Fatty liver disease

Fatty liver disease can progress through four stages, which include:

• Simple fatty liver: This stage refers to the deposition and buildup of excess fat in the liver. It is usually harmless if it doesn’t progress.
• Steatohepatitis: This stage involves inflammation in the liver along with fat deposition.
• Fibrosis: This stage occurs when constant inflammation in the liver begins causing scarring. However, the liver can still function normally.
• Cirrhosis: In this stage, scarring of the liver has become widespread, weakening the liver’s ability to function. This is a serious and irreversible stage.

With non-alcoholic fatty liver disease (NAFLD), there are usually no symptoms in the early stages. However, in some cases, the patient may experience:

• Tiredness and discomfort in the upper right side of the abdomen.

In cirrhosis, which represents the later stages of NAFLD, the following symptoms can be observed:

• Weakness or fatigue
• Swollen belly
• Abdominal pain
• Loss of appetite
• Weight loss
• Confusion
• Enlarged blood vessels underneath the skin
• Larger than normal breasts in men
• Edema (swelling), especially in the legs
• Fluid accumulation in the abdomen (ascites)
• Skin and eyes appearing yellow due to jaundice
• Dark-colored urine
• Pale stools

In fatty liver disease, excess fat gets stored in liver cells.

Insulin resistance is the primary reason leading to non-alcoholic fatty liver disease (NAFLD). Insulin resistance occurs when cells in your muscles, fat, and liver do not respond effectively to insulin, resulting in elevated glucose (sugar) levels in the blood. Additionally, increased insulin levels and insulin resistance contribute to the continuous synthesis of fat in the liver.

Numerous risk factors for the development of NAFLD have been identified, most of which involve some form of metabolic defect or insulin resistance at their core.

Don’t toy with your liver. Read about six habits that could be damaging it.

NAFLD is primarily caused by the deposition of fats in the liver. The various risk factors include:

• Diet and Dietary Habits: A high frequency of consuming fast foods and larger portions containing saturated fats and refined carbohydrates can increase the risk of NAFLD. Inappropriate mealtimes, such as excessive evening and nighttime eating, skipping breakfast, and eating too quickly, can also predispose individuals to insulin resistance and subsequently NAFLD.
• Overweight or Obesity: Obesity is a significant risk factor for NAFLD. Studies indicate that up to 75% of individuals who are overweight and 90% of those who are obese suffer from NAFLD.
• High BMI: Adults with a high Body Mass Index (BMI), a measure of body fat based on height and weight, may have an increased risk of NAFLD.
• Age: The risk of developing NAFLD increases with age, as older individuals often experience organ dysfunction. A considerable proportion of those with progressive forms of NAFLD develop cirrhosis by their 70s or later.
• Family History: Research indicates that liver fat fraction and fatty liver conditions are hereditary traits that tend to run in families.
• Type 2 Diabetes: Diabetes significantly elevates the risk of nonalcoholic fatty liver disease. In many cases, Type 2 diabetes mellitus and NAFLD coexist.
• High Cholesterol: Dyslipidemia, characterized by high levels of triglycerides and LDL (bad cholesterol) or low levels of HDL (good cholesterol), can predispose individuals to NAFLD.
• Metabolic Syndrome: Metabolic syndrome combines several risk factors that increase the likelihood of developing Type 2 diabetes and cardiovascular disease. The current diagnostic criteria require the presence of 3 out of 5 of the following factors:
  • Triglycerides (150 mg/dL or greater)
  • HDL cholesterol (less than 40 mg/dL in men and less than 50 mg/dL in women)
  • High fasting glucose (100 mg/dL or greater)
  • Increased waist circumference (defined by population-specific data)
  • High blood pressure (greater than 130/85 mmHg)
  The incidence of NAFLD has been observed to rise in conjunction with increasing rates of metabolic syndrome.
• Polycystic Ovary Syndrome (PCOS): The prevalence of NAFLD is higher in women with PCOS, which increases the risk of insulin resistance, a critical factor in liver damage.
• Obstructive Sleep Apnea: Evidence suggests that obstructive sleep apnea can contribute to non-alcoholic fatty liver disease by increasing insulin resistance, inflammation, and dyslipidemia.
• Hepatitis Infections: HBV and HCV (hepatitis B and C viruses) affect millions globally and are major causes of chronic liver disease, including NAFLD.
• Genetic Conditions: Defective LIPA gene, clinically known as Wolman’s disease and cholesterol ester storage disease (CESD), can lead to chronic liver diseases. Fibrosis leading to cirrhosis is observed in two-thirds of patients with LIPA deficiency.
• Certain Medications: Side effects of specific medications, such as corticosteroids, antidepressants, and antipsychotics, can induce fatty liver disease.
• Smoking: Smoking contributes to the development of insulin resistance and metabolic syndrome, which are significant risk factors for fatty liver disease. Tobacco use is responsible for over 7 million deaths worldwide.

