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LIFESTYLE RELATED CHRONIC LIVER DISEASE – THE SILENT EPIDEMIC, SAYS DR HARIKUMAR R NAIR

Liver disease is regularly associated with excessive alcohol use, but knowledge of Non-Alcoholic Fatty Liver Disease (NAFLD) is relatively less known. If undiagnosed and untreated, it may ultimately lead to cirrhosis of the liver. Liver diseases are largely silent without causing any signs or symptoms in the patient. The damage which happens at liver tissue level through the stages of fatty liver, fatty hepatitis and liver scarring is silent until very late stage where liver function dips. This entire injury happens over a span of 2 decades or more. Most of the time in countries like India where screening programs are not active, liver cirrhosis is detected at a stage when patient needs liver transplant to survive. This underlines the necessity to undergo screening to detect this silent epidemic and arrest progression into late stages of liver scarring and liver cancer. Once significant liver scarring or liver cirrhosis sets in; reversibility cannot be guaranteed.

According to Dr Harikumar R Nair, Sr Consultant Hepatologist & Liver Transplant Physician, Gleneagles Global Health City Said, Prevention is the way to go-early detection of the silent liver disease and treatment before permanent damage sets in should be aimed at. Nowadays, is not uncommon to find youngsters in their thirties developing liver cirrhosis. Alcoholism which begins in campuses (and even schools!) clubbed with genetically linked lifestyle liver disease namely NAFLD probably is the reason behind this alarming phenomenon. Creating awareness among young generation, from school days onwards regarding how over nutrition, lack of exercise along with abuse of alcohol is the way to go to curb this liver health crisis added Dr Harikumar.

In India, Paradoxically economic evolution in our country has gifted few lifestyle illnesses with far reaching consequences and health care burden. Rising affluence, changes in lifestyle, junk food habits, obesity and rising incidence of diabetes have all contributed in varying degrees to the “lifestyle health crisis”. Sedentary lifestyles clubbed with high liquor consumption is a problem in urban setting which results in metabolic imbalance, diabetes and ultimately various organ damage, said Dr Harikumar.

Non-alcoholic steatohepatitis (NASH) is the worst form of fatty liver seen in 10% of patients with fatty liver. It is a progressive condition characterized by inflammation of liver leading to cell death! Long standing inflammatory mileu leads to fibrosis (liver scarring)and eventually to cirrhosis. Studies show that many cases of cirrhosis of unknown cause are probably due to ‘burnt out’ NASH. In addition, NASH cirrhosis increases the risk of hepato cellular carcinoma by several folds.

Non-alcoholic fatty liver disease (NAFLD) and metabolic syndrome (MS)
Fatty liver! The latest emerging health problem in our population! It is alarming to know that at least 30% of us are estimated to have Non-alcoholic fatty liver disease (NAFLD). It is the most common cause of abnormal liver tests in the community and is closely associated with his ‘big brother’ metabolic syndrome (MS) comprised of central obesity, type 2 diabetes mellitus (DM), hypertension and hyperlipidemia. NAFLD may be present in at least 50-70% of patients with type 2 DM. India being the diabetic capital one would anticipate much higher prevalence of NAFLD. In patients with NAFLD, the prevalence of MS is around 40%. NAFLD is emerging as an important health issue of concern in both adults and children because it increases the risk of type 2 diabetes mellitus, hypertension, heart attacks and death. Studies are being conducted around in many liver centers to identify genetic, ethnic and environmental risk factors for NAFLD and MS.

How it happens?
NAFLD patients have been found to have complex metabolic imbalance in fat cells in the belly (adipocytes) and liver. Increased intake of carbohydrate and fructose containing diet results in high insulin levels which doesn’t reduce sugar. Hyperlipidemia and hepatic steatosis causes inflammation in the liver leading to NASH, fibrosis and cirrhosis.

Treatment of NASH / NAFLD
Right now there are no drugs proven to reduce NASH. Current therapy is multi-dimensional approach such as life style modification, weight loss, change in dietary habit and exercise. Weight loss of 5-10% over 6 months has been shown to improve NAFLD and obesity.
Diet
High calorie intake and diet rich in carbohydrates and saturated fats should be avoided. Most of the fast-foods contain trans-fat which has been shown to worsen liver injury and increase hepatic triglycerides. Therefore they should be avoided. Poly unsaturated fatty acid seem to improve liver enzymes and are recommended. Many soft drinks contain fructose that increases lipogenesis, insulin resistance and NAFLD.
Exercise
Both the ‘brothers’ are susceptible to exercise. It helps weight reduction, improvement in liver enzymes and decreases the risk of type 2 DM. Moderate exercise with expenditure of at least 400 calories for 3-4 times a week has shown to improve NAFLD in the short term.
Summary
NAFLD and MS are increasingly recognized health problem in the community. It has emerged as the commonest cause of abnormal liver enzymes. NAFLD increases the risk of type 2 DM and vice-versa. Unrecognized steatosis may lead to NASH and eventually to cirrhosis. There is an urgent need to address this growing epidemic

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