Liver health: Why lifestyle matters

The shift in socioeconomic status and lifestyle in India, starting from the Nineties, has meant a major uptick in the number of eateries, ready-to-eat meals, consumption of processed foods, and most recently home delivery of literally anything and everything. This was, however, accompanied by burgeoning health-related risks. Stress levels and systemic inflammatory counts were elevated. Body roundness indices, waistlines, insulin resistance, HbA1c levels, blood pressure and triglyceride levels headed further north. The country was booming in more ways than one. Indeed, on a recent visit to Bengaluru, this author frequently observed relatively young people whose body mass index (BMI) appeared to exceed 35.

The association between metabolic syndrome, a cluster of biochemical and physiological abnormalities, and cardiovascular and/or cerebrovascular accidents has long been recognised. Most of the diagnostic testing continues to be geared toward these endpoints. Kidney health is now gaining attention, and rightly so, as diabetes with or without hypertension is the leading cause of end-stage renal disease. 

Liver disease: How and why

What is little known is that the liver equally plays Hercules in bearing the brunt of metabolic syndrome. In so far as the liver is concerned, end-organ damage manifests as metabolic dysfunction-associated steatotic liver disease (MASLD). In addition to metabolic syndrome, emerging research indicates that risk-conferring genetic variations and the gut microbiome play a significant role in this disease. A continuum, MASLD starts with lipid accumulation in the liver, and can progress to inflammation (metabolic dysfunction-associated steatohepatitis - MASH), scarring and cirrhosis. Cirrhosis without obvious cause, i.e., cryptogenic cirrhosis, is now being linked to MASLD.

Hepatocellular carcinoma or liver cancer is the culmination of MASLD and can follow cirrhosis, albeit studies demonstrate MASLD-related liver cancer in the absence of cirrhosis. Over the next few decades, MASLD is projected to be the leading cause for liver transplantation and/or liver cancer. A Swedish study demonstrated that it is already the leading cause of liver cancer in that country. Sobering news: alcohol intake, even in moderate doses, fast tracks this disease and is known as metabolic dysfunction and alcohol-related liver disease (MetALD). 

Wide prevalence

Prevalence of MASLD has reached epidemic proportions, affecting over 200 million adults in India, and more than a billion worldwide. Unfortunately, both patients and community-based providers remain largely oblivious to this disease, both from a general lack of awareness, and the asymptomatic nature of the disease, at least early within the continuum. Diagnosis is often made late and by exclusion, and upon referral to a specialist when presentation may include fatigue, drowsiness, prominent hepatomegaly, mild encephalopathy and ascites or fluid build-up in the abdomen. At this stage, liver-specific testing can reveal progression to extensive scarring and in certain cases, hepatocellular carcinoma.

Societal awareness and effective management of this disease are under-met and urgent needs. Fortunately, endocrinologists and radiologists are becoming sensitive to this disease, judging by the number of workshops and conferences on MASLD. Radiologists can serve as first responders to this disease as they are uniquely positioned to visualise early changes in the liver.

In terms of management, a framework is emerging for the treatment of patients with MASLD. While diet and lifestyle modifications remain the first line, there are options for the patient resistant or refractory to behavioural modifications.

Sodium-glucose co-transporter-2 inhibitors and incretins are currently being prescribed to combat diabetes and obesity. The USFDA has approved two drugs, with differing mechanisms of action for treatment of MASLD-MASH. Taken together, it is anticipated that these drugs confer additive benefit.

Surveillance and aggressive management of MASLD can ensure we detect and treat any underlying disease before it is too late. 

Lifestyle changes

•Maintain a healthy, regimented (brown: rice, bread, chapati) diet with moderate exercise at least five days a week. 
•Undergo an annual physical or see your general practitioner at least twice a year, even if you appear outwardly healthy.
•Get a clinical chemistry (and CBC) test at least annually.
Ask questions of your doctor; bring up concerns; do not conceal symptoms.

(The author is the founder and CEO of a US-based firm offering STEM research mentorship and training for students.)