
biopsy
Traditionally liver biopsy (taking
liver piece from the liver by a needle) remains the gold
standard for determination of hepatic fibrosis in NAFLD.
However, liver biopsy is an invasive procedure (putting needle
in the liver) and may be associated with complications like pain
and bleeding. Moreover, the sample obtained with liver biopsy is
very small and sometimes, may not represent the disease process
going on in the whole liver. Liver biopsy sample has to be sent
to pathology lab and the whole process of interpretation of the
biopsy takes few days before the final report, which may also be
associated with some inter- and intra-observer variation among
the pathologists analysing the liver biopsy. In addition,
because of the invasive nature of the liver biopsy, it is
difficult to do it repeatedly in order to assess the effect of
various treatment modalities in NAFLD.
Fibroscan for the assessment of liver fibrosis
(scarring)
Hence there has always been a need for various
non-invasive test which are simple, accurate, less time
consuming and could act as an alternative to liver biopsy for
the assessment of liver fibrosis in patients with fatty liver.
Fibroscan or Transient Elastography is one such alternative to
liver biopsy and has the advantage of being purely non-invasive,
safe, accurate, operator-independent and can be repeated any
number of times.
Technique of Fibroscan
Patient needs to
come for the Fibroscan test with 2-3 hours of fasting and the
test is done with a machine similar to ultrasound machine and
the examination takes less than five minutes and the report is
given immediately to the patient. The principle of Fibroscan is
to measure the hepatic fibrosis by assessment of liver stiffness
by assessing the speed of the travelling shear waves generated
by the transducer (probe) of the machine. Higher the liver
stiffness or hepatic fibrosis, higher would be the Fibroscan
value which is measured in kilopascals (kPa) and varies from 2.5
to 75 kPa. In patients with overweight and obesity and with high
fat below the skin of the right side of the chest (where probe
is kept for examination), the values may not be accurate with
the standard probe (M probe) and may require the use of the XL
probe. Similarly, there is a separate probe for doing Fibroscan
test in children (S probe).
Sometimes patients with NAFLD
or fatty liver can have various other reasons which can falsely
elevate the Fibroscan value which may not be truly
representative of hepatic fibrosis. Hence the Fibrocan
interpretation should be done by the treating doctor in the
clinical context.
Estimation of liver fat with
Fibroscan
Another advantage of Fibroscan is
that, in addition to measuring fibrosis in the liver, it can
simultaneously also measure the presence and severity of the fat
in the liver by a built-in software called controlled
attenuation parameter (CAP).
Other tests for liver fibrosis
In addition
to Fibroscan, various blood tests and other elastography
techniques are also available these days to assess the presence
and extent of hepatic fibrosis in patients with NAFLD.
Lean NAFLD
Q: Can NAFLD occur in Lean people, i.e. persons who are not
obese?
A: Yes NAFLD [Fatty Liver]
can occur in Lean people, i.e. persons who are not
obese.
Q: What proportion of NAFLD patients are
lean NAFLD?
A: Upto about one
sixth of NAFLD patients may not be obese.
Q: Why
does NAFLD [Fatty Liver] occur in Lean people, despite than not
being obese?
A: Most of the persons who are not
obese and yet have NAFLD are metabolically abnormal. Like overweight
or obese NAFLD, they also generally have resistance to action of
insulin at different levels inside the body. What this means is that
most of them have either central obesity without excess weight
[their waist or central part of body at around level of navel is
more than normal], or they have lipid abnormalities like high bad
cholesterols or low good cholesterol [HDL] and may often have
disturbances in their glucose metabolism. Uncommonly this may even
be due to certain genetic disorders.
Q: How does one treat NAFLD in patients
who are lean?
A: In Lean NAFLD patients who
are not obese, unlike obese/overweight NAFLD patients, reduction
of weight is not a target for treatment. However these patients
should also exercise regularly and avoid fatty food, because
this can ameliorate their fatty liver without weight reduction.