NAFLD can be hard to diagnose because many people do not have any signs and symptoms initially. A combination of laboratory and imaging tests is required to confirm a diagnosis. The diagnostic procedures include:

1. Medical history: Your doctor will evaluate the presence of risk factors and the absence of excessive alcohol intake.
2. Physical examination: During a physical examination, your doctor will look for any physical signs of impaired liver function, such as:
   • Pale yellow skin
   • Jaundice
   • Red palms
   • Enlarged breast tissue in men (gynecomastia)
   • Small or enlarged testicles
   • Swelling of the upper stomach
   To check for liver inflammation, they may press on your abdomen, as an enlarged liver can be felt along the lower edge of the right rib cage.
3. Blood tests:
   • Liver function test (LFT): This test helps show the abnormal levels of enzymes and proteins produced by the liver, including bilirubin, albumin, and lactate dehydrogenase.
   • Complete blood count (CBC): This test may help detect any infection or anemia that may be caused due to internal bleeding.
   • Fasting serum glucose: Increased levels correlate with the degree of steatosis in NAFLD patients and may be used as a marker of severe hepatic steatosis.
   • Hepatitis antibody test: This test may help rule out hepatitis B and C virus infections that can cause serious liver inflammation and damage.
   • Other blood tests: Antibodies are screened for autoimmune liver conditions, including antinuclear antibody (ANA), anti-smooth muscle antibody (SMA), and anti-mitochondrial antibody (AMA) tests.
4. Imaging tests: The doctor may advise imaging tests to better understand the patient’s condition. The following imaging tests can show the size, shape, texture, and inflammation of the liver:
   • Abdominal ultrasound: A non-invasive, widely available, and accurate procedure for detecting fatty liver disease. Fatty liver appears brighter than normal liver on ultrasound images, while cirrhotic livers look lumpy and shrunken.
   • Abdominal computed tomography (CT): This procedure uses x-ray equipment with computers to produce multiple detailed digital images of the liver, helping detect mild to advanced steatosis as well as other liver diseases.
   • Magnetic resonance imaging (MRI): This technique uses a magnetic field, radio frequency pulses, and a computer to produce detailed pictures of the liver. A dye injected into the veins helps visualize the liver more clearly on the scan, allowing for accurate detection of damage caused by various liver diseases.
   • Magnetic resonance cholangiopancreatography (MRCP): A special type of MRI used to evaluate a part of the liver and gallbladder.
   • Magnetic resonance elastography (MRE): This test assesses the stiffness, inflammation, and severity of scarring in the liver.
   • Transient elastography (FibroScan): This test quantifies liver fibrosis (scarring).
5. Liver biopsy: In this procedure, fine tissue samples are collected from the liver with a needle or during surgery. The liver biopsy should be considered in all patients with unexplained elevations in serum aminotransferases (e.g., with findings negative for viral markers or with no history of alcohol use). It offers high accuracy in detecting fatty liver disease.

A healthy lifestyle prevents fatty liver disease and its potential complications. Following are a few tips to keep the liver, the only body organ with the superpower to grow back, healthy:

1. Eat right

   A wholesome, well-balanced, healthy diet is the cornerstone for preventing fatty liver. This can be achieved by:

   • Consuming green vegetables, fresh seasonal fruits, whole grains, lean protein sources, nuts, seeds, and low-fat dairy products.
   • Adding healthy fats (polyunsaturated omega-3 fats) to the diet and avoiding saturated and trans fats.
   • Increasing intake of dietary fiber.
   • Avoiding fast food, canned, and packaged food items.
   • Limiting sugar intake.

   If you're trying to reduce sugar and calories in your diet, you may be considering artificial sweeteners or other sugar substitutes. Watch this video to learn whether sugar alternatives are as healthy as they claim and how to include healthy alternatives to sugar in your life.

2. Keep your weight in check

   Moderate weight loss is associated with improvement in insulin sensitivity. Energy restriction of about 25–30 kcal/kg/day with a target weight loss of about 10% of body weight over six months can prevent and manage fatty liver. Struggling to lose weight? Here are a few weight loss tips and tricks that can work like magic!

