Over the decades, the causes and prevalence of fatty liver disease have undergone significant changes. From the 1940s to the 1990s, alcohol was widely recognised as the most important cause of fatty liver. However, from the early 2000s onwards, non-alcoholic fatty liver disease (NAFLD) has emerged as the leading cause of this condition, mainly due to dramatic shifts in lifestyle patterns. The rise in sedentary behaviour, unhealthy dietary habits, and chronic stress have all played a major role in this transformation.
The liver is a vital organ responsible for numerous essential functions. It aids in digestion, stores energy, manufactures important proteins and enzymes, detoxifies the blood, and stores nutrients. A healthy liver is indispensable for maintaining overall well-being.
Fatty liver disease is a condition in which excess fat accumulates in liver cells. In medical terms, this means fat constitutes between 5% and 10% of the liver’s total weight. When this occurs in the absence of significant alcohol consumption, it is termed non-alcoholic fatty liver disease (NAFLD). This condition is now being referred to as a silent epidemic—not just in Goa or India, but globally.
It is estimated that 30% of the world’s population is affected by NAFLD. In India, the number is slightly higher, with 33% of the population believed to have some form of fatty liver disease. A 2022 study by Dr P A Vagurmekar and colleagues in Goa found that the local prevalence of NAFLD stood at 34.8%. Alarmingly, another study showed that 84% of IT professionals surveyed had NAFLD, highlighting the serious impact of sedentary work environments and digital lifestyles.
The major risk factors contributing to NAFLD include a sedentary lifestyle, prolonged hours of desk work, lack of physical activity, poor dietary habits, inadequate sleep, mental stress, smoking, alcohol consumption, and regular intake of aerated sugary drinks. The condition is often found alongside diabetes, hypertension, high blood lipids, and obesity. It is also occasionally associated with underlying conditions such as hypothyroidism and polycystic ovarian syndrome (PCOS). Studies suggest that up to 71% of IT professionals are either overweight or obese—making them particularly vulnerable to NAFLD.
Urban populations, which are generally exposed to fast-paced and often unhealthy lifestyles, show higher prevalence rates. Fatty liver is often asymptomatic in its early stages. However, as the disease progresses, individuals may experience symptoms such as dull or aching pain in the upper right abdomen, persistent fatigue, weakness, jaundice, and swelling. If left untreated, the liver undergoes progressive damage including inflammation, fibrosis, and eventually cirrhosis. Cirrhosis, or scarring of the liver, can ultimately result in liver failure, hepatocellular carcinoma (a form of liver cancer), coma, and even death.
Diagnosis of NAFLD begins with a thorough history and clinical examination, supported by blood tests and imaging studies. Modern imaging technologies, including high-resolution scanners and elastography machines, can now measure fat accumulation and fibrosis levels in the liver with remarkable accuracy. These systems are non-invasive, offering an effective way to monitor disease progression. However, the definitive diagnosis is still made through liver biopsy, which provides detailed insight into the nature and extent of liver damage.
Normally, fat is not visible in the liver cells of a healthy individual. However, in fatty liver disease, fat accumulates in the form of vacuoles within the cells, giving them a characteristic "signet ring" appearance under the microscope. In routine histopathological tissue processing, fat is typically dissolved by alcohol and other chemical reagents, making it appear as empty spaces or vacuoles. To demonstrate fat deposits more clearly, frozen section biopsies and special fat stains like Oil Red O, Sudan III, and Sudan IV are used.
Fat can accumulate in any part of the liver lobule but is usually distributed in a generalised pattern. In addition to identifying fat, liver biopsies also reveal the presence and extent of fibrosis. For this, special stains such as reticulin and Mason’s trichrome are employed. When fibrosis increases, it signals the onset of cirrhosis. Cirrhosis is irreversible and indicates advanced liver damage, which can eventually lead to liver failure, hepatic coma, and death.
The advanced form of NAFLD is called NASH—non-alcoholic steatohepatitis—which includes inflammation and varying degrees of liver cell injury. The progression from NAFLD to NASH is dangerous, and early intervention is critical. Once fibrosis and cirrhosis have set in, the damage is largely permanent, reinforcing the importance of prevention.
NAFLD is increasingly being seen in younger populations, particularly those in their 30s and 40s, which is a troubling development for public health and the economy. Affected individuals often require time off work, reducing productivity and increasing healthcare costs.
The key to controlling NAFLD lies in prevention. Lifestyle modifications are of paramount importance. This includes a healthy, balanced diet rich in fibre from fruits and vegetables, sufficient intake of lean proteins, and minimal consumption of fats, sugars, and salt. Refined carbohydrates and simple sugars should be avoided. Meals should be smaller, and individuals should be encouraged to eat only until they feel about 80% full.
Regular exercise, good quality sleep, stress management, and avoiding harmful substances like tobacco, alcohol, and narcotics are crucial. Even alcohol in small quantities can exacerbate liver conditions and should be avoided or minimised. Adequate hydration is equally important. Children, in particular, should be encouraged to spend more time playing outdoors, limit screen time, and eat healthy home-cooked meals rather than processed or fast foods.
There are also natural remedies that have been found to support liver health. Beverages like ginger tea, green tea, aloe vera juice, amla juice, turmeric milk, beetroot juice, lemon juice, and black coffee (unsweetened) are considered beneficial. Foods like garlic, broccoli, cabbage, sprouts, walnuts, and apples help reduce liver inflammation and promote fat metabolism.
Incorporating positive lifestyle habits such as maintaining social relationships, spending time in nature, engaging in intergenerational conversations, and regularly monitoring blood pressure and blood sugar levels can go a long way in preserving liver health. A nutritious, vitamin- and mineral-rich diet forms the foundation of prevention.
In conclusion, fatty liver disease, particularly NAFLD, is a growing health challenge that mirrors our changing lifestyles. As society continues to evolve with modernisation, automation, and increasing dependence on technology, the importance of conscious living cannot be overstated. Prevention remains the only reliable cure. By adopting a holistic approach to health and making informed choices, we can protect not just our livers, but our overall quality of life.
(The writer is a professor of pathology, former Dean of Goa University and president of the Asian Society of Cytopathology)