Besides, other accompaniments like diabetes, high blood pressure
and abnormalities of lipids have to be treated appropriately
too.
Q: What other precautions are needed for
Lean NAFLD patients? A: Lean NAFLD patients should
avoid overeating and putting on weight. Besides they should
avoid cola drinks in particular. They should not smoke and
should not drink too. They should also avoid medications which
are harmful to liver, and ideally be vaccinated against
Hepatitis B and Hepatitis A.
Prof. Dr S.P. Singh, MBBS, MD,
DM, FSGEI, FACG, AGAF, FRCP [Edin], FRCPS
[Glasgow].
Chairman, Kalinga Gastroenterology
Foundation [KGF],
President, South Asian Association
for Study of the Liver [SAASL],
Chairman, Kalinga
Gastroenterology Foundation [KGF].
Common Myths about Fatty Liver disease
Dr Akash Shukla
Professor and Head, Department of
Gastroenterology,
King Edward Memorial Hospital,
Mumbai.
Myth 1: Fatty liver is nothing to worry
about
A: Fact: Most people with
fatty liver don’t get any symptoms.In a proportion of
patients, fatty liver can progress to significant liver damage in
the form of steatohepatitis, fibrosis, cirrhosis (scarring of the
liver) andliver cancer. This happens because prolonged fat
deposition in the liver cells causes inflammation and then scarring.
The scar tissue builds up, causing fibrosis which may progress to
cirrhosis. In rare cases it may cause liver cancer also. Presence of
fatty liver is associated with increased risk of heart disease,
different cancers in the body, diabetes, hypertension, obstructive
sleep apnea syndrome etc. Therefore, diagnosis of fatty liver should
not be ignored and thorough evaluation for liver and non-liver
related complications should be done.
Myth 2: “there’s nothing that
can be done for treatment
NAFLD”
A: Fact : Many
treatment options are available today for management of NAFLD.
Lifestyle modifications like (proper diet and weight loss) and
various medical and surgical treatments are effective in the
management of NAFLD. All patients with NAFLD should be try to
lose weight. Even a 5-7% weight loss can have beneficial
effects. In addition, appropriate management of co-morbid
metabolic conditions like dyslipidemia and diabetes is of
paramount importance.
Myth 3: “The
patients of NAFLD don’t need to see a liver
specialist?”
A: Fact: A consultation
with a liver specialist is an important step in the management
of NAFLD. The liver specialist will first distinguish patients
with simple steatosis (who have a good liver related prognosis
but needs close monitoring for other organs) from those who have
NASH and are at risk for progressive liver injury. He will also
ensure that there is no alternative / additional disease in the
liver. Based upon the staging of NAFLD he will be able to
provide valuable prognostic information and suggest appropriate
line of treatment.
This staging is often done by a
combination of blood tests, imaging and elastography based (like
MR Elastography, ARFI, Fibroscan etc) methods. Although liver
biopsy remains the gold standard for NAFLD diagnosis and
staging, determining which patient requires liver biopsy is
another important aspect of specialist evaluation of
NAFLD.
Myth 4: “There are no drugs for
patients with NAFLD”
Fact: There are
several drugs which have shown benefits in patients with NAFLD.
The most commonly used medicine is Vitamin E. Recently, newer
drugs like saroglitazar and obeticholic acid have shown
improvement in liver biopsies of patients with NAFLD. There are
many drugs like pioglitazone, GLP-1 inhibitors like liraglutide,
SGLT 2 inhibitors (gliflozins) which when given for diabetes
treatment, help improve the liver also. It should be noted that
these drugs are more effective when combine with life-style
modification, diet and exercise.
