Ultrasound imaging found his liver white and bright with fat. Unknown to him, fatty tissues had spread their tentacles, hardening the soft organ. As he entered the painful world of liver biopsies, injections and drugs, he asked his doctors: "Why didn't I ever get a hint?" "It's like that with the liver," they said.
If your stomach sticks out more than your chest, if you find it tough to bend and tie your shoelaces, if you can't keep your shirts tucked in, you know you are piling on the pounds. It's hardly news anymore that Indians are bloating up. But now a raft of new studies are showing that predicting a person's long-term health may not be as simple as measuring the waistline. Doctors are adding a new warning about invisible fat lurking in an organ no one thinks twice about: The liver. Fatty liver disease, in the absence of alcohol intake, is rapidly emerging as a health crisis in urban India. And every plumped-up liver can lead to heart attack, stroke and even cancer. India's obesity problem just turned deadly.
To capture the girth of the nation through its liver, consider the facts:
- 32% Indians are believed to have some degree of fatty liver disease.
- 70-90% people with obesity and diabetes suffer from fatty liver disease.
- 54% people who are neither overweight nor have abdominal obesity have fatty livers.
- 24% Indian men are afflicted by fatty liver compared to 13% women.
- 20% fatty liver patients go on to develop serious liver conditions.
- Urban Indians suffer from twofold increased risk of dying of heart attack or stroke due to liver fat.
- Liver fat is the third most common cause of chronic liver disease in India.
There is twice as much fat in Indian livers compared to people in the west with similar weight.
The liver is the new front in the battle of the bulge. "Fatty liver damage is no longer limited to people who drink excessively," says Dr Shiv Sarin, director of the Institute of Liver and Biliary Sciences (ILBS) in Delhi, who co-authored the global guidelines on non-alcoholic fatty liver disease (NAFLD) brought out by the World Gastroenterology Organisation in June this year. "Negative lifestyle choices are creating biochemical reactions that cause NAFLD. If we are not careful, it will soon become an epidemic in India because there is no treatment for NAFLD as yet," he says. Studies show that Indian men might be particularly prone to NAFLD.
The liver is the missing link in the obesity crisis. And the pace of new research in this area is accelerating. In the absence of all-India studies, piecemeal research from across the country is creating the contours of this crisis. "While a medical data search of 'non-alcoholic fatty liver' on the Internet via PubMed yielded only 14 research papers in 1995 and 36 in 2000, publications on this topic have accelerated to over 200 a year in the last five years," says Dr Anoop Misra, chief of obesity, diabetes and metabolic diseases at Fortis Hospital in Delhi. PubMed is an Internet search and comprises 22 million biomedical citations.
"Earlier, fat accumulation in the liver was considered innocuous. But today, it is being seen as a dangerous metabolic state," adds Mishra. According to Dr Ajay Duseja of Postgraduate Institute of Medical Education and Research (pgimer), Chandigarh, NAFLD has been recognised as a disorder recently in India. There is still very little published work on it, possibly because of the earlier presumption that it is benign and that the damage does not progress. Also, the attention has been focused on viral hepatitis.
It took Ratan Dharkar years of careless eating to wake up to his liver. "I have done this to myself by skipping meals and then binging on junk food," he says. The distress signals-slight ache in the upper right side of his abdomen, occasional fatigue and nausea-have always been there. "I simply did not take them seriously."
That's typical because the second largest organ of the body is a silent worker, says gastroenterologist Dr Samiran Nundy, chairman, Surgical Gastro and Liver Transplant, Sir Gangaram Hospital, Delhi. The liver does not beat, pulsate, growl or contract. Unlike the heart, it can be counted on to perform even under pressure. For all the complex work the liver executes that is vital to good health, it never signals its presence unless something goes seriously wrong. "The liver has an amazing ability to regenerate and repair itself," he says. It can keep functioning despite damage for years. But over time, damage can change the structure of the liver irreparably. Hence liver diseases are often called "silent killers" by doctors.