3. Always take time to exercise

   Regular exercise is essential to prevent fatty liver. Set realistic goals while working out, such as daily 15-minute walks and 15-minute exercises. Small, achievable goals will help you be consistent and make working out a part of your daily routine.

4. Protect yourself from hepatitis

   By avoiding hepatitis infection (particularly hepatitis B and C), the risk of developing liver cirrhosis can be limited. Use the following methods to reduce the risk of infection:

   • Avoid unprotected sex.
   • Do not get body piercings or tattoos in an unsterilized environment.
   • Get vaccinated for hepatitis B and hepatitis C.
   • Do not share needles.

   Vaccination is not just for children. As you age, your immunity decreases, making you susceptible to various diseases. Read more about various adult vaccines.

5. Manage diabetes and cholesterol

   These two conditions can be primary culprits causing NAFLD. It is essential to keep them in check by consuming a healthy diet, incorporating exercise into your routine, monitoring levels, and seeing your doctor regularly for follow-ups.

   NAFLD is a growing epidemic not just in India, but worldwide. Listen to our experts discuss liver detox tips that help you take care of your liver.

The first-line treatment for fatty liver disease is lifestyle intervention with diet modifications and an exercise regime.

1. Dietary Modifications

Healthy, mindful eating is key to induce weight loss without malnutrition. The following tips can be of great help. However, it is always advisable to work in conjunction with regular interactions with a dietician.

• Avoid fast food, canned, and packaged food items.
• Limit sugar intake.
• Count your calories. It is advisable to consume 1000-1200 calories per day for women and 1200-1600 calories per day for men.
• The goal is to achieve a weight loss of 0.5 to 1.0 kg per week.
• Aim for gradual but consistent weight loss over 6 to 12 months.

At the same time, macronutrients including carbohydrates, proteins, fats, and micronutrients including vitamins, minerals, and supplements must be well balanced. Here is your guide to eating habits that lead to a healthy weight without compromising on all-around nutrition.

2. Exercise Regime

120 minutes of aerobic exercise, such as running and swimming, every week increases glucose uptake by improving insulin sensitivity and reducing hepatic fat content.

NAFLD is also improved with resistance exercises, which may be more tolerable for patients who suffer from poor cardiorespiratory fitness and cannot tolerate intense aerobic workouts.

A study has shown that modified high-intensity interval training (HIIT) of five cycles of high-intensity cycling followed by 3-minute recovery periods, three times a week for 12 weeks, leads to a reduction in liver fat.

However, it is important that an individualized exercise plan be developed based on:

• The severity of underlying liver dysfunction from NAFLD.
• Class of obesity.
• Exercise tolerance status.
• Presence of individual components of metabolic syndrome and other comorbid medical problems.

3. Weight Loss Using Medications

While weight can be mostly managed by caloric restriction from dietary modifications and physical exercise, medications like Orlistat can aid in moderate weight loss by reducing the absorption of fat.

4. Bariatric Surgery

Sometimes, exercise and diet modifications fail to result in weight loss in excessively obese individuals. Bariatric surgery increases insulin sensitivity in the liver, muscles, and fat, along with improving overall metabolic health.

5. Dietary Supplements

Certain vitamin supplements can assist in managing fatty liver disease. These include:

• Vitamin E: Reduces triglycerides and oxidative stress, contributing to decreased progression of fatty liver in patients. Natural sources include wheat germ oil, sunflower seeds, almonds, peanuts, spinach, pumpkin, and red bell pepper. Supplements can also be considered if your diet is insufficient.
• Vitamin C: Provides protective effects against liver oxidative damage and prevents fatty accumulation in the liver. Include vitamin C-rich items like lemons, oranges, strawberries, blackcurrants, and broccoli in your diet.
• Vitamin D: Deficiency can result in insulin resistance, metabolic syndrome, and NAFLD. Appropriate levels of vitamin D can help in managing fatty liver disease. Sun exposure and supplements can aid in achieving adequate levels.

6. Medications

There are no specific medicines for fatty liver disease. However, the doctor may prescribe medications for the management of underlying conditions like:

• High Triglycerides and Cholesterol: Medications include Atorvastatin and Lovastatin.
• Viral Hepatitis: If fatty liver disease is long-term, the doctor may prescribe antiviral medicines like Lamivudine, Entecavir, and Tenofovir disoproxil fumarate.
• Diabetes or Insulin Resistance: Antidiabetic medicines include Metformin, Rosiglitazone, and Pioglitazone.

