Times of India
15 March 2011
By Umesh Isalkar
Pune, India

Health Matters
Exercise, eating right, losing weight may reverse disorder
Indians are prone to fatty livers because of higher body fat percentage and distribution
Poor eating habits, too much of fat content in your diet, obesity and lack of hygiene can stress your liver out. Prolonged negligence can result in fat deposition and eventually end up in non–alcoholic fatty liver disease (NAFLD).

The condition can cause serious liver disorders like cirrhosis and even cancer. While there is medical treatment, prevention by lowering the fat content by eating right and losing weight is the best option, say medical experts.

Studies show that Indians are prone to the fatty liver condition where the condition varies in the general population varies from 9 per cent to 24 per cent. The situation is similar to that of western countries as young India prospers and adapts a similar lifestyle.

"Fatty liver is the building up of fat in the liver's cells. There are two types –one that develops due to excessive consumption of alcohol and the other that develops in non drinkers termed as non–alcoholic fatty liver disease (NAFLD). It is becoming a public health problem due to rising incidence of obesity and type 2 diabetes," said consultant gastroenterologist and hepatologist Deepak Amarapurkar from Bombay Hospital and Medical Research Centre, Mumbai.

It is being increasingly recognised that non–alcoholic fatty liver disease is a cause of end–stage liver disease and a potential risk factor for hepato–cellular cancer.

"A simple accumulation of fat in liver cells is termed as stenosis or fatty liver," he added. Doctors also see a connection between fatty liver, diabetics and obesity struck patients.

City–based consultant gastroenterologist and hepatologist Parimal Lawate said, "Obesity is the condition most often reported in association with NAFLD. In morbidly obese patients where BMI exceeds 35kg /m2 the frequency of NAFLD is as high as 80 per cent. NAFLD can occur even in people with normal body weight.

NAFLD is strongly associated with type II diabetes mellitus and glucose intolerance with or without superimposed obesity. The association between type II diabetes mellitus and NAFLD appears strongest in morbidly obese patients."

Gastroenterologist and hepatologist Shabir Kayamkhani said, "Prevalence of NAFLD is directly related to the body mass index (BMI) with over 80 per cent of subjects with BMI of 35 having NAFLD. The waist circumference may be an even better predictor of underlying insulin resistance and NAFLD."

Moreover, it occurs at a younger age among Indians since the obesity prevalence in urban population is a high 30 per cent, Kayamkhani said.

Indians are particularly prone to fatty livers because of the higher body fat percentage and fat distribution around the abdomen even when the BMI is within limits. These factors – central obesity and waistto–hip ratio– make them NAFLD prone.

The trend is of particular concern in children where the prevalence of fatty liver has been as high as 50 per cent in obese children, say experts.

With the number of young people being struck by the disease, the Indian Council of Medical Research (ICMR) has decided on a task force to oversee research on NAFLD and devise ways to prevent, diagnose and treat it.

"Usually, NAFLD is asymptomatic. Hence, most parents don't know that their children are suffering from it. An ultrasound test is the easiest way of early diagnosis of NAFLD. The primary cause behind the disease is a faulty lifestyle," said Lawate He added, "We know that obese children run a high risk of NAFLD.

So paediatricians testing children for lipids, BP and insulin resistance must not forget to undertake an ultrasound of the liver. Those diagnosed with NAFLD must be immediately put on a diet regimen and exercise routine – six times a week, 30 minutes a day."

Insulin resistance can trigger disorder
Medical experts believe that most cases of NAFLD are caused by a condition known as insulin resistance.
"Insulin is made by the pancreas and released into the blood stream in response to elevated blood glucose (sugar) levels which occurs, for example, after eating a meal. Insulin keeps the glucose levels from becoming too elevated. It pushes glucose out of the blood stream and into the cells of the body. The cells that are mainly involved with insulin are the fat cells, the muscle cells and the liver cells. These cells have insulin receptors on their surfaces," said Amrapurkar.

When insulin reaches these cells, it attaches itself to these receptors and the activation of insulin receptors sets in motion a series of complex biochemical signals within the cells that allow them to take in the glucose and convert it to energy.

If the pancreas fails to produce enough insulin or the insulin receptors do not function properly, the cells cannot take in the glucose and the level of glucose in the blood remains high.

To clear excess glucose from the blood, the pancreas has to produce additional insulin. This results in an over abundance of insulin in the blood, a condition referred to as hyperinsulinemia. By a complex mechanism, high level of insulin in the blood also causes high level of free fatty acids to accumulate in the blood. This, in turn, causes fatty acids to be deposited in the liver causing NAFLD.

"Increased levels of free fatty acids (FFA) can be directly toxic to liver cells through a number of mechanisms. NAFLD may progress to NASH (Non Alcoholic Steato–Hepatitis) a more sinister disease that progresses gradually to end–stage liver disease, and hepatocellular cancer," says Amrapurkar.

Blood test will indicate, biopsy will tell all
Patients do not complain of any symptoms, but some may have a persistent ache in the upper right abdomen. They may suffer from fatigue.

Blood tests show whether one has high levels of certain liver enzymes, a marker of fatty liver. An ultrasound examination of the abdomen for some other affliction may show fat in the liver. However, a sure–fire test is a liver biopsy.

The condition is treated by recommending weight loss, purging of offending drugs and toxins and control of diabetes mellitus and hyperlipidemia. As with all liver diseases avoiding alcohol before, during or after treatment is essential.

Alcohol may worsen the fat deposits, fatty inflammation and fatty scarring in the liver.
Precautions while losing weight a necessary. Weight loss must be sustained or the disease may recur. Weight reduction must occur at a slow pace. People should lose half to one kg per week. Rapid weight reduction or starvation techniques can worsen or even precipitate progression to cirrhosis and liver failure. Regular aerobic exercises are necessary, said Kayamkhani.

What is Nafld
Non–alcoholic fatty liver disease (NAFLD) is one cause of fatty liver changes, when fat is deposited (steatosis) in the liver not due to excessive alcohol use. It is related to insulin resistance and the metabolic syndrome, and may respond to treatments developed for diabetes mellitus type 2, such as weight loss, metformin and thiazolidinediones. Nonalcoholic steatohepatitis is the most extreme form of NAFLD, which is regarded as a major cause of cirrhosis of the liver of unknown cause

Symptoms
Most people with simple fatty liver or NASH have no symptoms. However, some people have a nagging persistent pain in the upper right part of the abdomen, over an enlarged liver. You may feel generally tired if you have NASH. The diagnosis is often first suspected when an abnormal blood test result occurs. Some people with NAFLD develop cirrhosis

How to Manage it nn Lose Weight
If you are overweight, reduce the number of calories you eat each day and increase your physical activity to lose weight. Aim to reduce one or two pounds a week

nn Choose a Healthy Diet
Eat a healthy diet that’s rich in fruits and vegetables. Reduce the amounts of saturated fats in your diet and instead select healthy unsaturated fats such as those found in fish, olive oil and nuts. Include whole grains in your diet
nn Exercise and be More Active
Aim for at least 30 minutes of exercise most days of week. Choose aerobics

nn Control Your Diabetes
Follow your doctor's instructions to stay in control of your diabetes. Take your medication as directed and closely monitor your blood sugar

nn Lower Your Cholesterol
A healthy plant based diet, exercises and medications can help keep your cholesterol and your triglycerides at healthy levels

nn Protect Your Liver
Avoid things that will put extra stress on your liver. For instance, don't drink alcohol. Follow the instructions on all medications and over–the–counter drugs