NAFLD starts when fat molecules accumulate inside liver cells. It is essentially a consequence of obesity and diabetes. As research shows, 70-90 per cent people with obesity and diabetes suffer from it. NAFLD can stay as a low-grade condition for years with just vague symptoms. But a prolonged build-up can start a cascade of serious liver damage. Once that happens to a person who does not consume alcohol, or drink far less than 20 gm/day, doctors call it non-alcoholic steatohepatitis (steato stands for fat and hepatitis for inflammation) or nash. If nash damages the liver irreversibly, it can lead to cirrhosis, liver failure or even cancer. It is impossible to predict who will develop cirrhosis or cancer, but the longer NAFLD remains hidden the stronger the chances are.
NAFLD is an obvious outcome of obesity but it does not always manifest in obvious ways.
Liver fat can hide in people who are neither overweight nor have abdominal obesity. A 2010 study conducted by researchers at the Institute of Postgraduate Medical Education and Research in Kolkata on a sample size of nearly 2,000 people shows intriguing results: 75 per cent of those with NAFLD had a Body Mass Index (weight by height square) less than normal, while 54 per cent were not even overweight.
About 90 per cent of heart diseases are caused by nine risk factors, say doctors: Smoking, high blood pressure, abnormal cholesterol, diabetes, abdominal obesity, psychosocial factors, poor diet, alcohol consumption, and lack of regular physical activity. Now fatty livers are being seen as the tenth risk factor. An article published in The New England Journal of Medicine in 2009 argues that liver inflammation damages the insides of arteries and makes blood clot. "It's a combination that can lead to heart attack or stroke," says Sarin.
Obesity has invaded India since the 1990s. That's when the first foreign fast food chain opened shop in Delhi. In the last two decades, as income has grown over fourfolds, so has the girth of the nation. At its root is a 'nutrition transition', as a consequence of globalisation of economies. Food balance data from the Food and Agriculture Organisation (FAO) of the United Nations shows that coarse grains have been largely substituted by polished cereals while consumption of meat, fat and sugar has more than doubled in affluent Indian cities since the 1990s. The rise of animal products in diet has pushed up the supply of dietary energy at a time when physical activity has declined as a result of increasing mechanisation.
Liver damage is the body's slow response to this changing nutritional challenge. According to World Health Organisation, liver diseases snuff out 200,000 lives in India every year. It is one of the top 10 causes of death. Hospital records show that fatty livers account for a third of such cases.
Unfortunately, there is still no cure for NAFLD or nash. With changes in diet, increase in physical activity and weight loss, prevention is the only hope. "Weight loss has a remarkable effect," says Misra. "It makes livers less fatty." Rapid weight loss, however, hurts the liver.
But it's not all gloom and doom where fatty livers are concerned. Activists as well as doctors are engaging in awareness drives in schools, walking the corridors of power to sensitise the nation's high and mighty and alerting the international health bodies. The Centre for Science and Environment in Delhi has announced its plans to limit junk food in schools. The Delhi High Court has asked the Food Safety and Standards Authority of India to frame guidelines on a pil seeking a ban on junk food and carbonated drinks within a 1,500 ft radius of schools. The Union Ministry of Health has requested the Ministry of Human Resource Development to ensure withdrawal of junk food from school and college canteens. "Junk the junk food" is the slogan that is being heard from the campus.
Urban India needs to go on a diet. But isolated changes will fail to make a difference without a broader shift in our new food culture. For now, doctors are happy that most fatty livers tend to stay stable and silent. But an inflamed liver can also mean the end of life.
What Plumps Up the liver?
Doctors are not too sure but a wide range of conditions can increase your risk
Diet
Junk food, binging and skipping meals can pile up excess fat in liver.
Diseases
Fatty liver is linked to type II diabetes, high cholesterol and high triglyceride levels in blood.
Chemicals Pesticides in food, steroids and antivirals can cause liver fat.
Conditions Obesity is the main reason behind NAFLD. Surprisingly, crash diets and malnutrition can also lead to NAFLD.
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