7. Liver Transplantation

In advanced cases of fatty liver disease, when the liver completely loses its ability to function, a liver transplant is the last treatment option. This procedure replaces a patient’s liver with a healthy liver from a deceased donor or with part of a liver from a living donor. Candidates for liver transplants undergo extensive testing to determine if they are healthy enough to have a good outcome following surgery.

The following home remedies can be used as an adjunct to lifestyle modifications and other treatment options for fatty liver:

• Coffee: A study has found that coffee of all kinds lowers the risk of fatty liver disease, with a significant risk reduction of fibrosis. Know more about the benefits of drinking coffee. Watch this video by our expert.
• Turmeric: It has antiseptic, antibacterial, antifungal, and antioxidant properties and can do wonders in treating liver disease. Add a pinch of turmeric in hot milk with honey and drink it once a day. Have all your questions answered regarding turmeric tea. Click to watch the video.
• Apple cider vinegar (ACV): ACV helps improve fat metabolism and detoxify the liver. Quick Tip! Always consume ACV with a straw to prevent tooth erosion. Buy apple cider vinegar products online with just a click.
• Green tea: It has high antioxidant properties that reduce oxidative stress, which initiates fibrosis and cirrhosis of tissues. It also provides a protective effect against liver disease and has antiviral properties that help fight viral hepatitis. Explore our wide range of green teas.
• Milk thistle: Studies show that it is a powerful liver cleanser and has the property of rebuilding liver cells. It helps in reducing liver damage and removing toxins from the body that are processed through the liver.

Fatty liver disease can turn into a life-threatening condition if it progresses into inflammation, fibrosis, and cirrhosis of the liver. If left untreated, it can eventually lead to the following complications:

• Bleeding: Inflammation, fibrosis, and cirrhosis can affect the liver's ability to produce sufficient clotting factors, increasing the risk of severe bleeding.
• Jaundice: Fatty liver disease may impair the liver’s ability to eliminate high levels of bilirubin, a waste product, from the blood, leading to jaundice.
• Infections: Fatty liver disease reduces the body’s immunity to fight infections, resulting in recurrent bacterial infections.
• Chronic viral hepatitis: Progression to fibrosis and cirrhosis is more rapid when there is any form of concomitant liver infection with fatty liver disease.
• Osteoporosis: Some patients may experience a loss of bone strength and an increased risk of fractures. Research indicates that patients with NAFLD are 1.35 times more likely to develop osteoporosis compared to individuals without NAFLD.
• Diabetes: Diabetes may worsen in individuals who already have it if they develop cirrhosis and complete liver damage.
• Liver failure: Patients with long-term fatty liver disease face the highest risk of liver failure.
• Liver cancer: Scarring and cirrhosis elevate the chances of developing liver cancer, particularly hepatocellular carcinoma (HCC).
• Acute fatty liver of pregnancy (AFLP): This rare but serious complication can occur during the third trimester of pregnancy. Proper delivery and supportive care can facilitate better recovery. Note: Liver health typically returns to normal within a few weeks of giving birth.

Complementary therapies that can help manage the symptoms of NAFLD include:

• Traditional Chinese Medicine (TCM) - TCM has been widely used to treat NAFLD for centuries in Asia. Its holistic approach focuses on preventing liver damage, increasing insulin sensitivity, and improving the immune system.
• Acupuncture therapy - This traditional Chinese medicine-based approach involves inserting thin needles into the body to promote healing. Studies have demonstrated that acupuncture can effectively treat NAFLD by inhibiting inflammation and enhancing fat metabolism in liver cells.
• Yoga - Yoga positions can strengthen and stimulate the liver, aiding in the release of stored fat as energy. Certain poses are particularly beneficial for improving liver function and addressing fatty liver disease.

Recommended Yoga Poses:

• Garland Pose (Malasana)
• Bhujangasana (Cobra Pose)
• Adho Mukha Svanasana (Downward Facing Dog Pose)
• Naukasana (Boat Pose)
• Plough Pose (Halasana)
• Balasana (Child Pose)
• Mandukasana (Frog Pose)
• Dhanurasana (Bow Pose)
• Anulom Vilom Pranayama (Alternate Nostril Breathing)
• Kapalbhati Pranayama (Skull Shining Breath)

Yoga can not only benefit your liver condition but also have a very positive impact on your overall well-being. Learn more about the other benefits of yoga.