Myth 5:
Fatty liver disease cannot be reversed Fact: In the
early stages of the disease, fatty liver can be reversed
completely. This can be achieved by the following
measures:
� Avoid alcohol
� Reduce sugar intake
�
Cut out saturated fats in diet
� Exercise regularly
(Aerobic and Isometric)
� Maintain a healthy weight
�
Control blood sugar levels
� Eating a healthy diet with
plenty of fresh fruits, vegetables, whole grains and lean meats
like chicken and fish
Even in those patients who have
fibrosis, there is some hope of halting the disease and possibly
reversing the damage with appropriate
management.
Myth 6: Fatty liver disease is
only seen in the rich and those who are
obese
Fact: NAFLD is common across all
socio-economic strata and in rural as well as urban population.
While, it is more common in the obese, it may also be seen even
in a proportion of people with normal BMI and is referred to as
‘lean NASH’. This is likely to be due to excessive
visceral fat without significant increase in body weight. Lean
NASH appears to be more common in India as compared to the
west.
Myth 7: If the liver function tests
(LFT) are normal, the liver does not have
disease Fact: Most people with fatty liver will
have a normal or near normal LFT. Often, the LFT remain normal
till the liver disease becomes very advanced. A normal LFT does
not rule out significant liver disease. A combination of blood
tests, imaging and elastography-based (like MR Elastography,
ARFI, Fibroscan etc) tests and sometimes liver biopsy is used
for assessment of liver status.
Practical Tips for Indian diet in NAFLD
NAFLD is a multisystem disorder that has a
significant correlation with diet.
In order to follow
a NAFLD friendly diet it is advised to reduce portion sizes, use
smaller plates and bowls to lower calorie
intake.
Most of the time it is assumed
“fat” is the biggest culprit in NAFLD but mainly it
is sugar and carbohydrate. Though it’s important to avoid
saturated fat for overall health and weight loss, reducing
carbohydrate intake is of prime importance.
To
achieve this following a Mediterranean-style diet that is high
in green vegetables, low-sugar fruits, lean meats and whole
grains is suggested in preventing and also treating fatty liver
along with other life-style changes.
Every meal
should be based on – whole Grain, cereals, nuts, seeds,
legumes, fruits & vegetables.
The plate could be
filled using high fibre breads and cereals, vegetables, legumes
and fruit, which is filling. With these choices we eat a larger
volume of food but with fewer calories.
Options
in Indian diet
1. Cereal: Brown rice, whole
wheat, oats, jowar, bajra, ragi|
2. Pulses: red gram, green
gram, black gram, bengal gram
3. Vegetables: all
gourds-bitter gourd, snake gourd, ridge gourd, bottle gourd, ivy
gourd, ladies finger, tinda, all green leafy vegetables
4.
Fruits: citrus fruits-orange, mousambi, grape fruit, lemon;
strawberry, blueberry, black berry; cranberry, cherries, papaya,
pineapple, guava.
5. Milk and milk products: low fat milk,
low fat curd.
6. Meat, fish& egg: Skin out chicken, egg
white, fish like salmon, sardines, trout, mackerel,
tuna.
7. Other beverages: green tea, black tea, black
coffee
Do’s
AndDont’s
Do’s
1.
Eat whole grain cereals
2. Include more salad in
meals.
3. Eat fruits in between main meals
4. Snacks-
use nuts like almond, sprouts
5. Eat whole fruit instead of
fruit juice
6. Plan for food when you are not
hungry
Dont’s
1. More oil
for the food preparation
2. Fast foods, Fried foods
3.
Sweets, pastries, baked foods and all bakery products
4.
Red meat and Organ meat
5. Alcohol and alcoholic
beverages.
6. No extra salt to be added and limit salt
while cooking ( < 1500mg/day)
How to
choose a cooking oil
1. Amount of saturated
fats: 7-10%
2. Ratio of essential fatty acids: PUFA ratio
Omega 6/Omega 3 – 5:1 to 10:1
3. There should be
presence of natural anti-oxidants
Trans fat :
nil/low
Cholesterol:nil/low
(unrefined cold-pressed
oils better)